# HADS-Anxiety: item-level investigation of the lack of longitudinal measurement invariance in melanoma and breast cancer patients

Yseulys Dubuy, Myriam Blanchin, Marianne Bourdon, Bastien Perrot, Véronique Sébille

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Yseulys Dubuy, Myriam Blanchin, Marianne Bourdon, Bastien Perrot, Véronique Sébille. HADS-Anxiety: item-level investigation of the lack of longitudinal measurement invariance in melanoma and breast cancer patients. The 10th European Congress of Methodology (EAM2023), 2023, Ghent, Belgium. hal-04769443

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Submitted on 6 Nov 2024

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Distributed under a Creative Commons Attribution 4.0 International License
# HADS-Anxiety: item-level investigation of the lack of longitudinal measurement invariance in melanoma and breast cancer patients

Yseulys Dubuy¹, Myriam Blanchin¹, Marianne Bourdon¹,², Bastien Perrot¹, Véronique Sébille¹

¹ UMR INSERM 1246 SPHERE "methodS in Patient-Centered Outcomes and Health ResEarch", Nantes University, University of Tours, Nantes, France
² Integrated Center for Oncology, Nantes, France

## Background

### Lack of longitudinal measurement invariance?

Longitudinal self-reported questionnaire data can be **challenging to analyze and interpret**. Indeed, patients may give different answers to a questionnaire over time, not only because their level of the target construct (e.g., anxiety) has changed but also because their interpretation of the items aiming at measuring the construct has changed.

What we observe

<figure><img src="image_2.png" /></figure>

≠

<figure><img src="image_3.png" /></figure>

What we aimed to measure

Initiation of cancer treatments may rapidly trigger changes in the patients' internal standard of measurement (i.e., **recalibration response shift**), resulting in a lack of measurement invariance over time. Those changes may also differ according to the cancer site.

### Why does it matter?

This phenomenon is crucial to investigate as it can help to better understand psychological changes after a cancer diagnosis and to make unbiased comparisons.

**Aim:** To investigate the lack of longitudinal measurement invariance within the items of the anxiety subscale of the HADS (Hospital Anxiety and depression scale) among breast cancer and melanoma patients during the 6 months following cancer diagnosis.

## Materials & Methods

### Participants and data

- Data from the French cohort ELCCA (NCT02893774)

- 337 breast cancer and 110 melanoma patients

- Patients completed HADS [1] several times after their cancer diagnosis:

<figure><img src="image_4.png" /></figure>

### Statistical analysis

- Lack of longitudinal measurement invariance among the items of the anxiety subscale was investigated using the **ROSALI algorithm** [2,3] which is based on Rasch family models.

- ROSALI is an iterative item-by-item procedure dedicated to the detection of **recalibration at the item level**. For each item, ROSALI determines whether the item is affected by recalibration, that is: whether its thresholds change over time.

- Besides, if two patient groups are considered, ROSALI determines whether recalibration is similar in both groups or differential.

## Results

- Recalibration between $M_1$ and $M_6$ was assumed to occur on item 3: 'I get a sort of frightened feeling as if something awful is about to happen'. Indeed, shifts over time within this item thresholds were evidenced (identical shifts for all thresholds: +0.55, se = 0.12).

- This recalibration was similar for the two cancer sites:

<figure><img src="image_5.png" /><figcaption>item 3: 'I get a [...] frightened feeling as if something awful is about to happen'</figcaption></figure>

$\theta$: Level of anxiety (the lower the better)

For a given level of anxiety (e.g, $\theta = 0$), melanoma and breast cancer patients tended to give a more favorable response to item 3 at $M_6$ than at $M_1$

→ Wrongly presuming longitudinal measurement invariance (MI) would have resulted in overestimating the decrease of anxiety over time among patients:

<figure><img src="image_6.png" /><figcaption>Change over time in anxiety among breast cancer and melanoma patients</figcaption></figure>

Time since diagnosis (months)

## Conclusion

Investigating recalibration in patient-reported outcome measures is crucial to:

- better interpret patients' responses to items

- understand the psychological changes patients experience during the treatment period.

## References, acknowledgements, funding

**References:**
[1] Zigmond & Snaith (1983) in Acta psychiatrica Scandinavica
[2] Hammas et al. (2020) in Frontiers in Psychology
[3] Blanchin et al. (2022) in Methods

**Acknowledgements:** the authors sincerely thank the Integrated Center for Oncology for this collaboration

**Funding:** ELCCA was financially supported by the "Ligue Nationale contre le Cancer" and the "Institut pour la Recherche en Santé Publique"
**Title**

HADS-Anxiety: Investigation of the scale longitudinal measurement invariance in melanoma and breast cancer patients

**Author(s)**

Yseulys Dubuy, Myriam Blanchin, Véronique Sébille

Nantes Université, Université de Tours, INSERM, MethodS in Patient-centered outcomes and Health Research, SPHERE, Nantes, France

**Abstract**

**Background:** Patient-reported outcome measures (PROM) data are challenging to analyze and interpret in longitudinal settings. Indeed, patients may give different answers to a ques tionnaire over time, not only because their level of the target construct has changed but also because their interpretation of the items aiming at measuring the construct has changed. For instance, cancer treatment may trigger changes in the patients’ internal standard of measure ment (i.e., recalibration), resulting in a lack of measurement invariance over time. In addition, those changes can differ according to the cancer site. This phenomenon is crucial to investigate as it can help to better understand psychological changes after a cancer diagnosis and to make unbiased comparisons.

**Methods:** We aimed to investigate longitudinal measurement invariance of the HADS-A (a scale measuring anxiety disorders) in breast cancer and melanoma patients over the year following the cancer diagnosis (ELCCA cohort NCT02893774 comprising 337 breast cancer and 110 melanoma patients). Lack of measurement invariance among the items of the HADS A was investigated using the ROSALI algorithm (a method based on Rasch Measurement Theory to detect recalibration at the item level).

**Results:** Recalibration was found for one item: ‘I get a (...) frightened feeling as if something awful is about to happen’; despite equal levels of anxiety disorder over time, melanoma and breast cancer patients were less likely to endorse the item one year post-diagnosis than in the month following diagnosis.

**Discussion:** Investigating recalibration in PROMs is crucial to better understand the psycho logical changes that patients experiment throughout treatments.