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Development and validation of a psychosocial screening instrument for cancer Linden, Wolfgang; Yi, Dahyun; Cristina Barroetavena, Maria; MacKenzie, Regina; Doll, Richard Sep 7, 2005

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ralHealth and Quality of Life OutcomesssBioMed CentOpen AcceResearchDevelopment and validation of a psychosocial screening instrument for cancerWolfgang Linden*1,2, Dahyun Yi1, Maria Cristina Barroetavena2,3, Regina MacKenzie2 and Richard Doll2Address: 1Psychology Department, The University of British Columbia, 2136 West Mall, Psychology/UBC, Vancouver BC, V6T 1Z4, Canada, 2British Columbia Cancer Control Agency, Canada and 3Health Care and Epidemiology, University of British Columbia, CanadaEmail: Wolfgang Linden* - wlinden@psych.ubc.ca; Dahyun Yi - dyi@hotmail.com; Maria Cristina Barroetavena - mbarroet@bccancer.bc.ca; Regina MacKenzie - gmacken@bccancer.bc.ca; Richard Doll - rdoll@bccancer.bc.ca* Corresponding author    Screeningdistressdepressionanxietyhealth-related quality of lifesocial supportnormsreliabilityvalidityAbstractBackground: We are reporting on the development of a psychosocial screening tool for cancerpatients. The tool was to be brief, at a relatively low reading level, capture psychological variablesrelevant to distress and health-related quality-of-life in cancer patients, possess good reliability andvalidity, and be free of copyright protection.Method: Item derivation is described, data on reliability and validity as well as norms are reportedfor three samples of cancer patients (n = 1057; n = 570, n = 101).Results: The resulting 21-item psychological screen for cancer (PSCAN) assesses perceived socialsupport, desired social support, health-related quality-of-life, anxiety and depression. It has goodpsychometrics including high internal consistency (alpha averaging .83, and acceptable test-reteststability over 2 months (averaging r = .64). Validity has been established for content, construct andconcurrent validity.Conclusion: PSCAN is considered ready for use as a screening tool and also for following changesin patient distress throughout the cancer care trajectory. It is freely available to all interested non-profit users.BackgroundCancer is now the leading cause of early death in Canadahttp://www.bccancer.bc.ca. A diagnosis of cancer is veryemotionally threatening, may provoke anxiety or depres-sion, and is difficult to live with because all aspects of lifeare overshadowed by the typical prognostic uncertaintyexplained by the nature and quality of support thatpatients have, individual coping skills and by the meaningthat they can learn to assign to this threat [4]. Psychologi-cal interventions for distress reduction can enhance qual-ity-of-life, and help patients and families better cope[2,5,6] but distress often remains unrecognized and there-Published: 07 September 2005Health and Quality of Life Outcomes 2005, 3:54 doi:10.1186/1477-7525-3-54Received: 13 April 2005Accepted: 07 September 2005This article is available from: http://www.hqlo.com/content/3/1/54© 2005 Linden et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 7(page number not for citation purposes)[1-3]. Nevertheless, there is great variability in howpatients respond to the diagnosis and this may be partlyfore untreated [7].Health and Quality of Life Outcomes 2005, 3:54 http://www.hqlo.com/content/3/1/54A number of critical questions for clinical practice arisefrom these insights, namely which intervention worksbest, and which patients are particularly needy and poten-tially responsive to a professional intervention. Screeningfor psychological distress and identification of emotionalneeds have important practical implications because prac-titioners want to responsibly serve their clientele and,given the scarcity of professional psychological resources,they want to make these resources available in the mostequitable and efficient manner possible [5]. Researcherscan help by extracting critical information from basicresearch for the explicit purpose of informing clinicians[8] and to ascertain best patient care.Screening research has its own theoretical basis and con-cerns [1,5,9,10,12]. Screening can be expensive and hasbuilt into it the moral and professional imperative thatone needs to act on urgent needs once identified. Alongthese lines, Rodin [8] and Ryan et al. [7] stress that screen-ing and feedback does not necessarily lead to betterpatient outcomes unless such measures are accepted bythe institutions and are supported by corresponding allo-cation of resources. However, only about one in fourpatients who report significant distress are actuallyreferred to psychosocial care [9,13]. This, in turn, suggeststhat screening research is best done in a clinical settingwith the active involvement of those professionals whoare also key players in its intended subsequent routineimplementation.Given the high incidence of cancer, screening for distressrequires tools that are psychometrically sound, inexpen-sive and quick, accepted by patients and staff, and of suf-ficient simplicity to be accessible to as many patients aspossible [5]. In a review of the most frequently used toolsfor psychosocial distress screening [9], it became apparentthat (a) most often measured are anxiety and depression,(b) there is no agreement on the best screening tool, (c)many of these measures are too long for routine screening,and (d) almost all of the tools used are copyrighted pro-tected and would have to be purchased for every applica-tion. For the sake of parsimony, we decided to focus onpsychological concepts that are know to be particularlycritical for cancer patients, namely anxiety, distress [2,9],but also wanted to measure patient characteristics thatreflect more positive aspects of life namely social supportand quality-of-life [4,6,11,13]. Aside from the primaryobjective of developing a screening tool, we hoped thatthe psychometrics would support use of the same tool fortracking emotional adjustment in patients. Lastly, wewanted to include an instruction that questionnaire com-pletion would imply permission for clinicians andresearchers to directly contact patients to offer services orpatient identification for research are made much lesscumbersome.In light of these observations, we intended to develop atool that embraced all of the desired features listed above.While our work on a brief psychosocial tool does notclaim to break completely new ground (see the review ofpreviously used screening tools [9] and the NCCN guide-lines [5], we posit that it stands out because of (a) its brev-ity, (b) its development in the clinical context where it wasto become implemented, (c) the scope of the domainsincluded, (d) that it measures both negative and positiveaspects of the patients' quality of life, and (e) its non-com-mercial nature. A series of three studies (subdivided intoPhase Ia, Ib, and Phase II) was planned to establish psy-chometrics and norms in two test phases. The objectivesfor Phase Ia were determination of item clarity, basic reli-ability, and validity features including internal consist-ency, desired and undesired factor correlations as a test ofconstruct validity, as well as to generate initial norms fora cancer patient population. A second sample was testedin Phase Ib to also identify cancer-type specific norms,and gender-specific norms.For Phase II, a third (smaller) sample was evaluated ini-tially and then retested for establishment of test-retest reli-ability; in addition, participants completed a larger testpackage that permitted concurrent validation of thePSCAN subscales with well established and substantiallylonger versions of tests that we considered "industrystandard" in order to show adequacy of content samplingand concurrent validity for PSCAN.MethodsPhase IThe instrumentAfter extensive discussion of existing instruments andtheir respective strengths and weaknesses, the authors anda group of practicing clinicians agreed to focus on anxiety,depression, social support, and health-related quality-of-life. The final version of the full scale as described here isfound in the Additional file 1 as are instructions for howto obtain permission for its use from the authors. (Giventhat no acceptable measure of anxiety and depressioncould be found that did not have to be purchased from acommercial publisher, a number of popular scales werestudied to obtain a clear sense of content domains). Fiveitems each were written to elicit patients' level of anxietyand depression. Each item is scaled as 1–5 ('not at all' to'very much so')The social support items are derived from a social supportscale used in the Epidemiological Study of the Elderly [14]Page 2 of 7(page number not for citation purposes)invite research participation. If agencies and patients givesuch permission, both clinical service provision andthat is considered to be in the public domain. It provides5 items that, when clustered, are referred to as Social Net-Health and Quality of Life Outcomes 2005, 3:54 http://www.hqlo.com/content/3/1/54work and Support Assessment (SNSA) which taps intoavailable informational, instrumental, and emotionalsupport. One additional item (not part of the SNSA) askshow much social support people desire (Item 6). TheSNSA has been reported to have internal consistencies of.47 to .61 [15]. The SNSA was found to predict mortalityin epidemiological studies [14] and has also been used incancer populations [15]; the existence of distinct subscaleswas shown to possess discriminant validity because ther-apy-induced changes were apparent on instrumental andinformational support but not on other items [15].Given that desired support and received support generallydo not intercorrelate and that mismatched supportattempts are not constructive [6,16], the 'desired support'item was written as a single item scale with a 1–9 rating('not at all' to 'very much so') to permit variability in rat-ings. This single item scale has already shown remarkableclinical usefulness because Krumholz et al. [17] foundthat, in a sample of 292 elderly patients with heart failure,those patients not seeking and not receiving support werethree times more likely to be alive one year later that thosepatients who did seek support but did not receive it. Appar-ently, social support is only useful when its availability isactually also desired. All other social support items (items1–5) are rated as yes/no and coded 0 or 1. While the direc-tion of scoring is ultimately arbitrary, we treated positivesupport ratings as high scores.Quality-of-life measures are generally distinguished asbeing either broad and generic or disease-specific withresearchers favoring the inherent sharper focus of disease-specific tools. That notwithstanding, we did not decide ona highly disease-specific measure because many distress-ing physical aspects of cancer (like pain and functionallimitations) are only salient in late stage cancer and are,fortunately, of limited importance to the lives of early-stage cancer patients who form the majority of study par-ticipants. We therefore decided to keep the assessment ofhealth-related quality-of-life (HRQoL) sufficiently broadand generic to embrace cancer patients in all stages. Thechosen items are from the Health Related Quality of Lifequestionnaire developed by the Centers for Disease Con-trol [18] and are part of the Behavioural Risk Factor Sur-veillance System since 1993. The questions seek to learnabout HRQoL by distinguishing between global, self-rated health and numbers of days negatively affected bypoor mental or physical health (PSCAN items 7–11). Test-retest stability of this tool was established in a sample of868 adults with kappas ranging from = .58 to .75; reliabil-ity was not affected by gender or race [19]. The scale hasalso been used in a Canadian sample of 926 men andwomen age 65 or over and revealed that those with poorStudy populationSample 1Participants were 1057 consecutive cancer patients com-ing into first contact with the Vancouver Cancer Centre(i.e., after a positive diagnosis had been established). Nodemographic information was collected at this timebecause the data were only to be used in the item develop-ment process and not any kind of hypothesis testing. Par-ticipants were asked by the receptionist to complete the21-item PSCAN after they had read the instructions andagreed to participate. The plan was to collect initial datafor a 3-month time period rather than setting a particularsample size as a target; the rationale for this decision wasto allow us later determination what percentage of thetotal number of eligible patients had actually participated;of all patients who had made initial contact with the can-cer agency during this same time period, about 90% hadindeed completed PSCAN which suggests that this sampleis quite representative of the typical patient populationseen by this agency.Feedback from patients suggested that the wording of twoitems was somewhat ambiguous and these were subse-quently changed prior to the recruitment of sample 2.Sample 2Participants were 547 consecutive cancer patients (averageage 66.5 yrs (SD = 14.5), 304 women and 243 men) com-ing into first contact with the Fraser Valley Cancer Centre(i.e., after a positive diagnosis had been established). Theprocedure was the same as the one applied to sample 1.Phase IIThe sample consisted of 101 cancer patients making firstcontact with the BC Cancer Agency at the VancouverCenter (41 male, 60 female). Eligible patients wererecruited consecutively by two trained research assistantsover a period of one month. The research assistants werephysically located in the reception area, were alertedabout potentially eligible patients by the receptionist, andthen approached patients individually to explain thestudy, seek consent, and request completion of a test pack-age. Patients were explicitly recruited to participate in atest-retest study and indicated whether they preferredrecontact by mail or telephone. Two months later,patients were recontacted according to their preferredmethod. If no contact could be made by telephone afterthree attempts, no further attempts were made. Patientswho received the questionnaire package by mail, were notfurther reminded to return them. This relatively 'lowpressure approach' still resulted in a 65% return rate ofcompleted retest materials. The questionnaire packageconsisted of the PSCAN as described above, the HospitalPage 3 of 7(page number not for citation purposes)self-rated health showed a 17-fold increase in the numberof unhealthy days [20].Anxiety and Distress Scale (HADS) and the ENRCHDSocial Support Instrument [ESSI; [21,22]].Health and Quality of Life Outcomes 2005, 3:54 http://www.hqlo.com/content/3/1/54The HADS is a very frequently used 14-item scale tappinganxiety and depression. Bjelland et al. [23] provided areview of the psychometrics of HADS based on 747 pub-lished studies and reported Cronbach's alphas of .68 to.93 for anxiety and .67 to .90 for depression. Factor anal-yses routinely confirm the underlying 2-factor structure.The ESSI is a 7-item instrument with strong test-retest reli-ability (means one month apart were 27.8 and 27.8), andinternal consistency in a sample of 271 cardiac patientswas .88. Concurrent validity was shown by relating ESSIscores to established psychiatric diagnoses of depressionand an index of social functioning [21,22].ResultsThe findings obtained from the three samples duringPhase I and II testing are presented in aggregated form thatpresents findings organized around the test's propertiesregarding means and reliability (Tables 1, 2, 3), and thenreports on evidence of validity. Finally, raw means andstandard deviations are provided for each cancer type andeach gender group (Table 4). This presentationalapproach appeared more parsimonious and provided amore logical organization than a mere sequential listingof each temporal step of the result finding process.As the mean scores in Table 1 show, indices of variabilityreveal that participants used a wide range of scores that inturn suggests that PSCAN is sensitive in discriminatingReliabilityAs Table 2 reveals the internal consistencies for these foursubscales are high and satisfy traditional cutoffs for full-length tests despite their brevity in PSCAN. Internal con-sistency was not computed for the Social Support items,because each item was designed to tap somewhat differentdimensions of support and the yes/no scoring method didnot create much item response variability that could thenbe meaningfully analyzed.Scores for social support variables were very stable over 2months whereas QOL and distress-related variablesshowed less stability although they were still moderatelyhigh (Table 3).ValidityA number of steps were undertaken to establish constructvalidity. Basic requirements for test creation [24] arestated below and corresponding results are listed for each:(a) the items that make up a distinct subscale (and thatpresumably reflect an underlying 'factor') intercorrelatewith each other (but not so highly that they suggest dupli-cation) and that they load (i.e., correlate) with the totalsubscale score. Given the complexity of results, they arenot reported in detail but the pattern of results clearlyindicates that this requirement was met. For example, theQuality-of-Life items correlated between r = .49 and r =.95 with the average of inter-item correlations being r =.73.(b) the subscale scores themselves should correlate witheach other if they are conceptually related. Based onextant literature, it is expected that anxiety and depressionwill partly overlap, and high social support and QoLshould correlate to some degree with low depression andanxiety. This was confirmed with r's ranging from .55 to.92.(c) generally, subscale scores across domains should notTable 1: Subscale Descriptive Data (Means, and variability), Phase IRange of scores Mean sample 1 SD sample 1 Mean sample 2 SD sample 2SS_Total 0–5 4.6 .82 4.5 .99SS_Desired 0–10 4.0 3.5 3.7 3.4QOL, Perceived 0–20 6.5 5.4 6.7 5.5QOL, Days 0–120 31.6 29.3 24.0 24.3Anxiety 5–24 8.1 3.8 8.2 4.2Depression 5–25 8.1 3.9 8.2 5.1Table 2: Internal ConsistencyInternal Consistency Alpha Sample 1QOL_Days 0.79QOL_Perceived 0.89Anxiety 0.83Depression 0.79Page 4 of 7(page number not for citation purposes)among patients. Means for the two samples were quitesimilar.highly intercorrelate with each other because that wouldsuggest redundancy that is especially undesirable in a briefHealth and Quality of Life Outcomes 2005, 3:54 http://www.hqlo.com/content/3/1/54screening tool. These test properties were determined witha series of correlational analyses and supported the notionof minimal overlap in general [20]. The data suggest thatthe three 'QoL days' items and the two 'QoL Perceived'items overlap but still tap different aspects of QoL; eachrespective item correlates highly with its own subscaletotal score. This finding supports the continued inclusionof these two sets of QoL items.Anxiety and depression were predictably intercorrelated (r= .71 and r = .55 in sample 1 and 2 respectively) andexplain about 30–50% of each other's variance.tests strongly support concurrent validity. The r-scores forsamples 1 and 2 respectively were .72 and .82 for anxiety;.59 and .75 for depression, and .61 and .61.Lastly, we computed means for men and women and eachsubscale as a function of cancer type. Only those types ofcancer were listed where at least 5 men and 5 women werefound to fill each cell (with the exception of frequent can-cers that are only found in one gender). Results are dis-played in Table 4. No inferential testing was conductedbecause the power for tests varies greatly as a function ofthe varying sample sizes per cell; we do, however, reporteffect sizes because this display of psychological profilesTable 3: Test-retest stabilitySubscale Stability coefficient r M and SD Time 1 M and SD Time 2Social Support Total .87 5.3 (.73) 5.3 (.74Social support desired .59 4.2 (3.3) 4.4 (3.4)Anxiety .67 7.4 (3.3) 6.6 (2.4)Depression .61 7.7 (3.8) 7.0 (2.4)QoL Perceived .59 4.2 (4.3) 5.6 (5.6)QoL Days .49 22.3 (26.5) 20.5 (27.4)Table 4: Subscale means for each gender and cancer typeCancer Type Subscale – Mean (SD)Depression Anxiety QoL-P QoL-D SS-Tot SS-DesGastro-IntestinalFemale (n = 39) 18.3 (12.9) 8.4 (3.7) 6.2 (5.7) 26.7 (23.9) 4.9 (.5) 4.0 (3.9)Male (n = 39) 13.3 (4.4) 6.7 (2.7) 7.1 (4.6) 31.3 (21.7) 4.9 (.4) 2.7 (3.5)LungFemale (n = 35) 17.6 (8.6) 9.2 (4.5) 8.7 (4.9) 30.6 (22.9) 4.0 (1.2) 4.4 (3.6)Male (n = 42) 17.0 (6.9) 8.9 (5.6) 11.7 (6.1) 41.3 (22.8) 4.6 (.7) 3.9 (3.2)LymphomaFemale (n = 12) 22.6 (8.6) 12.1 (4.4) 9.9 (7.9) 35.6 (28.4) 4.9 (.3) 5.9 (4.0)Male (n = 13) 19.6 (11.9) 9.6 (6.4) 11.0 (6.6) 35.0 (24.6) 4.7 (.5) 4.2 (3.9)BreastFemale (n = 133) 15.6 (6.5) 7.9 (4.3) 5.0 (4.4) 21.3 (21.3) 4.5(.9) 3.8(3.4)Male (n = 1) 10.0 (na) 5.0 (na) 2.0 (na) 0 (na) 5.0 (na) 5.0 (na)MelanomaFemale (n = 9) 14.5 (7.1) 8.3 (5.1) 2.1 (3.4) 12.3 (21.5) 4.7 (.5) 5.0 (3.5)Male (n = 12) 13.2 (4.2) 6.6 (1.8) 3.9 (2.6) 4.2 (5.2) 4.6 (.7) 1.7 (2.2)Head & NeckFemale (n = 12) 26.1 (16.0) 11.0 (3.7) 8.7 (5.9) 25.0 (21.9) 4.3 (.8) 5.6 (3.2)Male (n = 18) 15.3 (5.8) 8.3 (4.0) 6.6 (5.8) 20.8 (24.7) 4.5 (1.2) 3.6 (3.1)Genito-Urinary (incl Prostate)Female (n = 5) 12.0 (2.8) 6.2 (2.2) 6.4 (3.8) 17.4 (24.8) 4.8 (.5) 1.3 (1.5)Male (n = 83) 14.6 (6.5) 7.4 (3.5) 5.9 (5.1) 14.6 (27.6) 4.4 (1.2) 2.8 (3.4)QoL-P = Quality-of-Life Perceived; QoL-D = Quality-of-Life Days; SS-Tot = Social Support Total; SS-Des = Social Support DesiredPage 5 of 7(page number not for citation purposes)Correlation coefficients of the rather short PSCAN sub-scales with equivalent longer version from establishedfor all cancer types can serve as a hypothesis generator forHealth and Quality of Life Outcomes 2005, 3:54 http://www.hqlo.com/content/3/1/54future studies and may enable power calculations for sam-ple size estimation.It is tempting to interpret the results shown in Table 4 butgiven that no inferential tests were computed, any inter-pretation is speculative should be kept at a minimum. Itappears that men typically report less negative affect thanwomen and that there is considerable variability in dis-tress and QoL as a function of cancer type. This suggestsan urgent need for the accrual of a larger sample includingall cancer types such that sufficiently powered inferentialtests can be conducted.DiscussionThe objective of this tool development process was togather enough information so that readers could poten-tially make a decision to adopt the scale for their own usewith cancer populations, knowing that adequate reliabil-ity and validity testing had been undertaken. We considerthe psychometric characteristics of PSCAN to be satisfac-tory especially when considering that it is a very brief tool[6]; the scale characteristics typically met even the desiredstandards for longer scales. Subscale means for two largesamples recruited at different sites were very similar sug-gesting stability of the scale scores. Practitioners can nowchoose to use PSCAN instead of the recommended single-item distress thermometer [5] or use it in a complemen-tary fashion, as a second step, if the single item distressthermometer suggests elevated distress. A second advan-tage of PSCAN is that the standard instructions caninclude a statement about the patient having consented tobe contacted for offers of professional help or participa-tion in research. This feature has been found very useful inclinical settings where research is also being conductedbecause Ethics Reviews Boards do not usually permitdirect contacting (i.e., "cold calls") of patients for studyrecruiting.ReliabilityInternal consistency was good across the two independentsamples and test-retest stability was also acceptable. Notethat at the time of recruitment for the test-retest study(Phase II), patients had come for their first visit to the can-cer center. During the 8-week interval for test and retest,these patients typically learned more about their diagno-sis and many began active treatment. It was thereforeexpected that these experiences would affect distress andquality-of-life, and that the test-retest scores would onlybe moderately high. In fact, had the test-retest scores comeclose to r = 1, this would have suggested that PSCAN wasinsensitive to measuring change and that would havebeen indicative of a significant weakness in the test.ValidityIndividual item correlations with their respective subscalescores were high, suggesting that they load appropriatelyon the constructs to be measured. All relationshipsbetween constructs measured by the PSCAN were of astrength and direction so as to be consistent with the liter-ature and that, in turn, suggests that PSCAN possessesconstruct validity. The newly written anxiety and depres-sion items not only formed cohesive subscales with somepredicted overlap of anxiety and depression but also cor-related highly with longer versions of anxiety and depres-sion scales of well established tools thus indicating highconcurrent validity. There is no firm consensus on how toestablish content validity other than finding that expertsagree. The research group who developed PSCAN, the can-cer agency staff who worked with it, and the patients whoresponded, all considered the items as meaningful andsensitive. It was also interesting to see that once Phase Ihad been completed and PSCAN-derived patient distressinformation became known to the psychosocial supportstaff, they reported quickly occurring changes in their cli-entele's composition because the patients now seen byfamily and patient counseling included more men andmore minority patients who apparently had gone unde-tected by previous practice patterns. Interestingly, the useof PSCAN and especially the inclusion of an item on sui-cidal thinking, also led the agency' s staff to review andclarify their policy on how to respond to highly distressed,potentially suicidal patients. Hence, the development ofthis screening tool by a 'mixed' team of researchers andservice providers also led to ready acceptance of the toolby service providers and triggered prompt changes in theirpractice patterns. This could be considered a form of eco-logical validity.ConclusionWe conclude that there is sufficient psychometric evi-dence to support PSCAN's use as a screening tool and pos-sibly as a tool for tracking patient changes in emotionalwell-being. Consistent with the larger literature on distressscreening, it is likely that PSCAN's strength is in sensitivityof detection, not in specificity; in order to advance to afull-fledged psychiatric diagnosis, further standardizedtesting as well as individual histories and assessments willneed to be considered. At this time, there are enough nor-mative data available so that one can decide on a clear,replicable cutoff based on percentile scores such that anagency might decide to offer psychological services to allpatients scoring above 80th percentile of depression forexample. However, we believe strongly that more infor-mation is needed before establishing a cutoff that also hasa clinical meaning, like a demonstration of the healthconsequences of not offering services to patients above aPage 6 of 7(page number not for citation purposes)given cutoff. We also recommend that norms be compiledfor a large, representative cancer sample that fairly repre-Health and Quality of Life Outcomes 2005, 3:54 http://www.hqlo.com/content/3/1/54sent both sexes, all cancer subtype populations, and cul-tural minorities. Compilation of norms for differentstages in the trajectory of cancer care should equally beconsidered. This, in turn, will aid empirically-based,future decisions about use of cutoffs [25]. Furthermore, itwill be important to collect normative data from a physi-cally and psychologically healthy sample and anothermedical sample so as to place the data obtained from can-cer patients in a larger population context, and to serve asreference levels. Although PSCAN was explicitly devel-oped and validated for cancer patients, the measured con-cepts are not uniquely relevant for cancer but appearpertinent for other chronic disease populations as well[1].Lastly, PSCAN, is freely available to non-profit users whoneed, however, to contact the copyright holder for permis-sion and conditions of use via our website:http:www.bccancer.bc.ca/RES/SBR/Research/Psychosocial.htm.Instructions for scoring and status quo of knowledgeabout norms and cutoffs will be made available at thattime.List of abbreviationsESSI ENRICHD Social Support InstrumentHADS Hospital anxiety and Distress ScalePSCAN Psychosocial Screen for CancerHRQoL Health-Related Quality of LifeSNSA Social Network and Support AssessmentAdditional materialReferences1. Coyne JC, Thompson R, Klinkman MS, Nease DE: Emotional disor-ders in primary care.  J Cons Clin Psychol 2002, 70:798-809.2. 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