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MHNMEB4120- cancer
1.
Please read the privacy policy before opting in our panel
https://murrayhillnational.com/privacy-policy/
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1.
The project will take the form of 15-minute pre-task and a 60-minute video interview (or telephone interview if you prefer). The objective of this project will be to explore your journey with early breast cancer, from diagnosis to treatment. It is not clinical in nature and there will be no direct impact on any treatment you receive.
(Required.)
Name:
*
Company:
Address:
City/Town:
State:
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Email Address:
*
Phone Number:
*
2.
How young are you?
Under 18
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
3.
Which stage of breast cancer have you been diagnosed with by a healthcare professional (i.e. told by a healthcare professional that your breast cancer is this stage)?
Non-metastatic
Metastatic
I don’t know
4.
Which of the following type of breast cancer have you been diagnosed with by a healthcare professional?
ER+, HER2 negative breast cancer
HR+, HER2 negative breast cancer
None of the above
Don’t know
5.
Which of the following types of treatments, if any, have you undergone for your ER+, HER2 negative early breast cancer?
Surgery
Chemotherapy
Radiation Therapy
Targeted Therapy (A type of cancer treatment that uses drugs or other substances to precisely identify and attack certain types of cancer cells)
Other
None of the above
Don’t know
6.
Which of the following treatments, if any, have you received to date for your ER+, HER2 negative early breast cancer after surgery? Please can you tell us the order in which you received these treatments, from first treatment to current treatment.
This includes any treatments that were added on to existing treatment you were received, as well as treatments where you stopped and then switched to a new one
Aromatase Inhibitors (AI) alone
Tamoxifen alone
Aromatase Inhibitors (AI) + LHRH (Lutenising Hormone-Releasing Hormone)
Tamoxifen + LHRH agonist
Ribociclib combinations
Abemaciclib combinations
Other
7.
Which of the following treatment options did your doctor present to you before you chose [insert first treatment from s10]?
Armidex (anastrozole)
Femara (letrozole)
Aromasin (exemestane)
Nolvadex
Soltamox (oral liquid)
Tamofen
Prostap (leuprorelin)
Zoladex / Zoladex LA (goserelin)
Decapeptyl / Decapeptyl SR (triptorelin)
ribociclib (Kisqali)
abermaciclib (Verzenios)
8.
What is your ethnicity?
Asian / Pacific islander
Black / African / Caribbean
Mixed ethnic origin
North African / Middle Eastern
Latin American
Other origin
9.
Please upload proof of diagnosis. Thank you!
Choose File
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