Qual Life Res (2015) 24:339–362
DOI 10.1007/s11136-014-0785-6
REVIEW
A methodological review of the Short Form Health Survey
36 (SF-36) and its derivatives among breast cancer survivors
Charlene Treanor • Michael Donnelly
Accepted: 11 August 2014 / Published online: 20 August 2014
Ó Springer International Publishing Switzerland 2014
Abstract
Purpose A systematic review of the validity, reliability
and sensitivity of the Short Form (SF) health survey
measures among breast cancer survivors.
Methods We searched a number of databases for peer-
reviewed papers. The methodological quality of the papers
was assessed using the COnsenus-based Standards for the
selection of health Measurement INstruments (COSMIN).
Results The review identified seven papers that assessed
the psychometric properties of the SF-36 (n = 5), partial
SF-36 (n = 1) and SF-12 (n = 1) among breast cancer sur-
vivors. Internal consistency scores for the SF measures
ranged from acceptable to good across a range of language
and ethnic sub-groups. The SF-36 demonstrated good con-
vergent validity with respective subscales of the Functional
Assessment of Cancer Treatment—General scale and two
lymphedema-specific measures. Divergent validity between
the SF-36 and Lymph-ICF was modest. The SF-36 demon-
strated good factor structure in the total breast cancer sur-
vivor study samples. However, the factor structure appeared
to differ between specific language and ethnic sub-groups.
The SF-36 discriminated between survivors who reported or
did not report symptoms on the Breast Cancer Prevention
Trial Symptom Checklist and SF-36 physical sub-scales, but
not mental sub-scales, discriminated between survivors with
C. Treanor (&)
M. Donnelly
UKCRC Centre of Excellence for Public Health, Queen’s
University Belfast, Belfast, Northern Ireland
e-mail: c.treanor@qub.ac.uk
C. Treanor
M. Donnelly
Cancer Epidemiology and Health Services Research Group,
Centre for Public Health, Queen’s University Belfast, Institute of
Clinical Sciences-B Building, Royal Victoria Hospital Site,
Grosvenor Road, Belfast BT12 6BJ, Northern Ireland
or without lymphedema. Methodological quality scores
varied between and within papers.
Conclusion Short Form measures appear to provide a reli-
able and valid indication of general health status among breast
cancer survivors though the limited data suggests that par-
ticular caution is required when interpreting scores provided
by non-English language groups. Further research is required
to test the sensitivity or responsiveness of the measure.
Keywords Breast cancer
Quality of life
Systematic
review
Psychometric properties
Short Form health
survey
SF-36
Introduction
Breast cancer is one of the most commonly occurring and
most widely studied cancers in developing countries
worldwide with 5-year relative survival rates which exceed
80 % [1]. Breast cancer survivors may experience adverse
or late effects following treatment [2], and it is important to
understand the impact of these effects on the health and
well-being of cancer survivors [3, 4]. Increasingly, health
care programmes are shifting focus from traditional clinical
outcomes to patient-reported outcomes such as quality of
life and health status (e.g. UK National Cancer Survivor-
ship Initiative, 2010), particularly with respect to the new
chronic condition-like model of cancer and the recognised
importance of capturing the patient perspective in order to
aid patient-centred practice, health care policy and the
configuration of cancer services [5].
The Short Form (SF) health survey measure is a widely
used, generic, self-report measure of health status. We
conducted a systematic review of studies which assessed
the validity, reliability and sensitivity of the SF-36 and
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340 Qual Life Res (2015) 24:339–362

briefer versions (SF-12 and SF-8) among breast cancer
survivors. The methodological quality of the papers was
assessed using the COnsenus-based Standards for the
selection of health Measurement INstruments (COSMIN)
and related checklist [5].
Methods
Review method
PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO and
the Social Sciences Citation Index were searched using
terms which link breast cancer survivor, psychometric
properties and SF measures. The search terms for mea-
surement properties were based on a sensitive search filter
developed by the COSMIN initiative which is appropriate
for identifying papers which focus on the psychometric
properties of a specific patient-reported outcome measure
(see Fig. 1).
Titles identified from the electronic search were expor-
ted to Refworks, and duplicates were removed. The eligi-
bility of a paper was assessed independently by two
reviewers, firstly according to its title followed by its
abstract and the full paper. The bibliographies of included
papers were searched for further eligible papers. Data

Fig. 1 Complete search

(breast) AND (cancer OR neoplasm) AND (survivor* OR patient*)
strategy

AND

(medical outcomes study SF-36 OR medical outcomes study SF36 OR medical outcomes

study SF 36 OR medical outcomes study short form-36 OR medical outcomes study short

form 36 OR SF-36 OR SF36 OR SF 36 OR short form-36 OR short form 36 OR MOS SF-36

OR MOS SF36 OR MOS SF 36 OR MOS short form-36 OR MOS short form 36) OR

(medical outcomes study SF-12 OR medical outcomes study SF12 OR medical outcomes

study SF 12 OR medical outcomes study short form-12 OR medical outcomes study short

form 12 OR SF-12 OR SF12 OR SF 12 OR short form-12 OR short form 12 OR MOS SF-12

OR MOS SF12 OR MOS SF 12 OR MOS short form-12 OR MOS short form 12) OR

(medical outcomes study SF-8 OR medical outcomes study SF8 OR medical outcomes study

SF 8 OR medical outcomes study short form-8 OR medical outcomes study short form 8 OR

SF-8 OR SF8 OR SF 8 OR short form-8 OR short form 8 OR MOS SF-8 OR MOS SF8 OR

MOS SF 8 OR MOS short form-8 OR MOS short form 8)

AND

(reproducib*[tw] OR methods [sh] OR valid*[tiab] OR reproducibility of results [MeSH]

OR reliab*[tiab])

NOT

(child* OR paed* OR ped*) AND (hospital OR inpatient) AND (pallia* OR end of life* OR

terminal*)

123
Qual Life Res (2015) 24:339–362 341

extraction unto a standardised pro-forma was conducted Results

independently.
The search identified 270 papers after duplicates were
removed—see Fig. 2 for complete process of study selec-
Inclusion/exclusion criteria
tion. Tables 1 and 2 present the summary characteristics
and findings of included papers.
Only papers that covered survivors of breast cancer were
Five studies were conducted in the United States, and
included. Survivors were defined as individuals who had
the remaining two studies were conducted in Dutch-
completed treatment with curative intent (including sur-
speaking countries—Belgium and The Netherlands,
gery, radiotherapy and/or chemotherapy); survivors who
respectively. The SF-36 was the focus of all but one study
were in receipt of adjuvant hormone therapy for pro-
which focussed on the SF-12. One study included four
phylactic purposes were also included. Papers with sur-
subscales only of the SF-36. The English language versions
vivors from sites other than breast cancer were included
of the SF measures were used in three studies, other lan-
if a separate analysis was provided for breast cancer.
guage versions include: Chinese (n = 2), Dutch (n = 2),
Papers which assessed the psychometric properties of the
Korean (n = 1) and Spanish (n = 1). Of the studies that
SF-36, or its derivatives, the SF-12 and the SF-8 were
primarily aimed to assess the psychometric properties of
included. Four papers met the above inclusion criteria.
the SF measures, they focussed on internal consistency
Three papers which utilised the SF measures to assess the
(n = 3), construct validity (n = 3), concurrent validity
psychometric properties of other measures e.g. Functional
(n = 3) and discriminant validity (n = 1). The studies
Assessment of Cancer Treatment-General scale (FACT-G)
which provide psychometric information on the SF mea-
were also included. We focused on the taxonomy
sures when used to assess other measures focussed on
developed by the COSMIN initiative which covers three
convergent and divergent validity (n = 1), discriminant
main domains and related measurement properties: reli-
validity (n = 1) and concurrent validity (n = 1). Due to
ability (internal consistency and measurement error);
the small number of papers identified, no exclusions were
validity (content validity, construct validity, and criterion
made based on methodological quality.
validity); and responsiveness. Peer-reviewed papers which
assessed one or more of these measurement properties
Quality appraisal
were included.
Papers were excluded if they covered individuals in
Methodological quality scores varied between and within
receipt of curative treatment (defined above) or palliative
papers. The quality assessment of internal consistency
care; did not cover breast cancer survivors; did not assess
included scorings of excellent (n = 1), good (n = 1) and
the psychometric properties (defined above) of the SF-36 or
fair (n = 1). Methodological quality scores for construct
its derivatives; and were not published in peer-review
validity (including discriminant validity which the COS-
journals.
MIN initiative includes under construct validity) included
good (n = 1) and poor (n = 3). The methodological
Quality assessment quality of concurrent validity was assessed as fair in each
study (n = 4). Within studies, methodological quality
The COSMIN checklist and scoring manual were used to ranged from excellent to poor [10] and from good to fair
appraise the methodological quality of studies. The [11, 12]. In general, the main reason for reduced method-
checklist addresses the general requirements of psycho- ological quality across and within studies was the use of
metric studies, followed by separate sections on individual less-than-optimal sample sizes, particularly for analyses by
psychometric properties [6, 7]. In total, there are 114 sub-group. Additionally, many of the studies did not
checklist items. A four-point scoring system from clearly state a priori which hypotheses they were testing
‘excellent’, ‘good’, ‘fair’ to ‘poor’ has been developed for when assessing convergent and divergent validity, includ-
each property [8]. Many checklist items require subjective ing the direction and size of association between conver-
judgements, and this aspect may account for low inter- gent or divergent constructs.
rater reliability, thus the authors recommend independent
quality assessors to decide a priori how items are to be Internal consistency
interpreted [9]. Methodological quality was appraised
independently by two reviewers with high agreement. It is A range of ethnic and language groups were the focus of
not necessary to complete all items in the checklist, as interest in the three US studies which assessed the internal
each included study may address one or more psycho- consistency of the SF measures. The Chinese language SF-
metric properties. 12; Spanish, Korean Chinese and English language SF-36;

123
342
Fig. 2 Number of papers after implementation of search strategy
and 4 subscales of the English language SF-36 were the
measures of interest. A Cronbach’s alpha co-efficient (a)
score of greater than 0.7 indicates acceptable internal
consistency.
123
Qual Life Res (2015) 24:339–362
Two of the studies calculated internal consistency scores
for the overall breast cancer sample as well as ethnic and
language sub-groups. Internal consistency scores for the
overall sample across the SF subscales were acceptable in
both studies: from a = 0.76 to a = 0.91 [10] and a = 0.72
to a = 0.90 [12]. Only one study assessed the internal
consistency scores for the SF-36 subscales among a
European-American population; the scores were acceptable
(range a = 0.76–0.90) [10].
Two studies assessed the internal consistency of the SF-
36 among African-American breast cancer survivor popu-
lations. Similar internal consistency scores were reported in
both studies, and with the exception of the social func-
tioning subscale, these scores were in the acceptable to
good range [10, 12]. For the purposes of comparison to the
Ashing-Giwa et al. [10] study which utilised the full SF-36
to the Ashing-Giwa and Rosales [12] study which imple-
mented only four SF-36 subscales, internal consistency
scores for social functioning (a = 0.64; a = 0.68), physi-
cal role limitations (a = 0.86; a = 0.87), bodily pain
(a = 0.86; a = 0.84) and general health (a = 0.79;
a = 0.78) are highlighted, respectively.
Two studies included Latina-American breast cancer
survivors. One study administered the Spanish language
SF-36 [10], whereas the other study administered the
English language SF-36 (4 subscales) to two groups: sur-
vivors who were English language proficient (EP) and
survivors who had limited English language proficiency
(LEP) [12]. Nevertheless, internal consistency scores were
all acceptable and generally similar across each sub-group
between and within the two studies. For the purposes of
comparison of the Ashing-Giwa et al. [10] study which
utilised the full SF-36 to the Ashing-Giwa and Rosales
(2013) study [12] which implemented only four SF-36
subscales, internal consistency scores for social functioning
(a = 0.71; EP: a = 0.75; LEP: a = 0.73), physical role
limitations (a = 0.94; EP: a = 0.87; LEP: a = 0.93),
bodily pain (a = 0.84 EP: a = 0.89; LEP: a = 0.88) and
general health (a = 0.84 EP: a = 0.74; LEP: a = 0.76) are
highlighted, respectively [10, 12].
Among Chinese-American breast cancer survivors,
internal consistency scores for the Chinese language SF-12
at both baseline and at one-year follow-up for the physical
and mental component summary scores were acceptable
(range a = 0.81–0.82 and a = 0.79–0.80) [13]. Internal
consistency scores on the eight subscales of the SF-36 among
Asian-American breast cancer survivors were also accept-
able in an additional study (range a = 0.79–0.89) [10].
Concurrent validity: convergent
Two studies assessed the extent of convergence between
subscales of the FACT-B and FACT-G measures and the
 Table 1 Study characteristics of papers which focussed on the psychometric properties of the SF measuresa
Study Ashing-Giwa et al. [10]
Country USA
Measure(s) of interest SF-36 Spanish-, Korean, Chinese
and English language versions
Functional Assessment of Cancer
Therapy-Breast (FACT-B)
Life Stress Scale
Quality of medical care
satisfaction (study specific)
Spirituality (study specific)
Body image (study specific)
Sexual impact (study specific)
Short Acculturation Scale for
Hispanics
Aim(s) To assess the construct validity of
the QoL measures
To assess the internal consistency
of the measures by ethnic group
To assess the concurrent validity
of the FACT-B and the SF-36
Study design Cross-sectional telephone or postal
survey
Population Criteria
123
Ashing-Giwa et al. [13]
USA
SF-12 Chinese language
version
Functional Assessment of
Cancer Therapy-General
(FACT-G)
To assess the internal
consistency and construct
validity of the SF-12 and
the FACT-G among
Chinese-American breast
cancer survivors
Longitudinal postal survey
Criteria
Ashing-Giwa and Rosales [12]
USA
SF-36 4 sub-scales only (general
health; pain; role limitations due
to physical health and social
functioning) English language
version
FACT-G
MOS Social Support Survey
Centre for Epidemiology
Studies—Depression (CES-D)
To assess the reliability and
validity of HRQoLb measures in
minority ethnic populations
(African-American; English
language proficient (EP) Latina-
American and limited English
language proficient (LEP)
Latina-American)
To assess the concurrent validity
of the FACT-G with the other
outcome measures
Cross-sectional survey (baseline)
data obtained from an
intervention study
Criteria
Wilson et al. [11]
USA
SF-36 English language version
Functional Living Index-Cancer
(FLIC)
Qual Life Res (2015) 24:339–362
To assess whether the SF-36 and
the FLIC can be used
interchangeably to measure
HRQoL among breast cancer
survivors
To assess whether similarly named
sub-scales on the SF-36 and the
FLIC measure similar
dimensions of HRQoL
To assess the extent to which the
SF-36 and the FLIC are able to
detect differences in HRQoL
between breast cancer survivors
with and without lymphedema
Cross-sectional survey
Criteria
343
 Table 1 continued
Study Ashing-Giwa et al. [10]
Country USA
123
African-American, European-
American, Asian-American and
Latina-American breast cancer
survivors between 1 and 5 years
post-diagnosis (stages 0-III),
aged 18 and over with no other
cancer or major medical or
psychiatric condition and
identified from cancer registry
and community groups
Sample
n = 703
African-American n = 135; age:
mean = 56 years; age at
diagnosis: mean = 52; time
since diagnosis:
mean = 3.6 years; 80 %
diagnosed stages I-II
80 % more than high school
education; 30 % low income less
than $25,000
European-American n = 179;
age: mean = 57 years; age at
diagnosis: mean = 55; time
since diagnosis:
mean = 2.7 years; 74 %
diagnosed stages I-II
344
Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
USA USA USA
Chinese-American Breast Breast cancer survivors (with no Breast cancer survivors aged
cancer survivors between other cancer type) between 1 and 18-65 years, at least 3 months
6 months and 3 years 6 years post-diagnosis (stages post-surgery recruited from
post-diagnosis (stages 0-III), aged over 18 years, self- outpatient lists
0-III), aged over 18 years identified as African- or Latina-
and identified from a American and identified from
cancer registry cancer registries, clinics and
support groups
Sample Sample Sample
n = 74 completed survey n = 320 Lymphedema group n = 32; age:
at both time-points; age: mean = 50.6 years, SD = 10.1;
mean = 54.6 years, time since diagnosis:
SD = 9.1, mean = 2.6 years, SD = 2.1
range = 31–83 years; age
at diagnosis:
mean = 52.7,
SD = 8.7 years; time
since diagnosis:
mean = 2.4 year,
SD = 2.0; 79 %
diagnosed stage I-II
78 % more than high African-American n = 88; age: Non-lymphedema group n = 78;
school education; 40 % 70 % \ 65 years; 77 % age: mean = 52.8 years,
low income less than diagnosed stage I-II; 82 % more SD = 9.1; time since diagnosis:
$25,000 than high school education; mean = 2.1 years, SD = 1.7
31 % low income less than
$25,000
EP Latina-American n = 95;
84 % \ 65 years; 79 %
diagnosed stage I-II; 28 % more
than high school education;
31 % low income less than
$25,000
LEP Latina-American n = 137;
85 % \ 65 years; 78 %
diagnosed stage I-II; 14 % more
than high school education;
71 % low income less than
$25,000
Qual Life Res (2015) 24:339–362
 Table 1 continued
Study Ashing-Giwa et al. [10] Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
Country USA USA USA USA

90 % more than high school

education; 14 % low income less
than $25,000
Latina-American n = 183; age:
mean = 53 years; age at
diagnosis: mean = 50; time
since diagnosis:
Qual Life Res (2015) 24:339–362

mean = 2.9 years; 75 %

Psychometric properties assessed
Results
diagnosed stages I-II
47 % more than high school
education; 50 % low income less
than $25,000
Asian-American n = 206; age:
mean = 54 years; age at
diagnosis: mean = 51; time
since diagnosis:
mean = 2.9 years; 74 %
diagnosed stages I-II
82 % more than high school
education; 25 % low income less
than $25,000
Internal consistency Internal consistency Internal consistency Convergent validity
Construct validity Construct validity Construct validity (confirmatory Discriminative validity
(exploratory factor factor analysis based on original
analysis at baseline and factor structure)
Confirmatory factor
analysis at 1-year follow-
up)
Concurrent validity Concurrent validity
Internal consistency Internal consistency Internal consistency Convergent validity
Overall sample: physical Baseline: SF-12 physical SF-36 social functioning, Total SF-36 PCS vs. SF-36 MCS: tau-
functioning a = 0.91, physical component summary sample: a = 0.72; African- b = 0.247
role limitations a = 0.89, (PCS) score a = 0.82; American sample: a = 0.68;
emotional role limitations SF-12 mental component LEP Latina-American sample:
a = 0.86, vitality = 0.85, summary score (MCS) a = 0.73; EP Latina-American
mental health a = 0.84, social a = 0.80 sample: a = 0.75
functioning a = 0.76, bodily
pain a = 0.84, general health
a = 0.80
345

123
 Table 1 continued
Study Ashing-Giwa et al. [10]
Country USA
123
African-American sample:
physical functioning a = 0.93,
physical role limitations
a = 0.86, emotional role
limitations a = 0.84,
vitality = 0.87, mental health
a = 0.82, social functioning
a = 0.64, bodily pain a = 0.86,
general health a = 0.79
European-American sample:
physical functioning a = 0.88,
physical role limitations
a = 0.87, emotional role
limitations a = 0.83,
vitality = 0.90, mental health
a = 0.86, social functioning
a = 0.88, bodily pain a = 0.86,
general health a = 0.76
Latina-American sample:
physical functioning a = 0.93,
physical role limitations
a = 0.94, emotional role
limitations a = 0.86,
vitality = 0.86, mental health
a = 0.84, social functioning
a = 0.71, bodily pain a = 0.84,
general health a = 0.80
Asian-American sample: physical
functioning a = 0.89, physical
role limitations a = 0.88,
emotional role limitations
a = 0.88, vitality = 0.79,
mental health a = 0.83, social
functioning a = 0.79, bodily
pain a = 0.80, general health
a = 0.84
346
Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
USA USA USA
One-year follow-up: SF-12 SF-36 physical role limitations, SF-36 PCS vs. FLIC total score:
PCS a = 0.81; SF-12 Total sample: a = 0.90; African- tau-b = 0.556
MCS a = 0.79 American sample: a = 0.87;
LEP Latina-American sample:
a = 0.93; EP Latina-American
sample: a = 0.87
Construct validity SF-36 pain, Total sample: SF-36 MCS vs. FLIC total score:
a = 0.88; African-American tau-b = 0.490
sample: a = 0.84; LEP Latina-
American sample: a = 0.88; EP
Latina-American sample:
a = 0.89
Baseline: two factors SF-36 general health, Total SF-36 physical functioning vs.
emerged sample: a = 0.77; African- FLIC physical functioning: tau-
American sample: a = 0.78; b = 0.616
LEP Latina-American sample:
a = 0.76; EP Latina-American
sample: a = 0.74
Factor 1: All 6 MCS items Construct validity SF-36 mental health vs. FLIC
loaded (not mental health: tau-b = 0.586
careful = 0.432, social
time = 0.585,
energy = 0.632,
accomplished less
emotional = 0.798, blue/
sad = 0.849,
peaceful = 0.896), as
well as 1 PCS item
(general health = 0.426)
Qual Life Res (2015) 24:339–362
 Table 1 continued
Study Ashing-Giwa et al. [10]
Country USA
Construct validityc
Only data from the SF-36 general
health Perception items were
presented in the paper
Overall sample (n = 676):
emotional role limitations,
physical role limitations, pain
and mental health loaded onto a
single factor each; general
health, physical functioning and
vitality each had mostly good
factor structure with a few
inconsistencies; social
functioning did not load onto any
factors
African-American (n = 131):
general health, emotional role
limitations and pain items had
good factor structures; other
items had loadings on multiple
factors or no factors
123
Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
USA USA USA
Factor 2: All 6 PCS items Total sample: 4-factors explained SF-36 social functioning vs. FLIC
loaded (accomplished less 72 % of the variance and social functioning: tau-
physical = 0.444, general represented the factorial b = 0.526
health = 0.476, pain structure of the original SF-36
interference = 0.589, measure
limited in kind of
Qual Life Res (2015) 24:339–362
work = 0.698, moderate
activities = 0.742, climb
several flights = 0.940)
One-year follow-up: Factor 1: physical role limitations SF-36 general health vs. FLIC
58.1 % of common (all 4 items): range = 0.82–0.86; general health: tau-b = 0.503
variance explained social functioning (1 out of 2
items): 0.49
Factor 1: 5/6 PCS items Factor 2: general health (4 out of Discriminative validity
(general health = 0.531, 5 items): range = 0.60–0.72
accomplished less
physical = 0.728, pain
interference = 0.735,
moderate
activities = 0.846, climb
several flights of
stairs = 0.977) but one
(limited in kind of work)
loaded and 3/6 MCS
items (energy = 0.526,
accomplished less
emotional = 0.480 and
not careful)
loaded = 0.448
Factor 2: 1/6 PCS item Factor 3: general health (2 out of SF-36 PCS (d = 1.20) but not
loaded (limited in kind of 5 items): range = 0.46-0.51; MCS (d = 0.19) and each of the
work = 0.502), and 4/6 bodily pain (all 2 items): subscales (physical functioning:
MCS items (social range = 0.68-0.82 d = 1.11; physical role
time = 0.733, not limitations: d = 1.02; emotional
careful = 0.403 role limitations: d = 0.72;
peaceful = 0.879 and vitality: d = 0.74; social
blue/sad = 0.827) loaded functioning: d = 0.60; bodily
pain: d = 0.72 and general
health: d = 0.69) with the
exception of mental health
(d = 0.35) had significant effect
sizes
347
 Table 1 continued
348

Study Ashing-Giwa et al. [10] Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
Country USA USA USA USA

123
European-American (n = 174): Factor 4: general health (1 out of
discrepancies with factor loading 5 items): 0.72; social functioning
for physical functioning (items (all 2 items): range = 0.54–0.75
loaded onto two separate factors)
and general health (3/5 items
loaded onto one factor); other
subscale items had consistent
factor loadings
Latina-American (n = 170): African-American sample:
physical role limitations, 4-factors explained 73 % of the
emotional role limitations and variance
mental health items had
consistent factor loadings; other
subscale items had less
consistent factor loadings
Asian-American (n = 201): Factor 1: physical role limitations
consistent factor loadings for (all 4 items): range = 0.77–0.89;
general health, emotional role social functioning (1 out of 2
limitations and pain; other items): 0.57
subscale items loaded onto
multiple or no factors
Concurrent validitye Factor 2: general health (3 out of
5 items): range = 0.74–0.84;
bodily pain (1 out of 2 items):
0.45
Sub-scales of the FACT-G were Factor 3: general health (1 out of
significantly correlated to 5 items): 0.74; bodily pain (all 2
respective sub-scales of the SF- items): range = 0.69–0.71 and;
36 social functioning (all 2 items):
range = 0.51–0.71
Qual Life Res (2015) 24:339–362
 Table 1 continued
Study Ashing-Giwa et al. [10] Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
Country USA USA USA USA

Total sample: SF-36 general Factor 4: general health (1 out of

health and FACT-G functional 5 items): 0.93
Well-being (q = 0.62); SF-36
physical functioning and FACT-
G physical well-being
(q = 0.60); SF-36 physical role
Qual Life Res (2015) 24:339–362

limitations and FACT-G physical

well-being (q = 0.61); SF-36
emotional role limitations and
FACT-G functional well-being
(q = 0.51); SF-36 vitality and
FACT-G functional well-being
(q = 0.64) and physical well-
being (q = 0.64); SF-36 mental
health and FACT-G emotional
well-being (q = 0.65); SF-36
social functioning and FACT-G
functional well-being
(q = 0.62); SF-36 bodily pain
and FACT-G physical well-being
(q = 0.68)
African-American: SF-36 general LEP Latina-American sample:
health and FACT-G functional 4-factors explained 75 % of the
Well-being (q = 0.60); SF-36 variance
physical functioning and FACT-
G physical well-being
(q = 0.65); SF-36 physical role
limitations and FACT-G physical
Well-being (q = 0.62); SF-36
emotional role limitations and
FACT-G functional well-being
(q = 0.51) and FACT-G
emotional Well-being
(q = 0.51); SF-36 vitality and
FACT-G functional well-being
(q = 0.63); SF-36 mental health
and FACT-G emotional well-
being (q = 0.66); SF-36 social
functioning and FACT-G
functional well-being
(q = 0.67); SF-36 bodily pain
and FACT-G physical well-being
(q = 0.70)
349

123
 Table 1 continued
350

Study Ashing-Giwa et al. [10] Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
Country USA USA USA USA

123
European-American: SF-36 Factor 1: physical role limitations
general health and FACT-G (all 4 items): range = 0.84–0.89;
functional Well-being bodily pain: (1 out of 2 items):
(q = 0.59); SF-36 physical range = 0.47; social functioning
functioning and FACT-G (1 out of 2 items): 0.42
physical well-being (q = 0.48);
SF-36 physical role limitations
and FACT-G physical well-being
(q = 0.64); SF-36 emotional
role limitations and FACT-G
functional well-being
(q = 0.61); SF-36 vitality and
FACT-G functional well-being
(q = 0.68); SF-36 mental health
and FACT-G functional well-
being (q = 0.75); SF-36 social
functioning and FACT-G
functional well-being
(q = 0.65); SF-36 bodily pain
and FACT-G physical well-being
(q = 0.68)
Latina-American: SF-36 general Factor 2: general health (3 out of
health and FACT-G functional 5 items): range = 0.43–0.81
Well-being (q = 0.60); SF-36
physical functioning and FACT-
G physical well-being
(q = 0.64); SF-36 physical role
limitations and FACT-G physical
Well-being (q = 0.61); SF-36
emotional role limitations and
FACT-G physical well-being
(q = 0.54); SF-36 vitality and
FACT-G physical well-being
(q = 0.66); SF-36 mental health
and FACT-G emotional well-
being (q = 0.64); SF-36 social
functioning and FACT-G
functional well-being
(q = 0.61); SF-36 bodily pain
and FACT-G physical well-being
(q = 0.63).
Qual Life Res (2015) 24:339–362
 Table 1 continued
Study Ashing-Giwa et al. [10] Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
Country USA USA USA USA

Asian-American: SF-36 general Factor 3: general health (3 out of

health and FACT-G functional 5 items): range = 0.52–0.81;
well-being (q = 0.66) and bodily pain (1 out of 2 items):
FACT-G physical Well-being 0.51
(q = 0.66); SF-36 physical
functioning and FACT-G
Qual Life Res (2015) 24:339–362

functional well-being
(q = 0.57); SF-36 physical role
limitations and FACT-G
functional Well-being
(q = 0.53) and FACT-G
physical Well-being (q = 0.53);
SF-36 emotional role limitations
and FACT-G functional well-
being (q = 0.50); SF-36 vitality
and FACT-G physical well-being
(q = 0.72); SF-36 mental health
and FACT-G emotional well-
being (q = 0.62); SF-36 social
functioning and FACT-G
physical well-being (q = 0.56);
SF-36 bodily pain and FACT-G
physical well-being (q = 0.68)
Factor 4: general health (1 out of
5 items): 0.74; bodily pain (all 2
items): range = 0.59–0.61;
social functioning (all 2 items):
range = 0.59–0.81
EP Latina-American sample:
4-factors explained 73 % of the
variance
Factor 1: physical role limitations
(all 4 items): range = 0.77–0.82;
social functioning (1 out of 2
items): 0.52
Factor 2: general health (2 out of
5 items): range = 0.66–0.88
Factor 3: general health (2 out of
5 items): range = 0.40–0.62;
bodily pain (all 2 items):
range = 0.85–0.88
351

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 Table 1 continued
352

Study Ashing-Giwa et al. [10] Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
Country USA USA USA USA

123
Factor 4: general health (2 out of
5 items): range = 0.54–0.84;
social functioning (all 2 items):
range = 0.52–0.71
Concurrent validityd
African-American: SF-36 general
health vs. FACT-G physical
well-being (q = 0.60); vs.
FACT-G social/family well-
being (q = 0.01 n.s.*); vs.
FACT-G emotional well-being
(q = 0.39); vs. FACT-G
functional well-being (q = 0.43)
SF-36 social functioning vs.
FACT-G physical well-being
(q = 0.69); vs. FACT-G social/
family well-being (q = 0.16
n.s.*); vs. FACT-G emotional
well-being (q = 0.37); vs.
FACT-G functional well-being
(q = 0.59)
SF-36 physical role limitations vs.
FACT-G physical well-being
(q = 0.56); vs. FACT-G social/
family well-being (q = -0.01
n.s.*); vs. FACT-G emotional
well-being (q = 0.22); vs.
FACT-G functional well-being
(q = 0.51)
SF-36 bodily pain vs. FACT-G
physical well-being (q = 0.69);
vs. FACT-G social/family well-
being (q = 0.04 n.s.*); vs.
FACT-G emotional well-being
(q = 0.20 n.s.); vs. FACT-G
functional well-being (q = 0.52)
Qual Life Res (2015) 24:339–362
 Table 1 continued
Study Ashing-Giwa et al. [10] Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
Country USA USA USA USA

LEP Latina-American: SF-36

general health vs. FACT-G
physical well-being (q = 0.54);
vs. FACT-G social/family well-
being (q = 0.42); vs. FACT-G
emotional well-being
Qual Life Res (2015) 24:339–362

(q = 0.44); vs. FACT-G

functional well-being (q = 0.56)
SF-36 social functioning vs.
FACT-G physical well-being
(q = 0.56); vs. FACT-G social/
family well-being (q = 0.40);
vs. FACT-G emotional well-
being (q = 0.43); vs. FACT-G
functional well-being (q = 0.61)
SF-36 physical role limitations vs.
FACT-G physical well-being
(q = 0.51); vs. FACT-G social/
family well-being (q = -0.17);
vs. FACT-G emotional well-
being (q = 0.25); vs. FACT-G
functional well-being (q = 0.44)
SF-36 bodily pain vs. FACT-G
physical well-being (q = 0.62);
vs. FACT-G social/family well-
being (q = 0.21 n.s.*); vs.
FACT-G emotional well-being
(q = 0.27); vs. FACT-G
functional well-being (q = 0.53)
EP Latina-American: SF-36
general health vs. FACT-G
physical well-being (q = 0.50);
vs. FACT-G social/family well-
being (q = 0.36); vs. FACT-G
emotional well-being
(q = 0.42); vs. FACT-G
functional well-being (q = 0.53)
353

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 Table 1 continued
Study Ashing-Giwa et al. [10]
Country USA
123
Authors conclusions Internal consistency
The SF-36 was assessed as having
moderate-to-strong reliability
across the different ethnic groups
Construct validity
Overall, the SF-36 presented good
factor structure, with the
exception of the social
functioning scale
354
Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
USA USA USA
SF-36 social functioning vs.
FACT-G physical well-being
(q = 0.49); vs. FACT-G social/
family well-being (q = 0.43);
vs. FACT-G emotional well-
being (q = 0.44); vs. FACT-G
functional well-being (q = 0.62)
SF-36 physical role limitations vs.
FACT-G physical well-being
(q = 0.50); vs. FACT-G social/
family well-being (q = -0.23);
vs. FACT-G emotional well-
being (q = 0.18 n.s.); vs. FACT-
G functional well-being
(q = 0.53)
SF-36 bodily pain vs. FACT-G
physical well-being (q = 0.71);
vs. FACT-G social/family well-
being (q = 0.22); vs. FACT-G
emotional well-being
(q = 0.25); vs. FACT-G
functional well-being (q = 0.63)
Internal consistency Internal consistency Convergent validity
The SF-12 has good The SF-36 had acceptable internal SF-36 PCS and MCS measure
internal consistency and consistency across the three sub- distinct domains of HRQoL
the measure is reliable in groups
a Chinese-American
population
Construct validity Construct validity There is a modest degree of
construct overlap between the
SF-36 PCS and MCS and the
FLIC total score
The SF-12 at baseline had The SF-36 role limitations due to The physical, mental and social
good factor structure physical health subscale had domains of HRQoL are similar
which closely reflected good factor structure across each in the two measures, but general
the 2 constructs of the sub-group health is not similar
measure
Qual Life Res (2015) 24:339–362
 Table 1 continued
Study Ashing-Giwa et al. [10] Ashing-Giwa et al. [13] Ashing-Giwa and Rosales [12] Wilson et al. [11]
Country USA USA USA USA

Factor structures by ethnic groups
were less consistent
The factor structure of the The SF-36 general health, pain Discriminative validity
SF-12 at follow-up was and social functioning sub-scales
less robust, and this may had inconsistent factor structures
be due to a response shift across the three sub-groups
in cancer survivor’s
interpretation of the
Qual Life Res (2015) 24:339–362

items.
Concurrent validity The SF-36 is acceptable for use in SF-36 is able to discriminate
breast cancer survivor between breast cancer survivors
populations from ethnic minority with and without lymphedema in
and low-literacy groups terms of physical HRQoL, but
not mental HRQoL
There was good concurrent Concurrent validity
validity demonstrated between
the FACT-G and the SF-36
There was good concurrent
validity demonstrated between
the FACT-G and the SF-36
Quality Assessment Internal consistency Internal consistency Internal consistency Concurrent validity
Excellent Fair Good
Construct validity Construct validity
Poor Poor
Concurrent validity Construct validity Concurrent validity
Fair Good Fair Fair
a
Unless where necessary information regarding the SF measures only is reported
b
HRQoL = health-related quality-of-life
c
Participants with missing data were excluded from this analysis
d
Although, the FACT-G was focus of the analysis, psychometric information on the SF-36 is also provided
e
Only the highest, positive correlations are reported in the table
* n.s. = non-significant
355

123
356
SF-36 [10, 12]. The Ashing-Giwa et al. [10] study analysed
convergent validity among the total sample and four ethnic
and language sub-groups: African-American, European-
American, Latina-American and Asian-American. The
strength and direction of associations between respective
SF and FACT-B subscales were similar across the total
sample and ethnic and language sub-groups—see Table 2.
The Ashing-Giwa and Rosales [12] study analysed the
concurrent validity between the FACT-G and four sub-
scales of the SF-36 among three sub-groups: African-
American; LEP and EP Latina-Americans. Except for a
few discrepancies, the strength and direction of associa-
tions were similar between the FACT-G and SF-36 sub-
scales among each of the sub-groups—see Table 2. Of
note, a strong association was found between the SF-36
social functioning and the FACT-G social/family well-
being subscales among the African-American group com-
pared to low-moderate correlations observed among the
LEP and EP Latina-American groups.
Two additional studies assessed the convergent validity of
SF-36 subscales and respective lymphedema-specific mea-
sures among breast cancer survivors in Dutch-speaking
countries. One of the studies stated five a priori hypotheses to
assess convergent validity between the Lymph-ICF and the
SF-36. Each of the hypotheses was supported and listed in
Table 2 [14]. The second study demonstrated acceptable
convergent validity with the ULL27 [15]. The highest, posi-
tive correlations were between the SF-36 psychological sub-
scales (with the exception of the emotional role limitations
subscale), and social subscales and respective psychological
and social domains of the ULL27. However, the SF-36 vitality
and physical role limitations subscales did not correlate very
strongly with the physical domain of the ULL27 [15].
Both studies demonstrated moderate correlations
between the SF-36 bodily pain subscale and respective
physical scales of the lymphedema scales in the expected
direction. Similar results were demonstrated between the
SF-36 social functioning subscale and respective Lymph-
ICF and ULL27 social scales. The Devoogdt et al. [14]
study found that the SF-36 mental health subscale was
correlated strongly with the Lymph-ICF mental function
scale; however, the Viehoff et al. [15] study reported
similar findings except for the respective ULL27 psycho-
logical scale and SF-36 emotional role limitations.
Concurrent validity: divergent
One study stated five hypotheses to assess the divergent
validity of SF-36 and the Lymph-ICF—see Table 2. Three
of the five hypotheses were supported. The authors
expected the greatest divergence and thus weakest associ-
ation to be between the Lymph-ICF life and social and the
SF-36 physical functioning subscales; however, the lowest
123
Qual Life Res (2015) 24:339–362
correlation was reportedly with SF-36 emotional role lim-
itations. Moreover, Lymph-ICF mobility activities subscale
was negatively, but moderately associated with the SF-36
emotional role limitations subscale (q = -0.42) which
deviated from the a priori hypothesis [14].
Construct validity
Based on the original factor structure of the SF-36, one
study utilised Confirmatory Factor Analysis to test the
factor structure of four subscales of the SF-36 for their total
sample and three sub-groups: African-American; LEP and
EP Latina-American. For the total sample, the 4 factors
explained 72 % of variance and generally represented the
structure of the SF-36. Four distinct factors emerged for
each SF-36 subscale with few inconsistencies—see
Table 1. Although, the four factors of the SF-36 explained
between 73 and 75 % of the variance in quality-of-life
scores within the respective ethnic and language sub-
groups, the factor structure of the subscales—with the
exception of the physical role limitation subscale—was
less consistent. The general health items loaded onto three
factors across the three sub-groups, and each of the items
for the bodily pain and social functioning subscales loaded
onto one factor among the African-American and LEP
Latina-American sub-groups—see Table 1 [12].
Exploratory factor analysis data across the total sample
and ethnic and language sub-groups were presented for the
general health perception items only in one paper [10].
According to the authors’ descriptions of the results for the
other subscales (except for SF-36 social functioning), the
factor structure was generally consistent for the total
sample. The most consistent factor structure was within the
European-American sub-group whereby inconsistencies
were found only within the general health and physical
functioning subscales. The factor structure of the SF-36
performed similarly within the Asian- and African-Amer-
ican sub-groups. The most inconsistent pattern of factor
loadings was within the Latina-American sub-group; good
factor structure was identified among the emotional role
limitations subscale only [10].
Both studies demonstrate good factor structure of the SF-
36 within the total samples under study; however, factor
structures were less consistent within the ethnic and lan-
guage sub-groups. A few notable discrepancies can be found
between the two studies. Within the African-American sub-
group, discrepancies can be seen for the factor structure of
the physical role limitations, general health and bodily pain
subscales. Moreover, within the Latina-American sub-
group, the only discrepancy can be seen in the factor struc-
ture for the physical role limitations subscale [10, 12].
A further study assessed the factor structure of the SF-12
within a Chinese-American breast cancer survivor sample.
 Table 2 Study characteristics of papers which provide psychometric information on the SF measures but focussed on other measuresa
Study Devoogdt et al. [14] Terhorst et al. [16] Viehoff et al. [15]
Country Belgium USA The Netherlands

Measure(s) of Lymphedema Functioning, Disability and Health Breast Cancer Prevention Trial Symptom Checklist Upper limb lymphedema 27-item questionnaire (ULL27)
interest questionnaire (Lymph-ICF) (BCPT)
SF-36 Dutch language version SF-36 English language version SF-36 Dutch language version
Study-specific questionnaire
Aim(s) To assess the validity and reliability of the Lymph-ICF To assess the psychometric properties of the BCPT with To translate the ULL27 into Dutch (from French) and
questionnaire a sample of breast cancer patients before and after determine its psychometric properties in a population
Qual Life Res (2015) 24:339–362

adjuvant therapy of patients with lymphedema

Construct validity assessed using the SF-36
Study design Longitudinal survey: baseline at outpatient
appointment; follow-up 24–48 h later to be returned
by post.
Population Criteria
Dutch-speaking breast cancer survivors who had
undergone unilateral axillary dissection at least
12 months previously, recruited from hospital-based
physiotherapy and breast clinic appointments
Sample
n = 90 breast cancer patients
n = 30 with objective lymphedema; age:
mean = 61.2 years; SD = 10.0 years
n = 30 with subjective lymphedema; age:
mean = 56.7 years; SD = 9.3 years
n = 30 with no reported lymphedema; age:
mean = 58.3 years; SD = 11.9 years
Psychometric Construct validity (Convergent and Divergent)
properties
assessed
Convergent validity hypotheses
(1) Lymph-ICF physical function and SF-36 bodily
pain
(2) Lymph-ICF mental function and SF-36 mental
health
(3) Lymph-ICF household activities and SF-36
physical functioning
To determine the discriminant validity of the presence/
absence of symptoms on the BCPT using the SF-36
Baseline and follow-up data obtained from a
longitudinal cohort study
Criteria
Breast cancer survivors diagnosed with stages I-IIIa
who were part of the Anastrozole use In Menopausal
women (AIM) cohort study
Sample
n = 27 chemotherapy only group; age:
mean = 58.9 years; range = 49–73 years; education:
mean = 14.6 years; 81.5 % white ethnicity
n = 157 anastrozole only group; age:
mean = 61.6 years; range = 45–75 years; education:
mean = 14.8 years; 98.1 % white ethnicity
n = 94 chemotherapy and anastrozole combined group;
age: mean = 59.0; range = 44–68 years; education:
mean = 14.7 years; 94.7 % white ethnicity
Discriminant validity
To assess the concurrent validity of the ULL27 using the
SF-36
Cross-sectional survey and clinical assessment of
lymphedema
Criteria
Dutch women with breast cancer with unilateral edema
of the upper limb (no distinction made between
primary and secondary lymphedema). Patients with
progressive disease or infection of the upper limb in
the last 2 months were excluded
Sample
n = 84; age: mean = 59 years; SD = 11.79; onset of
edema after surgery: mean = 26 months;
SD = 56.61 months
Concurrent validity
357

123
 Table 2 continued
358

Study Devoogdt et al. [14] Terhorst et al. [16] Viehoff et al. [15]
Country Belgium USA The Netherlands

123
(4) Lymph-ICF mobility activities and SF-36 physical
functioning
(5) Lymph-ICF life and social activities and SF-36
social functioning
Divergent validity hypotheses
(1) Lymph-ICF physical function and SF-36 role-
emotional and mental health
(2) Lymph-ICF mental health and SF-36 physical
functioning and physical role limitations
(3) Lymph-ICF household activities and SF-36
emotional role limitations and mental health
(4) Lymph-ICF mobility activities and SF-36
emotional role limitations and mental health
(5) Lymph-ICF life and social activities and SF-36 –
physical limitations
Results Construct validity Discriminant validity Concurrent validity
5 convergent validity hypotheses were supported Low, negative correlations between the symptoms The Dutch ULL27 domains were significantly
reported on the BCPT and scores on the SF-36 correlated with most of the respective SF-36
summary component scores at both baseline
(range = -0.401 to 0.016) and 6-month follow-up
(range = -0.308 to -0.007)
(1) Lymph-ICF physical function and SF-36 bodily The ULL27 physical domain correlated highly with SF-
pain (q = -0.52) 36 bodily pain (q = 0.69), general health (q = 0.60)
and social functioning (q = 0.55) domains, but not
physical role limitations (q = 0.38) or vitality
(q = 0.47) domains as would be expected
(2) Lymph-ICF mental function and SF-36 mental The ULL27 psychological domain correlated highly
health (q = -0.70) with SF-36 general health (q = 0.54), vitality
(q = 0.55), mental health (q = 0.66) and social
functioning (q = 0.51) domains as would be expected,
but not the emotional role limitations (q = 0.42)
domain
(3) Lymph-ICF household activities and SF-36 The ULL27 social domain correlated highly with SF-36
physical functioning (q = -0.51) physical functioning (q = 0.64), general health
(q = 0.56) and social functioning (q = 0.45) domains
(4) Lymph-ICF mobility activities and SF-36 physical
functioning (q = -0.62)
(5) Lymph-ICF life and social activities and SF-36
social functioning (q = -0.33)
3 of the 5 divergent hypotheses were supported
Qual Life Res (2015) 24:339–362
 Table 2 continued
Study Devoogdt et al. [14] Terhorst et al. [16] Viehoff et al. [15]
Country Belgium USA The Netherlands

(1) Lymph-ICF physical function and SF-36 role-

emotional (q = 0.03) and mental health (q = -0.14)
(2) Lymph-ICF mental health and SF-36 physical
functioning (q = -0.24) and physical role limitations
(q = -0.25)
(3) Lymph-ICF household activities and SF-36
Qual Life Res (2015) 24:339–362

emotional role limitations (q = -0.22) and mental

health (q = -0.27)
(4) Support for emotional role limitations only and not
mental health-Lymph-ICF mobility activities and SF-
36 emotional role limitations: (q = -0.15) and
mental health: (q = -0.42)
(5) Unsupported-Lymph-ICF life and social activities
and SF-36 physical functioning (q = -0.25); (role
limitations—emotional had lowest correlation q = -
0.19)
Authors Construct validity Discriminant validity Concurrent validity
conclusions The Lymph-ICF demonstrated good convergent and Discriminant validity was reported in the expected The lower concurrent validity between the ULL27
divergent validity with respective sub-scales of the direction that a higher number of reported symptoms is physical domain and the respective SF-36 domains
SF-36 associated with lower scores on the SF-36. This finding may be explained by the focus of lower limb
is supported by other research functioning in the SF-36 as compared to upper limb
focus in the ULL27
There was good concurrent validity between the
psychological and social domains of the ULL27 and
respective SF-36 domains
Quality Construct validity Construct validity Construct validity
assessment Poor Fair Fair
a
Unless where necessary information regarding the SF measures only is reported
359

123
360
The authors utilised exploratory factor analysis at baseline
to explore the factor structure of the measure within this
population. The factor structure largely mirrored that of the
original measure, all MCS items (with one PCS item) and
PCS items loaded onto two emergent factors, respectively.
Confirmatory Factor Analysis was used to assess how the
SF-12 performed in the same population, 1 year later. Two
factors emerged, but the pattern of factor loadings reflect-
ing the MCS and PCS items was less consistent, and
58.1 % only of variance was explained [13].
Discriminant validity
One study administered the English language SF-36 in
order to differentiate between groups of breast cancer
survivors with and without lymphedema [11], and a second
study used the SF-36 to assess the discriminant validity of
the Breast Cancer Prevention Trial Symptom Checklist
(BCPT) measure [16].
At baseline and 6-month follow-up, low correlations
(range q = -0.401 to 0.016 and q = -0.308 to -0.007,
respectively) were reported between the SF-36 component
summary scores and BCPT scores. The BCPT requires the
presence or absence of a number of symptoms related to
breast cancer treatment to be reported, and higher scores on
the SF-36 indicate better HRQoL. The findings indicated
the SF-36 has good discriminant validity [16].
The SF-36 was able to differentiate between survivors
with and without lymphedema in the expected direction
(i.e. survivors with lymphedema have lower SF-36 scores)
in terms of physical component summary score (d = 1.20),
physical role limitations (d = 1.02), physical functioning
(d = 1.11), emotional role limitations (d = 0.72), vitality
(d = 0.74), social functioning (d = 0.60), bodily pain
(d = 1.20) and general health (d = 0.69). The SF-36
mental component summary score (d = 0.19) and mental
health subscale were not able to differentiate between
survivors with and without lymphedema [11].
Discussion
Seven studies assessed the psychometric properties of the
SF measures within diverse ethnic and language breast
cancer survivor samples. Overall, the SF measures were
found to have good psychometric properties. Further sup-
port for the use of the SF-36 among cancer survivor pop-
ulations is provided by the assessment of the psychometric
properties of the SF-36 within a British, childhood cancer
survivor cohort [17].
Internal consistency ranged from acceptable to good
across the SF-36 subscales and SF-12 component summary
scores within breast cancer survivor populations of varying
123
Qual Life Res (2015) 24:339–362
spoken languages and ethnicities. The social functioning
subscale had the lowest internal consistency scores
(a = 0.64 and a = 0.68) among African-American breast
cancer survivors in two studies; however, the scores were
not low enough to warrant cause for concern.
The SF-36 and FACT-G were assessed concurrently in
two studies within various ethnic and language sub-groups;
comparisons between the two studies were, however, limited
as one study included only four of the eight SF-36 subscales
and included only two similar ethnic and language sub-
groups. Differences in study design between the two studies
may account for some of the discrepancies in concurrent
validity results (e.g. SF-36 subscales and FACT measures
social/family well-being subscales) among the African-
American samples. One of the studies conducted a popula-
tion-based cross-sectional telephone or postal survey to
investigate different recruitment strategies among different
ethnic and language groups and to assess the psychometric
properties of health-related outcome measures [10], whereas
the other study utilised baseline data from a psycho-educa-
tion intervention study to undertake a secondary assessment
of psychometric properties [12]. No further details of the
psycho-education intervention are reported in the study or
published elsewhere, in particular how the sample was
selected. Breast cancer survivors who already have a good
knowledge of breast cancer and its impact may have ‘self-
selected’ for the psycho-education intervention compared to
survivors with less knowledge; therefore, items on the can-
cer-specific FACT-G may have more salience for them
compared to items on the generic SF-36. A further study
assessed the convergent validity of the SF-36 and FLIC to
good effect [11]. Given that the SF-36 is a generic measure of
health status and the FACT and FLIC are measures specific
to cancer populations, it shows promise that the measures
seemingly measure the same constructs in diverse ethnic and
language breast cancer survivor groups. It would appear that
the SF-36 may be a suitable generic alternative to both
cancer-specific measures, particularly to make comparisons
of the health status of cancer survivors to population norms,
the general population or other disease groups.
The concurrent validity of respective subscales of the
Dutch language SF-36 and lymphedema-specific measures
(ULL27 and Lymph-ICF) was assessed for convergent
validity in two studies and divergent validity (Lymph-ICF)
in one study to good effect. One of the studies found a less
strong association between respective physical subscales of
the two measures. The authors report that this is likely due
to the lower limb focus of the SF-36 e.g. ability to climb a
flight of stairs compared to the upper limb focus of the
ULL27 [15]. Thus, the SF-36 may be more appropriate for
use among survivors with lower limb lymphedema [18],
although this would need to be psychometrically assessed.
In order to accurately capture the health outcomes of breast
Qual Life Res (2015) 24:339–362
cancer survivors with lymphedema, the SF-36 may not be
an adequate substitute for lymphedema-specific measures
in terms of capturing similar aspects of health; however,
more research is needed in this area due to the limited
number of studies identified.
Subscales of the SF-36 (e.g. vitality and bodily pain)
have been implemented in studies to assess cancer-related
fatigue [19] and cancer-related pain [20], respectively,
among breast cancer survivors. No studies were identified
which assessed the psychometric performance of these
subscales compared to cancer-specific or symptom-specific
measures. To use fatigue as an example, scales which
define and measure fatigue exclusively as a multidimen-
sional construct may be more reliable than measures that
include fatigue as a series of unidimensional items within a
domain or subscale [21]. Moreover, variation in the types
(i.e. generic, cancer-specific or symptom-specific) of
patient-reported outcome measures may account for vari-
ance in prevalence rates of fatigue and other cancer-related
effects [19, 22]. Therefore, there is a need for further
research to identify the psychometric performance of sub-
scales of the SF-36 that may be used to measure cancer-
related effects among breast cancer survivors (and other
cancer groups) to ensure that health care providers and
commissioners adequately capture this information to
inform service provision and delivery.
The factor structure of the SF-36 was good for overall
study samples and reflected the original measure, but
inconsistencies in the factor structure were reported within
language and ethnic sub-groups. These consistencies may
result from the loss of nuances of language or the failure to
adequately or at all represent cultural norms when trans-
lations are made [23]. However, the inconsistencies may
also be partially explained by a lack of statistical power to
conduct sub-group analyses due to small sample sizes. The
COSMIN manual provides recommendations for adequate
sample size to undertake factor analysis. For example, a
‘good’ sample size for factor analysis should include more
than 100 participants and at least five times the number of
measure items [24]. Only one [13] of the three studies
which assessed the factor structure of the SF measures had
a ‘good’ sample size, perhaps due to using the smaller SF-
12 measure and not undertaking sub-group analysis; the
other studies had a an under-powered, ‘poor’ sample size
for sub-group analysis of the SF-36 [10, 12]. Specific
inconsistencies between comparable aspects of the two
studies may be accounted for by differences in sources of
data—see above [10, 12]. The Chinese language SF-12
demonstrated good factor structure (closely reflecting the
original SF-12) at baseline, but less consistent factor
structure at 1-year follow-up within a Chinese-American
breast cancer survivor sample. This may be explained by a
response shift in the meaning or interpretation of the SF-12
361
items in the light of changes that have occurred as a result
of diagnosis and treatment as breast cancer survivors live
longer with the disease [25]. Further research with ade-
quate sample size should be undertaken to ensure that the
factor structure of the SF-36 for use within diverse ethnic
and language groups is adequately assessed.
The SF-36 was able to discriminate between breast
cancer survivors with and without lymphedema in terms of
physical health, but not in terms of mental health. This is
supported by further research which found that there was a
significant reduction in scores on the SF-36 MCS and
mental health subscale associated with arm and shoulder
problems which were not lymphedema among breast can-
cer survivors. However, this significant reduction was not
seen among breast cancer survivors with lymphedema [26].
In contrast to this, results from a population-based survey
of cancer survivors (the majority of which were breast
cancer survivors), scores on the SF-36 MCS and mental
health subscale were significantly lower among cancer
survivors with late effects compared to those without late
effects. Although this discrepancy may be explained by a
lack of focus on lymphedema, only and many of the
experienced late effects may have been psychological in
nature [4]. The authors of one paper suggest that the dis-
criminant validity findings for the MCS and mental health
subscales may be accounted for by the limited number of
SF-36 items to address issues of anxiety, depression, or
distress which may be experienced by many breast cancer
survivors post-treatment [11]. One study utilised the SF-36
to assess the discriminant validity of the BCPT, to good
effect. This study provides a good illustration of how the
SF-36 has been used to validate other measures [16].
Strengths and limitations
A major strength of the review was the use of COSMIN
resources including a well-developed search strategy and the
use of a methodological quality assessment tool. The COS-
MIN initiative recommend their checklist to be scored using a
‘worse score counts’ approach. Therefore, papers which have
generally ‘excellent’ or ‘good’ scores may score ‘poor’ on one
item and receive an overall ‘poor’ rating, as was the case with
the assessment of construct validity in one paper [10].
The inclusion of additional studies (n = 3) which did
not primarily assess the psychometric properties of the SF
measures but which nevertheless provide this information
may be questionable [24]. In the light of this, these studies
demonstrate similar results to studies where the SF mea-
sures were the primary focus. Moreover, many psycho-
metric properties of the SF-36 were not assessed in the
breast cancer survivor population, for example respon-
siveness to assess the ability of the SF-36 to detect change
and this would warrant further research attention.
123
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Conclusion
Nuances in language and cultural norms have an important
influence on how individuals perceive and interpret items
on patient-reported outcome measures, particularly as
concepts may not be adequately or accurately represented
after translation. The SF measures to assess health status
have good internal consistency, convergent validity,
divergent validity and moderately good construct validity
within diverse language and ethnic breast cancer survivor
groups. The SF measures would provide a useful aide for
health care providers to assess health-related outcomes of
breast cancer survivors in their care.
Acknowledgments CT received funding support from UKCRC
Centre of Excellence for Public Health, Queen’s University Belfast to
undertake the review.
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