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Understanding the Experiences of Young with Breast Cancer
Thank you for your interest in participating in this survey. Your input is invaluable in helping us better understand the experiences and needs of young patients navigating breast cancer diagnosis and treatment. Participation is completely voluntary, and you may exit the survey at any time. This survey takes about 15 minutes to complete. To participate, you must have been diagnosed with breast cancer at age 45 or younger and be age 18 or older. Share your experience and enter to win a $100 gift card.
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About You
Are you a United States citizen or resident?
*
Yes, I live in the U.S.
No, I live in another country
What country do you live in?
*
Have you been diagnosed with breast cancer?
*
Yes
No
Have you ever been diagnosed with another type of cancer?
Yes
No
What other cancer have you been diagnosed with?
What is your current age (years)?
*
What was your age (years) when you were first diagnosed with breast cancer?
*
Which of the following best describes your first breast cancer diagnosis?
*
Involves the breast only
Involves the breast and lymph nodes only
Involves the breast and other parts of the body (like lung, bone, liver or brain)
I'm not sure
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Was this your most recent breast cancer diagnosis?
*
Yes
No, I was diagnosed with a new breast cancer diagnosis in a different location
No, I was diagnosed with a recurrence
No, I was diagnosed with a progression (the cancer spread)
Approximately what date was your most recent breast cancer diagnosis?
-
Month
-
Day
Year
Date of most recent breast cancer diagnosis
Which of the following best describes your most recent breast cancer diagnosis?
*
Involves the breast only
Involves the breast and lymph nodes only
Involves the breast and other parts of the body (like lung, bone, liver or brain)
I'm not sure
Have you been diagnosed with Triple-Negative Breast Cancer (TNBC)?
*
Yes
No
I'm not sure
What is the HER2 status of the breast cancer?
*
HER2-positive
HER2-negative
I'm not sure
What is the hormone-receptor status of the breast cancer?
*
Hormone-receptor positive (the tumor responds to estrogen and/or progesterone, ER+ or PR+)
Hormone-receptor negative (estrogen and progesterone receptors were not present)
I'm not sure
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Which of the following best describes the current status of your breast cancer treatment?
*
I haven’t started treatment yet
In treatment before surgery (neoadjuvant chemotherapy, radiation, hormonal therapy, targeted therapy)
In treatment after surgery (adjuvant chemotherapy, radiation, targeted therapy)
Completed treatment
Ongoing treatment for early-stage/non-metastatic breast cancer, such as with hormonal/endocrine therapy, targeted therapy
Stopped treatment for early-stage/ non-metastatic breast cancer, such as hormonal/endocrine therapy, targeted therapy
Ongoing treatment for advanced/metastatic breast cancer (breast cancer that involves other parts of the body)
Stopped treatment for advanced/metastatic breast cancer (breast cancer that involves other parts of the body)
Are you in remission or declared no evidence of disease (NED)?
*
Yes
No
I'm not sure
What long-term effects are your primary health concern following breast cancer diagnosis and/or treatment? (Select all that apply)
*
Risk of recurrence or progression
Physical health (fatigue, pain, neuropathy, lymphedema, skin/hair)
Hormonal changes (menopausal symptoms)
Fertility issues
Bone health (osteoporosis)
Cardiovascular issues
Cognitive health (memory, “chemo brain”)
Mental health (fear, anxiety, depression)
Other
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Treatment
What type of breast cancer treatment are you currently receiving and/or previously completed? (select all that apply)
*
Surgery
Radiation therapy
Chemotherapy
Hormonal (endocrine) therapy
Targeted therapy
Immunotherapy
None
Other
What type of chemotherapy did you receive? (select all that apply)
Anthracyclines, such as doxorubicin (Adriamycin; also known as the “Red Devil”) and epirubicin (Ellence)
Taxanes, such as paclitaxel (Taxol) and docetaxel (Taxotere)
5-fluorouracil (5-FU) or capecitabine (Xeloda)
Cyclophosphamide (Cytoxan)
Carboplatin (Paraplatin)
I don't know/don't remember
What type of chemotherapy did you receive? (select all that apply)
Taxanes: Paclitaxel (Taxol), docetaxel (Taxotere), and albumin-bound paclitaxel (Abraxane)
Ixabepilone (Ixempra)
Eribulin (Halaven)
Anthracyclines: Doxorubicin (Adriamycin, or “Red Devil”), liposomal doxorubicin (Doxil), and epirubicin (Ellence)
Platinum agents (Cisplatin, carboplatin)
Vinorelbine (Navelbine)
Capecitabine (Xeloda)
Gemcitabine (Gemzar)
I don't know/don't remember
What type of hormonal therapy were you prescribed? (select all that apply)
Tamoxifen (Nolvadex, Soltamox and others)
Toremifene (Fareston)
Raloxifene (Evista)
Anastrozole (Arimidex)
Exemestane (Aromasin)
Letrozole (Femara)
Fulvestrant (Faslodex)
Leuprolide (Lupron), Triptorelin (Triptodur, Trelstar and others), Goserelin (Zoladex and others)
I don't know/don't remember
Other
In total, how long have you been taking hormonal therapy? (months)
Months
What surgeries have you had? (select all that apply)
*
Breast-conserving surgery (lumpectomy or partial mastectomy)
Lymph Node Removal
Single mastectomy
Double mastectomy
Implant reconstruction
Tissue flap reconstruction
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Did your healthcare provider discuss mental health with you at any point during your treatment?
*
Yes, and they provided resources or referrals for mental health support
Yes, but they didn’t offer specific support or resources
No, but I wish they had
No, it didn’t seem necessary to me
After your breast cancer diagnosis, did you seek any form of emotional support or counseling?
*
Yes, I saw a mental health professional (therapist, counselor, psychologist, psychiatrist)
Yes, I talked to a social worker or patient navigator
Yes, I leaned on family and friends for emotional support
No, I did not seek emotional support
Other
Did your provider talk to you about mental health medications, such as antidepressants or anxiety medications, as part of your care?
Yes, and they prescribed or recommended medication
Yes, but I chose not to take medication
No, but I would have liked to discuss it
No, it didn’t seem necessary
Did you participate in any peer support programs or connect with others who had a similar diagnosis?
*
Yes, I joined a support group (online)
Yes, I joined a support group (in-person)
Yes, I connected with other survivors individually
Yes, but I didn’t find it helpful
No, but I wanted to
No, I wasn’t interested
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Pathway to Diagnosis
Detection
Before your diagnosis, did you regularly do breast self-exams to check for lumps and other breast changes?
*
Yes
No
How often did you do breast self-exams to check for lumps and other breast changes?
Never
Occasionally
Monthly
Weekly
Daily
At what age did you start doing breast self-exams?
years old
How was your breast cancer first detected?
*
I found a symptom myself (such as a breast lump or other breast changes)
A healthcare provider found symptoms (such as a breast lump) during a routine visit
I did not have a symptom of breast cancer but I had an imaging test (mammogram, MRI, or ultrasound) because I was identified as higher-than-average risk for breast cancer
Routine screening and imaging (mammogram, MRI, ultrasound)
I had an imaging test done for other medical reasons.
Other
How much time passed between when you first noticed symptoms and when you received your diagnosis?
*
Less than 1 month
1-3 months
4-6 months
7-12 months
More than 12 months
Other
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Diagnosis Challenges
Did you experience any barriers to getting diagnosed with breast cancer? (Select all that apply)
*
Healthcare providers dismissed my concerns due to my young age
Told it was a benign condition or finding
Told to "wait and see" despite persistent symptoms
Financial barriers
Insurance issues
Lack of access to healthcare facilities/specialists
Access to translation services
Initial misdiagnosis that delayed proper diagnosis
Medical mistrust or fear about a diagnosis
Lack of information about breast cancer risk in young women
No barriers experienced
Other
How many different healthcare providers did you see about your symptom(s) before receiving your diagnosis?
*
1 provider
2 providers
3 providers
4 or more providers
Did a healthcare provider tell you any of the following before your diagnosis? (Select all that apply)
*
“You're too young to have breast cancer"
"It's probably just hormonal changes"
"Let's wait until your next visit to see if it changes"
"It's likely nothing to worry about"
"We don't typically screen/test women your age"
None of the above
Other dismissive comments
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Family History & Risk Assessment
Risk Assessment
Before your diagnosis, did a healthcare provider ever do a risk assessment by asking you a series of questions about your individual risk for breast cancer (such as questions about your family history of cancer)?
*
Yes, a healthcare provider asked me questions/had a conversation with me about risk and family history
Yes, a healthcare provider gave me a questionnaire to fill out about my family history
No, before my diagnosis there was no discussion about my risk
No, but after my diagnosis my healthcare provider did discuss this with me
No, but I did an online risk assessment on my own
I don't remember
Were you identified as being at “high risk” for breast cancer before your diagnosis?
*
Yes
No
I'm not sure
Do you have a family history of breast or ovarian cancer?
*
Yes
No
I'm not sure
Were you aware of this family history before your diagnosis?
*
Yes
No
Do you feel you were given adequate guidance on your cancer risk due to family history after diagnosis?
*
Yes
No
I'm not sure
Did knowledge of your family history influence your decision to get imaging tests (or other tests) to screen for breast cancer?
*
Yes
No
I'm not sure
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Screening & Imaging
When trying to get breast imaging, which of the following did you experience? (Select all that apply)
*
I received imaging promptly when requested
I had to strongly advocate for myself to get imaging
I was told imaging wasn't necessary due to my young age
I was told to "wait and see" if symptoms persisted
I needed to get a second opinion to receive imaging
I had no difficulties accessing imaging
Other
Before the imaging that led to your diagnosis, have you ever had breast imaging?
*
Yes
No
I don't remember
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At what age did you first have imaging or screening for breast cancer?
years old
What was the reason for your previous breast imaging? (Select all that apply)
I had breast symptoms or concerns (lump, pain, discharge, etc.)
I had a family history of breast cancer
I had a known genetic mutation (BRCA1/2, etc.)
It was recommended as routine screening
For an unrelated medical issue
Follow-up for a previous benign finding
Other
If you had previous breast imaging, what were you told about the results? (select all that apply)
Normal/Negative (no concerning findings)
Benign finding requiring follow-up
Dense breast tissue making imaging difficult to interpret
Inconclusive results
Suspicious finding, but not cancer
I was never informed of the results
Other
Prior to your breast cancer diagnosis, how frequently did you have imaging tests for screening?
Never
Irregularly (no set schedule)
Every 2 years
Annually
Every 6 months
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Which types of imaging did you receive before your diagnosis? (Select all that apply)
*
Clinical breast exam (physical exam by healthcare provider)
Mammogram
Breast MRI
Breast Ultrasound
Other
How effective do you feel current screening guidelines are for detecting breast cancer at an early stage in young women?
*
Very Ineffective
1
2
3
4
Very Effective
5
1 is Very Ineffective, 5 is Very Effective
Did you experience any of these barriers to getting breast imaging? (Select all that apply)
*
No barriers experienced
Insurance denied coverage
Difficulty obtaining a physician's referral despite symptoms
Told to wait until age 40 despite symptoms or concerns
Cost/financial barriers
Lack of information about screening options for young women
Other
If you feel like there was a delay in your diagnosis, what would have helped you get diagnosed earlier? (Select all that apply)
*
I did not feel like there was a delay in diagnosis
I should have seen a provider sooner for my symptoms
Better education about breast cancer risk for young women
Better education about possible breast cancer symptoms
Healthcare providers taking my symptoms more seriously
More accessible genetic testing
Better insurance coverage for diagnostic imaging
More knowledge about my family history
Information about breast self-exams at a younger age
Other
Why were you delayed seeing a provider for your symptoms? (For example: fear, disbelief, finances, life was busy)
What advice would you give to healthcare providers about diagnosing breast cancer in young women?
Do you have any advice to share with other young women about breast health and advocating for themselves?
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Genetic Testing
Genetic Counseling Services and Testing
Before your diagnosis or genetic testing, were you aware genetic mutations exist that increase breast cancer risk, such as mutations in the BRCA1, BRCA2, ATM, PALB2, and TP53 genes?
*
Yes
No
Somewhat
Were you informed about genetic counseling services available?
*
Yes
No
Were you offered genetic testing as part of your diagnosis or treatment?
*
Yes, it was recommended immediately
Yes, but only after I requested it
Yes, but only after my diagnosis was confirmed
No, I had to seek it independently
No, I was never offered genetic testing
Other
Have you had genetic testing done?
*
Yes, before my diagnosis
Yes, during my initial diagnosis and treatment
Yes, but only after completing initial treatment
No, but I plan to
No, and I don't plan to
Other
Why have you not had genetic testing, what were the reasons? (Select all that apply)
Cost
Lack of information/referral
Difficulty finding providers for genetic testing or counseling
Fear of results
Physician's advice
I haven’t had time or haven’t prioritized it
I simply didn’t want genetic testing
Other
If you had genetic testing, were you found to have any genetic mutations associated with breast cancer (such as mutations in the BRCA1, BRCA2, ATM, PALB2, or CHEK2 genes)?
*
Yes
No
Test was inconclusive
Still waiting for results
What mutations were detected?
(such as mutations in the BRCA1, BRCA2, ATM, PALB2, or CHEK2 genes)
If you tested positive for any genetic mutations (such as BRCA1 or BRCA2), did you experience any of the following concerns or anxieties? (Select all that apply)
Anxiety about your personal health outcomes
Worries about passing the mutation on to your children
Stress or emotional distress surrounding family planning or decisions about risk-reduction or disease prevention surgeries (prophylactic)
Concern about discussing or disclosing your genetic mutation(s) to family members
No significant concerns
Other
How did your genetic testing results influence your treatment decisions? (Select all that apply)
Chose more extensive surgery (e.g., double mastectomy instead of single mastectomy or lumpectomy)
Opted for preventive surgery
Influenced chemotherapy decisions
Qualified me for specific targeted therapies
Did not influence treatment decisions
Other
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Fertility
Current Family & Fertility Status
Did you have biological children before your diagnosis?
*
Yes
No
How many biological children did you have at the time of your diagnosis?
At the time of your diagnosis, were you a stepparent, adoptive parent, foster parent, or guardian?
*
Yes
No
At the time of your diagnosis, what was your fertility status?
*
I was able to get pregnant (pre-menopausal)
I was experiencing perimenopause
I was in menopause (natural)
I was in menopause (medically induced)
I had previously undergone a hysterectomy or oophorectomy
I wasn’t sure if I could get pregnant
Other
Were you struggling with infertility issues or have a high-risk pregnancy before being diagnosed with breast cancer?
*
Yes
No
Not applicable
What were your struggles with fertility and pregnancy?
At the time of your diagnosis, what were your thoughts about the possibility of having children in the future?
*
I was planning to have children in the future
I was actively trying to conceive
I was pregnant at the time of diagnosis
I was undecided about having children
I had completed my family and did not want additional children
I had decided not to have children
Other
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Fertility Discussions with Healthcare Team
Did your healthcare provider(s) discuss how treatments like chemotherapy, hormonal/endocrine therapy, or others might impact your fertility or lead to early menopause?
*
Yes
No
I don't remember
Which provider(s) discussed this with you? (Select all that apply)
Oncologist
Surgeon
Primary Care Provider
OB/GYN
Fertility specialist/Reproductive Endocrinologist
Oncology nurse navigator
I had to bring it up myself
Other
How concerned were you about issues with fertility after you were diagnosed with breast cancer?
*
Not at all concerned
1
2
3
4
Very Concerned
5
1 is Not at all concerned, 5 is Very Concerned
Did you feel supported by your healthcare team in managing fertility-related concerns?
*
Not at all supported
1
2
3
4
Very supported
5
1 is Not at all supported, 5 is Very supported
Did any healthcare provider discuss fertility services and preservation options with you before you started treatment?
*
Yes, it was discussed thoroughly and promptly
Yes, but only briefly or after I brought it up
No, despite my expressing concerns about fertility
No, and I didn't know to ask about it
Other
If fertility services and preservation was discussed, how soon after your diagnosis did this conversation occur?
*
Immediately (during diagnosis discussions)
Before my treatment began
After treatment had already begun
Other
Which provider(s) initiated discussions about fertility? (Select all that apply)
Oncologist
Surgeon
Primary Care Provider
OB/GYN
Fertility specialist/Reproductive Endocrinologist
Oncology nurse navigator
None — I had to bring it up myself
Other
Did you research fertility services on your own (in addition to or instead of talking with your healthcare team about it)?
*
Yes, in addition to talking with my healthcare team
Yes, instead of talking to my healthcare team
No, I didn’t research it myself
Did you feel pressure to make quick decisions about fertility services and preservation?
*
Not at all
1
2
3
4
Very much
5
1 is Not at all, 5 is Very much
How did concerns about fertility influence your treatment decisions? (Select all that apply)
*
Fertility did not influence my treatment decisions
I decided not to have a biological child (or to have more biological children) in order to get the treatments my doctor recommended
I delayed starting treatments
I chose a different chemotherapy regimen to reduce fertility impact
I decided against hormone/endocrine therapy
Shortened planned duration of hormone/endocrine therapy or took a break
I used ovarian suppression medicine (such as Zoladex or Lupron) during treatment
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Fertility Services and Preservation Options
Were you referred to a fertility specialist? (Select all that apply)
*
Yes, and I had time to see them before treatment
Yes, but I was referred or had an appointment after treatment began
Yes, but I couldn't get an appointment quickly enough
Yes, but I couldn't afford the consultation or services
Yes, but I declined the referral
No, my cancer care team didn’t discuss fertility preservation at all
No, I was told it would delay treatment too much
No, I was told my cancer type/treatment wouldn't affect my fertility
No, I was told I wouldn't be a good candidate for fertility preservation
No, my provider didn't think it was important given my age/relationship status
No, because I was already pregnant at diagnosis
Other
Which fertility preservation options were discussed with you? (Select all that apply)
Egg freezing
Embryo freezing
Ovarian tissue freezing
Ovarian suppression during chemotherapy (with medicines like Lupron)
None were discussed
Other
If you pursued fertility services, which methods did you use? (Select all that apply)
Egg freezing
Embryo freezing
Ovarian tissue freezing
Ovarian suppression during chemotherapy (with medicines like Lupron)
None
Other
If you pursued fertility preservation, how many cycles were you able to complete before starting treatment?
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Barriers to Fertility Services and Preservation
If you considered pursuing fertility services, what barriers made it difficult to pursue them? (Select all that apply)
*
I didn’t consider fertility services
I didn’t qualify because of my age
Lack of information/referral
Cost and/or insurance coverage
Difficulty finding fertility specialists
Geographic distance to fertility specialists/centers
Difficulty getting a timely appointment with a fertility specialist, or other timing and logistics challenges
Emotional distress/difficulty making decisions (like fear and uncertainty about delaying treatment)
Medical or other physical issues (such as weight)
Other
What medical or other physical issues were a barrier to fertility services?
Were fertility services covered by your insurance plan?
*
Yes, it was fully covered
I had some coverage, but it wasn’t sufficient to keep my out-of-pocket costs low
No, it wasn’t covered
I didn’t have insurance
I'm not sure
What was the approximate out-of-pocket cost if you wanted to pursue fertility preservation?
Under $1,000
$1,000-$2,500
$2,500-$5,000
$5,000-$10,000
$10,000-$15,000
$15,000-$20,000
More than $20,000
I don't know
How did concerns about cost impact your decision to pursue or not pursue fertility services?
Were you made aware of financial assistance options for fertility services (e.g., discounts or payment plans offered by companies that offer fertility preservation services, the Livestrong Fertility Discount Program, grants from organizations like Worth the Wait)?
Yes, and I was able to use them
Yes, but I didn't qualify or they weren't enough help
No, I wasn’t informed about any programs
Other
Do you regret any decisions made about fertility services or fertility treatment?
Yes
No
I'm not sure
If yes, what would you have done differently?
What would have improved your experience regarding fertility preservation and family planning? (Select all that apply)
Earlier discussions about fertility
More comprehensive information about options
A referral to a good fertility specialist
Better insurance coverage
More time to make decisions
Better care coordination (for example, between oncology and fertility preservation teams)
Access to fertility counseling
Nothing — my experience was positive
Other
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Pregnancy and Fertility Outcomes
If you were able to get pregnant, were you pregnant during any part of your treatment?
Yes, I was pregnant during treatment
No, I wasn’t pregnant during treatment
Have you attempted pregnancy after treatment for breast cancer?
Yes, and I became pregnant
Yes, but I wasn’t able to get pregnant
Yes, but I experienced pregnancy loss
I am currently trying to get pregnant
Not yet, but I plan to attempt pregnancy
No, and I don't plan to
I have (or I plan to) become a parent in a way other than carrying the child myself
Other
Were you advised to wait a specific period after treatment before attempting pregnancy?
Yes
No
Not applicable
If you wanted to get pregnant or were pregnant, how did this impact your treatment decisions?
Since your diagnosis and treatment, did you do any of the following: (Select all that apply)
Have one or more biological children you carried yourself
Had one or more children through surrogacy or gestational carrier
Adopted one or more children
Became a foster parent to one or more children
Became a stepparent or a guardian
None
Please describe your surrogacy experience. Did you or your partner contribute genetic material (eggs/sperm)? Did you use eggs from a relative or work with a donor? Feel free to share any aspects of your surrogacy journey that you're comfortable discussing.
If you were considering breastfeeding, did you have concerns about breastfeeding during or after treatment?
Yes, and I received guidance from my medical team
Yes, but I didn’t receive guidance from my medical team
Yes, and I received guidance from people who were not part of my medical team/did research on my own
No, I don’t have concerns
Not applicable
If applicable, what challenges have you experienced with breastfeeding after treatment? (Select all that apply)
Not applicable
Physical limitations due to surgery and/or radiation
Concerns about safety
Milk production issues
Lack of support/guidance
Other
What advice would you give to newly diagnosed young women about fertility preservation?
What would you like healthcare providers to know about supporting young breast cancer patients with fertility concerns?
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Relationships and Support
Friends
Have you experienced any of the following changes in friendships after your diagnosis? (Select all that apply)
Friends withdrew or distanced themselves
Friends provided emotional support
Friends assisted with practical needs (e.g., transportation, meals)
Friendships became stronger
Friendships became strained
No change in friendships
Other
If applicable, describe how some of your friendships changed.
How comfortable are you discussing your diagnosis and treatment with your friends?
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Did you make any new friends for reasons connected to your diagnosis and treatment?
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Family (Parents, Siblings, and Extended Family)
Did your relationship with your parents, or siblings, or extended family change during or after your diagnosis?
If applicable, did you move back in with your parents/siblings or rely on them for caregiving support during treatment?
Yes
No
Not applicable
What types of support did your family provide during your diagnosis and treatment? (Select all that apply)
Emotional support
Financial support
Assistance with daily tasks or caregiving
Assistance with managing your medical appointments/medical care
No support provided
Other
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Children
How did your breast cancer diagnosis and treatment affect your relationship with your children?
Did you have to make adjustments to your caregiving or parenting roles during your treatment?
If you’ve had challenges managing your caregiving or parenting roles during and after treatment, please describe those challenges.
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Demographic Information
In this section, we will ask you questions about your personal characteristics so we can better understand how these factors impact care and outcomes.
What is your sex assigned at birth?
*
Female
Male
Prefer not to answer
What is your gender?
*
Woman
Man
Non-binary
Prefer not to answer
Other
What is your zip code?
What is your marital status?
*
Single
Married
In a committed partnership (e.g., domestic or life partner)
Divorced or separated
Widowed
Prefer not to answer
How do you identify your racial and/or ethnic identities? (Select all that apply)
*
Alaskan Native
American Indian / Native American
Ashkenazi Jewish (Eastern European)
Asian
Black or African American
Hispanic / Latin American
Middle Eastern or North African
Pacific Islander
White
Prefer not to answer
Other
What is your employment status? (select all that apply)
*
Employed full-time
Employed part-time
Self-employed
On short-term disability
On long-term disability
On leave from your job (using a form of leave other than disability leave)
Looking for a job
Unemployed
Retired
Student
Homemaker / stay-at-home parent
Not looking for a job
Prefer not to answer
What is the highest level of education you have completed?
*
Less than high school
High school
Some college/university or vocational training
Associate’s degree
Bachelor’s degree
Masters/Graduate degree
Doctorate
Prefer not to answer
Other
What kind of health insurance do you have? (select all that apply)
*
Medicare
Medicaid
Private insurance purchased through a current or former employer or union
Private insurance purchased directly from an insurance company (e.g., through the Health Insurance Marketplace)
Private Insurance (such as Blue Cross, Aetna, etc.)
Military or Veterans Affairs insurance (such as TriCare or CHAMPVA)
Health Savings Account (HSA)
I don't know / I'm not sure
No insurance
Other
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The Human Flourishing Measure
The “Flourish” measure consists of two questions or items from five domains: happiness and life satisfaction, mental and physical health, meaning and purpose, character and virtue, and close social relationships. This section is optional.
Happiness and Life Satisfaction
Overall, how satisfied are you with life as a whole these days?
Not Satisfied at All
1
2
3
4
5
6
7
8
9
Completely Satisfied
10
1 is Not Satisfied at All, 10 is Completely Satisfied
In general, how happy or unhappy do you usually feel?
Extremely Unhappy
1
2
3
4
5
6
7
8
9
Extremely Happy
10
1 is Extremely Unhappy, 10 is Extremely Happy
Mental and Physical Health
In general, how would you rate your physical health?
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
How would you rate your overall mental health?
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Meaning and Purpose
Overall, to what extent do you feel the things you do in your life are worthwhile?
Not at All Worthwhile
1
2
3
4
5
6
7
8
9
Completely Worthwhile
10
1 is Not at All Worthwhile, 10 is Completely Worthwhile
I understand my purpose in life.
Strongly Disagree
1
2
3
4
5
6
7
8
9
Strongly Agree
10
1 is Strongly Disagree, 10 is Strongly Agree
Character and Virtue
I always act to promote good in all circumstances, even in difficult and challenging situations.
Not True of Me
1
2
3
4
5
6
7
8
9
Completely True of Me
10
1 is Not True of Me, 10 is Completely True of Me
I am always able to give up some happiness now for greater happiness later.
Not True of Me
1
2
3
4
5
6
7
8
9
Completely True of Me
10
1 is Not True of Me, 10 is Completely True of Me
Close Social Relationships
I am content with my friendships and relationships.
Strongly Disagree
1
2
3
4
5
6
7
8
9
Strongly Agree
10
1 is Strongly Disagree, 10 is Strongly Agree
My relationships are as satisfying as I would want them to be.
Strongly Disagree
1
2
3
4
5
6
7
8
9
Strongly Agree
10
1 is Strongly Disagree, 10 is Strongly Agree
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Your Current Life Situation
Please answer the following questions to help us better understand you and your current situation. This section is optional.
Which of the following best describes your current living situation?
Live alone in my own home (house, apartment, condo, trailer, etc.); may have a pet
Live in a household with other people
Live in a residential facility where meals and household help are routinely provided by paid staff (or could be if requested)
Live in a facility such as a nursing home which provides meals and 24-hour nursing care
Temporarily staying with a relative or friend
Temporarily staging in a shelter or homeless
Other
In the past 3 months, did you have trouble paying for any of the following? (select all that apply)
Food
Housing
Heat and electricity
Medical needs
Transportation
Childcare
Debts
None of these
Other
Has lack of transportation kept you from medical appointments or from doing things needed for daily living? (select all that apply)
Kept me from medical appointments or from getting medications
Kept me from doing things needed for daily living
Not a problem for me
If for any reason you need help with activities of daily living such as bathing, preparing meals, shopping, managing finances, etc., do you get the help that you need?
I don’t need any help
I get all the help I need
I could use a little more help
I need a lot more help
Are you a primary caregiver for a child under the age of 18 or for someone who is frail, chronically ill, or has a physical or mental disability? (select all that apply)
Yes, 1+ child(ren)
Yes, someone who is frail, ill or has a disability
No
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?
Never
Rarely
Sometimes
Often
Always
How often do you feel lonely or isolated from those around you?
Never
Rarely
Sometimes
Often
Always
How often do you see or talk to people that you care about and feel close to? (For example, talking to friends on the phone, visiting friends or family, going to church or club meetings)
Less than once a week
1-2 days a week
3-4 days a week
5 or more days a week
How confident are you that you can manage your current medical conditions day-to-day?
Very confident
Somewhat confident
Not confident
How overwhelmed are you with your healthcare?
Not at all
Somewhat
Very
Extremely
In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
On average, how many alcoholic drinks do you consume per WEEK?
Drinks per week
On average, how many DAYS PER WEEK do you consume alcoholic drinks?
Days per week
Do you use tobacco products?
Yes
No
I used in the past but no longer use tobacco
Did your doctor counsel you on smoking cessation?
Yes
No
I don't remember
In the past year, how often have you used cannabis products (including edibles, smoking, vaporizers, CBD)
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Has your doctor counseled you on diet and physical activity?
Yes
No
I don't remember
language
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