Do You Qualify? – BreastCancerClinicalTrial.org 
    
    		
		



		
	







    

        
                    
                

        

            
            

              
            


            

            
            

                
            


	        
            
            

                DO YOU QUALIFY?
            


        

    






    

        

            
 Find Out if You Qualify

        

    





    



    
    
TRUSTe


Answer a few simple survey questions to learn if you qualify for clinical trials in your area.


BreastCancerClinicalTrial.org is intended for U.S. audiences only.





    
Please review your entries:

    





    
        

            

                
1) Have you been diagnosed with breast cancer by a physician?

                
Yes
No
Not Sure

                

                    
This is a required question. Please answer and resubmit.

                

            

        


        

            

                
2) If you have been diagnosed with breast cancer, at what Stage was the diagnosis?

                
Stage 0 (in situ)
Stage 1
Stage 2
Stage 3
Stage 4 (metastatic)
Not Sure / I haven’t been diagnosed

                

                    
This is a required question. Please answer and resubmit.

                

            

        



            

                
3) Do you know your breast cancer sub-type? (Check all that apply.)
 

Note: Hormone receptor (HR)-positive patients encompass ER+ and PR+ so please check both.

                
Estrogen Receptor Positive (ER+)
Progesterone Receptor Positive (PR+)
HER2 Protein Positive (HER2+)
Triple-Negative
Do not know/Unsure of Sub-type

                

                    
This is a required question. Please answer and resubmit.

                

            

        



            

                
4) How long has it been since you received your diagnosis? (If your breast cancer has recurred, how long has it been since your most recent diagnosis?)

                
Less than 3 months
3 to 6 months
6 months to a year
More than one year 
Not sure / I haven’t been diagnosed

                

                    
This is a required question. Please answer and resubmit.

                

            

        



        

            

                
5) Is your breast cancer recurrent?

                
No, this is the first time I’ve been diagnosed
Yes: local recurrence
Yes: regional recurrence
Yes: distant recurrence

                

                    
This is a required question. Please answer and resubmit.

                

            

        

       

            

                
6) What treatments, if any, have you received for your breast cancer? (Check all that apply.)

                
Lumpectomy
Mastectomy
Radiation therapy
Chemotherapy
Hormonal therapy
Targeted therapy
Biologic Therapy (Immunotherapy)
Other
Not sure

                

                    
This is a required question. Please answer and resubmit.

                

            

        
 
       
        

            

                
7) What is your gender?

                
Female
Male
Other/Prefer not to say

                

                    
This is a required question. Please answer and resubmit.

                

            

        

        

            

                
8) What is your 4-digit year of birth?

                
                

                    
This is a required question. Please answer and resubmit.

                

            

        

        

            

                
9) What is your 5-digit ZIP code?

                
                

                    
This is a required question. Please answer and resubmit.

                

            

        

        

            

                
10) What is your email address?

                
                

                    
This is a required question. Please answer and resubmit.

                

            

        

        

            

                
11) What is your telephone number? (optional)

                
            

        

        

            


      TRUSTe
    

        

    




Your Privacy is Important


We take the privacy and security of your personal information seriously and employ advanced information security controls to protect it.  We only share your identifiable information with third parties if there is a potential match with a clinical trial, if they are bound by a confidentiality agreement, and to the extent necessary to accommodate your request. To read the complete privacy policy, click here.


    







    

        

            
            

                

                    
                    
                    
                    
                

            

	        
        

    


    

        

	        

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