Identification:_________
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First keyer:
Name: _______________
Second keyer:
Shanghai Breast Cancer Survival Study Questionnaire
(English Translation)
Hello! I am one of the researchers from the Shanghai Municipal Center for Disease Control & Prevention and
Shanghai Institute of Public Health. We are conducting a survey to study the factors that are related to treatment
of and recovery from breast cancer. We will be asking some questions related to your diagnosis and treatment
for the disease, and a few questions related to your quality of life. You don’t have to answer the questions
that you don’t feel comfortable with. Your interview will be audiotaped for quality control purpose. All
the information collected will be kept strictly confidential. The knowledge gained from this study will benefit
other women who have the same disease as you. We would greatly appreciate your participation in this
important study. Participation in this study is entirely voluntary and will not affect your relationship with your
physician and treating hospital. For those who have passed away we feel very sorry and will be very grateful to
their family for their help to complete the first three parts of the questionnaire.
Interviewer: _______________________
Date of interview:
Time of interview:
Year
Month
Morning……..1
Afternoon……2
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day
Time:_______
Record tape number: ________________
1
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Part One
General Information
A1. District of interviewee on resident registration card:_____________
Address:
.
Telephone No.:
Current address:______________________________________
Telephone No.:_______________________________________
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A2. Date of birth:______Year_____Month_____Day
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A3. ID number:
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A4. Have you ever suffered any other tumors before being diagnosed with breast cancer?
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1…Yes
2…No
8…Don’t know
A5. Survival status
1…Alive (Skip to question A6)
2…Died
8…Unknown (Skip to question A6 after question A5a)
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A5a. The last known date of being alive (If already died, fill in the date of death):
Year
Month
Day
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A5b. Cause of death:
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A5c. Place of death:
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1…Hospital
2…Home
3…On the way to hospital
4…Other (Please specify)
A5d. Criteria for establishing the cause of death:
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1…Clinical manifestations
2…Laboratory examinations (e.g., CT, X-ray, ultrasound, and bone scan, etc.), which
confirmed occurrence of metastasis before death
3…Autopsy
4…Other (Please specify)
A6. We would like to keep in contact with you periodically to update the information about your health
condition. If you plan to move soon or cannot be reached at home for any reason, please tell us the name of one
of your relatives or friends, as well as his/her address, phone number and workplace, etc.
.
.
2
Part Two
Disease Information
B1. When were you diagnosed with breast cancer?
Year
Month
Day
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B1a. Hospital where first diagnosis was given:
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B1b. Site of cancer
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1…Left breast
2…Right breast
3…Both breasts
B1c. Pathologic number:______________
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B2. Have you ever received operation over breast since being diagnosed with breast cancer?
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1…Yes
2…No (Skip to question B3)
8…Don’t know (Skip to question B3)
B2a. Date of operation:
Year
Month
Day
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B2b. Hospital of operation:
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B2c. Site of operation:
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1…Left breast
2…Right breast
3…Both breasts
B2d. Type of operation:
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1…Needle aspiration biopsy
2…Partial/subtotal mastectomy
3…Total (simple) mastectomy without removing axillary lymph nodes
4…Radical mastectomy
5…Other (Please specify)
.
B2e. Hospitalization No.:_______________
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B3. Have you ever received estrogen receptor (ER) and progesterone receptor (PR) testing? What about the
results?
No
- (negative) +- (neutral) +
++
+++ Positive
Unknown
ER:
1
2
3
4
5
6
7
8
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PR:
1
2
3
4
5
6
7
8
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B4. Have you ever received radiation therapy of chest wall since being diagnosed with breast cancer?
1…Yes
2…No (Skip to question B5)
8…Other (Skip to question B5)
B4a. Date of first therapy:
Year
Month
B4b. Date of last therapy:
Year
Month
B4c. Total amount of therapy time (not including therapy-free interval)
1…Week(s)
2…Month(s)
B4d. Hospital of radiotherapy:________________
B4e. Admission/X-ray number:________________
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B5. Have you ever received chemotherapy since being diagnosed with breast cancer (e.g., doxorubicin,
cyclophosphamide, etc.)?
1…Yes
2…No (Skip to question B7)
8…Don’t know (Skip to question B7)
3
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B6. Please provide some information on chemotherapy:
B6.a
Chemotherapy
regimen/
Drug name
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1.
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B6.b
Date of
first therapy
B6.c
Date of
last therapy
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B6.h
Outpatient No.
/Hospitalization
No.
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6.
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B6.g
Hospital
name
|Month
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5.
|Year
B6.f
Amount
of actual
therapy time
(days)
|Month
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4.
B6.e
Total cycle
Of therapy
|Month
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3.
B6.d
Dose/time
1…g 2…ml
3…pill 4..mg
5…unit
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B7. Have you ever taken Tamoxifen or other similar medications (such as Toremifene or Raloxifene)
since being diagnosed with breast cancer?
1…Yes
2…No (Skip to question B8)
8…Don't know (Skip to question B8)
B7.a
Drug name
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1.
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2.
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3.
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4.
B7.b
Date of
first use
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B7.c
Date of
last use
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B7.d
Dosage
(mg/day)
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B7.e
Amount of actual time
on medication
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B8. Have you ever received immunotherapy (e.g., IL-2, Lak cell, interferon, etc.) since being diagnosed with
breast cancer?
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1…Yes
2…No (Skip to question C1)
8…Don’t know (Skip to question C1)
B9. Please provide some information on immunotherapy:
B9.a
Immunotherapic
agent
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B9.b Administration
1...Oral
2...Injection
3...Other
(Specify)
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B9.c
Date of
first therapy
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1.
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B9.d
Date of
last therapy
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Year
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B9.f
Amount
of actual
therapy time
(weeks)
|Month
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3.
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B9.e Frequency of
therapy
1...Daily
2...Every other
day
3...Cyclically
4…Irregularly
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