10.5826/dpc.1301a1
Introduction: Skin cancer is the third most common type of cancer worldwide that has increased in incidence. Quality of life (QoL) instruments have been developed to measure the efficacy of treatments of &nbsp;cancers.
Objectives: The only validated tool that can be used in both nonmetastatic skin cancer types is the SCQOLIT. This study aimed to validate the Turkish version of the Skin Cancer Quality of Life Impact Tool (SCQOLIT).&nbsp;&nbsp;
Methods: A total of 141 patients diagnosed and treated for skin cancer within the previous 3 months were included.&nbsp; The tool was translated into Turkish in accordance with International Translation Guidelines. The Dermatology Quality of Life Index that was used for external validation. Patient demographics were recorded.
Results: Question 3 had a factor load of 0.372, indicating the inadequacy of this question in predicting QoL, a point that the original study did not mention. The SCQOLIT had external validity, convergent validity and internal consistency (Cronbach alpha=0.863), and test-repeat-test correlation coefficient was 0.824 (95% confidence interval; 0.644 – 0.918). Patients diagnosed with melanoma had poorer QoL scores. High-risk tumor characteristics in nonmelanoma skin cancer and stage of melanoma had no impact on QoL (p=0.235 for basal cell carcinoma, p=1.00 for squamous cell carcinoma, p=0.635 for melanoma).&nbsp;
Conclusions: The Turkish version of the SCQOLIT is validated. Age was shown to have a statistically significant negative correlation with QoL, while Fitzpatrick skin type, gender, risk classification, stage, history of skin cancer, family history of skin cancer and treatment modality had no effect on QoL.&nbsp;
text/xml
2160-9381
2090
en
Serdal Kenan Kose
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
squamous cell carcinoma
Validation of the Turkish Version of the Skin Cancer Quality of Life Impact Tool (SCQOLIT): A Health Related Quality Of Life Questionnaire for Non-Metastatic Melanoma and Non-Melanoma Skin Cancer
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2023-01-31
2021-10-07
2023-01-31
2023-02-27
e2023001
Dermatol Pract Concept
Introduction: Skin cancer is the third most common type of cancer worldwide that has increased in incidence. Quality of life (QoL) instruments have been developed to measure the efficacy of treatments of &nbsp;cancers.
Objectives: The only validated tool that can be used in both nonmetastatic skin cancer types is the SCQOLIT. This study aimed to validate the Turkish version of the Skin Cancer Quality of Life Impact Tool (SCQOLIT).&nbsp;&nbsp;
Methods: A total of 141 patients diagnosed and treated for skin cancer within the previous 3 months were included.&nbsp; The tool was translated into Turkish in accordance with International Translation Guidelines. The Dermatology Quality of Life Index that was used for external validation. Patient demographics were recorded.
Results: Question 3 had a factor load of 0.372, indicating the inadequacy of this question in predicting QoL, a point that the original study did not mention. The SCQOLIT had external validity, convergent validity and internal consistency (Cronbach alpha=0.863), and test-repeat-test correlation coefficient was 0.824 (95% confidence interval; 0.644 – 0.918). Patients diagnosed with melanoma had poorer QoL scores. High-risk tumor characteristics in nonmelanoma skin cancer and stage of melanoma had no impact on QoL (p=0.235 for basal cell carcinoma, p=1.00 for squamous cell carcinoma, p=0.635 for melanoma).&nbsp;
Conclusions: The Turkish version of the SCQOLIT is validated. Age was shown to have a statistically significant negative correlation with QoL, while Fitzpatrick skin type, gender, risk classification, stage, history of skin cancer, family history of skin cancer and treatment modality had no effect on QoL.&nbsp;
Serdal Kenan Kose
2023/01/31
10.5826/dpc.1301a1
e2023001
Ankara University Faculty of Medicine, Department of Biostatistics
2160-9381
squamous cell carcinoma
en
e2023001
Validation of the Turkish Version of the Skin Cancer Quality of Life Impact Tool (SCQOLIT): A Health Related Quality Of Life Questionnaire for Non-Metastatic Melanoma and Non-Melanoma Skin Cancer
https://dpcj.org/index.php/dpc/article/download/2090/1904
     Validation of the Turkish Version of the Skin
    Cancer Quality of Life Impact Tool (SCQOLIT):
  A Health-Related Quality of Life Questionnaire for
   Non-metastatic Melanoma and Non-melanoma
                     Skin Cancer
                  Hilayda Karakok1, Seher Bostanci2, Bengu Nisa Akay2, Deniz Calıskan3,
                                        Can Ateş4, Kenan Köse5


1 Sifa Okulu, Private Practice Office of Dermatology and Venereology, Ataturk Bulvarı, Tasbası Mahallesi, Altınordu - Ordu, Turkey
2 Department of Dermatology and Venereology, Ankara University School of Medicine, Turkey
3 Department of Public Health, Ankara University School of Medicine, Turkey
4 Department of Biostatistics, Van Yüzüncü Yıl University, School of Medicine
5 Department of Biostatistics, Ankara University School of Medicine, Turkey



Key words: skin cancer, skin cancer related quality of life, melanoma, non-melanoma skin cancer
Citation: Karakok H, Bostanci S, Akay BN, Calıskan D, Ateş C, Köse K. Validation of the Turkish Version of the Skin Cancer Quality of
Life Impact Tool (SCQOLIT): A Health Related Quality Of Life Questionnaire for Non-Metastatic Melanoma and Non-Melanoma Skin
Cancer. Dermatol Pract Concept. 2023;13(1):e2023001. DOI: https://doi.org/10.5826/dpc.1301a1
Accepted: April 24, 2022; Published: January 2023
Copyright: ©2023 Karakok et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Hilayda Karakok, Sifa Okulu, Private Practice Office of Dermatology and Venereology by
Dr. Hilayda Karakok, Kosk Apt, no:84/A, Ataturk Bulvarı, Tasbası Mahallesi, Altınordu - Ordu, Turkey. Telephone number: 0090 0452
225 00 25 E-mail address: hk@hilaydakarakok.com




Introduction                                                             validated for non-metastatic skin cancers, the Skin Cancer
                                                                         Quality of Life Impact Tool (SCQOLIT) [9].
Quality of life instruments (QoL) have been developed                         Numerous tools have been developed to measure QoL.
to measure the efficacy of treatments in chronic illnesses               Important characteristics of the tools are validity, reliabil-
and cancers [1]. Skin cancers, including melanoma and                    ity, interpretability, structure (using factor analysis or item
non-melanoma (NMSC), are the third most common                           response theory), responsiveness, interpretability, brief re-
type of cancer worldwide and have been increasing in                     sponse burden and an acceptable administrative burden [10].
­incidence [2].                                                               While both generic and specific tools are used to measure
    There have been plenty of investigations on the QoL                  QoL in various types of chronic diseases, specific tools give
of patients with skin cancers and several instruments were               more accurate information and may detect aspects not iden-
developed [3-8]. There is only one instrument which was                  tified with generic tools [11].


Research Letter | Dermatol Pract Concept. 2023;13(1):e2023001                                                                           1
    There are two validated disease-specific QoL instru-                   The SCQOLIT was originally developed by Burdon-Jones
ments for melanoma. The EORTC-MM was developed for                     et al to measure the QoL of patients with non-metastatic skin
metastatic melanoma. FACT-MM can assess all the stages                 cancers. The permission for the translation and validation of
of melanoma. Patients diagnosed with melanoma had lower                the tool was granted by Burdon-Jones. The tool was trans-
emotional well-being on FACT-MM scale than normal pop-                 lated into Turkish by 2 specialists in the Department of Der-
ulation [12].                                                          matology and by a scientist of Foreign Languages Department
    There are several instruments developed for the assess-            in accordance with international translation guidelines. Three
ment of QoL of patients with NMSC. The questionnaire de-               documents were created. One by the 2 specialists of Dermatol-
veloped by Esser et al, was made to assess the health status           ogy. The other two by independent translators who translated
of patients with basal cell carcinoma (BCC) before a surgical          it back to English. The text was evaluated by a scientific team
procedure. It is not clear whether this tool may be used to            including a foreign linguist and a specialists of Dermatology.
evaluate QoL and the reliability of the tool has not been in-              A total of 141 patients who had been diagnosed and
vestigated [13]. SCQoL was developed from a questionnaire              treated for skin cancer within the previous 3 months were
originally developed to evaluate the QoL in patients with ac-          included in this study. Patients younger than 18 years and
tinic keratosis. Only the term ‘sun damage’ has been changed           patients with impaired cognitive functions and illiterate
as ‘skin cancer’ for this tool. It is not clear if this tool is able   ­patients were excluded from the study.
to measure all the aspects affected by skin cancer [14].                   Confirmatory factor analysis was used for the internal
    Facial Skin Cancer Index was developed for NMSC                    validation of the SCOQLIT. Comparative compliance statis-
located on the head and neck region. The validity and re-              tics (Comparative Fit Index [CFI], Tucker-Lewis Index [TLI],
liability are well established, the instrument is designed to          Root Mean Square Error of Approximation [RMSoA]) were
measure the dimensions affected by NMSC. On the other                  used to evaluate the efficacy of the model which was pro-
hand, it cannot be used for NMSC located anywhere but the              duced as a result of the confirmatory factor analysis.
head and neck region [5].                                                  The Dermatology Quality of Life Index (DLQI) was
    A specific QoL tool BasQol was developed by                        translated into Turkish and has been used in various stud-
Waalboer-Spuijr et al. face, content and construct val-                ies since. The DLQI was used for external validation of the
idation, reliability and internal consistency of BasQol was            ­SCQOLIT. The hypothesis to be tested was whether DLQI
proven. The validation of the English version of BasQol is             and SCQOLIT had same directional correlations.
currently being searched. The tool is designed for BCC and                 The SCQOLIT was tested to discriminate melanoma and
­squamous-cell carcinoma (SCC) [15].                                   NMSC to evaluate the convergent validity.
    The only validated tool which is used in non-metastatic                The internal consistency was assessed by using Cronbach
skin cancer types is the SCQOLIT. The SCQOLIT was shown                alpha and intraclass correlation coefficient (ICC) in terms of
to have construct and external validation, reliability, internal       reliability (defined by test-retest method).
consistency and responsiveness [9]. Wali et al also showed                 Demographic characteristics of the patients and tumor
feasibility of this tool in dermatology skin cancer clinics for        characteristics were recorded to investigate their impact on
patients with NMSC [16].                                               QoL. Mplus trial version and SPSS 20.0 programs were used
                                                                       for statistical analyses.

Objectives                                                                 For BCC, size and location of the tumor, primary or re-
                                                                       current origin, histopathological subtype, presence or lack
The objective of this study is to validate the Turkish version of      of perineural invasion, history of radiotherapy at the site of
the Skin Cancer Quality of Life Impact Tool (­ SCQOLIT) [9]).          the tumor and immunological status of the patient were re-
    The translation and validation of the Turkish version of           corded to assess risk analysis. For SCC, size and location
the SCQOLIT provides a tool that can be used to measure                of the tumor, primary or recurrent origin, histopathological
QoL of NMSC in Turkish populations. The current study                  features (differentiation, tumor thickness, presence of peri-
aims to investigate internal validation, construct validation,         neural, lymphatic or vessel invasion), immunological status
external validation and convergent validity, reliability and           of the patient, history of radiotherapy and the presence of a
internal consistency of the Turkish version of the tool.               chronic inflammation or a scar at the site of the tumor were
                                                                       recorded to assess the risk analysis. High risk tumor features

Methods                                                                were classified in accordance with NCCN guidelines [17].
                                                                       Melanoma risk analysis was conducted in accordance with
The study was carried out at Ankara University School of               the NCCN guidelines [18]. Breslow thickness, Clark level,
Medicine, Department of Dermatology and Venereology                    ulceration, presence of regression, and mitosis rate were
­between December 2015 and September 2016.                             ­recorded to define the stage of the melanoma.



2                                                                          Research Letter | Dermatol Pract Concept. 2023;13(1):e2023001
   The Ethics Committee Approval was granted (10-439-16)            with BCC, 11 of the patients with SCC and 24 of the patients
All the participants gave written informed consent.                 with melanoma were females (Table 1).
                                                                       Patients data, number of nevi, personal and family his-

Results                                                             tory of skin cancer, Fitzpatrick skin type and treatment
                                                                    ­modality are shown in Table 2.
   The mean ages were 63.75 ± 12.07, 66.53 ± 13.55, 49.24              Thirty-eight BCC (N = 65) and 10 SCC (N = 30) had high
± 16.67 in patients with BCC (N = 65), SCC (N = 30) and             risk features. Forty melanoma patients were found to be at the
melanoma (N = 46), respectively. Twenty-nine of the patients        first stage and 6 of them were at the second stage (Table 1).



       Table 1. Age, gender, risk classification of non-melanoma skin cancer and stage of melanoma
                                                                                      Risk classification of non-melanoma
                                                           Gender                                   skin cancer:
                           Mean age              Female             Male                  High risk              Low risk
 BCC (n=65)               63.75 ±12.07              29                36                     38                      27
 SCC (n=30)               66.53±13.55               11                19                     10                      20
                                                                                                  Melanoma stage:
                                                                                           Stage 1                Stage 2
 M (n=46)                 49.24 ±16.67              24                22                     40                          6



                                 Table 2. Sociodemographic features of the patients
                                              Number of         Median score of the SCOQLIT               Mean score of the
                                               patients                 (min-max)                          SCOQLIT ± SD
 Age
   ≤65                                             83                        11 (0-28)                       12.25 ± 7.038
   > 65                                            53                         6 (0-28)                       7.81 ± 6.864
 Gender
   Female                                          64                        11 (0-28)                     11.59 ± 7.648 SS
   Male                                            77                         9 (0-28)                       9.65 ± 7.045
 Number of nevi
   <100                                           125                         9 (0-28)                       10.41 ± 7.42
   >100                                            16                        10 (3-28)                       11.50 ± 7.04
 History of skin cancer
   Positive                                       108                        12 (0-27)                       12.36 ± 7.61
   Negative                                        33                         9 (0-28)                        9.97 ± 7.22
 Family history of skin cancer
   Positive                                        23                       12.5 (0-27)                      11.81 ± 8.07
   Negative                                       119                         9 (0-28)                        10.52 ±7.59
 Fitzpatrick skin type
   Type 1                                            1                           17                                 17
   Type 2                                          53                        9 (0 - 28)                       10.51 ± 7.1
   Type 3                                          74                        9 (0 - 28)                      10.04 ± 7.49
   Type 4                                          13                        10 (5-28)                       12.92 ± 7.79
 Treatment modality
   İmiquimod                                         1                           1                                  1
   Cryotherapy                                       1                           28                                 28
   İmiquimod + excision                              1                           7                                  7
   Primary excision                                89                         9 (0-27)                       10.44 ± 7.49

                                                                                                                  Table 2 continues



Research Letter | Dermatol Pract Concept. 2023;13(1):e2023001                                                                       3
                         Table 2. Sociodemographic features of the patients. (continued)
                                              Number of           Median score of the SCOQLIT             Mean score of the
                                               patients                   (min-max)                        SCOQLIT ± SD
  Excision+ sentinell ymph node                  16                         12 (0-28)                        12.56 ± 6.59
   dissection
    Excision+ flap or graft procedure             27                            9 (0-28)                      9.26 ± 6.74
    Amputation                                     1                               7                                7
    Radiotherapy                                   2                         16 (15-17)                        16 ± 1.41
    Vismodegib                                     3                            9 (0-21)                       10 ± 10.53



    Table 3. Mean and median total score of the SCQOLIT in patients with melanoma and NMSC
                                     Median score of the SCOQLIT                                      Mean
                                             (min-max)                                     score of the SCOQLIT ± SD
 Melanoma                                     11 (2-28)                                           11.96 ± 5.94
 NMSC                                          9 (0-28                                             9.84 ± 7.885



             Table 4. Total Score of the SCQOLIT of patients under and above the age of 65
                                               Median score of the SCOQLIT
    Age          Number of patients                    (min-max)                           Mean score of the SCOQLIT ± SD
 ≤65                       83                             11 (0-28)                                 12.25 ± 7.038
 ≥65                       53                               6 (0-28)                                 7.81 ± 6.864


    The SCQOLIT was shown to have one dimensional                      The relationship between age and QoL was found to have
structure in the original study. In the current study, the         a statistically significant negative correlation (r = -0.333,
question items of the Turkish version of the SCQOLIT               P < 0.001). Patients under the age of 65 had poorer QoL
were assessed with confirmatory factor analysis to demon-          (Table 4).
strate tools one-dimensional structure. The compliance to              There was no statistically significant relation with gender
the model was found to be efficient (CFI:0.952, TLI:0.938,         and QoL (P = 0.101). Personal and family history of skin can-
­RMSEoA:0.102). Most of the question items had a factor            cer had no effect on QoL (P = 0.099, P = 0.132 ­respectively).
load greater than 0.4 except for question 3 with a factor load     There was neither statistically significant relation between
of 0.372, indicating the inadequacy of this question in pre-       Fitzpatrick skin type, the number of Nevus and QoL (P = 0.589,
dicting QoL, a point that the original study did not mention.      P = 0.536).
Internal validity of the Turkish version of the SCQOLIT was            Furthermore, high-risk tumor characteristics in non-­
excellent (Cronbach alpha = 0.863). Test-re-test correlation       melanoma skin cancer and stage of melanoma had no impact
coefficient was found as high as 0.824 (%95 confidence in-         on QoL (P = 0.235 for BCC, P = 1.00 for SCC, P = 0.635 for
terval 0.644 – 0.918).                                             melanoma).
    The scores for SCQOLIT and DQLI were both statisti-
cally significant with same directional correlations, confirm-
                                                                   Conclusions
ing external validity of the tool.
    To test the convergent validity of the SCQOLIT, the t­ otal        In the current study, the Turkish version of the tool was
score of the patients with melanoma and non-melanoma               shown to have internal validation, construct validation,
skin cancer was compared. Total score of the SCQOLIT in            ­external validation and convergent validity, reliability and
patients with melanoma was statistically significantly higher      internal consistency. The factor load of question 3 was lower
than NMSCs indicating the tool ability to discriminate these       than 0.4 indicating the inadequacy of this term in predicting
2skin cancer types (P = 0.024) (Table 3).                          QOL. This was not investigated in the original study.
    The administrative and response burden of the tool was             SCQOLIT is a well-established tool in terms of inter-
found to be quite low as it took 2.5 to 4 minutes to respond       nal validation, construct validation, external validation
to all the questions and the recording process of the data         and convergent validity, reliability, internal consistency and
was easy.                                                          ­feasibility [9,16].



4                                                                      Research Letter | Dermatol Pract Concept. 2023;13(1):e2023001
   The mean scores of SCQOLIT of the patients with mel-          can be used to measure QoL of non-metastatic skin cancers
anoma were similar in both the current and the original          in Turkish- speaking populations. This tool can be used to
study. On the other hand, the mean scores (mean = 9, range       investigate QoL and many parameters mentioned above in
0-28) of the SCQOLIT of patients with NMSC in the current        further studies.
study was higher than those in the original study (mean = 4,
range 0-19)].
   The percentage of patients with SCC in the present            References
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