Cancer Treatment Survey (CaTS)

Abstract

The Cancer Treatment Survey (CaTS) is a psychometrically validated, patient-reported outcome measure developed to evaluate cancer patients’ preparation, informational needs, and anticipatory concerns prior to commencing cytotoxic chemotherapy or external beam radiotherapy. Emerging from psycho-oncology research addressing high rates of pre-treatment distress, the instrument quantifies the degree to which patients perceive a need for additional preparatory support and procedural guidance. The instrument comprises 25 items organized into two distinct, psychometrically robust subscales: Sensory/Psychological Concerns (11 items) and Procedural Concerns (14 items). Each item is rated on a 5-point Likert scale ranging from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”).

Psychometric evaluation demonstrates high structural integrity and internal consistency. Factor analytic investigations confirm a stable two-factor solution accounting for substantial variance, achieved after systematically removing 11 non-performing items from an original 36-item developmental pool. Both subscales display internal reliability coefficients with Cronbach’s alpha exceeding α = 0.90, alongside average inter-item correlations surpassing r = 0.30, indicating strong item homogeneity without excessive redundancy. Divergent validity is demonstrated through modest correlations (r < 0.30) with the Hospital Anxiety and Depression Scale anxiety (HADS-A) and total (HADS-T) indices, confirming that CaTS captures treatment-specific preparatory deficits rather than general, non-specific psychological distress. Furthermore, the measure exhibits known-groups validity, detecting significantly elevated procedural concerns among younger patients under 65 years of age. The CaTS provides oncologists, clinical psychologists, and cancer care teams with an actionable framework for pre-treatment triaging and supportive care optimization.

Keywords

Cancer Treatment Survey, CaTS, psycho-oncology, chemotherapy preparation, radiotherapy anxiety, pre-treatment distress, sensory concerns, procedural concerns, patient-reported outcome measures, oncology patient education, treatment-related anxiety, health psychology

Authors

The Cancer Treatment Survey was developed by Penelope Schofield and colleagues within the Department of Cancer Experiences Research at the Peter MacCallum Cancer Centre in Melbourne, Victoria, Australia, in collaboration with the University of Melbourne and Swinburne University of Technology.

Lead Author: Professor Penelope Schofield, PhD, is an internationally recognized behavioral scientist and psycho-oncology researcher specializing in supportive cancer care, patient education interventions, preparation for threatening medical procedures, and digital health interventions. Correspondence regarding the original validation study was directed to the Department of Cancer Experiences Research, Peter MacCallum Cancer Centre, St Andrew’s Place, East Melbourne, Victoria 3002, Australia.

Purpose

The initiation of cancer-directed therapies—specifically chemotherapy and radiotherapy—represents a critical juncture characterized by severe psychological morbidity, existential vulnerability, and acute anticipatory anxiety. Empirical studies indicate that up to 47% of women with early-stage breast cancer experience clinically significant anxiety prior to starting adjuvant chemotherapy, while over 50% of patients awaiting radiotherapy report marked pre-treatment apprehension, with approximately 40% maintaining elevated anxiety throughout their treatment trajectory. Patients face an array of unfamiliar clinical environments, complex procedural demands, and feared somatic sequelae including severe nausea, fatigue, alopecia, neutropenic infection, neuropathic pain, and mucositis.

Despite the prevalence of pre-treatment distress, routine oncology assessments historically relied on generic affective inventories such as the Hospital Anxiety and Depression Scale (HADS) or generalized distress thermometers. While these instruments identify affective disruption, they lack the operational granularity required to pinpoint what specific aspects of the upcoming treatment are driving the patient’s distress. Consequently, clinicians have often been unable to determine whether elevated anxiety reflects informational deficits regarding daily clinic logistics, terror regarding specific physical side-effects, or inadequate psychological coping mechanisms.

The primary purpose of the Cancer Treatment Survey (CaTS) is to fill this clinical and evaluative gap by serving as a standardized, multidimensional diagnostic instrument. It measures patient preparation for chemotherapy and radiotherapy across two complementary axes: somatic/psychological threat appraisals and procedural informational deficits. Specifically, the CaTS is designed to:

• Systematically audit pre-treatment informational and coping needs directly from the patient’s perspective before medical interventions commence.
• Differentiate between affective-somatic concerns (e.g., worries about hair loss, intractable nausea, sexual dysfunction, affective depression) and structural-procedural knowledge deficits (e.g., navigating hospital logistics, understanding step-by-step technical delivery, recognizing adverse events).
• Facilitate personalized psychoeducational interventions, allowing nurses, oncologists, and psycho-oncologists to target tailored preparatory consultations rather than relying on one-size-fits-all informational pamphlets.
• Serve as an evaluative endpoint in clinical trials testing the efficacy of pre-treatment preparatory programs, multimedia educational tools, and nurse-led navigation interventions.

Psychological Construct

The CaTS operationalizes the construct of patient preparation for medical treatment, defining it not merely as the passive reception of medical facts, but as an active cognitive-affective state wherein the individual possesses sufficient procedural knowledge, cognitive schema, and coping mechanisms to face threatening clinical interventions with reduced distress and heightened perceived control. Psychometrically, the instrument divides this macro-construct into two core operational dimensions:

1. Sensory/Psychological Concerns

This subscale captures the patient’s anticipatory emotional distress, threat appraisals, and perceived need for assistance in managing the subjective, affective, and somatic sequelae of cancer therapy. Rather than measuring current somatic symptom burden, this dimension assesses the degree of anticipatory anxiety and the felt inadequacy of coping resources regarding prospective physical deterioration and psychological decompensation.

Key facets evaluated within this dimension include:

• Anticipatory Somatic Threats: Fears regarding treatment-induced physical symptoms, including intractable fatigue, respiratory difficulties, severe nausea, hair loss (alopecia), gastrointestinal disruptions (constipation, diarrhea), and oral mucositis (mouth ulcers).
• Affective and Identity Concerns: Apprehensions regarding the emotional toll of therapy (fears of treatment-induced depression) and disruptions to body image, self-concept, and interpersonal functioning (impact on sexuality and intimate relationships).
• Catastrophic Treatment Appraisals: Pervasive, generalized worry that “something might go wrong during or after treatment,” persistent uncertainty, and overall affective dread regarding upcoming clinical interventions.

2. Procedural Concerns

This subscale assesses the patient’s perceived deficits in instrumental, logistical, and behavioral knowledge required to navigate the medical treatment regimen. Rooted in self-efficacy and behavioral control paradigms, this construct reflects the patient’s demand for explicit, concrete guidance regarding their active role within the treatment process.

Key facets evaluated within this dimension include:

• Logistical and Spatial Orientation: Knowledge deficits regarding physical hospital geography (e.g., “where to go in the hospital for treatment”) and schedule sequencing.
• Temporal and Procedural Sequencing: Understanding the step-by-step technological process of chemotherapy administration or radiation delivery, clarifying how the treatment will actually feel during administration.
• Behavioral Guidelines and Action Plans: Concrete comprehension of what behaviors are recommended, permissible, or prohibited prior to, during, and immediately following treatment sessions.
• Symptom Self-Regulation and Monitoring: Information on how to manage emerging side effects at home, how to distinguish normal post-treatment sensations from abnormal or dangerous medical events, and knowing precisely which subjective experiences require immediate consultation with the clinical team.

Theoretical Framework

The architecture of the CaTS is grounded in two primary health psychology frameworks: Jean Johnson’s Theory of Preparatory Information and Howard Leventhal’s Common-Sense Model of Self-Regulation of Health and Illness.

Johnson’s Dual-Process Preparatory Information Framework

Jean Johnson’s pioneering work on preparation for threatening medical procedures posits that distress during noxious physical interventions is heavily mediated by the discrepancy between what patients expect to experience and what they actually experience. When unexpected sensations occur, patients tend to interpret them as indicators of physiological danger or error, triggering heightened autonomic arousal, cognitive catastrophic appraisal, and behavioral distress.

Johnson demonstrated that preparatory communications must provide two distinct types of information to be maximally effective:

1. Sensory Information: Precise descriptions of the subjective physical sensations the patient will likely feel, see, smell, or taste (e.g., cold sensations during intravenous bolus infusion, mechanical sounds of the linear accelerator, acute fatigue patterns).
2. Procedural Information: Concrete explanations of the steps, environmental layout, equipment, and duration of the procedure.

By mapping out both domains, the patient forms an accurate cognitive schema prior to entering the clinical environment. When physical sensations or procedural steps unfold, they match the pre-formed cognitive representation, thereby neutralizing threat appraisal. The two subscales of the CaTS directly map onto these theoretical divisions, evaluating whether the patient has received adequate preparatory support across both the sensory-affective and procedural domains.

Leventhal’s Common-Sense Model (CSM) of Self-Regulation

Under Leventhal’s Common-Sense Model, individuals confronted with health threats construct parallel cognitive and emotional representations of the illness and its treatment. The cognitive representation comprises five core attributes: identity (labels and symptoms), cause, timeline, consequences, and control/cure. In tandem, an emotional representation develops, eliciting fear, anxiety, and depressive reactions.

The CaTS operationalizes treatment-related self-regulation by evaluating the patient’s perceived illness coherence and control. When procedural knowledge is incomplete, patients lack behavioral control schemas, resulting in elevated Procedural Concerns. Similarly, when the emotional and somatic consequences are poorly understood or perceived as uncontrollable, patients experience heightened Sensory/Psychological Concerns. The CaTS assesses the specific gaps within the patient’s mental model before treatment commences, identifying where cognitive and emotional self-regulation remains vulnerable.

Validity

The validation of the CaTS involved a prospective psychometric cohort of 286 cancer patients scheduled to undergo chemotherapy or radiotherapy across major Australian tertiary oncology centers (Schofield et al., 2012). The authors subjected the scale to rigorous construct, convergent, divergent, and known-groups validity testing.

Construct and Structural Validity

During scale development, an initial pool of 36 items was generated through systematic clinical observations, qualitative patient interviews, and multidisciplinary expert consensus panels (oncologists, radiation therapists, oncology nurses, psycho-oncologists). Following field testing, an extensive item-reduction protocol eliminated 11 items exhibiting poor distributional characteristics, floor/ceiling effects, severe multicollinearity, or cross-loadings in exploratory factor models. The final 25-item structure cleanly confirmed two robust latent factors with clear conceptual integrity.

Divergent (Discriminant) Validity

A crucial psychometric challenge in pre-treatment oncology assessment is demonstrating that an instrument does not simply mirror general psychiatric morbidity or non-specific negative affectivity. To establish divergent validity, CaTS subscale scores were correlated against the Hospital Anxiety and Depression Scale (HADS). Correlations between the CaTS subscales and HADS Anxiety (HADS-A), HADS Depression (HADS-D), and HADS Total (HADS-T) were all low to modest (all correlation coefficients r < 0.30). This empirical divergence confirms that the CaTS measures specific unmet preparatory and informational needs rather than baseline affective disorders or generalized trait neuroticism.

Known-Groups and Clinical Validity

Known-groups validity was demonstrated through demographic and clinical comparisons. Chronological age emerged as a prominent predictor: younger participants (aged under 65 years) exhibited significantly higher scores on the Procedural Concerns subscale compared to older cohorts (p < 0.001, exhibiting a medium effect size). This finding aligns with established oncology literature showing that younger patients often demand greater informational autonomy, express higher need for behavioral control, and experience more severe lifestyle and vocational disruption from cancer treatment schedules.

Reliability

The CaTS demonstrates exceptional internal consistency across clinical settings and diverse cancer populations. Psychometric evaluations reported by Schofield et al. (2012) yield the following reliability metrics:

• Internal Consistency: Both subscales exhibit internal consistency estimates well above standard psychometric thresholds (α ≥ 0.70 for research instruments, α ≥ 0.90 for individual clinical decision-making):
  • Sensory/Psychological Concerns (11 items): Cronbach’s alpha α > 0.90.
  • Procedural Concerns (14 items): Cronbach’s alpha α > 0.90.
• Homogeneity and Inter-Item Correlations: The average inter-item correlation for both subscales exceeded r = 0.30, fulfilling the criteria established by Briggs and Cheek (1986). This confirms that while the items measure unified constructs, they do not suffer from excessive item redundancy or semantic tautology.
• Scale Stability: Item-total correlation analyses confirmed that all 25 retained items correlated strongly with their designated subscale totals (corrected item-total correlations > 0.50), without any single item omission improving scale alpha coefficients.

Factor Analysis

The structural dimensionality of the CaTS was established using Exploratory Factor Analysis (EFA) with oblique rotation (Promax/Oblimin), reflecting the theoretical assumption that sensory-affective worries and procedural informational demands share common clinical variance while remaining distinct latent constructs.

Item Pruning and Extraction

The developmental 36-item questionnaire was evaluated on a sample of 286 patients preparing for chemotherapy or radiotherapy. Factor retention was guided by Kaiser’s eigenvalue criterion (eigenvalues > 1.0), scree plot inspection, and parallel analysis. Eleven items were eliminated due to:

• Low primary factor loadings (λ < 0.40).
• Complex cross-loadings on both factors with loading differentials < 0.15.
• Item skewness and limited variance across oncology diagnostic subgroups.

Final Factor Solution

The resulting 25-item structure yielded an interpretable, clean two-factor solution:

• Factor 1: Procedural Concerns (14 items). Items loading saliently onto this factor address practical, navigational, behavioral, and informational needs. Salient loadings (λ ranging from 0.52 to 0.84) include items regarding hospital location, step-by-step procedure, post-treatment restrictions, and distinguishing normal versus abnormal physical sensations.
• Factor 2: Sensory/Psychological Concerns (11 items). Items loading onto this factor capture visceral somatic fears and emotional distress. Salient loadings (λ ranging from 0.48 to 0.81) encompass worries about dyspnea, nausea, alopecia, mucositis, bowel alterations, depressive mood, sexual impairment, and general fears that treatment will go wrong.

The two latent factors exhibited a moderate inter-factor correlation (typically between r = 0.40 and 0.55), confirming their conceptual association as components of pre-treatment distress while demonstrating sufficient unique variance to justify independent subscale scoring.

Instrument / Measurement Tool

• Test Type: Patient-Reported Outcome Measure (PROM); self-administered pre-treatment assessment inventory.
• Target Population: Adult oncology patients (aged 18 and older) scheduled to begin systemic chemotherapy, external beam radiotherapy, or combined chemoradiotherapy regimens.
• Administration Format: Paper-and-pencil questionnaire or secure digital interface (tablet/computer/patient portal).
• Item Count: 25 items across two structured sections: Sensory/Psychological Concerns (11 items) and Procedural Concerns (14 items).
• Administration Time: Approximately 5 to 8 minutes.
• Response Scale: 5-point Likert scale formatted with standard anchors:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = In Between
  • 4 = Agree
  • 5 = Strongly Agree
• Scoring Protocol:
  • Subscale scores are calculated by summing the numerical ratings for all completed items within that subscale and dividing by the number of completed items in that subscale:
  • $$\text{Subscale Score} = \frac{\sum \text{Completed Item Scores}}{\text{Total Number of Completed Items}}$$
  • This produces a standardized score ranging from 1.0 to 5.0 for each subscale, where higher scores indicate greater perceived need for assistance, elevated informational deficits, and heightened pre-treatment concern.
  • Handling Missing Data: In accordance with standard scoring conventions established by Fayers et al. (1998) for quality of life instruments in oncology, if a patient leaves items blank, the mean of the non-missing items is utilized, provided that at least 50% of the items within that specific subscale have been answered. If fewer than 50% of items are completed, that subscale is classified as missing.

Permissions & Fee and Test Year

The Cancer Treatment Survey (CaTS) was developed and validated in 2012 by Professor Penelope Schofield and colleagues. The foundational development and validation study was published in the peer-reviewed journal Psycho-Oncology (John Wiley & Sons, Ltd.).

Licensing and Usage: The CaTS was designed for widespread use in both academic clinical trials and routine hospital quality-improvement programs. Non-commercial academic research and routine clinical practice generally do not incur fee requirements; however, formal notification or permission from the original developers is recommended prior to implementation. Researchers and clinical teams wishing to utilize, translate, or incorporate the CaTS into digital systems should contact the corresponding author, Prof. Penelope Schofield, through the Department of Cancer Experiences Research at the Peter MacCallum Cancer Centre or via academic institutional affiliations at Swinburne University of Technology.

References

• Briggs, S. R., & Cheek, J. M. (1986). The role of factor analysis in the development and evaluation of personality scales. Journal of Personality Assessment, 50(1), 106–114. https://doi.org/10.1207/s15327752jpa5001_14
• Fayers, P. M., Curran, D., & Machin, D. (1998). Incomplete quality of life data in randomized trials: Missing forms. Statistics in Medicine, 17(5–7), 679–696. https://doi.org/10.1037/h0034767
• Johnson, J. E., & Leventhal, H. (1974). Effects of accurate expectations and behavioral instructions on reactions during a noxious medical examination. Journal of Personality and Social Psychology, 29(5), 710–718. https://doi.org/10.1037/h0036611
• Leventhal, H., Brissette, I., & Leventhal, E. A. (2003). The common-sense model of self-regulation of health and illness. In L. D. Cameron & H. Leventhal (Eds.), The Self-Regulation of Health and Illness Behaviour (pp. 42–65). Routledge.
• Schofield, P., Gough, K., Lotfi-Jam, K., & Aranda, S. (2012). Cancer Treatment Survey (CaTS): Development and validation of a new instrument to measure patients’ preparation for chemotherapy and radiotherapy. Psycho-Oncology, 21(3), 307–315. https://doi.org/10.1002/pon.1895
• Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x

Items of the Scale