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Breast Cancer Questionnaire

Hello,

Thank you for participating in this research project about the cause of breast cancer. One of our research goals is to build a profile of women who have been diagnosed with breast cancer in an attempt to discover how we can reduce the frequency of this disease - before it starts. The results will be used to develop causal theory and some means of introducing women to potential causes of breast cancer as well as helping women like you reduce your chances of reoccurrence. The questionnaire is several pages long because, as you know, breast cancer is a very complex disease. So please take your time and answer the questionnaire completely.

Since we are interested in possible causes for the disease rather than treatment, it is extremely important for us to know how you felt before diagnosis. Therefore, even though your life may be quite different now, we are asking you to think back to the time before diagnosis to answer the questions about feelings and perceptions of life. The explanation at the beginning of such questions will repeat these instructions. Please notice that your name is not one of the questions thereby insuring your anonymity and insuring that your questionnaire answers can in no way be connected with you personally.

However, it is imperative that we have on file a signed copy of your Informed Consent . If you have any questions at all or wish to talk with me about the research, please do not hesitate to call me.

Please take your time to fill out the enclosed questionnaire fully and honestly, use the back of the sheets if necessary, and return it to me via email or print this out and fax it to 303-377-2203.

We greatly appreciate your cooperation with us to complete this important work.

Sincerely,

Dr. Martha Lucas
Crestone Research Group
331 Vine Street
Denver, Colorado 80206
303-698-5924; fax 303-377-2203;
lucasm@ecentral.com

Informed Consent

I, __________(print your name here), agree to participate in this study about the causes of breast cancer by completing the enclosed questionnaire. By signing below, I am consenting that I understand that my participation is completely anonymous, that I will not be identified in any publication, and that my participation is voluntary. I understand that my participation ends with the completion of the questionnaire and that I will not be contacted for any other purpose. I have also been informed that I may contact Dr. Lucas if I have any questions or would like to find out more about the outcome of the study. _________________________________________Signature _________________________________________Date

Questionnaire for women who have been diagnosed with breast cancer at any time during their life

Age at diagnosis: Please circle one of the following: Married Divorced Single (never married) & not currently in a relationship Single (never married) and currently in a relationship

Religion:
Race:
Are you employed outside the home?
Years of schooling: (Grade school = 8; high school = 12; some college = 12+; college through bachelor's degree = 16; and graduate school = 16+)
Have you had children?
If so, how many?
Do you usually feel that you are overweight?

How would you describe your feelings toward your body before diagnosis: (please check one)
I have been very happy with my body.
I have generally been satisfied with my body.
I have always wished I was thinner.
I basically haven't liked the shape of my body or how it looks.

Please check one of the following statements regarding how you felt about your breasts before diagnosis:
My breasts are just the right size.
I think that my breasts have always been too large.
I think that my breasts have always been too small.
I don't pay much attention to my breasts and how they look.

Do you have a family history of breast cancer?

If so, who in your family has been diagnosed with it?

Did you discover the lump or abnormality through self-exam or mammogram?

In the year immediately preceding your diagnosis, did you experience any traumatic emotional or physical events?

If so, please tell us what it was (or what they were) and when it (they) occurred.

How you feel about yourself and your life since your diagnosis may be quite different, or it may be very similar, to the way you felt before you were told you have (had) breast cancer. For the purposes of this research, it is extremely important that we measure how you felt or what your state of mind was BEFORE YOUR DIAGNOSIS. Please try to answer the questions with regard to your life BEFORE you found out about the breast cancer. A number of statements which people use to describe themselves are given below. Read each statement and then circle the appropriate number to the right of the statement to indicate how you generally felt before your diagnosis. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe how you generally felt before your diagnosis.
1 = ALMOST NEVER
2 = SOMETIMES
3 = OFTEN
4 = ALWAYS

1. I am a steady person………………………….…............. 1 2 3 4
2. I felt satisfied with myself …………………….. ...............1 2 3 4
3. I felt nervous and restless ……………………................. 1 2 3 4
4. I wished I could be as happy as other seem to be ..........1 2 3 4
5. I felt like a failure ………………………………................ 1 2 3 4
6. I got in a state of tension or turmoil as I thought over my concerns and interests ...................................................1 2 3 4
7. I felt secure …………………………………….. ...............1 2 3 4
8. I lacked self-confidence …………………………. . . . ......1 2 3 4
9. I felt inadequate …………………………………............... 1 2 3 4
10. I worried too much over something that really did not matter........................................................................... 1 2 3 4

For each of the following statements, circle the number that would be most nearly true for you BEFORE DIAGNOSIS. Note that the numbers always extend from one extreme feeling to its opposite kind of feeling. "Neutral" implies no judgment either way. Try to use the "Neutral" rating as little as possible.

1. I was usually:
1 2 3 4 5 6 7 completely bored (neutral) exuberant, enthusiastic

2. Life to me seemed:
1 2 3 4 5 6 7 completely routine (neutral) always exciting

3. In life I had:
1 2 3 4 5 6 7 no goals or aims at all (neutral) very clear goals & aims

4. My personal existence was:
1 2 3 4 5 6 7 utterly meaningless, (neutral) very purposeful without purpose and meaningful

5. Every day was:
1 2 3 4 5 6 7 exactly the same (neutral) constantly new

6. If I could choose, I would:
1 2 3 4 5 6 7 prefer never to (neutral) like 9 more lives have been born just like this one

7. After retiring, I would:
1 2 3 4 5 6 7 loaf completely for (neutral) do some exciting things the rest of my life I have always wanted to do

8. In achieving life goals I have:
1 2 3 4 5 6 7 made no progress (neutral) progressed to whatsoever complete fulfillment

9. I felt my life was:
1 2 3 4 5 6 7 empty, filled only (neutral) running over with with despair exciting, good things

10. If I should die today, I would feel that my life has been:
1 2 3 4 5 6 7 worthless (neutral) completely worthwhile

Below is a list of words that describe feelings people have. Please read each of them carefully. Then circle the number next to each one that best describes how you generally felt BEFORE YOUR DIAGNOSIS.

The following numbers refer to these phrases:
0 = NOT AT ALL
1 = A LITTLE
2 = MODERATELY
3 = QUITE A BIT
4 = EXTREMELY

1. Resourceful 0 1 2 3 4
2. Tense 0 1 2 3 4
3. Angry 0 1 2 3 4
4. Worn-out 0 1 2 3 4
5. Unhappy 0 1 2 3 4
6. Hurt 0 1 2 3 4
7. Lively 0 1 2 3 4
8. Confused 0 1 2 3 4
9. Sorry for things done 0 1 2 3 4
10. Shaky 0 1 2 3 4
11. Listless 0 1 2 3 4
12. Peeved 0 1 2 3 4
13. Loved 0 1 2 3 4
14. Sad 0 1 2 3 4
15. Active 0 1 2 3 4
16. On edge 0 1 2 3 4
17. Grouchy 0 1 2 3 4
18. Blue 0 1 2 3 4
19. Energetic 0 1 2 3 4
20. Panicky 0 1 2 3 4
21. Hopeless 0 1 2 3 4
22. Relaxed 0 1 2 3 4 Not at all Extremely
23. Unworthy 0 1 2 3 4
24. Spiteful 0 1 2 3 4
25. Calm 0 1 2 3 4
26. Uneasy 0 1 2 3 4
27. Restless 0 1 2 3 4
28. Unable to concentrate 0 1 2 3 4
29. Fatigued 0 1 2 3 4
30. Relaxed 0 1 2 3 4
31. Annoyed 0 1 2 3 4
32. Discouraged 0 1 2 3 4
33. Resentful 0 1 2 3 4
34. Nervous 0 1 2 3 4
35. Lonely 0 1 2 3 4
36. Miserable 0 1 2 3 4
37. Muddled 0 1 2 3 4
38. Cheerful 0 1 2 3 4
39. Bitter 0 1 2 3 4
40. Exhausted 0 1 2 3 4
41. Anxious 0 1 2 3 4
42. Ready to fight 0 1 2 3 4
43. Dependable 0 1 2 3 4
44. Gloomy 0 1 2 3 4
45. Desperate 0 1 2 3 4
46. Sluggish 0 1 2 3 4
47. Rebellious 0 1 2 3 4
48. Helpless 0 1 2 3 4 Not at all Extremely
49. Weary 0 1 2 3 4
50. Bewildered 0 1 2 3 4
51. Alert 0 1 2 3 4
52. Deceived 0 1 2 3 4
53. Furious 0 1 2 3 4
54. Efficient 0 1 2 3 4
55. Persistent 0 1 2 3 4
56. Full of pep 0 1 2 3 4
57. Bad tempered 0 1 2 3 4
58. Worthless 0 1 2 3 4
59. Forgetful 0 1 2 3 4
60. Carefree 0 1 2 3 4
61. Terrified 0 1 2 3 4
62. Guilty 0 1 2 3 4
63. Vigorous 0 1 2 3 4
64. Uncertain 0 1 2 3 4

Another important aspect of this research on the cause of breast cancer, is a description of your mother and her mother (your maternal grandmother). Please try to be as accurate as possible when answering the following. Circle the terms which describe your mother:

Panicky
Hopeless
Relaxed
Unworthy
Spiteful
Calm
Uneasy
Restless
Unable to concentrate
Fatigued
Relaxed
Annoyed
Discouraged
Nervous
Lonely
Miserable
Muddled
Cheerful
Bitter
Exhausted
Anxious
Ready to fight
Dependable
Gloomy
Tense
Resourceful
Angry
Worn-out
Unhappy
Hurt
Lively
Confused
Shaky
Sorry for things done
Listless
Peeved
Loved
Sad
Active
On edge
Grouchy
Blue
Energetic
Desperate
Sluggish
Rebellious
Helpless
Weary
Bewildered
Alert
Deceived
Furious
Efficient
Persistent
Full of pep
Worthless
Forgetful
Carefree
Bad tempered
Terrified
Guilty
Vigorous
Uncertain

Which of these statements characterizes your mother's feelings toward your father?
Check as many as are descriptive of her feelings toward him:
She is (was) very loving toward him; their relationship is (was) very good.
She is (was) bitter toward him; their relationship was a disappointment for her.
She nurtures(d) him and the relationship.
She enjoys(d) his presence; they do a lot together.
She is(was) resentful toward him; he didn't live up to her expectations. She has given up a lot for the relationship and knows it; maybe she's not sure how she feels about that.
They started out great and then their relationship deteriorated.

Please circle the terms which describe your maternal grandmother:
Panicky Hopeless Relaxed Unworthy Spiteful Calm Uneasy Restless Unable to concentrate Fatigued Relaxed Annoyed Discouraged Nervous Lonely Miserable Muddled Cheerful Bitter Exhausted Anxious Ready to fight Dependable Gloomy Tense Resourceful Angry Worn-out Unhappy Hurt Lively Confused Shaky Sorry for things done Listless Peeved Loved Sad Active On edge Grouchy Blue Energetic Desperate Sluggish Rebellious Helpless Weary Bewildered Alert Deceived Furious Efficient Persistent Full of pep Worthless Forgetful Carefree Bad tempered Terrified Guilty Vigorous Uncertain

How would you characterize your maternal grandmother's feelings toward your grandfather?
Check as many as are descriptive of her feelings toward him:
She is (was) very loving toward him; their relationship is (was) very good. She is (was) bitter toward him; their relationship was a disappointment for her. She nurtures(d) him and the relationship. She enjoys(d) his presence; they do a lot together. She is(was) resentful toward him; he didn't live up to her expectations. She has given up a lot for the relationship and knows it; maybe she's not sure how she feels about that. They started out great and then their relationship deteriorated.

Please list any recollections you have about your maternal great-grandmother and her relationship with her husband.

I really appreciate your help with this. Breast cancer is a disease which I dream of impacting in a positive way. Prevention is the key to many complementary medicines and, as a student of Traditional Chinese Medicine, I see that the "exceptional" physician or health practitioner is the one whose patients never get sick!
Dr. Martha Lucas

Dr. Martha Lucas, Research Psychologist, Clinical Instructor of Psychiatry, Univ. of CO School of Medicine. Dr. Lucas teaches medical students about complementary medicine. Crestone Research Group: Conducting research about the causes of breast cancer. Offering BREAST MEDICINE, a workshop for learning how to know and nurture our breasts. Reiki Master, Certified Colorpuncturist, Energy Healing before, during, and after surgery.

Dr. Martha Lucas
Crestone Research Group
331 Vine Street
Denver, Colorado 80206
303-698-5924; fax 303-377-2203
lucasm@ecentral.com