Breast Cancer and COVID-19 Ongoing Survey

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* 1. Are you a:

Breast cancer patient/survivor

Caregiver

Other (please specify)

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* 2. What stage is/was your diagnosis?

Newly diagnosed (not yet staged)

DCIS, Stage 1, Stage 2, or Stage 3

Stage 4/metastatic

N/A

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* 3. What year were you diagnosed?

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* 4. If you are a breast cancer patient/survivor, are you in active treatment at this time?

Please choose the option that best describes your current treatment status.

Yes (treatment pending from recent diagnosis)

Yes (oral treatment only)

Yes (regular infusions or chemotherapy)

Yes (radiation)

Yes (recent or upcoming surgery)

Other (please specify)

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* 5. Have you experienced any of the following challenges accessing care for your breast cancer care/treatment?

Select all that apply.

Delays in getting in to/reaching doctor

Routine blood tests canceled/postponed

Imaging/Scans canceled/postponed

Radiation treatment canceled/postponed

Follow-up visits with doctor canceled/postponed

Breast cancer surgery canceled/postponed

Reconstruction surgery canceled/postponed

Infusions/chemotherapy canceled/postponed

Having to have virtual visits instead of in-person

Getting medications

Not seeking needed treatment because I am worried about exposure to the coronavirus

Not yet - my appointments are in the future and not yet impacted

Other (please specify)

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* 6. If your breast cancer treatment/care has been delayed, please describe by how long your care has been delayed below:

Weeks:

Months:

Other:

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* 7. As a caregiver of someone with breast cancer, have you experienced challenges accessing breast cancer services/resources for the person you are caring for?

Yes

N/A

If yes, please explain.

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* 8. If you are presently in treatment, has your medical provider or healthcare system contacted you directly to provide medical advice on how to protect yourself against COVID-19 or access care should you have symptoms?

Yes

N/A

If yes, please explain:

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* 9. Was the information they provided helpful or satisfactory?

Extremely helpful

Very helpful

Somewhat helpful

Not so helpful

Not at all helpful

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* 10. Have you experienced symptoms, and have you reached out for COVID-19 testing and been denied access?

Yes

N/A

If yes, please explain:

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* 11. Do you have insurance or payment concerns related to your care and treatment should you be diagnosed with COVID 19?

Yes

N/A

If yes, please explain.

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* 12. Are there other challenges as a result of the pandemic you have experienced as a breast cancer patient or caregiver you’d like to share with NBCC?

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* 13. Have you previously completed and submitted this survey over the last 6 weeks?

Yes

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* 14. What state are you located in?

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* 15. If you are willing, please share your name and contact information.

Name

Email Address

Phone Number

Breast Cancer and COVID-19 Ongoing Survey

Question Title

* 1. Are you a:

Question Title

* 2. What stage is/was your diagnosis?

Question Title

* 3. What year were you diagnosed?

Question Title

* 4. If you are a breast cancer patient/survivor, are you in active treatment at this time? Please choose the option that best describes your current treatment status.

Question Title

* 5. Have you experienced any of the following challenges accessing care for your breast cancer care/treatment? ﻿Select all that apply.

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* 6. If your breast cancer treatment/care has been delayed, please describe by how long your care has been delayed below:

Question Title

* 7. As a caregiver of someone with breast cancer, have you experienced challenges accessing breast cancer services/resources for the person you are caring for?

Question Title

* 8. If you are presently in treatment, has your medical provider or healthcare system contacted you directly to provide medical advice on how to protect yourself against COVID-19 or access care should you have symptoms?

Question Title

* 9. Was the information they provided helpful or satisfactory?

Question Title

* 10. Have you experienced symptoms, and have you reached out for COVID-19 testing and been denied access?

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* 11. Do you have insurance or payment concerns related to your care and treatment should you be diagnosed with COVID 19?

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* 12. Are there other challenges as a result of the pandemic you have experienced as a breast cancer patient or caregiver you’d like to share with NBCC?

Question Title

* 13. Have you previously completed and submitted this survey over the last 6 weeks?

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* 14. What state are you located in?

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* 15. If you are willing, please share your name and contact information.

* 4. If you are a breast cancer patient/survivor, are you in active treatment at this time?

Please choose the option that best describes your current treatment status.

* 5. Have you experienced any of the following challenges accessing care for your breast cancer care/treatment?

Select all that apply.