Form Approved OMB# Exp. Date |
Your Experiences with Cancer |
2024 |
This survey is about the lasting effects of cancer and cancer treatments on the lives of those who have been diagnosed with cancer. The survey will ask about the effects of cancer, its treatment, or the lasting effects of that treatment on your employment, finances, and life in general. The goal of this survey is to help improve experiences of people diagnosed with cancer in the future.
Survey Instructions
Please take the time to answer these questions about your experiences with cancer.
Your participation is voluntary and all of your answers will be kept confidential as required by law. If you have any questions about how to complete this booklet, please call Alex Scott at 1-800-945-MEPS (6377).
Answer each question by marking your response or filling in a number when necessary. If you are unsure about how to answer a question, please give the best answer you can.
You may skip any questions you do not wish to answer or to stop taking the survey at any time.
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This survey is authorized under 42 U.S.C. 299a. Privacy is protected by the Privacy Act and Section 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. The confidentiality of your responses to this survey is protected by Section 944(c). Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.
The
Agency
for
Healthcare
Research
and
Quality
of the U.S. Department of Health and Human Services
Section 1. Cancer History
This first section asks about your cancer history.
Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind?
Yes
No
Was your only cancer diagnosis or treatment before the age of 18?
Yes
No
Are you currently being treated for cancer – that is are you planning or recovering from cancer surgery, or receiving chemotherapy, radiation therapy, or hormonal therapy for your cancer?
Yes
GO
TO
Question 7, Page 3
No
About how long ago did you receive your last cancer treatment?
Less
than 1 year
ago
1
year ago to less than 3 years ago
3
years ago
to less
than 5
years ago
5
years ago
to less
than 10
years ago
10
years ago to 20 years ago
More
than 20
years ago
I
have not been
treated for cancer
Did a doctor or other health professional ever tell you that your cancer had come back?
Yes
No
GO
TO
Section
2,
Page
3
What was the most recent year a doctor or health professional told you that your cancer had come back?
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YEAR
Is this the first time you have ever been treated for cancer?
Yes
No
Section 2. Impacts on Work
At any time from when you were first diagnosed with cancer until now, were you working for pay at a job or business (including being self-employed)?
Yes
No GO TO Question 18, Page 5
These next questions ask about different ways cancer, its treatment, or the lasting effects of that treatment may have affected your work – that is, your hours, duties, or employment status.
As you answer these questions, please think about the entire time from when you were first diagnosed with cancer to now.
If you have had more than one type of cancer, please think about your experiences across all of them. If that is not possible, please focus on the most severe, and if they were equally severe, please focus on the most recent.
Because of your cancer, its treatment, or its lasting effects, at any time since your first cancer diagnosis:
Mark yes or no for each item below.
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Y |
N |
a) Did you ever take extended (more than an occasional day off here and there) paid leave (vacation, sick leave, or disability leave) from work? |
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b) Did you ever take extended unpaid leave from work (including taking Family Medical Leave)? |
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c) Did you ever change from working full-time to working part-time or change to a less demanding job? |
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d) Did you ever quit your job (leave your job and plan to find another job at some point)? |
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e) Did you ever change from a set work schedule, where you start and end at the same time every day, to a flexible work schedule, where your start and end times vary from day-to-day? |
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Because of your cancer, its treatment, or its lasting effects, at any time since your first cancer diagnosis:
Mark yes or no for each item below.
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Y |
N |
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Did or does your cancer, its treatment, or its lasting effects limit the kind or amount of paid work you could do?
Yes
No
Because of your cancer, its treatment, or its lasting effects, did any of your employers do anything to help you out so that you can continue working?
Mark all that apply.
Get
someone to help you with your work duties
Shorten
your work days
Allow
you to change the time you came to and left work
Allow
you more breaks and rest periods
Change
the job to something you could do
Help
you learn new skills or get you special equipment or a computer for
the job
Assist
you in receiving rehabilitative services from an external provider
Allow
you to work from home
Any
other things to help you out
I
did not need help from my employer
My
employers didn’t offer me any help
Not
applicable
Because of your cancer, its treatment, or its lasting effects, did you ask any of your employers for help to do your job that you did NOT receive?
Yes
No,
because I didn’t need any help from my employer
No,
because I received all the help I needed
No,
but I would have liked to get help (or more help) from my employer
Because of your cancer, its treatment, or its lasting effects, at any time since your first cancer diagnosis, have you experienced any of the following?
Mark all that apply.
Had
job hours or wages reduced without your request
Was
let go, laid off, or fired from a job
Was
passed over for a promotion or job advancement
Was
assigned job duties or to a job location you didn’t want
Not
applicable / None of the above
Did you ever feel that, because of your cancer, its treatment, or the lasting effects of that treatment, you were less productive at work?
Yes
No
Did you ever worry that, because of the effects of cancer on your health, you might be forced to retire or quit work before you are ready?
Yes
No
Did you ever stay at a job in part because you were concerned about losing your health insurance?
Yes
No
Since your cancer diagnosis, did your spouse or significant other ever stay at a job in part because he/she was concerned about losing health insurance for the family?
Yes
No
No
spouse / significant other
Section 3. The Effects of Cancer and Its Treatment on Finances
The next questions ask about different kinds of financial burden you or your family may have experienced because of your cancer, its treatment, or the lasting effects of that treatment.
Please continue to think about all the time from when you were first diagnosed with cancer to now.
If you have had more than one type of cancer, please think about your experiences across all of them. If that is not possible, please focus on the most severe, and if they were equally severe, please focus on the most recent.
Because of your cancer, its treatment or the lasting effects of that treatment, did you have any costs you had to pay out of your own pocket in the following categories?
Mark all that apply.
Medical
expenses (e.g., medications, medical equipment or supplies)
Transportation
Lodging
Child
care
Home
or respite care
I
had no out-of-pocket costs
I
am not sure
Have you or has anyone in your family had to borrow money or go into debt because of your cancer, its treatment, or the lasting effects of that treatment?
Yes
No
GO
TO
Question
22, Page 7
How much did you or your family borrow, or how much debt did you incur because of your cancer, its treatment, or the lasting effects of that treatment?
Less
than $10,000
$10,000
to $24,999
$25,000
to $49,999
$50,000
to $74,999
$75,000
to $99,999
$100,000
or more
Have you or your family had to make any other kinds of financial sacrifices because of your cancer, its treatment, or the lasting effects of that treatment?
Mark all that apply.
Reduced
spending on vacation or
leisure activities
Delayed
large purchases (e.g.,
car)
Reduced
spending on
basics (e.g.,
food and clothing)
Used
savings set aside for other purposes
(e.g.,
retirement,
educational funds,
family support)
Made
a change
to living
situation (e.g.,
sold, refinanced,
or moved
to a
smaller residence)
Other
No
Please think about medical care visits for cancer, its treatment, or the lasting effects of that treatment. Have you ever been unable to cover your share of the cost of those visits?
Yes
No
Have you ever worried about having to pay large medical bills related to your cancer?
Yes
No
Have you ever worried about your family’s financial stability because of your cancer, its treatment or lasting effects of that treatment?
Yes
No
Have you ever been concerned about keeping your job and income, or that your earnings will be limited in the future because of your cancer?
Yes
No
Did you ever delay, forego, or have to make other changes to any of the following cancer care because of cost?
Mark all that apply.
Prescription
medicine
Visit
to specialist
Treatment
(other than prescription medicine)
Follow
up care
Mental
health services
Other
No
Section 4. Medical Care for Cancer
These next questions ask about certain experiences you may have had when receiving medical care for cancer from the time you were first diagnosed to now.
If you have had more than one type of cancer, please think about your experiences across all of them. If that is not possible, please focus on the most severe, and if they were equally severe, please focus on the most recent.
At any time since you were first diagnosed with cancer, did any doctor or other healthcare provider, including your current healthcare provider, ever discuss with you...
Your emotional or social needs related to your cancer, its treatment, or the lasting effects of that treatment?
Discussed
it with
me in
detail
Briefly
discussed it with me
Did
not discuss it at all
I
don’t remember
Participating in cancer clinical trials?
Discussed
it with
me in
detail
Briefly
discussed it with me
Did
not discuss it at all
I
don’t remember
Your costs for cancer care paid out of your own pocket?
Discussed
it with
me in
detail
Briefly
discussed it with me
Did
not discuss it at all
I
don’t remember
The impact of cancer, its treatment, or its lasting effects on your ability to work?
Discussed
it with
me in
detail
Briefly
discussed it with me
Did
not discuss it at all
I
don’t remember
The need for regular follow-up care and monitoring even after completing your treatment?
Discussed
it with
me in
detail
Briefly
discussed it with me
Did
not discuss it at all
I
don’t remember
Late or long-term side effects of cancer treatment you may experience over time?
Discussed
it with
me in
detail
Briefly
discussed it with me
Did
not discuss it at all
I
don’t remember
Lifestyle or health recommendations such as diet, exercise, quitting smoking?
Discussed
it with
me in
detail
Briefly
discussed it with me
Did
not discuss it at all
I
don’t remember
A summary of all the cancer treatments you received?
Discussed
it with
me in
detail
Briefly
discussed it with me
Did
not discuss it at all
I
don’t remember
Over the past year, have you experienced any of the following conditions that lasted longer than 3 months?
Mark yes or no for each item below.
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Y |
N |
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About how long ago was your most recent cancer diagnosis?
Less
than 2 years
GO
TO
Section 5, Page 12
2
years to less than 5 years
5
years to less than 10 years
10
years to less than 20 years
20
years or more
In the past 2 years, did you see any health care provider specifically for cancer-related follow-up care? This could either be a cancer specialist or some other health care provider.
Yes
No GO TO Question 36, Page 11
In the past 2 years, what were the reasons you saw any health care provider for cancer-related follow-up care?
Mark all that apply.
To
check for a recurrence or metastasis of your original cancer
To
receive additional treatment for your cancer if needed
To
determine if you have developed any health problems as a result of
your cancer or its treatment
To
receive treatment for any symptoms or side effects of treatment
To
receive a routine physical exam
To
receive any screening test for other cancers (including such tests as
mammogram or Pap smear for women, colonoscopy, sigmoidoscopy, stool
check for blood, or PSA or digital rectal exam for men)
To
obtain a referral to other specialist(s)
Other
In the past 2 years, how often did the health care provider(s) you saw for cancer-related follow-up care…
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N |
S |
U |
A |
a) listen carefully to you? |
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b) explain things in a way you could understand? |
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c) show respect for what you had to say? |
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d) spend enough time with you? |
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What were the specialties of the health care providers you saw for cancer-related follow-up care in the past 2 years?
Mark all that apply.
Primary
care (such as internal medicine, family medicine, or general
practice)
Medical
oncology or hematology
Radiation
oncology
Surgery
Obstetrics
/ Gynecology (Ob-Gyn)
Dental
or oral care
Other
medical or surgical specialties
I
am not sure
In the past 2 years, have you seen a mental health professional (psychiatrist, psychologist, or other mental health professional) for cancer-related follow-up care?
Yes
No
I
am not sure
GO TO Section 5, Page 12.
What are the main reasons you did NOT see a health care provider for cancer-related follow-up care in the past 2 years?
Mark all that apply.
I
felt I didn’t need follow-up care
My
health care provider(s) told me I didn’t need follow-up care
Cost
too much
Insurance
didn’t cover it
Problems
finding a health care provider, making an appointment, or getting to
an appointment
It
made me anxious or worried
Getting
to the doctor was just too hard
I
didn’t know about it
Section 5. The Effects of Cancer and Its Treatment on Life in General
The last few questions in the survey ask about how your cancer, its treatment and the lasting effects of that treatment may have influenced certain parts of your life.
If you have had more than one type of cancer, please think about your experiences across all of them. If that is not possible, please focus on the most severe, and if they were equally severe, please focus on the most recent.
Did your cancer, its treatment, or the lasting effects of that treatment ever limit the kind or amount of activities you do outside of work, such as shopping, child care, exercising, studying, work around the house, and so on?
Yes
No GO TO Question 40
How long were you or have you been limited in the kind or amount of usual daily activities?
Less
than 6
months
6
months to
less than
1 year
1
year to less than 3 years
3
years to less
than 5
years
5
years to
less than
10 years
More
than 10
years
Is this limitation ongoing?
Yes
No
Did you ever feel that your cancer, its treatment, or the lasting effects of that treatment interfered with your ability to perform any mental tasks as part of your usual daily activities?
Yes
No
Did you ever have a problem understanding health insurance or medical bills related to your cancer, its treatment, or the lasting effects of that treatment?
Yes
No
How often do you worry that your cancer may come back or get worse?
Never
Rarely
Sometimes
Often
All
the time
Have any of the following been positive things about your experiences with your cancer, its treatment, or the lasting effects of that treatment?
Mark yes or no for each item below.
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Y |
N |
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In general, how would you rate your physical health?
Excellent
Very
Good
Good
Fair
Poor
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?
Completely
Mostly
Moderately
A
little
Not
at all
In the past 7 days, how would you rate your pain on average?
0
– No
pain
1
2
3
4
5
6
7
8
9
10
– Worst
imaginable pain
In the past 7 days, how would you rate your fatigue on average?
None
Mild
Moderate
Severe
Very
Severe
In general, would you say your quality of life is:
Excellent
Very
Good
Good
Fair
Poor
In general, how would you rate your mental health, including your mood and your ability to think?
Excellent
Very
Good
Good
Fair
Poor
In general, how would you rate your satisfaction with social activities and relationships?
Excellent
Very
Good
Good
Fair
Poor
In the past 7 days, how often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?
Never
Rarely
Sometimes
Often
Always
In the last 30 days, did you ever cut the size of your meals or skip meals because there wasn’t enough money for food?
Yes
No
I
am not sure
Please indicate whether the following statements were often true, sometime true, or never true over the past 30 days:
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O |
S |
N |
a) The food that we bought just did not last, and we did not have money to get more. |
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b) We could not afford to eat balanced meals. |
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How worried are you right now about not having enough money for retirement?
Very
worried
Moderately
worried
Not
too worried
Not
worried at all
How worried are you right now about not having enough to pay your normal monthly bills?
Very
worried
Moderately
worried
Not
too worried
Not
worried at all
How worried are you right now about not being able to pay your rent, mortgage, or other housing costs?
Very
worried
Moderately
worried
Not
too worried
Not
worried at all
Please respond to each item by marking one box per row.
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N |
R |
S |
U |
A |
a) Do you have someone to help you if you are confined to bed? |
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b) Do you have someone to take you to the doctor if you need it? |
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c) Do you have someone to help with your daily chores if you are sick? |
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d) Do you have someone to run errands if you need it? |
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Date completed: / /
MONTH DAY YEAR
Who completed this form?
Person
named on front of this form
Someone else
If Someone Else, what is person’s relationship to the person named on the front of this form?
Husband
or wife
Unmarried
partner
Mother,
father, or guardian
Son
or daughter
Other
relative
Not
related
Thank you for taking the time to complete this survey.
Please place this survey in the envelope provided to you and give it to the MEPS interviewer.
If the interviewer is no longer available, place the survey in the return envelope provided to you by the interviewer and mail as soon as possible. If the envelope is missing, mail this survey to:
MEPS
c/o Westat
1600 Research Blvd, Room GA51
Rockville, MD 20850
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Your Experience with Cancer |
Subject | Cancer SAQ English |
Author | Agency for Healthcare Research and Quality |
File Modified | 0000-00-00 |
File Created | 2024-07-23 |