Psychometric validation study of the Korean version of the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index
Psychometric validation study of the Korean version of the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index
Myong Kim 0 1
Seung-June Oh 1
Cheol Kwak 1
Hyeon Hoe Kim 1
Ja Hyeon Ku 1
0 Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea, 2 Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine , Seoul , Republic of Korea
1 Editor: Mohammad Shahid, Aligarh Muslim University , INDIA
To evaluate the reliability and validity of a Korean version of the Functional Assessment of Cancer Therapy (FACT)-Vanderbilt Cystectomy Index (VCI) in Korean patients who underwent radical cystectomy (RC) and urinary diversion (UD). We prospectively recruited 108 RC and UD patients who did not have evidence of recurrence from 1994 December to 2015 March. All participants were instructed to complete the Korean FACT-VCI and Short-Form 36-Item Health Survey (SF-36; 1st measurement) and to repeat the Korean FACT-VCI survey one month later (2nd measurement). Statistical analysis included intraclass correlation, Cronbach's α, time and UD type fixed mixed linear model, principal components analysis, and criterion-related validity with SF-36.
Data Availability Statement: The release of patient
data to the public is not possible. The Institutional
Review Board of our institution (Seoul National
University Hospital Biomedical Research Institue,
Seoul, Republic of Korea) approved this study with
the condition that the security of patient personal
information be strictly maintained (Approval No.
H1307-127-508). Therefore, the release of patient
data to the public would be a violation of IRB terms
of approval. Researchers interested in data from
this study can contact the corresponding author
(Ja Hyeon Ku; E-mail: ) or our
Materials and methods
Korean FACT-VCI was internally consistent (α = 0.802) and had adequate test-retest
reliability (interclass correlation = 0.803 and 0.822). The three components model of principal
component analysis (cumulative explanatory power, 49.2%) confirmed the internal
structural validity of the additional concerns (AC) component of the Korean FACT-VCI, and each
component represented the ªvoiding problemº, ªbowel problemº, and ªsocial/functional
problem with equivalent explanatory power (19.5%, 15.4%, and 14.4%). Korean FACT-VCI
domain scores were generally well correlated with SF-36 domain scores (Pearson
correlation coefficients range: 0.286±0.688; all p <0.01). Mixed linear models revealed that the
major effect of measurement times was not significant on FACT-VCI (p = 0.589)
This prospective study confirms the reliability and validation of the Korean FACT-VCI. We
expect that this validated tool can be widely utilized in the health-related quality of life studies
of Korean patients.
Institutional Review Board (E-mail: 52113@snuh.
org). Upon request, researchers may be provided
the data to the extent that this does not violate IRB
Funding: This study is supported by grant no.
052013-0010 from Seoul National University Hospital
Research Fund. The funders had no role in the
design and conduct of the study; the collection,
analysis, and interpretation of the data; or the
preparation, review, or approval of the manuscript.
Radical cystectomy (RC) and urinary diversion (UD) remains the gold standard treatment
for invasive bladder cancer [
]. But, RC and UD for bladder cancer is one of the most
traumatic cancer surgeries causing psychological stress and alternation in life-style. Significant
morbidities include sexual dysfunction, voiding problem, or change in body image .
Furthermore, extension of RC indications in high risk T1 diseases [
] and increasing
longterm survival have increased the impact of the treatment on health-related quality of life
Several studies have addressed HRQOL following RC [4±8]. However, the tools used to
assess HRQOL were instruments for general disease [
] or other malignancies , or
lacked external validation[
]. To address these shortcomings, Cookson et al. developed a
novel questionnaire for patients receiving RC and UD. The questionnaireÐthe Functional
Assessment of Cancer Therapy (FACT)-Vanderbilt Cystectomy Index (VCI)±is based on the
FACT-General (FACT-G) questionnaire, whose reliability and validity have been confirmed
], in addition to items for concerning distressing symptoms following RC [
reliability and validity of the original version of FACT-VCI were also confirmed [
psychometric validation has been confirmed utilizing externally extended cohorts [
validated questionnaire is now generally accepted as a credible tool for assessment of
HRQOL in patients who have undergone RC and UD, and has been adopted in many
HRQOL studies of bladder cancer [12,13].
In the process of translation of a questionnaire written in one language into a version in
another language, the translated versions must reflect differences in the culture and custom of
subjects who use a given language. In a first step toward obtaining a validated assessment tool
for HRQOL of patients who underwent RC and UD in Korea, we previously performed the
translation and linguistic validation of the Korean version of the FACT-VCI (Korean
FACT-VCI), which consists of 27-items from the FACT-G component, and additional 17-items regarding RC-related concerns (FACT-AC component) . As the next step, we prospectively performed the psychometric validation of Korean FACT-VCI to establish its reliability and validity in Korean populations.
Matrials and methods
This prospective study was approved by the institutional review board (IRB) of Seoul National
University Hospital (Approval No. H-1307-127-508), Seoul, Republic of Korea. All participants voluntarily agreed to participate in this study and signed a written informed consent form which was approved by our IRB. All personal information was anonymized before analysis.
Establishment of Korean version of FACT-VCI questionnaire
The original English version of the FACT-VCI consists of 27-items derived from the FACT-G
(FACT-G component), which is divided into physical (GP), social/family (GS), emotional
(GE), and functional well-being (GF) domains [
], in addition to 17-items regarding RC and
UD-related concerns (FACT-AC component) that are specifically related to urinary, bowel,
and sexual function [
]. We previously performed the translation and linguistic validation of
Korean FACT-VCI . Briefly, translation and linguistic validation were carried out according to permission for translation, forward translation, reconciliation, backward translation, cognitive debriefing, and final proof-reading .
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Population size was determined by referral to the previous proposed optimal subject-to-item
ratios for internal component validation, which were suggested as being between 5:1 and 10:1
]. Patients who underwent RC and UC at our institution from 1994 December to 2015
March were prospectively recruited at least one month before the evaluation. Evidence of disease
recurrence, illiteracy, history of psychical disorder, and withholding of consent to participate
were exclusion criteria. All patients were instructed to complete the Korean FACT-VCI survey
and the Korean version of the Short-Form 36-Item Health Survey (SF-36) version 2.0 on the first
visit (1st measurement) [
], and to complete the Korean FACT-VCI in one month later (2nd
measurement). Basic demographic and disease-related variable were also prospectively collected.
Test-retest reliability of the Korean FACT-VCI including 17-items of the FACT-AC
component were determined by intraclass correlation coefficients with 95% confidence intervals
(CIs), using samples of patients who completed the 1st and 2nd measurements. Cronbach's α
was estimated to assess whether the 17-items of the FACT-AC component had a value >0.70,
which is considered indicative of internal consistency, using samples of persons who
completed the 1st measurement [
]. A linear mixed model with a fixed measurement time and
urinary diversion type was utilized to confirm the absolute agreement between repeated tests of
the 17-items of the FACT-AC component.
Principal components analysis was performed to determine the internal compositional validity
of 16 gender-neutral items (item BL3, able to have erection, was excluded a male-only item) of
the FACT-AC component. The varimax criterion was adopted for analytic rotation in this
factor analysis [
]. Following a previous study [
] and recommendations [
], item loading
0.30 was considered as substantive in each component. External validity was confirmed by
criterion-related association between the Korean FACT-VCI including the 17-items of the
FACT-AC component and SF-36 version 2.0. Pearson's correlation coefficients with p-values
were estimated for that purpose [
]. All statistical analyses were performed using
commercially available software (SPSS1 version 21.0, Chicago, IL, United States).
Demographics and clinical data
The study included 108 patients who met the inclusion criteria and who completed the 1st
measurement (FACT-VCI and SF-36 questionnaires) at median of 7.3 months (interquartile
range [IQR], 1.4±35.4) postoperatively. Median age at time of surgery was 66.8 years (IQR,
58.1±71.9). Of the 108 patients, 95 (88.0%) were male, 52 (48.1%) underwent orthotopic
neobladder (ONB) and 56 (51.9%) received ileal conduit (IC) as UD. Among the recruited
subjects, 14 (13.0%) could not complete the 2nd measurement (repeated FACT-VCI).
SD, standard deviation; FACT-G, FACT-general; C, FACT-Colorectal; BL, FACT- -Bladder Cancer; ITU, Functional Assessment of Incontinence Therapy-Urinary
, the intraclass correlation coefficients with 95% confidence interval using samples of persons who completed 1st and 2nd measurement (N = 95), coefficient >0.6 is
considered as indicative of good agreement
, presented by Cronbach's α of whole items and if item deleted, utilizing samples of persons who completed 1st measurements (N = 108), α >0.7 is considered as
indicative of internal consistency
², item is reverse scored
consistency of 17-items of the FACT-AC component was assessed. Cronbach's α indicated
ªgoodº internal consistency at the level of 0.802 in the FACT-AC component, and ranged
0.776 to 0.818 if one item was deleted (Table 1). Results of linear mixed model for repeated
measurement of Korean FACT-VCI showed that main effects of measurement time (1st or
2nd) on AC component score were not significant (p = 0.589), while diversion type (ONB or
IC) had trace effects on the score but failed to reach significance (p = 0.095; Table 2). The
findings imply the absolute agreement between repeated tests of FACT-VCI.
Principal components analysis for internal compositional validity
Principal components analysis was performed to determine the internal compositional validity of 16 gender-neutral items of the FACT-AC component (Table 3). This model showed
PLOS ONE | https://doi.org/10.1371/journal.pone.0190570
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Mean FACT-AC component sum scores were presented, higher sum scores indicated better health-related quality of life.
Main effect for measurement time, (1st measurement vs. 2nd measurement, 37.53 vs. 38.18; p = 0.589); main effect for diversion type, (orthotophic neobladder vs.ileal
conduit, 37.64 vs. 38.68; p = 0.095); interaction between measurement time and diversion type, p = 0.320
Bartlett's test of sphericity (p <0.001) and Kaiser-Meyer-Olkin measure of sampling adequacy
(0.718), indicating the adequacy of the model for factor analysis. Three components accounted
for 49.3% of the total item covariance: ªvoiding problemsº, ªbowel problemsº,
ªsocial/functional problemsº. However, a single component solution accounted for only 27.6% of the total
item covariance. All items except for C3 (diarrhea), ITU1 (comfortable discussing with
friends), and BL4 (interest in sex) were substantial (varimax-rotated loading 0.3) with the
one component solution.
Criterion-related validity in relation to the SF-36
Criterion-related validities of Korean FACT-VCI domains were also performed in relation to
the SF-36 domain as follows: physical functioning (PF), role-functioning physical (RP), body
pain (BP), general health (GH), vitality (VT), social functioning (SF), role-functioning
emotional (RE), mental health (MH) domains, physical component summary (PCS), and mental
health component summary (MCS). All domains of the FACT-G and FACT-AC components
were significantly associated with related domains of the SF-36 (Pearson's correlation
coefficients range: 0.286±0.688; all p <0.01), except for associations between GS domain of the
FACT-G component and related SF-36 domains (p = 0.775 and 0.057, respectively) and the
FACT-AC component (p = 0.105; Table 4). Generally, the Korean FACT-VCI correlated well
with the SF-36.
Although some other tools for HRQOL assessment in bladder cancer have been developed,
such as the FACT-Bladder Cancer (FACT-BL) [
], European Organization for Research and
Treatment of Cancer (EORTC) QLQ-BLS, EORTC QLQ-BLM , or the Bladder Cancer
Index (BCI) , only the BCI has psychometric validation . The reliability and validity of original English version of FACT-VCI has been established [10,11].
Reliability of original and Korean FACT-VCI
The test-retest reliability of FACT-VCI was first assessed by Cookson et al. [
]. The intraclass
correlation coefficient of the AC component sum of the original FACT-VCI was 0.79, which
indicated acceptable test-retest reliability [
]. A more recent psychometric validation study
reported a higher correlation rate (ρ = 0.89; p <0.001) [
]. However, this higher rate may
have been caused by the use of a different statistical methodology for the test-retest reliability
assessment (Spearman correlation) [
]. Presently, we used similar methods as Cookson et al.
] and demonstrated similar results (intraclass correlation coefficient = 0.822; Table 1).
Therefore, the Korean FACT-VCI is concluded to have adequate test-retest reliability.
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Moreover, items of the FACT-G comportment also demonstrated `good' reliability (intraclass correlation coefficient = 0.803; Table 1).
For the evaluation of internal consistency of the included items, the prior two studies simi
larly estimated the Cronbach's α and reported similar values (0.85 and 0.854) [
study also adopted the same methodology, and showed a slightly lower but comparable rate of
0.802 (Table 1). Moreover, that rates were constant (0.776±0.818) if one item was deleted
(Table 1), in agreement with one of the prior studies . Therefore, we conclude that Korean
FACT-VCI also has internal consistency among each item of the questionnaire.
To test the absolute agreement between repeated tests of FACT-VCI, a linear mixed model
with the measurement time and urinary diversion type fixed was performed. The main effect
of measurement time on the FACT-AC component score was not significant (p = 0.589;
Table 2), which was consistent with the same finding by Cookson et al. that the main effect of
measurement time was not significant (p = 0.66) [
]. However, our results differed in two
points. First, the mean values of the AC component sum (37.5 and 38.2; Table 1) were slightly
lower than those reported by Cookson et al. (44.38 and 45.21) [
]. The discrepancy is likely
mainly due to the difference of patient characteristics. Our cohorts comprised of Asian
populations with a shorter post-operative period (median 7.3 months) than the prior cohorts (more
than one year) [
]. Second, our data showed trend toward better HRQOL in patients with IC
than in patients with ONB (AC component score, 38.76 vs. 36.74; p = 0.095; Table 2), while the
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Physical well-being domain (GP)
Social/family well-being domain
Emotional well-being domain
Functional well-being domain
PF, physical functioning domain; RP, role-functioning physical domain; BP, body pain domain; GH, general health domain; VT, vitality domain; SF, social functioning
domain; RE, role-functioning emotional domain; MH, mental health domain; PCS, physical component summary; MCS, mental health component summary; FACT-G,
FACT-General; FACT-AC, FACT-Additional Concerns for Radical Cystectomy;
², presented by Pearson's correlation, it is generally considered that association is negligible at 0±0.3, with low positive at 0.3±0.5, moderate positive at 0.5-.7, and high
positive at 0.7±1.0;
, p <0.01;
, p <0.05
previous study demonstrated a trend toward compromised HRQOL in the IC cohort,
compared with the ONB cohort (AC component score, 40.91 vs. 47.45; p = 0.08) [
Anderson et al.  and other researchers [26,27] reported similar results with us; patients
with IC had better HRQOL outcomes compared to patients with ONB. These interesting
findings that seemingly contradict common sense might be because of that some voiding
problemrelated items, such as BL1 (trouble controlling urine), ITU7 (condition wakes me up at night),
VC1 (satisfied with urinary condition), or ITU2 (afraid to go far from toilet), can exaggerate the deterioration of HRQOL in ONB cohorts. However, to confirm this suggestion, a larger prospective study is needed.
Validity of original and Korean FACT-VCI
Principal components analysis results provide some interesting information regarding this
questionnaire (Table 3). The three component model accumulatively accounted for 49.3% of
total item covariance, and the rate was comparable with accumulative accounting rates
(58.0%) of the three component models of Anderson et al. [
]. This prior model could not
confirm the representative criteria of each components, perhaps because the model was made
using patients in a preoperative setting [
]. However, our three components were ªvoiding
problemsº, ªbowel problemsº, and ªsocial/functional problemsº (Table 3). Moreover, these
components provided equivalent explanation powers to the total score (19.5%, 15.4%, and
14.4%, respectively; Table 3), and cumulative explanation of its three components (49.3%) was
higher than that of the single component model (27.6%). Therefore, we believe that the
internal compositional validity of the Korean FACT-VCI is adequate.
In the results of criterion-related validities, FACT-AC component scores showed good
associations with all domains of SF-36 and FACT-G component, except for the GS (social/
familial well-being) domain (p = 0.105). The GS domain was not also associated with SF (social
functioning) domain and MCS (mental health component summary) of SF-36 (p = 0.775 and
0.057, respectively; Table 4). Similar findings were previously observed in the original version
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of FACT-VCI, in which the FACT-AC component score was not associated with the GS
domain score of FACT-G component [
]. Thus, the dissociation between the GS domain and
other domains stem from inherent characteristics of GS domain items, rather than being due
to mistranslation. However, since other domains were well correlated with each other, it can
be concluded that the Korean FACT-VCI has external validity.
Our study has some limitations. First, a substantial portion of the recruited subjects (14 of 108
subjects, 13.0%) did not complete the 2nd measurement. To ensure proper statistical power, we
endeavored to include maximal numbers of patient with available data required for analysis
]. Second, because our subjects were predominantly male (95 of 108 subjects, 88.0%), we
could not conclude whether the Korean FACT-VCI is gender-neutral. Instead, we excluded
gender-dependent item (BL3, able to have erection) from some analyses (Table 3). Lastly, our
cohorts did not comprise other UD types, such as Kock or Indiana pouch procedure.
Therefore, it is still unclear whether the Korean FACT-VCI is applicable for those patients.
This prospective study confirms the reliability and validation of the Korean FACT-VCI. The
Korean FACT-VCI demonstrates comparable test-retest reliability, internal consistency, and internal and external validity compared to the original English version. This validated tool could be widely utilized in HRQOL studies of Korean patients with bladder cancer.
This study is supported by grant no 05-2013-0010 from Seoul National University Hospital
Research Fund. Yu Kyoung Lee, Ha Young Kim, Yu Jin Lee, and Se Ra Park assisted with the development of the Korean version of FACT-VCI.
Conceptualization: Myong Kim, Ja Hyeon Ku.
Data curation: Myong Kim, Ja Hyeon Ku.
Formal analysis: Myong Kim, Ja Hyeon Ku.
Funding acquisition: Myong Kim, Ja Hyeon Ku.
Investigation: Myong Kim, Seung-June Oh, Cheol Kwak, Hyeon Hoe Kim, Ja Hyeon Ku.
Methodology: Myong Kim, Seung-June Oh, Cheol Kwak, Hyeon Hoe Kim, Ja Hyeon Ku.
Project administration: Myong Kim, Ja Hyeon Ku.
Supervision: Hyeon Hoe Kim, Ja Hyeon Ku.
Validation: Seung-June Oh, Cheol Kwak.
Visualization: Myong Kim.
Writing ± original draft: Myong Kim, Ja Hyeon Ku.
Writing ± review & editing: Seung-June Oh, Cheol Kwak, Hyeon Hoe Kim.
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