Study ID number:
Date of questionnaire completion: __ __ /__ __ / ______
Fertility Preservation Trends in Young Breast Cancer Patients
- How old were you when you were diagnosed with breast cancer?...... ______
- Do you still have menstrual periods?
Yes...... [ ]
No...... [ ]
Not sure...... [ ]
- What treatments did you receive for your breast cancer? (Mark all that apply)
Surgery...... [ ]
Radiation...... [ ]
Chemotherapy...... [ ]
Endocrine therapy (Tamoxifen, Arimidex,
Femara, Aromasin)...... [ ]
If you received endocrine therapy, please go to Question 4.
If you did not receive endocrine therapy, please go to Question 5.
- Are you still taking Endocrine therapy (Tamoxifen, Arimidex, Femara, Aromacin)?
Yes...... [ ]
No...... [ ]
Not sure...... [ ]
- When did you complete your last type of treatment (surgery, radiation, chemotherapy – excludingEndocrine therapy)?
Month: ______Year: ______
After answering questions 4 or 5, please go to question 6.
- What was your marital status when you were diagnosed with breast cancer?
Married/long-term partner...... [ ]
Separated/divorced...... [ ]
Widowed...... [ ]
Never married...... [ ]
Other...... [ ]
Please describe:______
- At the time of your cancer diagnosis, how many biological children (not adopted or children by marriage) did you have?
0...... [ ]
1...... [ ]
2...... [ ]
3 or more...... [ ]
- Since your diagnosis, have you had any biological children?
Yes...... [ ]
No...... [ ]
- Do you plan to have more biological children in the future?
Yes...... [ ]
No...... [ ]
Not sure...... [ ]
- Did anyone explain to you how cancer treatment affects your ability to have children?
Yes...... [ ]
No...... [ ]
Not sure...... [ ]
- Did anyone talk to you about egg or embryo freezing as a way to preserve your ability to have children after cancer treatment?
Yes...... [ ](Go to Question 11a)
No...... [ ](Go to Question 12)
Not sure...... [ ](Go to Question 12)
11a. Who talked to you about egg or embryo freezing as a way to preserve your ability to have children?
Breast Surgeon...... [ ]
Oncologist...... [ ]
Primary care doctor...... [ ]
Gynecologist...... [ ]
Nurse...... [ ]
Someone else...... [ ]
Please describe: ______
- Were you offered a consultation with a fertility specialist?
Yes...... [ ]
No...... [ ]
Not sure...... [ ]
- Did you actually see a fertility specialist?
Yes...... [ ](Go to Question 14)
No...... [ ](Go to Question 15)
Not sure...... [ ](Go to Question 15)
- Did you have egg/embryo freezing?
Yes...... [ ](Go to Question 16)
No...... [ ](Go to Question 14a)
Not sure...... [ ](Go to Question 14a)
14a.Why did you not have egg/embryo freezing (check all that apply)?
I was not interested in that option...... [ ]
I did not have a partner at this time...... [ ]
The procedure was not covered by my insurance...... [ ]
My family/spouse/friends discouraged me...... [ ]
I thought it is going to delay my treatment...... [ ]
I thought it was going to have a negativeeffect on my treatment...[ ]
I thought it was unethical...... [ ]
I have some other reason...... [ ]
Please describe:______
After answering Question 14a, please go to Question 16.
- Why did you NOT see a fertility specialist? (Mark all that apply)
I did not want any (more) children...... [ ]
I am not interested in that option...... [ ]
I don’t have a partner at this time...... [ ]
The visit is not covered by my insurance...... [ ]
My family/spouse/friends discouraged me...... [ ]
I think it is going to delay my treatment...... [ ]
I have some other reason...... [ ]
Please describe:______
15a.Do you want to see a fertility specialist now?
Yes...... [ ]
No...... [ ]
Not sure...... [ ]
- Whose opinion most affected your fertility decisions?
Please rank your answers from 1 to 5 with 1 being the person whose opinion was most important and 5 being the person whose opinion was least important.
Please rank “Other” as 5 if you don’t have a particular person in mind.
Parents......Spouse/partner......
Friends/family other than spouse/partner......
Doctor......
Other (please describe):
______
- Do you have any regrets regarding your fertility decisions after your cancer diagnosis?
Yes...... [ ]
No...... [ ]
Not sure...... [ ]
The last questions are about you. We ask these questions because it helps us understand more about which patients have or have not received information about preserving their fertility.
- What is your current age? ...... ______
- What is your current marital status?
Married/long-term partner...... [ ]
Separated/divorced...... [ ]
Widowed...... [ ]
Never married...... [ ]
Other...... [ ]
Please describe: ______
- What is your educational level?
High school or less/GED...... [ ]
Some college, including technical schools and certification programs [ ]
College graduate...... [ ]
More than college...... [ ]
- What is your race/ethnicity?(Please mark all that apply)
White, not of Hispanic origin...... [ ]
Black, not of Hispanic origin...... [ ]
Hispanic...... [ ]
Asian or Pacific Islander...... [ ]
American Indian or Alaskan Native...... [ ]
Other...... [ ]
Please describe:______
- What type of health insurance did you have at the time of your initial cancer diagnosis (check all that apply)?
Private HMO...... [ ]
Private PPO...... [ ]
Medicaid or Medicare...... [ ]
Military/VA...... [ ]
No insurance...... [ ]
Unsure...... [ ]
Other...... [ ]
Please describe:______
- What type of health insurance do you have now (check all that apply)?
Private HMO...... [ ]
Private PPO...... [ ]
Medicaid or Medicare...... [ ]
Military/VA...... [ ]
No insurance...... [ ]
Unsure...... [ ]
Other...... [ ]
Please describe:______
Comments:
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