{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T12:07:05Z","timestamp":1789214825100,"version":"build-2803163510"},"reference-count":50,"publisher":"SAGE Publications","issue":"10","license":[{"start":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T00:00:00Z","timestamp":1786406400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"funder":[{"name":"Cedars-Sinai Randall Department of Surgery","award":["Research Award"],"award-info":[{"award-number":["Research Award"]}]},{"DOI":"10.13039\/100005193","name":"American Academy of Otolaryngology-Head and Neck Surgery","doi-asserted-by":"crossref","award":["CORE Grant"],"award-info":[{"award-number":["CORE Grant"]}],"id":[{"id":"10.13039\/100005193","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Thyroid\u00ae"],"published-print":{"date-parts":[[2026,10,1]]},"abstract":"\n Background:<\/jats:title>\n Patient distress associated with thyroid cancer greatly influences treatment choice, yet is underestimated by clinicians. We developed and validated the Thyroid Cancer Modified Anxiety Scale (TC-MAX) to measure patient-reported thyroid cancer-related worry.<\/jats:p>\n <\/jats:sec>\n \n Methods:<\/jats:title>\n \n Development entailed (1) conceptualization (systematic literature review, expert panel [\n n<\/jats:italic>\n = 4], patient focus groups [\n n<\/jats:italic>\n = 10]); (2) qualitative revision (pilot testing [\n n<\/jats:italic>\n = 59], expert panel [\n n<\/jats:italic>\n = 4], patient feedback [\n n<\/jats:italic>\n = 4]); (3) internal validation (\n n<\/jats:italic>\n = 148); and (4) external validation (\n n<\/jats:italic>\n = 1002), with papillary thyroid cancer patients. Internal consistency, test\u2013retest reliability, exploratory\/confirmatory factor analysis, and construct validity were evaluated. Severity categories and minimal clinically important differences (MCIDs) were determined.\n <\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n \n An 18-question scale was constructed, encompassing three subscales (Collective Anxiety, Ultrasound Anxiety, and Fear of Recurrence\/Progression). Internal validation revealed high internal consistency (Cronbach\u2019s\n \u03b1<\/jats:italic>\n = 0.93), excellent test\u2013retest reliability (intraclass correlation coefficient [ICC] 0.86), and significant construct validity (Distress Thermometer [Spearman\u2019s\n \n \n \u03c1<\/mml:mi>\n <\/mml:math>\n <\/jats:inline-formula>\n = 0.56,\n p<\/jats:italic>\n < 0.001], Hospital Anxiety Depression Scale [HADS] [Spearman\u2019s \u03c1 = 0.52,\n p<\/jats:italic>\n < 0.001], and Functional Assessment of Cancer Therapy-General [FACT-G] [Spearman\u2019s\n \n \n \u03c1<\/mml:mi>\n <\/mml:math>\n <\/jats:inline-formula>\n = \u22120.50,\n p<\/jats:italic>\n < 0.001]). Exploratory factor analysis showed expected loadings for respective subscales, and confirmatory factor analysis confirmed that the structure was parsimonious. External validation exhibited similar psychometrics, including internal consistency (Cronbach\u2019s\n \u03b1<\/jats:italic>\n = 0.94), test\u2013retest reliability (ICC 0.87), and construct validity (Distress Thermometer [Spearman\u2019s\n \n \n \u03c1<\/mml:mi>\n <\/mml:math>\n <\/jats:inline-formula>\n = 0.54,\n p<\/jats:italic>\n < 0.001], HADS [Spearman\u2019s\n \n \n \u03c1<\/mml:mi>\n <\/mml:math>\n <\/jats:inline-formula>\n = 0.67,\n p<\/jats:italic>\n < 0.001], and FACT-G [Spearman\u2019s\n \n \n \u03c1<\/mml:mi>\n <\/mml:math>\n <\/jats:inline-formula>\n = \u22120.62,\n p<\/jats:italic>\n < 0.001]). Proposed ranges (low = 0\u201326, moderate = 26\u201343, and severe = 43\u2013100) were in excellent agreement between internal and external validation cohorts (weighted\n \u03ba<\/jats:italic>\n = 0.84,\n p<\/jats:italic>\n < 0.001). Anchor-based MCID was found to be 16.7 (active surveillance vs. surgery) (25.9 [standard deviation (SD) \u00b1 16.4] vs. 42.6 [SD \u00b1 23.3],\n p<\/jats:italic>\n < 0.001) or 16.9 (hemithyroidectomy vs. thyroidectomy) (33.6 [SD \u00b1 17.4] vs. 50.5 [SD \u00b1 24.1],\n p<\/jats:italic>\n = 0.005).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions:<\/jats:title>\n TC-MAX represents the first dedicated measure of anxiety in thyroid cancer. It exhibits robust psychometric properties in a vulnerable population, accounting for complex viewpoints. The scale effectively assesses preference and informs patients, including determining fit for active surveillance or extent of surgery.<\/jats:p>\n <\/jats:sec>","DOI":"10.1177\/10507256261475819","type":"journal-article","created":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T14:57:29Z","timestamp":1786460249000},"page":"1043-1052","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["The Thyroid Cancer Modified Anxiety Scale (TC-MAX): Development and External Validation of a Thyroid Cancer Distress Instrument"],"prefix":"10.1177","volume":"36","author":[{"given":"Amanda J.","family":"Bastien","sequence":"first","affiliation":[{"name":"Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sungjin","family":"Kim","sequence":"additional","affiliation":[{"name":"Cedars-Sinai Cancer Institute, Los Angeles, California, USA."},{"name":"Biostatistics Shared Resource, Cedars-Sinai Cancer Institute, Los Angeles, California, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cynthia","family":"Zalt","sequence":"additional","affiliation":[{"name":"Cedars-Sinai Cancer Institute, Los Angeles, California, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iris","family":"Cong","sequence":"additional","affiliation":[{"name":"Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4064-4292","authenticated-orcid":false,"given":"Jewel","family":"Ng","sequence":"additional","affiliation":[{"name":"Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caroline","family":"Marshall","sequence":"additional","affiliation":[{"name":"Medical Library, Cedars-Sinai Medical Center, Los Angeles, California, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher V.","family":"Almario","sequence":"additional","affiliation":[{"name":"Cedars-Sinai Cancer Institute, Los Angeles, California, USA."},{"name":"Department of Medicine, Division of Gastroenterology; 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