Annals of Oncology 22: 723–729, 2011
Published online 17 August 2010
Evaluation of the SCA instrument for measuring patient
satisfaction with cancer care administered via paper or
via the Internet
N. Kamo1?, S. V. Dandapani1?, R. A. Miksad1,2,3*, M. J. Houlihan1,4, I. Kaplan1,5, M. Regan1,6,
T. K. Greenfield7& M. G. Sanda1,8
1Harvard Medical School, Boston;2Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston;3Department of
Radiology, Institute of Technology Assessment, Massachusetts General Hospital, Boston;4Division of Breast Surgery, Department of Surgery;5Department of
Radiation Oncology, Beth Israel Deaconess Medical Center, Boston;6Department of Biostatistics, Dana Farber Cancer Institute, Boston;7Alcohol Research Group,
Public Health Institute, Emeryville;8Division of Urology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, USA
Received 20 May 2010; accepted 23 June 2010
Background: Patients’ perspectives provide valuable information on quality of care. This study evaluates the
feasibility and validity of Internet administration of Service Satisfaction Scale for Cancer Care (SCA) to assess patient
satisfaction with outcome, practitioner manner/skill, information, and waiting/access.
Patients and methods: Primary data collected from November 2007 to April 2008. Patients receiving cancer care
within 1 year were recruited from oncology, surgery, and radiation clinics at a tertiary care hospital. An Internet-based
version of the 16-item SCA was developed. Participants were randomised to Internet SCA followed by paper SCA 2
weeks later or vice versa. Seven-point Likert scale responses were converted to a 0–100 scale (minimum–maximum
satisfaction). Response distribution, Cronbach’s alpha, and test–retest correlations were calculated.
Results: Among 122 consenting participants, 78 responded to initial SCA. Mean satisfaction scores for paper/
Internet were 91/90 (outcome), 95/94 (practitioner manner/skill), 89/90 (information), and 86/86 (waiting/access).
Response rate and item missingness were similar for Internet and paper. Except for practitioner manner/skill, test–
retest correlations were robust r = 0.77 (outcome), 0.74 (information), and 0.75 (waiting/access) (all P < 0.001).
Conclusions: Internet SCA administration is a feasible and a valid measurement of cancer care satisfaction for
a wide range of cancer diagnoses, treatment modalities, and clinic settings.
Key words: health care delivery, Internet survey, oncology, patient satisfaction
Despite advances in cancer detection and treatment, many
patients perceive deficiencies in cancer care quality [1–4],
defined as ‘the degree to which health services for individuals or
populations increase the likelihood of desired health outcomes’
[5, 6]. Although cancer care quality can be evaluated from
multiple perspectives (patient, provider, insurer, etc.), patients
have been proposed as the ultimate arbiter of care quality .
Patients’ perspectives on cancer care processes and outcomes
provide unique and valuable information about the quality of
care. However, cancer care quality assessments generally
depend on medical claims data or medical records abstraction
and do not directly assess the cancer care from the patient’s
The three components of health care satisfaction are
satisfaction with (i) structure (e.g. organisation, accessibility),
(ii) process (e.g. technical and interpersonal competence of the
provider), and (iii) outcome (e.g. satisfaction with overall
perceived maintenance of health) . However, most previous
assessments of cancer care patient satisfaction focus only on
health care structure and process [10–19].
We previously developed a novel instrument, the Service
Satisfaction Scale for Cancer Care (SCA), to evaluate all three
dimensions of patient satisfaction with cancer care (process,
structure, and outcome) and validated it in a sample of
urological cancer survivors and their spouse partners . The
SCA consists of 16 items and is derived from a factor-based
reduced form of the Services Satisfaction Scale (SSS-30) [21, 22].
The SSS-30 scale distributions show lower ceiling effects and less
skew than a competing satisfaction measure, the Client
Satisfaction Questionnaire-8 . Developed as a self-reported
paper instrument, the SCA evaluates patient satisfaction in four
care domains on a 7-point Likert scale: (i) outcome of cancer
care, (ii) care provider manner and skill, (iii) information
provided about care, and (iv) waiting time/access to care. In
*Correspondence to: Dr. R. A. Miksad, Division of Hematology/Oncology, Department of
Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston,
MA 02215, USA. Tel: +617-667-4827; Fax: +617-667-9919;
?Both authors contributed equally to this work.
ª The Author 2010. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.5), which permits
unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
a multicentre study of prostate cancer survivorship, the SCA
demonstrated that changes in quality of life were significantly
associated with patient (and partner) satisfaction with treatment
outcome . However, the SCA has not been assessed for
patients with nonurological cancers and with alternative modes
of survey administration. In the current study, we (i) assessed the
feasibility and performance of the SCA for a wide range of
cancers and (ii) determined the validity of an Internet-based
version of the SCA. Electronic surveys may facilitate efficient
data collection, improve the convenience of questionnaire
completion [13, 23], and increase item responses [23, 24].
patients and methods
study population and design
We developed an Internet-based version of the SCA using the exact wording
and scale of the validated paper version. A secure password-protected
Universal Resource Locator  was created to allow anonymous survey
access. Item responses were recorded via a ‘drop-down’ box, which
represented the 7-point Likert scale (from 1 to 7: completely satisfied, very
satisfied, somewhat satisfied, mixed, somewhat unsatisfied, very unsatisfied,
and completely unsatisfied) (Appendix 1). Responses were stored on a secure
Web server accessible only to the study staff. A four-digit subject identification
number was used to match paper and Internet survey responses.
With approval from the Beth Israel Deaconess Medical Center (BIDMC)
Institutional Review Board, potential participants were identified through
a review of online medical records of patients seen by 21 participating
providers in medical, surgical, gynaecological, and radiation oncology
clinics at BIDMC from November 2007 to April 2008. Providers could
decline participation on behalf of individual patients. To confirm eligibility,
a research assistant not affiliated with clinics nor involved in patient care
approached all consecutive potentially eligible participants for each clinic
date. Eligible patients were all English-speaking adults who had completed
at least one standard cancer therapy (surgery, chemotherapy, and/or
radiation therapy) within the past year for any cancer of any stage. The
exclusion criteria were no computer/Internet access outside of the clinic.
Active cancer treatment at the time of screening did not qualify as
a completed cancer treatment course but was not an exclusion criterion.
Of 254 potential participants approached, 155 met all eligibility criteria.
The eligibility status of 10 participants could not be determined and were
considered ineligible (Figure 1). After eligibility verification, potential
participants were provided a written informed consent form to review and
were invited to sign if they wished to participate.
Consenting participants were randomly assigned to one of two groups.
The ‘Internet First’ group was asked to complete the Internet-based survey
at home within 2 weeks of study enrolment and was given written
instructions to access the survey. Two weeks after completion of the
Internet-based survey, a self-administered paper survey was mailed to the
subject, with instructions to complete and return the survey by mail
Figure 1. Participant enrolment flowchart.
*One participant with mutually exclusive responses to all items on the paper and Internet surveys was considered noninformative and was excluded from all
Annals of Oncology
724 | Kamo et al. Volume 22|No. 3|March 2011
within 2 weeks. The ‘Paper First’ group was asked to complete the
self-administered paper survey at home within 2 weeks of study enrolment
and was given a paper copy of the survey. Upon receipt of the paper survey,
instructions for accessing the Internet-based survey at home were mailed to
the patient, with a request to complete the Internet-based survey within 2
weeks. Participants were provided a preaddressed and stamped envelope in
which to return the paper survey. Participants received a telephone
reminder call if the survey was not completed within 2 weeks, a time period
associated with higher response rates for health-related quality of life
(HRQoL) surveys .
measures and statistical analyses
Baseline demographics, cancer diagnosis, cancer stage, and treatment
modalities were compared between the two randomised groups. Individual
items responses were linearly converted from a 7-item Likert scale to a 0–
100 scale (higher scores representing higher satisfaction) for item analysis.
For domain analysis, Likert scale raw item scores were summed and
averaged to create a raw Likert domain score. The domain score was then
linearly converted to a 0–100 linear scale. All available responses were
included for item and domain scores except as noted.
The responses of all participants who completed at least one survey were
analysed in order to compare the paper and Internet survey responses and
to evaluate the internal consistency of each survey version. For each
satisfaction domain, only those participants answering >65% of items
within the domain were analysed. Participants who did not meet the
minimum response criteria for a domain were excluded from analysis for
that domain. The mean score and standard deviations for individual items
and for each satisfaction domain were calculated separately for (i) paper
surveys alone, (ii) Internet surveys alone, and (iii) all surveys. To evaluate
the presence of a ceiling effect in the SCA, the percentage of participants
scoring the maximum (100) on each item and domain was calculated. In
order to evaluate internal consistency, Cronbach’s alpha was calculated for
each domain using SAS version 9 (SAS Institute Inc., Cary, NC).
To assess the validity of the Internet-based SCA, we conducted test–retest
analysis for each satisfaction domain for all participants completing both
surveys. Intraclass correlation coefficients were calculated and statistical
significance was determined by confidence intervals using Fisher’s z
transformation. A P value of <0.05 was considered statistically significant.
Analyses were performed using SAS version 9 and SigmaPlot software
(Systat, San Jose, CA).
One participant with mutually exclusive responses to all items on the
paper and Internet surveys was considered noninformative and was
excluded from all analysis. In addition, we performed a graphical inspection
of the linear regression plots during the test–retest analysis in order to
identify participants whose responses changed drastically between the paper
and Internet surveys. A single participant identified with disparate
responses was included in the overall analysis but was excluded from the
exploratory test–retest correlation analysis.
Of 122 consenting participants, 78 (64%) completed the initial
survey. The mean age (59 years; range 30–80), sex, and race
(>90% Caucasian) were well balanced between the two
randomised groups (Table 1). Participants were diagnosed with
a wide range of cancer types (breast, lung, gastrointestinal,
genitourinary, gynaecological, haematological, and skin) and all
stages (localised, locally advanced, recurrent, and metastatic)
were represented. Although breast and lung cancers were the
most common diagnoses in both groups, cancer diagnoses were
fairly well balanced between the two groups. More than 50% of
participants in each group were undergoing chemotherapy at
the time of study participation.
satisfaction with cancer care
For completed paper and Internet surveys, mean scores for all
16 questions ranged from 82 to 96, on a scale from 1 to 100.
The highest mean domain score (paper, Internet) was manner/
skill (94, 95), followed by outcome (91, 90), information (89,
90), and waiting/access (86, 86) (Table 2). Each domain score
showed internal consistency (Cronbach’s alpha ‡0.80), except
the Internet survey provider manner/skill and waiting/access to
care domains (Cronbach’s alpha = 0.69 and 0.62, respectively).
For participants who completed both versions of the survey
instrument, test–retest analysis showed significant correlations
(r = 0.48–0.78; P < 0.05) in all four satisfaction domains.
Outcome, waiting/access, and information domains had similar
intraclass correlation levels when evaluated as a group and by
subgroup (r = 0.74–0.77) (Table 2). Ordering (Paper First
versus Internet First) did not significantly change these results.
The manner/skill domain for the Paper First group produced
the weakest correlation (r = 0.48; P < 0.05). Graphical
Table 1. Characteristics of participants who completed initial survey
(n = 77)
Demographic items Internet First
Mean age (standard deviation)
Surgery 6 radiation
Radiation and chemotherapy
34.2 (15)53.8 (21)
10.5 (4) 7.7 (3)
aOne participant with mutually exclusive responses to all items on the paper
and Internet surveys was considered noninformative and was excluded
from all analysis.
bGastrointestinal cancer: oesophageal, colon, pancreatic, rectal, and
cOther cancers: melanoma, thymoma, multiple myeloma, and endometria
Annals of Oncology
Volume 22|No. 3|March 2011doi:10.1093/annonc/mdq417 | 725
inspection of the correlation plots for the Paper First group
revealed one subject with a substantial change in response for
the manner/skill domain between the two surveys. Exploratory
analysis excluding this potential outlier improved the test–
retest correlation for this domain (Paper First, r = 0.81, 95%
confidence interval = 0.59–0.91 and combined, r = 0.72, 95%
confidence interval = 0.56–0.83).
Of 78 participants completing the first version of the survey,
54 (69%) completed the retest survey. The proportion of
participants who completed the retest was higher for those who
completed the Internet survey first than for those who
completed the paper survey first: 32 of 39 (82%) versus 22 of 39
(56%), respectively. The mean time between initial consent and
completion of the first survey was 16.7 days (Paper First = 21.5
days and Internet First = 11.9 days). The mean time between
completion of the first and second surveys was 26.4 days (Paper
First = 30.6 days and Internet First = 23.6 days) (Figure 2).
A ceiling effect was apparent for all four domains in both
surveys, but a floor effect was not present (Figure 2). The
percent of responses at the ceiling were lowest for ‘waiting time
at appointment’ (Question 6) for both Internet (23%) and
paper (33%) and highest for ‘protected rights of patient’
(Question 9) for both Internet (77.1%) and paper (69%). The
average percent of responses at the ceiling was similar in both
the Internet and the paper SCA: 56% and 55%, respectively.
The number of missing item responses in paper and Internet
surveys was similar and the majority of items had zero missing
responses (Table 2; item missingness range = 0–15% per item
and overall item missingness = 1% for paper and 1.2% for
Internet versions). The proportion of scorable subscales (less
than one missing subscale item i) was 97.2% (paper) and 100%
(Internet) for outcome, 100% (paper) and 100% (Internet) for
practitioner, 100% (paper) and 100% (Internet) for access, and
100% (paper) and 100% (Internet) for information subscales.
Table 2. Comparison of satisfaction with cancer care (SCA) administered on paper versus Internet
Short descriptionMean score
Paper InternetInternet InternetInternetBoth
Help to deal with cancer
Quality of care
Listening and responding
Availability of information
Explanations of treatments
Helpfulness of information
Lag time after appt request
Wait after arrival
Availability of appt time
Italicized numbers are domain results.
Both = Internet-based and paper SCA (n = 131); paper = paper SCA (n = 70); Internet = Internet-based SCA (n = 61); Appt = Appointment.
aSee Appendix for details of each satisfaction domain question.
bCorrelation of paper and Internet survey responses of participants who completed both surveys.
SCA, Service Satisfaction Scale for Cancer Care.
Figure 2. Comparison of paper (P) versus Internet (I) surveys (all
participants)—lower boundary of the box represents 25th percentile—line
within the box represents median—upper boundary of the box represents
75th percentile—whiskers above and below the box represent 90th and
10th percentiles, respectively—points represent outliers.
Annals of Oncology
726 | Kamo et al.Volume 22|No. 3|March 2011
The highest number of missing responses for a single question
was the same for both Internet and paper surveys (‘What is
your overall feeling about the effect of your cancer treatment in
preventing cancer progression and recurrence?’) (paper = seven
missing responses and Internet = nine missing responses)
(Table 2 and Figure 2).
Our study establishes the feasibility and validity of the SCA for
assessment of patient satisfaction with cancer care outcome,
process, and structure via paper- or Internet-based
administration. The four SCA satisfaction domains
demonstrated test–retest reliability, internal consistency, and
validity for the paper- and Internet-based version. These
findings support the use of the SCA version most appropriate
for the study population. To our knowledge, this study is the
first to validate an electronic instrument that comprehensively
measures satisfaction with cancer care outcome (in addition to
cancer care process and structure) for patients with a wide
range of tumour types and stages [10–12, 15–19, 27].
The validation results of our study are supported by a meta-
analysis demonstrating that electronic and paper
administration of patient reported outcome instruments yield
equivalent results [10, 28–31]. The only electronic evaluation of
satisfaction with cancer care (SEQUS for medical oncology
outpatients) only evaluates structure and process but not
outcome. The top concern identified by SEQUS  (patient
waiting times) was also determined to be an area of relative
dissatisfaction in our study. However, additional satisfaction
with outcomes data from our study places this result in context,
potentially informing resource allocation decisions that
optimally improve cancer care quality.
The results of our study must be considered in contexts of its
limitations. Due to loss of follow-up, 64% of consented patients
completed the initial survey and 44% completed both surveys.
However, this completion rate is consistent with other
evaluations of patient satisfaction with cancer care (50%–
100%) [10–12, 14, 16, 17].
The relatively small sample size and the single urban
academic institution study population did not permit subset
evaluation and may limit generalisability of to other settings.
However, the results of our study for a wide range of cancer
diagnoses are consistent with a larger paper SCA study of
patients with prostate cancer at multiple institutions across
the United States . Additionally, due to the test–retest study
design for the study hypothesis, patients who were unable to
use or access a computer with Internet were excluded. Our
results, therefore, may have demographic, socioeconomic,
and/or functional status biases. However, others have
demonstrated validity of electronic HRQoL surveys for a wide
range of patients with varying levels of computer literacy,
education, age, sex, and race [13, 28, 32]. In addition, the off-
site design was chosen to minimise positive bias associated
with on-site surveys . Finally, we designed this study to
closely mirror real-life situations of future quality
improvement or research situations without on-site
computer/Internet access and in-person assistance for
A ceiling effect was present for both versions of the survey, as
commonly seen in patient satisfaction surveys [34–36]. Ceiling
effects may reflect prior findings that survey responders have
more positive experiences than nonresponders  and may
obscure the true magnitude of satisfaction differences .
However, the majority of responses for all domains in both
surveys were less than the maximum score, indicating that the
survey instrument can discriminate the level of patient
On average, the Paper First group had a longer time interval
between initial consent and completion of the first survey and
between the completion of the first and second surveys than the
Internet First group. This difference may be due to the longer
mailing times required for returning the paper survey and
receiving Internet survey instructions and may account for the
higher attrition rate for the Paper First group. A previous study
found higher response rates among cancer patients who
received a satisfaction survey more quickly . Although the
completion time interval difference may have affected survey
values, the presence of robust test–retest correlations suggests
minimal effect on validity testing.
To assess for potential response bias, we performed
exploratory chart reviews of patients with missing responses for
the question with the highest number of missing responses (n =
13): ‘What is your overall feeling about the effect of your cancer
treatment in preventing cancer progression and recurrence?’
Participants with missing responses tended to be undergoing
active cancer treatment (n = 7), have metastatic or recurrent
cancer (n = 7), and/or symptoms secondary to cancer or cancer
treatment complications (n = 5). These may be situations in
which nonresponders felt uncertain about their prognosis.
As a validation study, this study did not assess patient
preferences for survey version nor the impact of the Internet-
based instrument on practice patterns. Several studies
demonstrate that electronic collection of patient reported data
facilitates real-time feedback of survey results to clinicians and
may confer several advantages [29, 34, 38, 39]: (i) increased
clinician inquiries about HRQoL issues [34, 38], (ii) improved
clinician-perceived communication with patients , and (iii)
increased clinician-perceived tracking of HRQoL changes over
Patient satisfaction may vary due to factors beyond the
current care provider’s control, including the limitations of
current cancer treatments [27, 36, 40–43]. Further study is also
needed on how patient satisfaction data affects the patient–
provider relationship, particularly in cancer care where both the
provider and the patient may be disappointed with the
effectiveness of current therapies. Currently, some health payers
provide financial incentives for cancer care quality
improvement based on patient satisfaction data .
Assessment of satisfaction with outcome, such as provided by
the SCA, may highlight important gaps in quality, including
those due to socioeconomic disparities . However, the effect
of these financial incentives on patient outcome is unknown.
Cancer care quality assessment instruments that assess
satisfaction with outcome may be important to answer these
questions and generate new hypotheses.
In conclusion, our study demonstrates that the paper and
Internet-based versions of the SCA provide valid measures of
Annals of Oncology
Volume 22|No. 3|March 2011doi:10.1093/annonc/mdq417 | 727
patient satisfaction in multiple domains of cancer care,
including treatment outcome, and may be useful for evaluating
cancer care quality for a variety of cancer diagnoses, clinical
settings, and treatment modalities. Multiple options for patient
satisfaction survey completion (self-completion with a paper or
Internet version at home or in the clinic, in-person completion,
or over the telephone) may enhance patient response rates and
diversity. The SCA may help improve cancer care quality by
placing other metrics of patient satisfaction in context with
cancer treatment outcome.
National Institutes of Health (R01 CA95662) to MS and
Program in Cancer Outcomes Research Training (5R25CA
092203-04) to RM and the Department of Medicine, BIDMC,
and the Clinical Investigator Training Program:
BIDMC—Harvard/MIT Health Sciences and Technology, in
collaboration with Pfizer Inc. and Merck & Co to RM.
Funding sources had no role in study design, data collection,
data analysis, data interpretation, writing of this manuscript, or
the decision to submit for publication. We would like to thank
the patients at BIDMC and the participating clinicians (in
alphabetical order): Mary Buss, Mark Callery, Steven Come,
Daniel Costa, Malcolm DeCamp, Sidharta Ganghadharan,
Michael Goldstein, Sanjay Jain, Michael Kent, Tara Kent,
Young B. Kim, Corrine Zarwan, Anand Mahadevan, David
McDermott, Deborah Nagle, Elena Nedea, Lowell Schnipper,
Susan Schumer, Nadine Tung, and Andrew Wagner. In
addition, we gratefully acknowledge study support provided by
Gerardina Bueti, Kuan-Chi Lai and Jodi Mechaber.
The authors declare no conflict of interest.
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appendix 1. SCA survey questions
What is your overall feeling about the .
1. Effect of health care services in helping you deal with your cancer
and maintain your well being?
Professional knowledge and competence of your main cancer
Ability of your main cancer practitioner(s) to listen and respond to
your concerns or problems?
Personal manner of the main cancer practitioner(s) seen?
Waiting time between asking to be seen or treated and the
Waiting time when you come for an appointment?
Availability of appointment times that fit your schedule?
Effect of cancer treatment in preventing cancer progression or
How well your confidentiality and rights as an individual have been
Quality of cancer care you have received?
Availability of information on how to get the most out of the
cancer care and related services?
Explanations of specific procedures and treatment approaches
Effect of services in helping relieve symptoms of reduce
Thoroughness of the main cancer practitioner(s) you have
Helpfulness of the information provided about your cancer and its
In an overall general sense, how satisfied are you with the cancer
treatment you have received?
Annals of Oncology
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