The Mathematics of Breast Cancer Overtreatment: Improving Treatment Choice Through Effective Communication of Personalized Cancer Risk
Phase: NA
Conditions: Ductal Carcinoma in Situ
Sponsor: Duke University

Official Title: The Mathematics of Breast Cancer Overtreatment: Improving Treatment Choice Through 
Effective Communication of Personalized Cancer Risk 
NCT: NCT03775213 
Document Date: November 11th, 2022 
Principal Investigator (PI): 
Marc D. Ryser, PhD 
 
 
 
 
Duke University 
 
 
 
 
Durham, NC 27701 
 
 
 
 
Marc.ryser@duke.edu 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Table of Contents 
Purpose of the Study ..................................................................................................................................... 3 
Background & Significance ............................................................................................................................ 3 
Overtreatment in Breast Carcinoma in Situ (DCIS). .................................................................................. 3 
Scientific Premise for Active Surveillance in DCIS. .................................................................................... 3 
Empowering Patients through Personalized Decision Aids (DA). ............................................................. 3 
Design & Procedures ..................................................................................................................................... 4 
Introduction .............................................................................................................................................. 4 
Justification & Feasibility .......................................................................................................................... 4 
Research Design ........................................................................................................................................ 4 
Expected Outcomes .................................................................................................................................. 5 
Rigor and Transparency ............................................................................................................................ 5 
Potential Problems & Alternative Approaches ......................................................................................... 5 
Selection of Subjects ..................................................................................................................................... 5 
Subject Recruitment and Compensation ...................................................................................................... 5 
Subject’s Capacity to Give Legally Effective Consent .................................................................................... 5 
Risk/Benefit Assessment ............................................................................................................................... 6 
Benefits ..................................................................................................................................................... 6 
Costs to the Subject ...................................................................................................................................... 6 
Data Safety and Monitoring .......................................................................................................................... 6 
References .................................................................................................................................................... 7 
Appendix 1: Decision Support Tool Questionnaire ..................................................................................... 11 
 
 
 
 
 
 
 
 

Purpose of the Study 
Implement a RCT to test the main hypothesis that the use of personalized decision aids leads to (i) an 
increase in the proportion of women who would consider active surveillance as a viable management 
strategy for DCIS, and (ii) an increase in knowledge of the associated risk trade-offs. 
 
The central hypothesis is that communication of model-based personalized risk projections leads to an 
improved understanding of the trade-offs associated with different management strategies for DCIS. 
 
Background & Significance 
Overtreatment in Breast Carcinoma in Situ (DCIS). Each year in the United States alone, 
approximately 60,000 women will be diagnosed with DCIS (10). More than 97% of diagnosed women will 
choose immediate treatment, either surgery alone, or surgery in combination with radiation or 
chemotherapy (11). Since it is estimated that only 20-30% of DCIS lesions eventually become invasive 
(12, 13), this year, as many as 45,000 women will undergo radical surgery for a lesion that would not 
cause any harm in their remaining lifetime. The treatments, and thus the consequences of current DCIS 
management, are similar to those of treatment for invasive cancers. Consequences include pain (14-16), 
reduced quality of life (17, 18), increased risk of angiosarcoma and ischemic cardiac disease (due to 
radiation) (19, 20). 
 
Scientific Premise for Active Surveillance in DCIS. The concept of AS was introduced to manage 
prostate cancer, because many men die with their prostate cancer, rather than from it, and treatment 
can be associated with profound morbidity. In AS, definitive therapy is not implemented at diagnosis. 
Instead, decisions about whether and when to intervene are based on subsequent disease behavior 
during surveillance over time (21). The AS approach allows the biologic behavior of a monitored tumor 
to dictate therapy, thus effectively reducing overtreatment by reserving aggressive interventions only 
for those likely to derive benefit from them. Because it is a non-invasive lesion with unknown 
malignancy potential, DCIS is comparable to early-stage prostate cancers for which AS is effective. 
However, currently only 3% of patients diagnosed with DCIS elect AS (22). Retrospective studies suggest 
that surgery may not improve survival for low-grade DCIS (23); however, prospective data remain 
scarce. 
 
Empowering Patients through Personalized Decision Aids (DA). In the absence of prospective 
data for AS in patients with DCIS, the current paradigm of surgical treatment is unlikely to change in the 
near future. Since randomized controlled trials (RCTs) on AS have only recently started (7-9), relevant 
data is a long way off. At the same time, there is a great wealth of existing clinical and biological data on 
DCIS. However, because these resources are dispersed across a large number of data and knowledge 
sources, they remain largely inaccessible to patients and their physicians. To overcome this information 
barrier, the proposed research is expected to yield the best-possible individualized risk and uncertainty 
projections for patients diagnosed with DCIS, and to effectively communicate these projections via 
personalized DAs. This contribution is significant because it is expected to enable future DCIS patients to 
evaluate the trade-offs associated with different management strategies, and to make an informed 
decision that is aligned with their personal risk tolerance. By increasing the acceptability of AS through 
effective communication of personalized risks, the proposed research has a significant impact on the 
NIH’s mission to reduce morbidity and enhance health. 
 

Design & Procedures 
Implement an RCT to test the main hypothesis that the use of personalized decision aids leads to (i) an 
increase in the proportion of women who would consider active surveillance as a viable management 
strategy for DCIS, and (ii) an increase in knowledge of the associated risk trade-offs. The consents and 
associated documents will be uploaded for review and approval before recruitment/consent. 
 
Introduction. The objective of this study is to evaluate the impact of the DA on the understanding and 
acceptability of AS. For ethical reasons, we will test the main hypothesis in a hypothetical scenario in 
women without a personal history of cancer. The rationale for this aim is that, if successful in women 
with no personal history of cancer, we will advance towards the long-term goal of reducing 
overtreatment of DCIS. This aim will be informed by both the cognitive interviews (Aim R2a) and DA pre-
testing (Aim R2c). All documents that will be used during this aim will be uploaded to this application 
once they are developed. We will submit modifications before beginning any data collection. Materials 
and consent documents will be developed for both the 202 participants for the RCT as well as for the 
beta-testing portion. All documents will be uploaded to the IRB once they are developed. No 
participants will be recruited/consented until an amendment is reviewed and approved by the IRB. 
 
Justification & Feasibility. Because there is no clear distinction between attitude and choice in a 
hypothetical scenario, the commonly used evaluation measure of informed choice (39, 48) is unsuitable. 
We focus instead on the proportion of women who would choose AS as their preferred treatment 
option. Our working hypothesis is that the personalized DA will increase this proportion, because DCIS-
specific mortality under AS is comparable to early-stage prostate cancer-specific mortality under AS (49), 
and 35-50% of men diagnosed with early-stage prostate cancer choose AS (50-52). Thus, it is plausible 
that AS could be considered a viable option for DCIS if the trade-offs for different management 
strategies are effectively communicated. Similar to previous DA evaluations (40, 53), we will use an RCT 
design. Since many women are unaware of AS in breast cancer (54), the control arm plays a crucial role 
by accounting for potential novelty priming. 
 
Research Design. A parallel-arm double-blind RCT of 202 women to evaluate DST (decision support 
tool) with AS as an option (intervention) vs. DST without AS as an option (control) for a hypothetical 
diagnosis with low-grade DCIS. The primary outcome is treatment choice (binary: AS vs non-AS). 
Secondary outcomes include: acceptability of the different treatment options; perceived riskiness of the 
AS option, and pre- vs post-knowledge about DCIS (self-reported). Using the secure web portal REDCap, 
eligible consented women will complete three phases: randomization, baseline, and 
endline. Randomization phase: 1:1 randomization to control (surgery options only) or intervention 
(surgery options plus active surveillance option) arms, stratified by age group (< 65, 65+) to ensure 
balance of age-specific mortality risks. Block randomization (k=6) will be used. Baseline phase: all 
women will receive information about a hypothetical DCIS diagnosis and complete: 1) a baseline 
questionnaire about breast cancer and DCIS knowledge. Endline phase: after self-directed exploration of 
provided content, primary and secondary outcomes will be measured by questionnaire. A series of 
additional covariates and personality scales will also be elicited with the questionnaire. Each woman is 
expected to take at most one hour to complete the entire study task. In addition to the questionnaire, 
the team will collect basic website user analytics such as the order in which the website is explored, and 
how long participants spend on each page. Eligibility. Consented female participants of age 50-79 years, 
with no history of breast cancer and with a negative mammographic screen within the preceding 12 
months. A financial incentive will be provided. Beta-testing. Before roll-out of the RCT, beta-testing of 
the evaluation will be conducted in 30 women (15 in each trial arm). 

 
Expected Outcomes. An RCT-validated DA that improves understanding of the trade-offs associated 
with different management strategies for DCIS, and that increases acceptability of AS as a viable 
management strategy. 
 
Rigor and Transparency. Rigor in DA evaluation is achieved by using a parallel-arm, double-blind 
randomized controlled trial design. Highest possible robustness and transparency of the approach will 
be achieved by registering the trial with clinicaltrials.gov and adhering to CONSORT guidelines for 
analysis. 
 
Potential Problems & Alternative Approaches. Our working hypothesis is that the use of a 
personalized DA will increase the proportion of women who consider AS a viable management strategy 
for DCIS. Although our model projections (60) solidly support this hypothesis, it may not be confirmed 
here. In this unlikely case, we will analyze secondary outcomes and baseline risk measures to determine 
whether the lack of effect was due to poor understanding of DA content or was associated with low 
personal risk tolerance. Because the DA provides projections for all management modalities, it remains 
valuable even for women who are opposed to AS. 
 
Selection of Subjects 
Sex: Female 
Age: 50-79 years 
Has had a negative mammographic screen in the past 12 months 
No personal history of breast cancer 
Subject Recruitment and Compensation 
For beta-testing (n=30) and the full randomized study (n=202), a total of 232 women will be recruited 
from the Duke Mammography Clinic. We will use a MaestroCare MyChart recruitment invitation to help 
identify potential participants. Potential subjects are identified via a report generated within 
MaestroCare by the DOCR MaestroCare Analyst team. A recruitment invitation will be sent by a DOCR 
analyst to potential subjects via MyChart. The patient will indicate if they are interested and the study 
coordinator will be sent an Inbasket message (MaestroCare internal message) if they are interested. 
Only key personnel who are delegated the task of patient identification/recruitment will have access to 
the Inbasket messages. Only patients who express interest will be contacted by key personnel, who will 
then follow the recruitment process approved by the IRB for this study. The study coordinator may 
follow-up (up to 3 times) with patients (by phone, email, or via MyChart message) if they expressed 
initial interest in the study. Patients who have opted out of research contact, via yellow dot in Maestro, 
will not be contacted. Patients will not be contacted more than three times, including via phone and 
email. If a patient states they would like to opt out, the study team will follow the Duke Recruitment and 
Engagement policy. 
 
RCT beta-testing and randomized study compensation: $25/survey 
Subject’s Capacity to Give Legally Effective Consent 
Not applicable, only subjects capable of giving consent themselves will be eligible for inclusion in the 
study. 

Risk/Benefit Assessment 
The potential risks to RCT participants (Aim R3) include accidental disclosure of their identity or 
identifiable responses. This would result in the disclosure of the participant’s identity, their opinion 
about the utility of the decision aid for communicating risk, and the self-reported effect of decision aid 
material on their perceived acceptability of active surveillance as a management strategy for DCIS. 
Because the participants have had a negative mammogram within the past 12 months and have no 
personal history of breast cancer, the risks of psychological harms by engaging with the decision aid 
content is expected to be minimal. Because there are few anticipated risks, in our opinion, the benefits 
driven from the causally strong conclusions of the trial outweigh the very minimal risks to the 
participants. 
 
Only self-reported participant data and basic demographics will be collected for this study. The planned 
procedures for protecting against and minimizing potential risks include: use of a secure system for data 
collection; storage of data in a secure relational database requiring two-factor authentication. 
 
Benefits: 
Potential direct benefits of the research to research participants include intellectual satisfaction in 
participating in the pre-testing of a decision aid for breast cancer patients, and the satisfaction of 
contributing to the advancement of knowledge about decision aid development for breast cancer 
patients. The benefits to cancer care and society include the potential to generate new knowledge 
about informed decision making, and the potential for this work to steer future research in the 
management of breast carcinoma in situ. The minimal risks to subjects are considered reasonable in 
relation to the anticipated benefits to research participants and society overall. 
Costs to the Subject 
There are no costs that the subject will incur as a result of participation 
Data Safety and Monitoring 
The DA will be evaluated in women without a personal history of breast cancer. Participants will be 
presented with a hypothetical DCIS diagnosis scenario only, and the study does not involve medicinal 
products or medical devices. Furthermore, the DA will be developed following best practice guidelines 
from the Society of Medical Decision Making and with input from an expert in the user experience 
design industry. Most importantly, we will seek to minimize potential psychological risks to participants 
in the study. Based on these considerations, we anticipate minimal risks to the participants and very low 
risk of (serious) adverse events. In the case of an adverse event, however, it will be reported in 
accordance with Duke IRB guidelines. 
 
 
 
 

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Appendix 1: Decision Support Tool Questionnaire 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Survey: Decision support website
In this survey, we will ask you to explore a decision support website.
 
The website is designed for patients diagnosed with ductal carcinoma in situ (abbreviated as DCIS). It is okay if you
have never heard of DCIS before. The website will provide plenty of information about it.
 
After exploring the website, you will be asked to answer questions about your experience and what you learned.
2
One quick note before you get started: Please be sure you are on a laptop or desktop computer (not a tablet or
phone), using one of the browsers listed below. Microsoft Explorer is not supported.
o Google Chrome (Windows/Mac): Install Chrome
o Apple Safari (Mac): Install Safari
o Microsoft Edge (Windows): Install Edge
Please remember that to receive compensation for this study, you need to complete the survey. Information to
provide compensation will be collected at the end of the survey.
Before exploring the website, we have a couple of questions to help us understand how much you currently know
about breast cancer and DCIS.
Please rate on the scale, how much do you know about
1 I know very little about breast cancer
breast cancer?
2
3
4
5 I know a lot about breast cancer

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Please rate on the scale, how much do you know about
1 I know very little about DCIS
ductal carcinoma in situ, abbreviated as DCIS?
2
3
4
5 I know a lot about DCIS
For this study, we would like you to imagine you were just diagnosed with DCIS. 
 
With this in mind, we will ask you to carefully explore the DCIS website. To make your life easier, we will show you
the website content in three separate links on the following pages. 
 
When you are done exploring all three sections of the website, you will be asked to make a treatment decision.
Below is the link to the first section to explore, the Guide. It will open in a new window. When you are done exploring,
return back here and click 'Next Page.'
 
Please click the link below and use the following access code:  [record-name]
 
Click Here (Link 1 of 3): Guide
Below is the link to the second section to explore, the Decision Support Tool. It will open in a new window. When you
are done exploring, return back here and click 'Next Page.' 
 
Please click the link below and use the following access code:  [record-name]
 
Click Here (Link 2 of 3): Decision Support Tool
I confirm that I have finished exploring the Decision
Yes, I am ready to continue
Support Tool.
Below is the link to the last section to explore, the Information Center. It will open in a new window. When you are
done exploring, return back here and click 'Next Page.' 
 
Please click the link below and use the following access code:  [record-name]
 
Click Here (Link 3 of 3): Information Center

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I confirm that I have finished exploring the three
Yes, I am ready to continue
links provided and I am ready to continue the survey.
(If not, please finish exploring the three links; they
are provided at the bottom of this page)
 
Keep in mind, you can revisit any of the sections at
any time while completing the survey (your access
code: [record-name])
 Guide
Decision Support Tool
Information Center
If you were a patient diagnosed with DCIS, what
Active monitoring
treatment option would you choose?
Lumpectomy
Lumpectomy with radiation
Mastectomy
Why did you choose this treatment option? (You may
list several reasons)
 
__________________________________________
Please rate, how confident are you in your treatment
1 Not at all confident
choice?
2
3
4
5 Very confident
How comfortable would you be with active monitoring as
1 Not at all comfortable
your initial treatment for DCIS?
2
3
4
5 Very comfortable

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How comfortable would you be with lumpectomy as your
1 Not at all comfortable
initial treatment for DCIS?
2
3
4
5 Very comfortable
How comfortable would you be with lumpectomy with
1 Not at all comfortable
radiation as your initial treatment for DCIS?
2
3
4
5 Very comfortable
How comfortable would you be with mastectomy as your
1 Not at all comfortable
initial treatment for DCIS?
2
3
4
5 Very comfortable
If you choose active monitoring as your treatment, how
1 Not at all likely
likely is it that your DCIS will progress to invasive
2
cancer within 10 years after diagnosis?
3
4
5 Very likely
Please note: for the rest of the survey when we use the term 'DCIS website', we are referring to the collection of all
three links you reviewed (Guide, Decision Support Tool, and Information Center).
After you have reviewed the DCIS website, how much do
1 I know very little about DCIS
you know about ductal carcinoma in situ, abbreviated
2
as DCIS?
3
4
5 I know a lot about DCIS
What do you think about the amount of information on
1 Too little information was provided
the DCIS website?
2
3
4 The amount of information was just right
5
6
7 Too much information was provided
How clear was the information on the DCIS website?
1 Not at all clear
2
3
4 Somewhat clear
5
6
7 Extremely clear

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How helpful was the information on the DCIS website
1 Not at all helpful
for making a decision about DCIS treatment?
2
3
4 Somewhat helpful
5
6
7 Extremely helpful
Would you recommend the DCIS website to a friend
1 No
diagnosed with DCIS?
2
3
4 Not sure
5
6
7 Yes
How likely might a breast biopsy miss invasive cancer?
A biopsy will always show correctly if there is
invasive cancer
There is about a 1-5 % chance that biopsy misses
invasive cancer
There is about a 6-10 % chance that biopsy misses
invasive cancer
There is about an 11-15 % chance that biopsy
misses invasive cancer
There is a more than 15% chance that biopsy misses
invasive cancer
Is DCIS the same as invasive breast cancer?
Yes
No
The following options are used to treat DCIS patients
Active monitoring
(choose all that apply):
Endocrine therapy
Lumpectomy
Mastectomy
Chemotherapy
Radiation
For a woman diagnosed with DCIS, how much does waiting
A lot
3-4 weeks to make a treatment decision affect her
Somewhat
chances of survival?
A little or not at all
With active monitoring, about how many women diagnosed
Most will die of breast cancer
with DCIS do you think will die of breast cancer in 10
About half will die of breast cancer
years?
Most will NOT die of breast cancer
After which treatment is it more likely that women
Lumpectomy
will need to have a second surgery to remove leftover
Mastectomy without reconstruction
tumor cells?
Equally likely for both

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Which treatment option does NOT affect the appearance
Active monitoring
of the breast?
Lumpectomy
Lumpectomy with radiation
Mastectomy
On average, which DCIS patients do you think have the
Women who choose active monitoring
highest chance of being diagnosed with invasive cancer
Women who choose a mastectomy
in the same breast, within 10 years of diagnosis?
Women who choose a lumpectomy with radiation
There is no difference between the above options
After a lumpectomy, what is the traditional schedule
1 day a week for 5 to 6 weeks
for radiation treatment?
3 days a week for 6 weeks
5 days a week for 3 weeks
5 days a week for up to 10 weeks
Out of 100 women who have radiation treatment after
Fewer than 2
lumpectomy, how many will have serious side effects,
2-4
such as another cancer, heart problems, or lung
5-10
problems?
11-20
More than 20
Mark whether some women have this side effect from
Fatigue
radiation treatment after lumpectomy (choose all that
The breast skin might change color
apply):
The breast feels harder and thicker
Migraines

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In your opinion, does the DCIS website...
...help women recognize that a treatment decision
Not at all
needs to be made?
A little
Somewhat
Quite a bit
A great deal
...prepare women to make better treatment decisions?
Not at all
A little
Somewhat
Quite a bit
A great deal
...help women think about the pros and cons of each
Not at all
treatment option?
A little
Somewhat
Quite a bit
A great deal
...help women think about which treatment option pros
Not at all
and cons are most important?
A little
Somewhat
Quite a bit
A great deal

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In your opinion, does the DCIS website...
...help women know that the treatment decision depends
Not at all
on what matters most to them?
A little
Somewhat
Quite a bit
A great deal
...help women recognize their own thoughts about the
Not at all
treatment decision?
A little
Somewhat
Quite a bit
A great deal
...help women think about how involved they want to be
Not at all
in the treatment decision?
A little
Somewhat
Quite a bit
A great deal
...help women identify questions they want to ask
Not at all
their doctor?
A little
Somewhat
Quite a bit
A great deal
...prepare women to talk to their doctor about what
Not at all
matters most to them?
A little
Somewhat
Quite a bit
A great deal
To help us improve the DCIS website, please recommend
what we could change:
__________________________________
Now, we would like to ask you questions about you. While answering questions from now on, please think about
yourself and your personal experiences.
How often do you need someone to help you when you are
Rarely
given information to read by your doctor, nurse, or
Sometimes
pharmacist?
Often

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When you need help with medical information can you
Rarely
easily get a hold of someone to assist you?
Sometimes
Often
Do you need help to fill in official medical documents
Rarely
(such as an insurance application)?
Sometimes
Often
Are you someone who likes to find out different
Rarely
information about your health?
Sometimes
Often
How often do you think carefully about whether health
Rarely
information makes sense in your particular situation?
Sometimes
Often
How often do you try to find out whether information
Rarely
about your health can be trusted?
Sometimes
Often
Are you the sort of person who might question your
Rarely
doctor or nurse's advice based on your own research?
Sometimes
Often

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On the graph below, you see the percentage of people that die from different forms of cancer.
Approximately what percentage of people who die from cancer die from colon cancer, breast cancer, and prostate
cancer taken together?
100%
25%
75%
50%
Can't say

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In a magazine, you see two advertisements, one on page 5 and another on page 12. Each is for a different drug for
treating heart disease, and each includes a graph showing the effectiveness of the drug compared to a placebo
(sugar pill).
Compared to the placebo, which treatment leads to a
Crosicol
larger decrease in the percentage of patients who die?
Hertinol
They are equal
Can't say

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The following figure shows the number of men and women among patients with disease X. The total number of
circles is 100.
How many more men than women are there among 100 patients with disease X?
100
60
40
20
80
Can't say
In the newspaper you see two advertisements, one on page 15 and another on page 17. Each is for a different
treatment of psoriasis, and each includes a graph showing the effectiveness of the treatment over time.

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Which of the treatments contributes to a larger decrease in the percentage of sick patients?
Apsoriatin
Nopsorian
They are equal
Can't say

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Sometimes, medical action is clearly necessary, and sometimes it is clearly not necessary. Other times, reasonable
people differ in their beliefs about whether medical action is needed. 
In situations where it's not clear, do you tend to lean towards taking action or do you lean towards waiting and
seeing if action is needed?
I strongly lean toward waiting and seeing
I lean toward waiting and seeing
I somewhat lean toward waiting and seeing
I somewhat lean toward taking action
I lean toward taking action
I strongly lean toward taking action
Taking risks makes life more fun.
1 Strongly disagree
2
3
4
5 Strongly agree
My friends would say that I'm a risk taker.
1 Strongly disagree
2
3
4
5 Strongly agree
I enjoy taking risks in most aspects of my life.
1 Strongly disagree
2
3
4
5 Strongly agree
I would take a risk even if it meant I might get hurt.
1 Strongly disagree
2
3
4
5 Strongly agree
Taking risks is an important part of my life.
1 Strongly disagree
2
3
4
5 Strongly agree

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I commonly make risky decisions.
1 Strongly disagree
2
3
4
5 Strongly agree
I am a believer of taking chances.
1 Strongly disagree
2
3
4
5 Strongly agree
I am attracted, rather than scared by risk.
1 Strongly disagree
2
3
4
5 Strongly agree
Pain seems to cause my heart to pound or race.
0 Never
1
2
3
4
5 Always
When I hurt I think about pain constantly.
0 Never
1
2
3
4
5 Always
I dread feeling pain.
0 Never
1
2
3
4
5 Always
As soon as pain comes on, I take medication to reduce
0 Never
it.
1
2
3
4
5 Always

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Having a thin body shape is...
1 Not at all important compared to other things in
my life
2
3
4
5
6 The very most important thing in my life
Being physically attractive to other people is...
1 Not at all important compared to other things in
my life
2
3
4
5
6 The very most important thing in my life
My personal appearance is...
1 Not at all important compared to other things in
my life
2
3
4
5
6 The very most important thing in my life
Feeling good about the way I look is...
1 Not at all important compared to other things in
my life
2
3
4
5
6 The very most important thing in my life
Think about you and your attitude toward cancer in your life.
How worried are you about getting cancer someday?
1 Not at all
2
3
4
5 Almost all the time
How much does your worry affect your mood?
1 Not at all
2
3
4
5 Almost all the time
How much does your worry affect your ability to
1 Not at all
perform your daily activities?
2
3
4
5 Almost all the time

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To help you classify how healthy you feel, we have
drawn a scale for you to report how good or bad your
health is in general; 100 being the best health for
someone your age and 0 being the worst health for
someone your age.
To indicate how healthy you feel, please use the
0 = Worst health 
100 = Best health
slider to select the value that corresponds to your
for someone your
for someone your
response.
age
50
age
(Place a mark on the scale above)           
What is your current marital status?
In Relationship
Married
Divorced
Separated
Single
Other
What is your age in years?
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
Are you Hispanic or Latina?
Yes
No
With which of the following groups do you most closely identify (check all that apply)?
White
Black or African American
American Indian or Alaska Native
Asian or Pacific Islander
Other
If "Other," please specify
 
__________________________________

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What is your highest level of education?
Some high school
High school
Bachelor's degree
Master's degree
Professional degree (e.g., MD, JD)
Doctorate degree (e.g., Ph.D.)
How would you describe your household's financial situation right now?
After paying the bills, you still have enough money for special things you want
You have enough money to pay the bills, but little spare money to buy extra or special things
You have money to pay the bills, but only because you have cut back on things
You are having difficulty paying the bills, no matter what you do
Do you have a personal history of cancer (any type)?
Yes
No
Do you have a family history of cancer? (here, by family we mean those related to you by blood)
Yes
No
If yes please choose among options below, (you may choose several options):
My parent
Grandparent
Sibling
Other
If "Other," please specify:
 
__________________________________
Is English your main language at home?
Yes
No