Typical
American
Cancer Society Questionnaire
While reviewing the
following ACS questionnaire,
please keep it in your mind that there is no mention of prevention anywhere in
the questionnaire.
Treatment is the
main thrust of this organization, with little but lip service paid to
prevention.
Thank you for participating in our survey. The
information you provide will be kept confidential by ACS and
will not be distributed. Please answer the following
questions:
1) Which best describes your relationship to
cancer?
-
Newly diagnosed patient
(not yet in treatment)
-
Patient undergoing
treatment
-
Survivor (completed
treatment/in remission)
-
Supporter (family)
-
Supporter (friend)
2) What type of cancer does/did you or your loved one
have?
-
Breast
-
Colon/rectal
-
Leukemia
-
Lung
-
Melanoma
-
Non-Hodgkin’s lymphoma
-
Gynecological
-
Pancreas
-
Prostate
-
Other
3) What type of treatment does/did you or your loved one
receive?
-
Newly diagnosed patient
(not yet in treatment)
-
Patient undergoing
treatment
-
Survivor (completed
treatment/in remission)
-
Supporter (family)
-
Supporter (friend)
4) Which role(s) has been your primary focus during your
involvement with cancer?
- Patient - receive treatment/therapy and focus on
healing
- Advocate - ensure treatment decisions are
appropriate
- Researcher - interpret information for
diagnosis/treatment
- Liaison - primary link w/ medical team and
insurance companies
- Mentor - share experience w/ others to make
decisions
- Educator - raise awareness of cancer w/ wider
public
- Activist - participate in volunteer
activities
- Intimate supporter - provide comfort and assist
w/ care
- Empathetic supporter - provide support based on
experience
5) What are your most important goals?
For questions 6 & 7, please rank the goals for each question in order of
priority. For example, if "Evaluate treatment options" was your top
goal, please rank it "First priority". If a goal did not apply to your
situation, select N/A.
6) Deciding Goals - Prioritize goals you had when
deciding on a treatment.
1
First priority |
2
Second priority |
3
Third priority |
4
Fourth priority |
5
Fifth priority |
|
|
- Evaluate treatment options - research treatment issues, decide on a
doctor and treatment.
- Manage impacts of treatment - address logistics of
scheduling/record-keeping/transportation, consider how affects on
family and employment.
- Enlist a support network - ask others for help, gather
emotional/practical support from family and friends.
- Begin to seek a peer group - find and make contact with other patients
or supporters
- Acknowledge beginning of treatment - express reactions and process the
experience, both individually and collectively.
7) Coping Goals - Prioritize goals you had while
receiving treatment
1
First priority |
2
Second priority |
3
Third priority |
4
Fourth priority |
5
Fifth priority |
|
|
- Monitor treatment process - coordinate communication between
physician/patient/supporters, learn what to expect physically and
emotionally.
- Manage logistics of treatment - coordinate schedule, arrange
transportation, keep records, negotiate w/ insurance.
- Manage bodily changes - understand how treatment affects body, address
side effects, learn coping tips/tricks.
- Process the psychological impacts - reconcile changes in body with self
esteem and relationship w/ others.
What are your most important needs?
For questions 8 - 15, please rank the following needs in order of priority. The
needs are for the goals ranked previously in questions 6 & 7
8) Needs for "Evaluate treatment
options" goal -
1
First priority |
2
Second priority |
3
Third priority |
|
- Find info about the reputability of doctors and facilities
- Research concerning issues related to treatment
- Learn how to read and interpret medical info
9) Needs for "Manage impacts of
treatment" goal -
1
First priority |
2
Second priority |
|
- Consider how treatment will affect employment & family status
- Adress logistics of scheduling, record-keeping, and transportation for
treatment
10) Needs for "Enlist a support network"
goal
1
First priority |
2
Second priority |
3
Third priority |
|
- Ask others for help with treatment
- Gather emotional and practical support from family/friends
- Help members of support network allocate responsibilities to themselves
11) Needs for "Monitor treatment
process" goal
1
First priority |
2
Second priority |
3
Third priority |
|
- Coordinate effective communication between medical team, patient, and
family
- Learn how to read and understand medical results (possible treatment
outcomes expressed as percentages, ranges and thresholds, statistics)
- Conduct conversations with medical team about what to expect physically
and emotionally during treatment
12) Needs for "Manage logistics of
treatment" goal -
1
First priority |
2
Second priority |
3
Third priority |
4
Fourth priority |
|
- Coordinate treatment schedule
- Negotiate with insurance providers and managed finances
- Arrange transportation to and from treatment
- Establish record keeping routines for treatment
13) Needs for "Manage bodily changes"
goal
1
First priority |
2
Second priority |
3
Third priority |
|
- Evaluate how treatment process affected bodily changes
- Learn about coping tips and tricks from other cancer sufferers
- Address issues concerning side effects
14) Needs for "Process the psychological
impacts of treatment" goal
1
First priority |
2
Second priority |
|
- Reconcile experiences of feeling sick with medical evaluations of
treatment process
- Address impact of major bodily changes in regards to self esteem,
gender and sexuality, and relationships with others
15) Needs for "Build effective
relationships" goal
1
First priority |
2
Second priority |
3
Third priority |
|
- Communicate fears and concerns with medical team, family, and friends
- Help family and friends to accept changes in patient's body
- Seek other cancer patients who experienced similar bodily side effects
16) How useful is cancer.org in supporting your
goals and needs?
- Very useful
- Somewhat useful
- Neither useful nor unuseful
- Somewhat unuseful
- Very unuseful
17) How easy to use is cancer.org?
- Very usable
- Somewhat usable
- Neither usable nor unusable
- Somewhat unusable
- Very unusable
18) What is your level of computer experience?
- Non-user (can't use without help)
- Novice (can use with some help)
- Experienced (can use with little or no help)
- Expert (help others to use)
Thank you for your feedback. Your input will help cancer.org make an impact
in the fight against cancer
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