A New Psychosocial Screening Instrument for Use With

Cancer Patients

JAMES ZABORA, SC.D., KARLYNN BRINTZENHOFESZOC, D.S.W.

PAUL JACOBSEN, PH.D., BARBARA CURBOW, PH.D.
STEVEN PIANTADOSI, M.D., PH.D., CRAIG HOOKER, B.S.
ALBERT OWENS, M.D., LEONARD DEROGATIS, PH.D.

The authors performed a principal components factor analysis on the 18-item Brief Symptom In-
ventory (BSI-18), a new brief screening inventory. The factor analysis, in which four factors were
specified, is consistent with findings in a previous community sample. The study sample consisted
of 1,543 cancer patients who completed the full BSI as part of their entry into care at a regional
cancer center. The reliability of the BSI-18 was determined based on the calculation of the inter-
nal consistency, mean item scores, and correlations with the total score of the BSI. In addition,
sensitivity and specificity was calculated to determine the ability of the BSI-18 to discriminate
positive and negative cases. The BSI-18 is a shortened version of the BSI that can serve as a
brief psychological screening instrument. The BSI-18 can be incorporated into outpatient clinics
to prospectively and rapidly identify cancer patients with elevated levels of distress who are in
need of clinical interventions. Early identification of distress with appropriate interventions can
reduce distress, enhance quality of life, and decrease health care costs.
(Psychosomatics 2001; 42:241–246)

O ften the distress associated with the diagnosis of can-

cer may not become manifest to the health care team
until the patient reaches an observable crisis event.1 Fre-
quently, referrals to psychosocial providers occur when the
patient is severely depressed or anxious, is suicidal, or is
experiencing significant conflicts with the family.2 Al-
though psychosocial interventions at acute points in a pa-
tient’s care have been shown to be effective, the question
remains whether an early psychological screening program
would enable health care providers to identify patients at
risk for distress associated with a cancer diagnosis.3,4 If so,
clinical interventions could be initiated during the early
phase of care rather than at crisis events.5 Because psycho-
logical distress may actually increase health care costs and
prolong medical treatments,6 early identification and inter-
vention may also produce a significant financial benefit.
The costs associated with early identification and interven-
tion may be significantly less than the costs of adverse
medical events and unnecessary hospitalizations related to
elevated distress.
Several prevalence studies7–9 suggest that one of every
three newly diagnosed cancer patients will experience sig-
nificantly higher levels of distress and may benefit from
social work, psychological, or psychiatric intervention.10
Table 1 details the three major studies related to psycho-
logical distress among cancer patients. Given a relatively
consistent prevalence of distress at approximately 30%, use
of structured interviews or assessments in large-volume
Received April 28, 2000; revised November 27, 2000; accepted Novem-
ber 29, 2000. From The Johns Hopkins Oncology Center, Baltimore, MD;
the H. Lee Moffitt Cancer Center, Tampa, Florida; and the University of
Maryland, Baltimore, MD. Address reprint requests to Dr. Zabora, The
Johns Hopkins Oncology Center, 600 North Wolfe Street, Baltimore, MD
21287.
Copyright 䉷 2001 The Academy of Psychosomatic Medicine.

Psychosomatics 42:3, May-June 2001 241

Screening Instrument
clinics may require a significant amount of staff time with
a low positive case yield. Self-report measures for the pur-
pose of screening offer a valuable alternative for cancer
centers that see a high number of cancer patients per year
and wish to screen for psychological distress.11
Given these initial issues, screening should not be con-
fused with assessment. Screening is a rapid method to pro-
spectively identify patients who may potentially experi-
ence significant difficulty in their attempts to cope and
adapt to their diagnoses and treatments. Screening is a pre-
dictive model. Assessment seeks to accomplish a series of
tasks in the early phases of a relationship with a patient.
These tasks include an estimate of the severity of the pa-
tient’s distress, definition of the initial course of action,
development of a dynamic understanding of the patient,
the establishment of a diagnosis, and the first step in the
development of a therapeutic relationship.12
Any method of psychosocial screening must be brief
and pragmatic. Although improvements in screening tech-
niques continue to be developed, further research is nec-
essary to identify brief, simple, and accurate tools to ac-
complish this vital task. Through screening, the early
incorporation of psychosocial and behavioral interventions
in cancer treatment may be more readily accepted by pa-
tients and less stigmatizing.13 In addition, these interven-
tions complement cancer therapies and may enhance medi-
cal outcomes while reducing the overall costs of health
care.6
METHODS
Sample
Since 1988, staff in a comprehensive cancer center
have experimented with psychosocial screening in an effort
to develop a prospective model of psychosocial care with
early identification of risk linked to appropriate interven-
tions. Since the inception of these efforts, approximately
10,000 psychological profiles have been amassed through
the use of the Brief Symptom Inventory (BSI).14 For this
project, cases beginning in January 1995 were selected in
succession until an acceptable sample size was constructed
TABLE 1. Prevalence studies of psychological distress among cancer patients
Authors Year Measures
7
Derogatis et al. 1983 SCL-90 and psychiatric interview
Farber et al.8 1984 SCL-90
Stefanek et al.9 1987 BSI
242
in order to test the ability of the BSI-18, a recently abbre-
viated version of the scale,15 to successfully identify dis-
tressed cancer patients. An analysis was conducted to cal-
culate the alpha for the BSI-18 in an oncology population.
After this analysis, the BSI-18 was subjected to a principal
components factor analysis. This analysis was conducted
by specifying four factors consistent with the recent find-
ings of Derogatis,15 in an effort to further support the struc-
tural hypothesis of the BSI-18 in a cancer population.
Measures
Brief Symptom Inventory The full BSI is a 53-item mea-
sure of psychological distress that contains three global
scales and nine subscales.16 The BSI is written at a sixth-
grade reading level and only requires 5 to 7 minutes to
complete. Each item is rated on a 5-point Likert scale from
0 (not at all) to 4 (always). The patient is asked to respond
to each item in terms of “how they have been feeling during
the past 7 days.” Positive cases can be identified by a
Global Severity Index (GSI) score of ⱖ63 or any two sub-
scales where the T-score is ⱖ63.14 The BSI has been used
in prevalence studies related to psychological distress9,17
and has been tested for its efficacy as a screening instru-
ment against the omega instruments that are based on the
variables previously defined.3 In addition, the BSI pos-
sesses characteristics that are more suitable for screening
than other instruments, such as the General Hospital Ques-
tionnaire or the Hospital Anxiety and Depression Scale.18
Table 2 details the psychometric properties of the BSI.
Each BSI subscale consists of 4–7 items that account
for 49 of the overall 53 items. Four additional items (poor
appetite, trouble falling asleep, thoughts of death and dy-
ing, and feelings of guilt) load on more than one factor but
remain separate from the 9 subscales. These 4 configural
items have been maintained as part of the BSI due primar-
ily to their clinical predictive significance. For example,
“poor appetite” loads on both the depression and somati-
zation factors and can have discriminate significance re-
garding the nature of depressive symptoms.
N Rates of Distress
215 47% received a DSM-III diagnosis: 68% of these were adjustment disorders
141 34% had elevated distress scores
126 28% demonstrated moderate to high psychosocial distress
Psychosomatics 42:3, May-June 2001

Application of a Scale for Use With a Cancer Population
To validate the use of a scale on a specific population
(i.e., generalize its valid use in that population), a number
of issues must be considered. First, the scale, as a measure
of a concept such as distress, should be practical and ac-
ceptable to patients, clinicians, and investigators. Practi-
cality and acceptability can be achieved through short com-
pletion time, understandable directions and items, and low
costs for administration of the scale. Second, the funda-
mental principles of validity must be established for the
population. Finally, scales must minimize measurement er-
ror. Scales with measurement error produce the potential
for bias and misinterpretation of results.19
Statistical Analyses
As mentioned previously, internal consistency of the
BSI-18 in a cancer population was established through the
calculation of Cronbach alphas. In addition, the total score
on the BSI-18 was correlated with the GSI raw score of
the full BSI. We subjected the 18-item BSI to a principal
component factor analysis with a varimax rotation while
specifying four factors. Values are meansⳲstandard devi-
ations for each item calculated. The total variance ac-
counted for by the BSI-18 was also calculated. Finally, the
sensitivity and specificity were calculated to determine the
capability of the BSI-18 to discriminate positive from neg-
ative cases, and the positive predictive value was derived.20
RESULTS
Sample Our test sample consisted of 1,543 cancer pa-
tients with a mean age of 55.5Ⳳ14.5 (range⳱14–90
years). The majority of the sample were men (52.0%). Be-
cause consecutive cases were used, over 35 different di-
agnoses were represented in the total sample. The top ten
TABLE 2. Critical elements of the Brief Symptom Inventory
Number of
Items Global Scales Subscales
53-item Global Severity Index (GSI) Somatization
5 point Likert Positive Symptom Hostility
Distress Index Anxiety
Positive Symptom Depression
Total Phobic anxiety
Interpersonal Sensitivity
Obsessive-compulsive
Paranoid ideation
Psychoticism
Psychosomatics 42:3, May-June 2001
Zabora et al.
cancer diagnoses were as follows: breast (19.9%), prostate
(13.0%), leukemia (9.8%), lymphoma (9.7%), lung (5.5%),
head and neck (4.5%), pancreatic (4.1%), gynecological
(3.8%), and brain (2.1%). These cases represent patients
seen from 1995 to 1998, and the BSI forms from this time
period were computer scanned so that individual item re-
sponses could be analyzed. Table 3 presents characteristics
of the sample used in the analysis of the BSI-18.
Reliability and Validity of the BSI-18 MeansⳲstandard
deviations for the 18 items and total score for the sample
are given in Table 4. In addition, internal consistency re-
liability was examined for the BSI-18 and the 53-item BSI.
Cronbach’s alpha was 0.89 for the BSI-18 and 0.95 for the
full BSI. The BSI-18 total score was significantly corre-
lated with the GSI of the BSI with r⳱0.84 (P⬍0.001).
Item-to-total correlations ranged from 0.34 to 0.70.
Principal Components Factor Analysis A factor analysis
of the BSI-18 was conducted on our sample of 1,543 cancer
patients, which consisted of a principal components anal-
ysis with a varimax rotation. Four factors were identified
that had eigenvalues greater than (or very close to) 1.0 and
met the scree test for retention. The four factors accounted
for 57.8% of the variance in the matrix. The factor pattern
matrix from this analysis is given in Table 5.
The results of this analysis of the BSI-18 strongly con-
firm the hypothesized dimensional structure of the instru-
ment and are very similar to a factor analysis reported by
Derogatis15 on a community sample of 1,134 individuals.
That analysis also isolated four factors that met retention
criteria and accounted for 57.2% of the variance. Much as
was with the case of the Derogatis15 analysis with com-
munity individuals, even though the BSI-18 was hypoth-
esized to support a three-dimensional structure, the ob-
served four-dimensional solution fits well with the test’s
hypothesized dimensional composition.
Psychometrics
Alphas ⳱ 0.71 to 0.85
Test-retest coeff. 0.68 to 0.91
Convergent validity ⳱ r’s between the SCL-90 and the
BSI subscales range from 0.92-0.98
Construct validity ⳱ Principal components factor analysis
accounted for 44% of variance
243
Screening Instrument

TABLE 3. Characteristics of sample for analysis of the BSI-18 The first factor identified in the present analysis is
(Nⴔ1,543) clearly the anxiety factor, with 5 of the BSI-18 anxiety
Gender n(%) items demonstrating heavy loadings on this factor. Factor
Men 802(52.0) I accounted for approximately 20% of the variance in the
Women 741(48.0) matrix. Unexpectedly, the anxiety item, “Feeling so restless
Age
⬍ 20 14(0.9)
I couldn’t sit still” did not load on Factor I but instead
20-29 63(4.1) loaded on the second factor. In addition, the depression
30-39 175(11.3) item “Feeling lonely” showed a split loading on this factor
40-49 277(18.0)
and the second factor.
50-59 368(23.8)
60-69 380(24.6) Factor II is a very explicit representation of the BSI-
70-79 239(15.5) 18 depression factor. Five of the six hypothesized depres-
80 Ⳮ 27(1.7) sion items showed saturated loadings on this factor, which
Primary Diagnosis
Breast 302(19.9) accounted for an additional 17% of the variance. Of the
Lung 83(5.5) hypothesized depression items, only “Suicidal ideation”
Colon 84(5.5) did not load on Factor II.
Prostate 197(13.0)
Hodgkin’s 25(1.6)
Factor III demonstrates high loadings on all six items
Lymphoma 147(9.7) of the hypothesized somatization dimension of the BSI-18
Leukemia 149(9.8) and little else. Much as was the case in Derogatis’ test15 of
Liver 14(0.9)
the hypothesized structure in a community population, the
Melanoma 13(0.9)
Adenocarcinoma 21(1.4) somatization dimension showed almost perfect empirical
Brain 32(2.1) confirmation. Factor III accounted for 14% of the variance.
Head and neck 69(4.5) The fourth factor isolated in the analysis fell just short
Pancreas 62(4.1)
Gynecological 58(3.8) (0.98) of the eigenvalue retention criteria of ⱖ1.0, although
Multiple myeloma 31(2.0) it did pass the scree test. The final factor revealed only one
Kidney 27(1.8) item (“Suicidal ideation”) as correlating strongly with the
dimension and accounted for almost 7% of the variance.
Interestingly, although loadings fell slightly below the cut-
off for reporting (i.e., ⱖ0.40), the two items of “Feelings
of terror and panic” (0.38) and “Suddenly scared for no
reason” (0.35) both showed mild correlations with this di-
TABLE 4. BSI-18 item mean scores, standard deviations, and
factor loadings (Nⴔ1,543)
TABLE 5. BSI-18 factor pattern matrix (Nⴔ1,543)
BSI-18 Item Standard Factor
Number Mean Deviation Loading BSI-18 item
number Factor 1 Factor 2 Factor 3 Factor 4
1 0.31 0.69 0.408
2 0.41 0.77 0.732 18 0.771 0.307 3.E-02 3.8E-02
3 0.91 1.01 0.582 3 0.762 –9.E-03 0.246 –3.E-02
4 0.27 0.68 0.413 6 0.704 0.351 0.185 –1.E-02
5 0.42 0.77 0.691 8 0.638 0.505 0.129 2.0E-03
6 0.85 0.97 0.739 9 0.613 0.231 0.150 0.348
7 0.62 0.97 0.463 12 0.595 0.186 0.222 0.378
8 0.68 0.86 0.775 5 0.543 0.541 4.E-02 –2.E-02
9 0.24 0.64 0.678 11 0.132 0.740 0.191 0.199
10 0.35 0.76 0.446 14 0.364 0.623 0.163 0.218
11 0.23 0.61 0.651 15 0.293 0.613 0.164 0.140
12 0.20 0.63 0.663 2 0.386 0.597 0.218 0.188
13 0.58 0.92 0.431 16 0.118 0.403 0.679 –0.157
14 0.48 0.85 0.726 10 8.E-02 7.9E-02 0.666 0.284
15 0.35 0.70 0.644 4 0.159 –7.E-02 0.632 0.370
16 0.84 1.06 0.576 1 0.169 4.9E-02 0.620 –2.E-02
17 0.09 0.39 0.408 7 0.129 0.237 0.564 3.2E-02
18 0.72 1.02 0.707 13 6.E-02 0.383 0.493 –0.244
BSI-18 Total 8.42 8.62 17 7.E-02 0.335 4.E-02 0.721

244 Psychosomatics 42:3, May-June 2001


mension. This finding is analagous to the fourth factor re-
ported in the community population,19 which combined
items reflecting panic and suicidal thoughts. Suicidal ru-
minations are a unique aspect of psychopathology that re-
cent research (e.g., Vollrath et al.21) has demonstrated are
often associated with panic states, just as they are known
to accompany serious depression. Confronted with a di-
agnosis of cancer, and all the potential hardships that such
a diagnosis implies, it is understandable that vulnerable
individuals may experience panic, and with it, some cog-
nitive ruminations of an ultimate means of escape.
The current analysis provides strong confirmation of
the hypothesized dimensional structure of the BSI-18 in an
oncology population. In doing so, the results not only com-
plement prior research with the instrument in a community
population, but these results demonstrate a substantial level
of construct generalizability.22
Scoring the BSI-18 Standardized scores were developed
in psychometrics primarily to facilitate comparisons of the
standing or performance of an individual on some attribute
of interest (e.g., depression, intelligence, well-being, etc.)
to a relevant reference group (e.g., newly diagnosed cancer
patients). In a clinical application, such “norms” enable us
to better judge how distressed or ill a patient is, as well as
better appreciate the magnitude and significance of any
change observed over the course of treatment.
Norms for the BSI-18 have been developed by the
author of the BSI-1815 for the three primary dimension
scores (somatization, depression, and anxiety) and the
Global Severity Index (GSI) from approximately 1,500
cancer patients in the current sample. In addition, com-
munity norms are also available.19 In recognition of the
consistent observation that manifestations of symptomatic
distress differ substantially across men and women,14 all
norms are gender keyed.
As was the case with both the SCL-90-R23 and the
BSI,14 parent instruments to the BSI-18, the metric selected
to serve as the standardized score for the BSI-18 is the area
T-score. The area T-score is characterized like all T-scores
by a distribution with a mean of 50 and a standard deviation
of 10 but possesses substantial advantages over linear stan-
dardized scores. Because area transformations are normal-
izing transformations, the area T-scores carry with them
meaningful and interpretable percentile equivalents. An
area T-score of 60 always places the respondent in the 84th
percentile, while a score of 70 is equivalent to the 98th
percentile. This is true of linear standardized scores only
when the underlying distribution is normal. A detailed dis-
Psychosomatics 42:3, May-June 2001
Zabora et al.
cussion of characteristics of various standardized scores is
given elsewhere.24
To identify appropriate cutoff scores for the BSI-18,
the cases were separated by gender. In examining the dis-
tribution of the scores and what is known about the prev-
alence of distress using the 53-item BSI with this popula-
tion,17 the 25th percentile was used to determine the cutoff
point for caseness. For men, the 25th percentile fell at a
score of 10, and for women, it fell at 13. To further sub-
stantiate the norms for the BSI-18, sensitivity and specific-
ity were calculated to determine how well the BSI-18 iden-
tified positive cases using a score of 10 for men and 13 for
women. These results are detailed in Table 6. Finally, given
a sensitivity of 91.2% and a specificity of 92.6%, the posi-
tive predictive value (PPV) for the BSI-18 was also cal-
culated (Sens/1-Spec), which produced a PPV of 12.32.
Any PPV ⬎10 indicates that a test has a strong likelihood
for positive case identification.
DISCUSSION
These results furnish significant support for the use of the
BSI-18, a new psychosocial screening instrument, with
cancer patients. Principal components factor analysis
showed confirmation for the hypothesized dimensional
composition. The significant correlations between the BSI-
18 total score and the GSI score of the 53-item BSI sub-
stantiates the continuity of the BSI-18 in identifying the
psychological distress construct.
Significance of the Findings Given that 30% of all cancer
patients experience elevated levels of psychological dis-
tress, early identification of vulnerable patients is essential
to their comprehensive management. Undetected and un-
treated distress creates the potential for patients to medi-
calize psychological symptoms and greatly complicates
treatment of the primary neoplastic disorder. Because the
focal point of care is the tumor site, patients are often re-
luctant to consistently reveal their distress to members of
the health care team. Patients may perceive that a diversion
from the tumor to focus on an emotional response may
TABLE 6. Sensitivity and specificity of the BSI-18 (Nⴔ1,543)
BSI-53 GSI
Case No Case
Case 91.2% 7.4%
BSI-18 250 94
No Case 8.8% 92.6%
24 1,175
245
Screening Instrument
jeopardize the outcome of their cancer therapy. Given the
high patient volumes in many cancer centers, little time, if
any, is available for the health care team to assess the emo-
tional concerns of every patient. Further, even when con-
cerns are detected, the patient has often reached a crisis
state, and the increased distress has become apparent to
members of the team. At this point, referrals for psycho-
social care occur when the patient is agitated, acutely de-
pressed, or suicidal.2 Although clinical interventions can
be effective at these crisis points, the major question is,
“Could these patients be identified as being high risk early
in the course of their cancer treatment?” thus allowing ear-
lier initiation of preventive interventions.
These findings are an important step in the develop-
ment of a prospective psychosocial care delivery system
for cancer patients. The BSI-18 is a brief tool designed to
identify high-risk patients in the actual clinical setting
where cancer therapies are delivered. Given the brevity and
simple scoring, the BSI-18 can be easily incorporated into
the clinic registration areas and yields an outcome that al-
lows support staff to initiate a referral for psychosocial
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