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SECTION 2: Mini-Mental Adjustment to Cancer Scale [MiniMAC]

Test Development
The Mini-MAC was developed in order to include an assessment of avoidant coping and to further examine the structure of the original measure. A total of 573 patients were included in the analysis of the Mini-MAC. A new Cognitive Avoidance sub-scale resulted for this analysis. A new 29-item questionnaire was developed from this analysis; 16 of the original MAC items were retained and the original response dimensions were reproduced in this analysis. Cognitive Avoidance is evaluated by four items:

1. 2. 3. 4.

I make a positive effort not to think about my illness [0.78] Not thinking about it helps me cope [0.76] I deliberately push all thoughts of cancer out of my mind [0.65] I distract myself when thoughts about my illness come into my head [0.53]

Eigenvalues in paretheses; alpha coefficient = 0.74 For further details see Watson et al (1994) The Mini-MAC: Further development of the Mental Adjustment to Cancer Scale. J. Psychosoc.Onc. 12, 33-46

Calculation of cut-off points for the Mini-MAC Scale The dataset which had been originally used to develop the Mini-MAC scale [n=573] was employed to calculate cut-off points for each of the five subscales. Ideally two datasets would be used for this task: a test dataset on which to establish the cut-offs and an independent validation dataset on which to check them. The latter was not available and hence the available dataset was split randomly in half to obtain two best possible test/validation datasets. A number between 0 and 1 was randomly assigned to each patient and the dataset was split roughly in half according to whether the number assigned was <0.52 or 0.52. The first half of the dataset [n=288] was used to establish the best normalising transformations on which to determine the cut-off points for each subscale. These were then validated using the second half of the dataset [n=285]. If a single response to a question within a subscale was missing an adjusted subscale total was calculated using the formula Ti=(RixNi)/Fi [see page 10 of the Mac users manual], where Ni=Number of questions in the ith dimension, Fi =Number of questions completed in the ith dimension, Ri=Score obtained in the ith dimension and Ti=Total score for the ith dimension. If more than one question within a subscale had a missing response the questionnaire was considered spoilt for that subscale only and the existing responses were not used. This occurred in two patients on the helplessness/hopelessness [HH] scale, five on anxious preoccupation [AP], one on fighting spirit ([S] two on cognitive avoidance [A] and one on fatalism [F].

For three scales [CA, FS and HH], no transformation could be found which completely normalised the data. FS and HH were combined [see below] to obtain the best transformation possible. CA was transformed to improve its distributional properties but it was impossible to obtain a good normal fit. The problem particularly with the CA and FS scores may be due to the fact that only four questions contribute to the overall score on the subscale, which therefore gives a smaller range of values for the total score and less likelihood of spread. It was also thought that significant pvalues may partly have been obtained due to the large number of patients involved. Given this, it was decided to use the best estimates for the cut-off points that were available after transformation even though for some scales a normal distribution could not be reached. After transformation, the mean and median scores were within 10% of each other on each subscale, confirming at least that the distribution was tending to normality if it was not totally normal.

Statistics for subscales obtained using first half of the dataset [n=288]



[before transform -ation]

Transformation used

[after transform -ation]

[after transform -ation]

[after transformation]

Mean +s.d.
[after transformation]

Real scale cut-off point+


(8-32) (4-16) (5-20) (8-32) (4-16)

287 287 288 286 288

0.007 <0.001 0.075 <0.001

(AP)1/2 (CA)1/8 None (FS-H+29)2

>0.2 0.004 --0.0175

4.305 1.32 13.57 908.30

0.648 0.05 3.01 294.71

4.953 1.37 16.58 613.58

>24 >12 >17 <25



Kolmogorov-Smirnov test for non-normality Low FS total scores imply little fighting spirit. High HH scores imply increased helplessness. Low scores of (FS-HH+29)2 indicate possible cases and mean-sd is used to calculate cut-off scores. AP cut-off=(mean+s.d.)2 CA cut-off=(mean+s.d.)8 , FS-HH+29 cut-off=(mean-s.d.)1/2

These transformations and cut-off points were validated using the second half of the dataset [n=285]. The transformations on CA and FS/HH resulted in similar p-values on distributional tests and gave the same cut-offs as obtained previously. AP on initial test gave a cut-off level of 24.532 i.e. borderline between 24 and 25. On validation the non-normality p-value was the same [p<0.2], but the mean and the median were slightly closer than on first test and the cut-off level was calculated as 24.296. Thus combining these two results a cut-off of >24 has been suggested. Untransformed Fatalism had a non-normality test p-value of 0.006 on validation but the mean and median were within 10% of each other and the cut-off point using untransformed data was the same as shown above.

Mean, Standard Deviation, Median and Range for Mini-Mac subscales based on 573 subjects.
Sub scale N Helpless/hopeless 565 Anxious Preoccupation Fighting Spirit Cognitive Avoidance Fatalism 541 562 560 548 Mean 11.965 19.261 12.639 9.479 13.763 (SD) 3.915 5.148 2.209 2.504 2.906 Median 11.0 19.0 13.0 9.0 14.0 Range 8.0,32.0 8.0,32.0 5.0,16.0 4.0,16.0 5.0,20.0

Appendix III Test Form Mini-MAC Scale


Date :

Patient Number:

INSTRUCTIONS A number of statements are given below which describe peoples reactions to having cancer. Please circle the appropriate number to the right of each statement, indicating how far it applies to you at present. For example, if the statement definitely does not apply to you, then you should circle 1 in the first column. Definitely does not apply to me 1. At the moment I take one day at a time 2. I see my illness as a challenge 3. I've put myself in the hands of God 4. I feel like giving up 5. I feel very angry about what has happened to me 1 1 1 1 1 Does not apply to me 2 2 2 2 2 Applie s to me Definitely applies to me

3 3 3 3 3

4 4 4 4 4

6. I feel completely at a loss about 1 what to do 7. It is a devastating feeling 8. I count my blessings 9. I worry about the cancer returning or getting worse 10. I try to fight the illness 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

11. I distract myself when thoughts 1 about my illness come into my head 12. I can't handle it 13. I am apprehensive 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4 4

14. I am not very hopeful about the 1 future 15. I feel there is nothing I can do to 1 help myself 16. I think it is the end of the world 1

Definitely does not apply to me

Does not apply to me 2 2 2 2 2 2 2 2

Applies to me

Definitely applies to me 4

18. 19. 20. 21. 22. 23. 24.

Not thinking about it helps me cope

I am very optimistic I've had a good life what's left is a bonus I feel that life is hopeless I can't cope I am upset about having cancer I am determined to beat this disease Since my cancer diagnosis I now realise how precious life is and I'm making the most of it I have difficulty in believing that this happened to me I make a positive effort not to think about my illness I deliberately push all thoughts of cancer out of my mind I suffer great anxiety about it I am a little frightened

1 1 1 1 1 1 1 1

3 3 3 3 3 3 3

4 4 4 4 4 4 4

25. 26. 27. 28. 29.

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

M. Watson et al., 1992



Item Number
4, 6, 12, 14, 15, 16, 20, 21


5, 7, 9, 13, 22, 25, 28, 29


2, 10, 18, 23


11, 17, 26, 27


1, 3, 8, 19, 24


In addition to English there exist translations of the MAC scale in Chinese, Dutch, French, German, Hebrew, Italian, Japanese, Korean, Norwegian Polish, Portuguese Spanish, and Swedish Translations of the Mini-Mac are available in Chinese, Danish, Italian, Korean, Norwegian and Spanish. Please contact Dr. Maggie Watson for further details and copies of these translations A version also exists for use in HIV infection or AIDS. (MAHI). Further details of this can be obtained from Dr Rupert Whitaker, Psychiatry Fellow, MABRC, Room 2213

Institute for Social Research, 426 Thompson Street, Ann Arbor, MI 48104, USA.

Copyright 2008. Maggie Watson Use of the MAC, MINI-MAC and MAC-R is protected by copyright. Reproduction of the MAC Scale, the Users Manual or adjunctive materials is prohibited without prior written permission of the authors. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act or under the terms of a licence issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London, UK W1P 9HE, without the permission in writing of the author.

MAC Manual: Copyright 2008 Watson, M & Homewood, J