Please fill out AFTER your physician consult.Name:______

Patient Knowledge SurveyandTreatment Preference After Surgeon Consultation

This set of questions asks about some facts doctors think are important for patients to know about breast cancer and why patients make certain decisions about their surgery. The correct answers are based on medical studies. Please do your best and pick one answer for each question.

  1. On average, which women with early stage breast cancer live longer?

Women who have a mastectomy on one side

Women who have a lumpectomy and radiation

Women who have a double mastectomy

There is no difference in survival among the different types of surgery

Not sure

  1. With treatment, about how many women diagnosed with early breast cancer will eventually die of breast cancer?

Most die of breast cancer

About half will die of breast cancer

Most will die of something else

Not sure

  1. Who has the highest chance of breast cancer coming back somewhere in the body (not including either breast)?

Lumpectomy patients

Single mastectomy patients

Double mastectomy patients

There is no difference between the different procedures

Not sure

  1. For women with cancer in one breast, how does having a double mastectomy changethe chanceof breast cancer coming back elsewhere in the body (not including either breast)?

Increases the chance

Decreases the chance

Does not change the chance

Not sure

  1. If 100 women have cancer in one breast, about how many will develop cancer in the healthy breast in the five years after treatment?

0-9%

10-19%

20-29%

30-40%

Not sure

  1. Mastectomy surgery can result in complications such as infection and unplanned additional surgeries. On average, which women have a higher chance of complications from surgery?

Women who have a mastectomy on one side

Women who have double mastectomy

There is no difference

Not sure

  1. On average, which women have a higher chance of cancer coming back in

the breast that has been treated?

Women who have a single mastectomy

Women who have a double mastectomy

Women who have a lumpectomy and radiation

There is no difference

Not sure

  1. For most women with early breast cancer, how much would waiting a few

weeks to make a treatment decision affect their chances of survival?

A lot

Somewhat

A little or not at all

Not sure

9. Which of the following procedures does not require future mammogramsfor

follow-up?

Lumpectomy

Single mastectomy

Double mastectomy

Not sure

10. Which type of surgery are you leaning toward for your breast cancer?

Mastectomy on one side

Double mastectomy

Lumpectomy

Not sure (please skip question 12 and go directly to question 13)

Rev #5 11/2/15

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