584 Journal of Pain and Symptom Management Vol. 36 No. 6 December 2008

Original Article

New Insights in Symptom Assessment: TheChinese Versions of the Memorial SymptomAssessment Scale Short Form (MSAS-SF)and the Condensed MSAS (CMSAS)Wendy Wing Tak Lam, PhD, Chi Ching Law, FRCR, Yiu Tung Fu, FRCR,Kam Hung Wong, FRCR, Victor T. Chang, MD, and Richard Fielding, PhDCentre for Psycho-Oncological Research and Teaching (W.W.T.L., R.F.), Department of Community

Medicine & Unit for Behavioural Sciences, Li Ka Shing Faculty of Medicine, The University of Hong

Kong; Department of Clinical Oncology (C.C.L., Y.T.F., K.H.W.), Queen Elizabeth Hospital, Hong

Kong; Section Hematology Oncology (V.T.C.), VA New Jersey Health Care System, East Orange; and

Department of Medicine (V.T.C.), University of Medicine and Dentistry of New Jersey, Newark, New

Jersey, USA

Abstract

There are very few symptom assessment instruments in Chinese. We present the validity andreliability of the Memorial Symptom Assessment Scale Short Form (MSAS-SF) and theCondensed Form MSAS (CMSAS) in Chinese cancer patients. The Chinese version of the 32-item MSAS-SF, a self-report measure for assessing symptom distress and frequency in cancerpatients, was administered to 256 Chinese patients with colorectal cancer at a clinicaloncology outpatient unit. Highly prevalent symptoms included worrying (59%), dry mouth(54%), lack of energy (54%), feeling sad (48%), feeling irritable (48%), and pain(41%). Both the MSAS-SF and CMSAS demonstrated good validity and reliability. For theMSAS-SF subscales, Cronbach alphas ranged from 0.84 to 0.91, and for CMSAS subscales,from 0.79 to 0.87. Moderate-to-high correlations of MSAS-SF and CMSAS subscales withappropriate European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 subscales (0.42e0.71, Ps< 0.001) indicated acceptable convergent validity. Lowcorrelations with the Rosenberg Self-Esteem and Optimism Scale (0.22, P< 0.001) indicateddivergent validity. MSAS subscales varied as expected with other Chinese scalesdthe ChineseHealth Questionnaire (CHQ) and the Life Orientation Scale. Construct validity of bothMSAS versions was demonstrated by effective differentiation between clinically distinctpatient groups (Karnofsky scores <80% vs. $80% [P< 0.001]; no active treatment vs.active treatment [P< 0.002e0.034]; CHQ-12 scores #4 vs. CHQ-12 scores >4[P< 0.001]). The Number of Symptoms subscale correlated appropriately with the EORTCQLQ-C30 function (�0.46 to �0.60, P< 0.001) and symptom scales (0.31e0.64,P< 0.001). The average time to complete the MSAS-SF was six minutes. The Chinese

The views expressed herein do not necessarily re-flect the views of the Department of Veterans Affairsor the U.S. government.

Address correspondence to: Wendy Wing Tak Lam, PhD,Centre for Psycho-oncological Research and Train-ing, Department of Community Medicine & Unit

for Behavioural Sciences, 5/F, WMW Mong Block,Li Ka Shing Faculty of Medicine, The University ofHong Kong, 21, Sassoon Road, Pok Fu Lam, HongKong. E-mail: wwtlam@hku.hk

Accepted for publication: December 10, 2007.

� 2008 Published by Elsevier Inc. 0885-3924/08/$esee front matterdoi:10.1016/j.jpainsymman.2007.12.008

Vol. 36 No. 6 December 2008 585Chinese Version of the MSAS-SF

versions of the MSAS-SF and CMSAS are valid and practical measures. Further validationis needed for Chinese patients with other cancer types and with other symptominstruments. J Pain Symptom Manage 2008;36:584e595. � 2008. Published byElsevier Inc. All rights reserved.

Key Words

Symptom, assessment, validation, Chinese, colorectal cancer, distress, MSAS, QLQ-C30,quality of life

IntroductionSymptom assessment is pivotal for effective

and comprehensive cancer management. Can-cer patients often experience symptoms aris-ing from the disease or its treatments thatvary in severity, frequency, and duration. Unre-lieved symptoms are distressing, and measuresof symptom distress have been associated withpoor quality of life (QoL),1,2 impaired psycho-logical status,3 decreased functional capacity,2

and survival.2,4 Symptom assessment is a vitaltool enabling clinicians to systematically evalu-ate cancer patients’ symptom experience.

Portenoy et al. developed the Memorial Symp-tom Assessment Scale (MSAS) to measure 32physical and psychological symptoms in dimen-sions of frequency, intensity, and distress.5 TheMSAS has been widely used and validated inCaucasian and African American cancerpatients.2,4,6e9 To increase its clinical utility, anabbreviated version, MSAS-Short Form (MSAS-SF)10 and a short version, Condensed MSAS(CMSAS),11 were developed. The MSAS-SF mea-sures 32 symptoms in terms of distress or fre-quency, with four subscales measuring globaldistress, physical symptom distress, psychologicalsymptom distress, and total sum of symptoms.The MSAS-SF was tested in 299 cancer patientsin the United States with good reliability and val-idity.10 Moreover, its global distress and psycho-logical symptom distress subscales contributedindependently to prognostic models of survivalof advanced cancer patients.4 The CMSAS wasderived from MSAS-SF with the aim of enhanc-ing bedside ease of use. The CMSAS includes14 prevalent physical and psychological symp-toms measured by distress or frequency, andcomprises two subscales for physical symptomdistress and psychological distress. The CMSASwas derived from responses of 479 cancer pa-tients and demonstrated good validity and reli-ability in a second group of cancer patients.12

Han Chinese and indigenous Chinese mi-norities comprise the largest ethnic groupingworldwide, amounting to 1.3 billion people.Over 34 million Chinese live overseas, withlarge communities in mostly European, NorthAmerican, and Pan-Pacific conurbations.13 Mi-grant Chinese populations rapidly acquire pre-vailing disease patterns as they assimilate localdiets and habits, as illustrated by colorectalcancer (CRC).14 In 2002, CRC had the secondhighest cancer incidence and cancer mortalityin Hong Kong, and showed the greatest in-crease over the previous 10 years.15 Despitethe growing incidence of cancer in the Chi-nese, at the time this work commenced, therewere no symptom assessment tools adapted ordeveloped for Chinese cancer patients. Wepresent the first report on the Chinese versionof the MSAS-SF and the CMSAS in colorectalcancer patients in Hong Kong.

MethodsSample and Setting

From July 20, 2004 to March 24, 2005, allpatients who attended the clinical oncologyoutpatient unit who met inclusion criteria (Can-tonese-speaking Chinese, 18 years or older, di-agnosed with colorectal cancer) were invitedto participate in the study. Patients’ eligibilitywas determined through careful review of med-ical records. Exclusion criteria were linguistic orintellectual difficulties or concurrent activeAxis I psychiatric diagnosis.16

Study Procedure and Study MeasuresAfter institutional ethical approval, eligible

patients were recruited at the largest HongKong government-funded clinical oncologyoutpatient unit, located at a major regionalhospital in Hong Kong. Patients gave in-formed written consent and completed the

586 Vol. 36 No. 6 December 2008Tak Lam et al.

questionnaire either by self-completion or ina face-to-face interview during follow-up ap-pointments, or while awaiting treatment.

The MSAS-SF is a self-report instrument inwhich the patient indicates whether a symptomis present and, if present, the patient thenrates symptom distress of 28 physical and psy-chological symptoms, and symptom frequencyof four psychological symptoms during thepast seven days. These 32 items are scored us-ing the same response format used in the orig-inal study.10 Symptom distress is rated ona five-point (0e4) Likert scale: ‘‘Not at all,’’‘‘A little bit,’’ ‘‘Somewhat,’’ ‘‘Quite a bit,’’ and‘‘Very much’’ and scaled from 0.8 to 4.0. Symp-tom frequency is rated on a four-point (1e4)Likert scale: ‘‘Rarely,’’ ‘‘Occasionally,’’ ‘‘Fre-quently,’’ and ‘‘Almost constantly.’’ TheMSAS-SF consists of four subscales includingthe Global Distress Index (GDI), PhysicalSymptom Distress score (PHYS), PsychologicalSymptom Distress score (PSYCH), and TotalMSAS (TMSAS). The GDI comprises four psy-chological symptoms: feeling sad, worrying,feeling irritable, and feeling nervous, and sixphysical symptoms: lack of energy, pain, lackof appetite, feeling drowsy, constipation, anddry mouth; the PHYS comprises 12 prevalentphysical symptoms: lack of energy, pain, lackof appetite, feeling drowsy, constipation, drymouth, nausea, vomiting, change in taste,weight loss, feeling bloated, and dizziness;the PSYCH comprises six prevalent psycholog-ical symptoms: worrying, feeling sad, feelingnervous, difficulty sleeping, feeling irritable,and difficulty concentrating. The TMSAS isthe average of the symptom scores of all 32symptoms. NS is the total number of symptomspresent at the interview.

The CMSAS, a condensed form of theMSAS-SF, comprises 14 prevalent symptoms,with 11 items measuring symptom distress(lack of energy, lack of appetite, pain, drymouth, weight loss, feeling drowsy, shortnessof breath, constipation, difficulty sleeping, dif-ficulty concentrating, and nausea) and threeitems measuring symptom frequency (worry-ing, feeling sad, and feeling nervous). These14 items are scored using the same responseformat used in the MSAS-SF.11 The CMSASconsists of three subscales: Physical Symptom(CMSAS PHYS), Psychological Symptom(CMSAS PSYCH), and Total Score of the

CMSAS (CMSAS SUM). The CMSAS PHYS isthe average of the 11 items measuring symp-tom distress; the CMSAS PSYCH is the averageof the three items measuring psychologicalsymptom frequency; the CMSAS SUM is the av-erage of all 14 symptoms. CMSAS NS is the to-tal number of symptoms present at theinterview.

The MSAS-SF was translated into Chinese bya bilingual researcher (Fig. 1). This translationwas reviewed for clarity and wording by a pro-fessional teacher of Chinese. This Chinese ver-sion was then independently back-translatedinto English and compared with the original,and amendments then made to the Chinesewording. The process was repeated until thetwo English versions corresponded in termsof meaning. To enhance the applicability ofthe instrument to other Chinese communities,the Chinese terms selected are those used inStandard Chinese and not limited toCantonese.

To assess validity, additional instrumentswere concurrently administered. These in-cluded the Standard Chinese version of theEuropean Organization for Research andTreatment of Cancer (EORTC) general QoLquestionnaire (QLQ-C30),17 which measureshealth-related QoL issues relevant to a broadspectrum of cancer patients, to assess conver-gent validity. The EORTC QLQ-C30 includes30 items that measure five function scales(physical, role, emotional, cognitive, and so-cial), three symptom scales (fatigue, pain,and nausea/vomiting), a global health QoLsubscale, five single symptom items (dyspnea,appetite loss, sleep disturbance, constipation,and diarrhea) and financial difficulty.18 TheChinese version of the Rosenberg Self-Es-teem Scale (RSE),19 a measure of self-esteem,and the revised Chinese Life OrientationTest (C-LOT-R),20 a measure of optimism,were administered to assess divergent (dis-criminant) validity. The Chinese HealthQuestionnaire-12 scale (CHQ-12),21 a generalmeasure of psychological morbidity, andclinician ratings of the Karnofsky perfor-mance status,22 a measure of patients’ physi-cal functional level related to cancer andits treatment, were administered to furtherdetermine construct validity. The orderof questionnaires administered was non-randomized.

Fig. 1. Chinese version of the MSAS-SF.

Vol. 36 No. 6 December 2008 587Chinese Version of the MSAS-SF

588 Vol. 36 No. 6 December 2008Tak Lam et al.

Statistical AnalysesCronbach’s alpha coefficient was calculated

to assess the internal consistency of theMSAS-SF and CMSAS. Convergent validity issupported if the MSAS-SF scales correlate sig-nificantly highly with the QLQ-C30. We hy-pothesized that the physical symptom distresssubscale of the MSAS-SF would correlatemore highly with the QLQ-C30 functioningand symptom scales, whereas the psychologicalsymptom subscale of the MSAS-SF would corre-late more highly with the QLQ-C30 emotionalfunctioning. Because the QLQ-C30 function-ing scales measure functional well-being andsymptom scales measure the severity of thesymptom, we hypothesized that the MSAS-SFwould correlate negatively with the QLQ-C 30functioning scales and positively with theQLQ-C30 symptom scales, reflecting conver-gent validity. Divergent validity is supported ifthe MSAS-SF scales show low correlation withthe RSE and C-LOT-R. Pearson correlationanalysis was used to test the hypothesized cor-relations. Construct validity was tested byknown group comparisons (Karnofsky scores<80% vs. $80%; no active treatment vs. activetreatment; CHQ-12 scores #4 vs. CHQ-12scores >4, a score of >4 being the criterionfor CHQ-12 case definition21). Confirmationof convergent and divergent validitystrengthens support for MSAS construct valid-ity. The key test of construct validity hypothe-sizes that patients with psychological distressor with poorer physical functioning will reporthigher symptom distress. To test construct(known-groups) validity, analyses were per-formed in two steps. First, Student’s t-testswere performed to test these group differ-ences. Second, multiple discriminant analysiswas applied to determine the subscales thatbest discriminate and predict these group dif-ferences.23 We adopted the same validity anal-yses to test the validity of the CMSAS. SPSSversion 14.0 for Windows (Chicago, IL) wasused to analyze the data.

ResultsOf 313 eligible patients, 256 (82%) patients

provided full informed consent and com-pleted the questionnaires. Age ranged from27 to 75 years, with a mean of 59.0 years (SD

9.78). Most patients were male (66%), married(81%), and many were retired (49%). Forty-eight percent of the patients had secondaryor higher levels of education. The median Kar-nofsky performance status was 80. At interview,time since diagnosis ranged from less than oneyear to 11 years (mean 1.63, SD 2.03 years).Most patients were on active treatment(78%), including 14% on both adjuvant che-motherapy and radiation therapy, 20% on ad-juvant chemotherapy, and 40% on palliativetreatment for metastatic disease (Table 1).

Most patients (80%) completed the ques-tionnaire during a face-to-face interview. Pa-tients who completed the questionnaires byself-report were often younger (t¼ 6.81, df254, P< 0.001) and male (c2¼ 7.76, df¼ 1,P¼ 0.005). Their responses did not differfrom those interviewed. Most patients foundthe questions to be clear and the items werewell accepted, except for the item ‘‘problemswith sexual interest or activity,’’ for which 31(12%) declined to complete the item becausethey were sexually inactive. The average timerequired to complete the MSAS-SF was6 minutes.

Prevalence of the 32 Symptoms by MSAS-SFTable 2 shows the 28 physical symptoms and

four psychological symptoms rank orderedfrom highest to lowest in terms of the fre-quency. Of the 28 physical symptoms, the fivemost frequently reported symptoms were drymouth (54%), lack of energy (54%), pain(41%), feeling drowsy (40%), and itching(40%). With the exception of ‘‘lack of energy,’’‘‘difficulty sleeping,’’ ‘‘constipation,’’ and‘‘vomiting,’’ greater than 50% of the patientsin this sample experienced no or little distressresulting from the physical symptoms. Of thefour psychological symptoms, the most preva-lent symptoms were worrying (59%), feelingsad (48%), and feeling irritable (45%). Themajority of patients reported experiencing psy-chological symptoms at least ‘‘occasionally.’’

In addition to the prespecified 32 symptoms,patients were asked whether they had anyother unlisted symptoms. Four patients re-ported having other symptoms, including uri-nary incontinence (n¼ 1), muscle cramping(n¼ 2), and fever/chill (n¼ 2), with no or lit-tle distress from these symptoms.

Table 1Sample Characteristics

Characteristics n¼ 256

Age (years)Mean (SD) 59.0 (9.78)Range 27e75

Method of completionSelf-completion 52 (20.3%)Face-to-face interview 204 (79.7%)

Marital statusSingle 17 (7%)Married/cohabiting 208 (81%)Separate/divorced 13 (5%)Widowed 18 (7%)

GenderMale 170 (66%)

OccupationFull-time 41 (16%)Part-time 10 (4%)Retired 126 (49%)Housewife 41 (16%)Unemployed 38 (15%)

Educationa

No formal education 27 (11%)Primary only 107 (42%)Secondary 101 (40%)Tertiary 20 (8%)

Time since diagnosis (months)Mean (SD) 19.52 (24.4)Range 0.46e131.0

Treatment statusNo active treatment 56 (22%)Curative radiation therapy only 12 (5%)Curative radiation therapy

and chemotherapy35 (14%)

Curative chemotherapy 52 (20%)Palliative radiation therapy/

chemotherapy51 (20%)

Palliative symptomatic care 50 (20%)Stoma (colostomy bag)

Yes 87 (34%)

aPrimary education: Grade 1 to Grade 6; Secondary education:Grade 7 to Grade 13; Tertiary: Any education entered after success-ful completion of the secondary education.

Vol. 36 No. 6 December 2008 589Chinese Version of the MSAS-SF

Score Distributions of MSAS-SF and CMSASTable 3 summarizes the means and standard

deviations for the subscales of MSAS-SF andCMSAS. The average number of symptoms re-ported was 9.46 (SD 6.22), indicating multiplesymptoms. The mean scores of the subscales ofMSAS-SF and CMSAS are at the lower end, in-dicating a low level of symptom distress.

Score Distributions of the EORTC QLQ-C30,CHQ-12, C-LOT-R, and RSE

The mean scores of the functioning scales ofthe QLQ-C30 are at the higher end, indicatinga high level of functioning. Similar to the sub-scales of MSAS-SF and CMSAS, the mean score

of the symptom scales of the QLQ-C30 are atthe lower end, indicating a low level of symp-tom distress. The score distributions of theCHQ-12, C-LOT-R, and RSE showed thatpatients in this study reported a low level ofpsychological distress and high level of opti-mism and self-esteem (Table 3).

ReliabilityMSAS-SF. All of the MSAS-SF subscales dem-

onstrated good internal consistency, withCronbach’s a coefficient exceeding 0.70. TheCronbach’s a coefficient for the GDI, PHYS,PSYCH, and TMSAS scales, respectively, were0.85, 0.84, 0.85, and 0.91.

CMSAS. We also examined the internal con-sistency of the CMSAS subscales. The Cronba-ch’s a coefficient for the CMSAS PHYS,CMSAS PSYCH, and CMSAS SUM scales, re-spectively, were 0.84, 0.79, and 0.87, whichshows good internal consistency.

Convergent ValidityMSAS-SF. Using $0.40 as a criterion, all of

the MSAS-SF subscales demonstrated an ex-pected moderate to high negative correlationwith the EORTC QLQ-C30 global health status,physical functioning, emotional functioning,cognitive functioning, and social functioningscales. Higher scores on the MSAS instrumentsindicate more distress, and higher scores onthe EORTC are associated with better QoL.As hypothesized, the MSAS-PSYCH subscalecorrelated more highly with the QLQ-C30 emo-tional functioning scale, whereas the MSASPHYS subscale correlated more highly withthe QLQ-C30 physical functioning scale. TheMSAS-SF subscales showed a low-to-high posi-tive correlation with the QLQ-C 30 symptomscales. Compared to the MSAS-PSYCH sub-scale, the MSAS-PHYS subscale demonstratedan expected stronger correlation with theQLQ-C30 symptom scales (Table 4).

CMSAS. The CMSAS SUM, PHYS, and NSsubscales demonstrated moderate to high neg-ative correlation with the QLQ-C30 globalhealth status and functional scales. TheCMSAS PSYCH showed an expected low nega-tive correlation (r¼�0.37, P< 0.001) with theQLQ-C30 physical functioning scale, but mod-erate-to-high correlation with the QLQ-C30global health status and the remaining func-tional scales. As hypothesized, the CMSAS

Table 2Summary of Frequency of Symptoms and Level of Symptom Distress by MSAS-SF

Symptom

n Frequency (%)

How Much Did the Symptom Distress You? Frequency (%)a

Physical Symptoms Not At All/A Little Somewhat Quite a Bit/Very Much

Dry mouthb 256 139 (54) 94 (68) 23 (17) 22 (16)Lack of energyb 256 138 (54) 67 (49) 48 (35) 23 (17)Painb 256 105 (41) 61 (58) 26 (25) 18 (17)Feeling drowsyb 255 103 (40) 68 (66) 22 (21) 13 (13)Itching 256 101 (40) 71 (70) 16 (16) 14 (14)Difficulty concentratingb 255 96 (38) 58 (60) 32 (33) 6 (6)Sexual interest 224 84 (38) 56 (68) 12 (15) 14 (17)Difficulty sleepingb 256 92 (36) 37 (40) 28 (30) 27 (29)Numbness and tingling 256 92 (36) 50 (54) 27 (29) 15 (16)Changes in skin 256 89 (35) 48 (54) 29 (33) 12 (14)Cough 256 80 (31) 57 (71) 14 (18) 9 (11)Lack of appetiteb 256 75 (29) 42 (56) 16 (21) 17 (23)Feeling bloated 256 71 (28) 40 (56) 21 (30) 10 (14)Food taste 255 64 (25) 35 (55) 17 (27) 12 (19)Shortness of breathb 255 63 (25) 43 (68) 10 (16) 10 (16)Diarrhea 255 59 (23) 34 (58) 18 (31) 7 (12)Hair loss 256 59 (23) 38 (64) 11 (19) 10 (17)Nauseab 256 57 (22) 35 (61) 12 (21) 10 (18)Don’t look like self 255 56 (22) 27 (48) 16 (29) 13 (23)Dizziness 256 50 (20) 32 (64) 14 (28) 4 (8)Weight lossb 254 47 (19) 28 (60) 9 (19) 10 (21)Urination 256 46 (18) 27 (59) 10 (22) 9 (20)Constipationb 251 45 (18) 19 (42) 16 (36) 10 (22)Sweats 256 42 (16) 27 (64) 12 (29) 3 (7)Mouth sores 254 28 (11) 17 (61) 6 (21) 5 (18)Swelling of arms/legs 256 22 (9) 14 (64) 2 (9) 6 (27)Difficulty swallowing 256 19 (7) 14 (74) 3 (16) 2 (11)Vomiting 256 17 (7) 8 (47) 5 (29) 4 (24)

How frequently did you experience the symptom? Frequency (%)a

Psychological Symptoms Rarely Occasionally/Frequently Almost Constantly

Worryingb 256 150 (59) 32 (21) 114 (76) 4 (3)Feeling sadb 256 122 (48) 28 (23) 91 (75) 3 (3)Feeling irritable 256 116 (45) 23 (20) 90 (78) 3 (3)Feeling nervousb 256 94 (37) 32 (34) 59 (63) 3 (3)

aThe frequency and percentages of the responses are based on patients who answered yes to the presence of symptom.bThese are the 14 symptoms included in the CMSAS.

590 Vol. 36 No. 6 December 2008Tak Lam et al.

PHYS subscale correlated more highly with theQLQ-C30 physical functioning and symptomscales, whereas the CMSAS PSYCH showeda low correlation with most of the QLQ-C30symptom scales (Table 4).

Divergent Validity for MSAS-SF and CMSASAs hypothesized, all of the MSAS-SF and

CMSAS subscales demonstrated a low negativecorrelation with the RSE and the C-LOT-R (Ta-ble 4). The high convergent and divergent val-idities indicate construct validity for bothMSAS instruments.

Construct ValidityMSAS-SF. Both Student t-tests and stepwise

multiple discriminant analysis were used totest each of the known-group comparisons

(Karnofsky scores <80% vs. $80%; no activetreatment vs. active treatment; CHQ-12 scores#4 vs. CHQ-12 scores >4). Congruent with ex-pectations, patients with Karnofsky scores<80%, active cancer treatment, and CHQ-12scores #4 reported significantly higher scoresin all the subscales of MSAS-SF (Table 5).

For each known-group comparison usingmultiple discriminant analysis, all of theMSAS-SF subscales were entered into the anal-ysis to determine which subscale(s) signifi-cantly discriminate between groups. ForKarnofsky scores, the MSAS PHYS and PSYCHsubscales were the significant discriminators(c2(2)¼ 76.3, P< 0.001), correctly classifying82% of the patients into their respectivegroup. For treatment status, the MSAS PHYSemerged as the only significant discriminator

Table 3Descriptive Statistics for MSAS-SF, CMSAS,

EORTC QLQ-C30, C-LOT-R, RSE,and CHQ-12 (n¼ 256)

Scale Mean (SD) Range of Scores

MSAS-SFGDI 0.82 (0.71) 0e3.18PHYS 0.57 (0.59) 0e3.27PSYCH 0.87 (0.82) 0e3.83TMSAS 0.57 (0.50) 0e3.83NS 9.46 (6.22) 0e27.00

CMSASCMSAS SUM 0.72 (0.65) 0e3.17CMSAS PHYS 0.72 (0.73) 0e3.64CMSAS PSYCH 0.99 (0.93) 0e4.00NS 5.18 (3.49) 0e14.00

EORTC QLQ-C30GHS 64.50 (20.31) 0e100Physical functioning 87.10 (13.90) 0e100Role functioning 90.23 (17.65) 0e100Emotional functioning 83.43 (17.28) 8.33e100Cognitive functioning 85.35 (17.31) 0e100Social functioning 84.90 (22.52) 0e100Fatigue 23.56 (21.61) 0e100Nausea and vomiting 7.23 (13.16) 0e66.67Pain 16.99 (20.48) 0e100Dyspnea 9.12 (19.23) 0e100Insomnia 16.93 (25.73) 0e100Appetite loss 13.33 (23.03) 0e100Constipation 9.13 (19.06) 0e100Diarrhea 11.33 (19.52) 0e100Financial difficulties 26.04 (31.91) 0e100RSE 21.89 (3.00) 2e29C-LOT-R 15.90 (2.00) 10e21CHQ-12 7.34 (5.39) 0e26

GDI¼Global Distress Index; PHYS¼ Physical Symptom DistressSubscale; PSYCH¼ Psychological Symptom Distress Subscale;TMSAS¼ Total Symptom Distress; NS¼No. of Symptoms; CMSASSUM¼ CMSAS Summary Score; CMSAS PHYS¼ CMSAS PhysicalSymptom Distress Subscale; CMSAS PSYCH¼CMSAS Psychologi-cal Symptom Distress Subscale; GHS¼Global health status; g;RSE¼ Rosenberg Self-Esteem Scale; C-LOT-R¼ Revised ChineseLife Orientation Test; CHQ-12¼Chinese Health Questionnaire.For MSAS-SF subscales, CMSAS subscales, QLQ-C30 symptomscales, higher scores indicate greater symptom distress. For CHQ-12, higher scores indicate greater psychological distress. ForQLQ-C30 functioning scales, RSE, and C-LOT-R, higher scores in-dicate better functioning, self-esteem and more optimism.

Vol. 36 No. 6 December 2008 591Chinese Version of the MSAS-SF

(c2(1)¼ 10.1, P¼ 0.002), correctly classifying56% of the patients into their respectivegroup. For psychological distress, the MSASPSYCH and NS subscales were the significantdiscriminators (c2(2)¼ 91.7, P< 0.001), cor-rectly classifying 73% of the patients into theirrespective group.

CMSAS. As hypothesized, patients with Kar-nofsky scores <80%, undergoing active cancertreatment, and with CHQ-12 scores >4 re-ported significantly higher scores in all thesubscales of the CMSAS (Table 5).

Discriminant analysis showed that theCMSAS PSYCH and CMSAS SUM subscales

were significant discriminators of Karnofskyscores (c2(2)¼ 89.4, P< 0.001), correctly clas-sifying 83% of the patients into their respectivegroup. For treatment status, the CMSAS NSwas the significant discriminator (c2(1)¼ 8.5,P¼ 0.004), correctly classifying 57% of the pa-tients into their respective group. For psycho-logical distress, the CMSAS PSYCH and NSsubscales were the significant discriminators(c2(2)¼ 90.8, P< 0.001), correctly classifying71% of the patients into their respectivegroups.

DiscussionIn this paper, we provide evidence of the val-

idity and reliability of the Chinese version ofthe MSAS-SF and CMSAS. The completionrate for the MSAS-SF was very high. HongKong Chinese patients completed the instru-ment within five to seven minutes with no dif-ficulty, suggesting that it is easy to administerand puts little burden on patients. Althoughwe did not have the average time required tocomplete the CMSAS, a condensed form withonly 14 items likely enhances its ease of use,and would require less time.

The three most frequently reported physicalsymptoms, dry mouth, lack of energy and pain,correspond to those reported in the originalstudy.10 Conversely, the prevalence of psycho-logical symptoms ranked higher in our study.In contrast to the original study in whichonly ‘‘worrying’’ was rated as one of the tenmost frequently reported symptoms, the pres-ent study revealed that three of the four psy-chological symptoms (excepting ‘‘feelingnervous’’) were in the 10 most frequently re-ported symptoms, of which ‘‘worrying’’ wasthe most prevalent symptom. Moreover, com-pared to the original study, we found lowermean scores on the GDI, PHYS, TMSAS, andNS subscales, but a comparable mean scoreon the PSYCH subscale. Although the originalstudy showed the mean scores on the PHYSand GDI subscales were higher than for thePSYCH subscale, our study found the meanscores on the GDI and PSYCH subscales werehigher than the mean scores on the PHYS sub-scale. The differences in findings between thestudies remained after we excluded the inpa-tient data from the original study. These

Table 4Correlation Matrix for Convergent and Divergent Validitya

MSAS-SFdGDI MSAS-SFdPHYS MSAS-SFdPSYCH MSAS-SFdTMSAS MSAS-SFdNS CMSASdSUM CMSASdPHYS CMSASdPSYCH CMSASdNS

GHS �0.57 �0.55 �0.52 �0.58 �0.55 �0.59 �0.59 �0.48 �0.58PF �0.52 �0.54 �0.43 �0.55 �0.52 �0.57 �0.60 �0.37 �0.54RF �0.52 �0.51 �0.49 �0.56 �0.51 �0.53 �0.52 �0.43 �0.47EF �0.67 �0.48 �0.71 �0.60 �0.58 �0.62 �0.52 �0.69 �0.59CF �0.56 �0.47 �0.54 �0.55 �0.52 �0.56 �0.52 �0.44 �0.51SF �0.52 �0.42 �0.57 �0.55 �0.50 �0.52 �0.48 �0.52 �0.46Fatigue 0.64 0.65 0.54 0.66 0.64 0.68 0.70 0.46 0.69N&V 0.39 0.55 0.28 0.48 0.49 0.42 0.36 0.30 0.39Pain 0.58 0.63 0.43 0.59 0.53 0.60 0.63 0.36 0.55Dyspnea 0.31 0.32 0.22 0.32 0.31 0.38 0.42 0.20 (P¼ 0.002) 0.37Insomnia 0.46 0.44 0.48 0.48 0.45 0.52 0.54 0.32 0.48Appetite loss 0.51 0.64 0.35 0.55 0.50 0.55 0.57 0.32 0.51Constipation 0.25 0.29 0.13 (P¼ 0.047) 0.27 0.26 0.24 0.18 (P¼ 0.004) n.s. 0.24Diarrhea 0.17 (P¼ 0.008) 0.22 0.15 (P¼ 0.015) 0.26 0.28 0.21 (P¼ 0.001) 0.20 (P¼ 0.001) n.s. 0.21 (P¼ 0.001)FD 0.40 0.30 0.44 0.41 0.39 0.38 0.31 0.44 0.35RES �0.23 �0.21 (P¼ 0.001) �0.23 �0.26 �0.24 �0.24 �0.21 (P¼ 0.001) �0.22 (P¼ 0.001) �0.21 (P¼ 0.001)C-LOT-R �0.41 �0.32 �0.46 �0.41 �0.39 �0.40 �0.35 �0.45 �0.39

GHS¼ EORTC QLQ-C30 global health status; PF¼QLQ-C30 physical functioning; RF¼QLQ-C30 role functioning; EF¼QLQ-C30 emotional functioning; CF¼QLQ-C30 cognitive functioning; SF¼QLQ-C30 social functioning; N&V¼QLQ-C30 nausea and vomiting; FD¼QLQ-C30 financial difficulties; RSE¼ Rosenberg Self-Esteem scale; C-LOT-R¼ Revised Chinese Life Orientation Test.The negative correlation indicates the higher the MSAS/CMSAS symptom subscale scores, the poorer the QLQ functioning or the lower the self-esteem and optimism scores. The positive correlation indicatesthe higher the MSAS/CMSAS symptom subscale scores, the higher the QLQ symptom scores.aAll values P< 0.001 unless otherwise noted.

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Table 5Summary of Discriminant Test by Known-Groups Comparisons

KPSMean Scores

(SD) n P-value TxMean Scores

(SD) n P-value CHQ-12Mean Scores

(SD) n P-value

MSAS-SFGDI <80 1.75 (0.69) 30 <0.001 No 0.61 (0.63) 56 0.009 #4 0.33 (0.38) 91 <0.001

$80 0.70 (0.61) 226 Yes 0.88 (0.72) 200 >4 1.09 (0.70) 165PHYS <80 1.38 (0.73) 30 <0.001 No 0.43 (0.55) 56 0.034 #4 0.25 (0.32) 91 <0.001

$80 0.47 (0.48) 226 Yes 0.61 (0.60) 200 >4 0.75 (0.64) 165PSYCH <80 1.82 (0.85) 30 <0.001 No 0.56 (0.64) 56 0.002 #4 0.29 (0.41) 91 <0.001

$80 0.74 (0.72) 226 Yes 0.95 (0.84) 200 >4 1.19 (0.81) 165TMSAS <80 1.82 (0.85) 30 <0.001 No 0.42 (0.46) 56 0.007 #4 0.24 (0.23) 91 <0.001

$80 0.74 (0.72) 226 Yes 0.61 (0.50) 200 >4 0.75 (0.51) 165NS <80 1.24 (0.53) 30 <0.001 No 7.34 (5.80) 56 0.003 #4 5.13 (4.15) 91 <0.001

$80 0.48 (0.42) 226 Yes 10.06 (6.22) 200 >4 11.85 (5.88) 165

CMSASSUM <80 1.67 (0.63) 30 <0.001 No 0.51 (0.56) 56 0.005 #4 0.29 (0.33) 91 <0.001

$80 0.60 (0.54) 226 Yes 0.78 (0.66) 200 >4 0.96 (0.66) 165PHYS <80 1.79 (0.65) 30 <0.001 No 0.48 (0.60) 56 0.005 #4 0.29 (0.35) 91 <0.001

$80 0.58 (0.61) 226 Yes 0.79 (0.75) 200 >4 0.96 (0.77) 165PSYCH <80 1.87 (0.89) 30 <0.001 No 0.68 (0.83) 56 0.002 #4 0.36 (0.56) 91 <0.001

$80 0.87 (0.87) 226 Yes 1.08 (0.94) 200 >4 1.34 (0.91) 165NS <80 9.70 (2.10) 30 <0.001 No 3.98 (3.33) 56 0.003 #4 2.75 (2.61) 91 <0.001

$80 4.58 (3.19) 226 Yes 5.51 (3.47) 200 >4 6.52 (3.18) 165

KPS¼ Karnofsky performance status; CHQ-12¼ Chinese Health Questionnaire scores; Tx¼ Treatment.

Vol. 36 No. 6 December 2008 593Chinese Version of the MSAS-SF

findings suggest that Hong Kong Chinese pa-tients may be experiencing lower levels ofphysical symptoms due to lesser disease impactor greater acceptance of the physical impact,but experiencing higher levels of psychologicalsymptoms. Alternatively, differences in diagno-sis between the two samples may be responsi-ble, as the sample in the original studycomprised patients diagnosed with head andneck, lung, gastrointestinal, genitourinary,and hematologic cancer, whereas the samplein our study was comprised of only patients di-agnosed with colorectal cancer. Hong Kongpatients had higher functional levels reflectedby their EORTC QLQ-C30 scores.

Both the MSAS-SF and CMSAS showed goodconvergent validity as seen from inverse corre-lations with the EORTC QLQ-C30 globalhealth status and function scales and positivecorrelations with the QLQ-C30 symptomsscales. This is the first study we are aware ofwhere the psychometric properties of theMSAS have been studied concurrently withthe EORTC QLQ-C30. Divergent validity isalso good, as indicated by low correlation ofmost (or all) of the MSAS and CMSAS sub-scales with unrelated measures of self-esteem(RSE) and optimism (C-LOT-R). However,both the MSAS-SF PSYCH and CMSAS PSYCHsubscales correlated moderately with C-LOT-R.This is consistent with other reports that

optimism has a protective effect on psycholog-ical distress.24e26 These results point to goodconstruct validity and further confirm the ro-bust psychometric qualities of the MSAS-SF in-strument. An interesting finding was that justthe number of symptoms can correlate signifi-cantly with QoL indices and performance sta-tus. This may be useful in busy clinical settings.

Construct validity was good. Both the MSAS-SF and CMSAS demonstrated expected pat-terns for known group comparisons in termsof performance status, treatment status, andthe extent of psychological distress. Our datashow that performance status is best predictedby the MSAS PHYS and MSAS PSYCH sub-scales; treatment status by the PHYS subscale;and psychological distress by the PSYCH andNS subscales. For the CMSAS, the CMSASPSYCH subscale is a significant predictor ofall three clinically distinct patient groupings(by performance status, treatment status, andthe extent of psychological distress). TheCMSAS PHYS and NS subscales predict psycho-logical distress, whereas the CMSAS SUM sub-scale predicts performance status.

The CMSAS, a condensed form of the MSAS-SF, also shows good psychometrics, indicatingits high potential as a brief measure for symp-tom assessment. A brief instrument is particu-larly useful for patients with limited stamina,as well as for clinicians with limited time.11

594 Vol. 36 No. 6 December 2008Tak Lam et al.

There are several limitations to this study.First, the cross-sectional design precludedtesteretest reliability and instrument respon-siveness assessments. Longitudinal studieswill need to be carried out to evaluate thetesteretest reliability and the responsivenessover time of the Chinese MSAS-SF andCMSAS. However, care is needed in usingand interpreting testeretest reliability in in-struments that must measure quickly changingconditions, such as symptoms. Second, thepopulation was limited to Chinese outpatientswith colorectal cancer. Future studies shouldexamine the instruments’ validity for useamong Chinese patients with other types ofcancer and in other settings. In this context,it is relevant to note that the MSAS instru-ments have been successfully studied and ap-plied in a variety of settings and in patientswith different cancers.27 Third, we did not in-clude another symptom instrument. TheEORTC QLQ-C30 has symptom items, andwe wished to minimize respondent burden.Further studies with other symptom instru-ments should be done. Finally, the psychomet-ric properties of the Chinese CMSAS areinferred, and require field studies for furthervalidation.

We conclude that the Chinese versions ofthe MSAS-SF and CMSAS are valid and practi-cal measures for assessing symptom distressand frequency in Chinese patients diagnosedwith colorectal cancer. Both instrumentsshow good potential for use in symptom assess-ment for patients with colorectal cancer. Clini-cal experience has suggested that somepatients find a Likert scale a helpful alternativeif they have difficulty with a numerical scale.28

The field of symptom control and palliativemedicine is rapidly expanding for Chinesespeaking populations.29,30 We are optimisticthat these instruments will contribute to thesmall but growing number of Chinese lan-guage symptom and QoL instruments availableto clinicians and researchers.

AcknowledgmentsThe authors wish to thank Abby Lam and

Nancy Chau for help with the data collectionand Winnie Lam for help with the Chinesetranslation of the MSAS-SF.

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