Patient Empowerment Focus Group

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1. What is your name? (Required.)

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2. Do you have a known BRCA1 or BRCA2 gene mutation? (Required.)

Yes

I don't know

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3. What is your email address? (Required.)

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4. What is your phone number? (Required.)

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5. Please select the current stage of your diagnosis (Required.)

Stage 0 (DCIS or LCIS)

Stage 1

Stage 2

Stage 3

Stage 4 (metastatic breast cancer/MBC)

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6. Kindly confirm your availability below. Our sessions are scheduled to conclude promptly as scheduled to respect your time.

As a token of our appreciation, we will be providing a $250 Visa gift card at the end of your session as compensation for your participation.

Thank you once again for your support and collaboration. We look forward to seeing you at SABCS! (Required.)

MBC - Tuesday, December 5th (8:30am - 11am) *Open only to those living with MBC

Early-stage - Tuesday, December 5th (12pm-2:30pm)

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7. What was the date of your original diagnosis?

Month/Date/Year

Date

Time

AM/PM

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8. If you are living with MBC what was the date of your MBC diagnosis? If diagnosed de novo please skip.

Month/Date/Year

Date

Time

AM/PM

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9. What tumor characteristics best describe your diagnosis? (Required.)

Triple Negative

HR+/HER2-

HR-/HER2+

Triple Positive

Other (please specify)

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10. Do you use the Outcomes4Me app to navigate your cancer care?

Yes

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11. Do you spend time working as a patient advocate?

Yes

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12. Are you being treated at an academic setting (e.g. Memorial Sloan Kettering, Dana-Farber, MD Anderson, Seattle Cancer Care Alliance, etc.) or at a community hospital setting (e.g. Cancer Treatment Centers of America or similar)?

Academic Setting

Community Cancer Center

I don't know

Other (please specify)

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13. Where are you in your cancer care? Please select what best describes you. (Required.)

I just received a definitive diagnosis that I have breast cancer.

I am in active treatment for my initial diagnosis (select if still on endocrine therapy)

I am in ongoing treatment for MBC

I have completed treatment for an early stage diagnosis (including endocrine therapy)

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14. What is your age?

0-18

19-35

36-50

51-65

66+

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15. How do you identify your ethnicity?

Hispanic or Latino

White

Black or African American

American Indian and Alaska Native

Asian or Asian American

Native Hawaiian and Other Pacific Islander

Some Other Race alone

Multiracial

Other/Unknown

Prefer not to say

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16. Zip code

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17. What is the highest degree or level of education you have completed?

Some High School

High School

Bachelor’s Degree

Master’s Degree

Ph.D or higher

Trade School

Prefer not to say

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18. What type of health insurance coverage do you have?

Medicare

Medicaid

Employer-sponsored

Individual health insurance

None

Prefer not to say

Patient Empowerment Focus Group

Question Title

* 1. What is your name? (Required.)

Question Title

* 2. Do you have a known BRCA1 or BRCA2 gene mutation? (Required.)

Question Title

* 3. What is your email address? (Required.)

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* 4. What is your phone number? (Required.)

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* 5. Please select the current stage of your diagnosis (Required.)

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* 7. What was the date of your original diagnosis?

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* 8. If you are living with MBC what was the date of your MBC diagnosis? If diagnosed de novo please skip.

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* 9. What tumor characteristics best describe your diagnosis? (Required.)

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* 10. Do you use the Outcomes4Me app to navigate your cancer care?

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* 11. Do you spend time working as a patient advocate?

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* 12. Are you being treated at an academic setting (e.g. Memorial Sloan Kettering, Dana-Farber, MD Anderson, Seattle Cancer Care Alliance, etc.) or at a community hospital setting (e.g. Cancer Treatment Centers of America or similar)?

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* 13. Where are you in your cancer care? Please select what best describes you. (Required.)

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* 14. What is your age?

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* 15. How do you identify your ethnicity?

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* 16. Zip code

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* 17. What is the highest degree or level of education you have completed?

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* 18. What type of health insurance coverage do you have?

1. What is your name? (Required.)

2. Do you have a known BRCA1 or BRCA2 gene mutation? (Required.)

3. What is your email address? (Required.)

4. What is your phone number? (Required.)

5. Please select the current stage of your diagnosis (Required.)

7. What was the date of your original diagnosis?

8. If you are living with MBC what was the date of your MBC diagnosis? If diagnosed de novo please skip.

9. What tumor characteristics best describe your diagnosis? (Required.)

10. Do you use the Outcomes4Me app to navigate your cancer care?

11. Do you spend time working as a patient advocate?

12. Are you being treated at an academic setting (e.g. Memorial Sloan Kettering, Dana-Farber, MD Anderson, Seattle Cancer Care Alliance, etc.) or at a community hospital setting (e.g. Cancer Treatment Centers of America or similar)?

13. Where are you in your cancer care? Please select what best describes you. (Required.)

14. What is your age?

15. How do you identify your ethnicity?

16. Zip code

17. What is the highest degree or level of education you have completed?

18. What type of health insurance coverage do you have?