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CART T-Cell Therapy In Patients of Advanced Age
1.
I attended this web program as a: (select one).
Patient
Caregiver
Family Member
Friend/Concerned Individual
Healthcare Professional
Community Member
LLS Staff
LLS Volunteer
Other (please specify)
2.
What is your race or ethnicity?
Asian
Black or African American
Hispanic or Latino
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
White
Prefer not to disclose
3.
Are you Hispanic/Latino/a/x?
Yes
No
4.
What is your date of birth? (LLS is unable to correspond with minors.)
(MM/DD/YYYY)
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
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31
5.
Do you describe yourself as a man, a woman, or in some other way?
A Man
A Woman
Prefer not to answer
In some other way (with open text field)
6.
In what ZIP/Postal code is your home located?
7.
Have you or the patient been diagnosed with a blood cancer?
Yes
No
N/A
If no, please tell us the type of cancer with which you/patient were diagnosed:
8.
If yes, when were you/patient diagnosed?
(MM/DD/YYYY)
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
9.
If yes, please tell us what type of blood cancer (check all that apply):
Non-Hodgkin lymphoma (NHL)
Mantle cell lymphoma (MCL)
Hodgkin lymphoma (HL)
Chronic lymphocytic leukemia (CLL)
Chronic myeloid leukemia (CML)
Acute lymphoblastic leukemia (ALL)
Acute myeloid leukemia (AML)
Myelodysplastic syndromes
Myeloproliferative neoplasms (MPN) (polycythemia vera, essential thrombocythemia, myelofibrosis)
Multiple myeloma
Other (please specify)
10.
Are you or the patient currently being treated?
Yes
No
11.
What treatments have you or the patient had? (check all that apply):
Combination drug therapy (chemotherapy)
Single Drug Therapy
Allogeneic stem cell transplant (donor)
Autologous stem cell transplant
CAR T- cell Therapy
Radiation therapy
Immunotherapy
Blood transfusions
Watch & Wait
N/A
Other (please specify)
12.
Are you presently in or have you ever participated in a clinical trial?
Yes
No
N/A
13.
As a result of participating in this program, to what extent do you agree to the following statements? (Select one answer for each)
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
I am knowledgeable of which blood cancers benefit from CAR T-cell therapy.
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
I know when to discuss CAR T-cell therapy with my doctor.
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
I know the factors to consider regarding CAR T-cell therapy for older adults .
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
I know the potential side effects of CAR T-cell therapy.
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
14.
Following this program, do you feel more prepared to discuss CAR T-cell therapy with your healthcare team?
Yes
No
N/A
15.
Which form(s) of cancer education do you most prefer?
Webcasts (live or pre-recorded)
Short videos
Podcasts
Booklets
Other (please specify)
16.
Please describe any information you expected to get from this program but did not receive.
17.
Please give us any additional feedback about this program.
