The CAMDEN Study

Cancer and Medication, Diet, Exercise and Nature

Comprehensive Breast Cancer Survey

Version: B Nov. 2017

Family and friends of survivors of fewer than five years.

About the Undergraduate Investigators: Jordan Turner is a pre-medical Health Science Studies
student at Baylor University conducting research on the potential correlations between a wide
range of patient information and long-term metastatic breast cancer survival in hormone
receptor positive HER2 negative patients.

Primary Objective: To identify and investigate any correlations between lifestyle, diet, and
medications and the potential implications they may have on the long-term survival of stage IV
breast cancer patients.

All identifying information is kept confidential. Please answer correctly or to the best of your
ability; leave blank if unsure.

Qualifications to participate:

Diagnosis must be estrogen-receptor positive, HER2 Negative, Invasive Ductal Carcinoma

Stage IV Breast Cancer. No indications for BRCA-1, BRCA-2, or any likewise genetic mutations.

For the purposes of this study, the individual must have been diagnosed with stage IV or
metastatic disease and subsequently succumbed to it within five years.

Patient Information:

(1a) Gender:
(2a) Age (at time of diagnosis):
(3a) Location (State):
(4a) Date (mo/yr) of diagnosis:
(5a) Date (mo/yr) of stage IV diagnosis:
(6a) Date (mo/yr) of death:

(7a) Please list any general areas of the body where the cancer may have been:

(8a) Please list any other chronic diseases that the individual was diagnosed with (and the year
of diagnosis):
Medications:

(1b) Please indicate whether the patient participated in any clinical trials since time of diagnosis
and what each trial entailed and what therapies were administered. Please also indicate if you
believed the trial to have had beneficial, harmful or no effects.

(2b) Please list the medications and supplements taken five years prior to diagnosis (and
indicate how long the individual was taking each):

(3b) Please list the medications and supplements taken after diagnosis (and indicate how long
the individual was taking each):

(4b) Has the patient taken statin medications within five years prior to diagnosis (and indicate
how long they have been taking them and specify which ones):

(5b) Has the patient taken statin medications within five years after diagnosis (and indicate how
long they have been taking them and specify which ones):

(6b) Has the patient taken Metformin, Glucophage XR, Carbophage SR, Riomet, Fortamet,
Glumetza, Obimet, Gluformin, Dianben, Diabex, Diaformin, Siofor, Metfogamma and Glifor, or
Riomet within five years prior to diagnosis (and indicate how long they have been taking them
and specify whites ones):
(7b) Has the patient taken Metformin, Glucophage XR, Carbophage SR, Riomet, Fortamet,
Glumetza, Obimet, Gluformin, Dianben, Diabex, Diaformin, Siofor, Metfogamma and Glifor, or
Riomet within five years after diagnosis (and indicate how long they have been taking them and
specify whites ones):

(8b) What kind of surgery did the patient have for their cancer (mastectomy, lumpectomy, etc)?

Lifestyle:

(1c) Please indicate the individuals pre-diagnosis diet and how long they were engaging in each
(i.e. largely meat-based or American diet, plant-based, Mediterranean, etc.)

(2c) Please indicate the individuals post-diagnosis diet and how long they were engaging in
each (i.e. largely meat-based or American diet, plant-based, Mediterranean, etc.)

(3c) Please indicate the degree to which the patient exercised pre-diagnosis in terms of hours
per week?

(4c) Please indicate the degree to which the patient exercised post-diagnosis in terms of hours
per week?
(5c) How often did the individual consume alcohol pre-diagnosis (and indicate the amount in
ounces per day):

(6c) How often did the individual consume alcohol post-diagnosis (and indicate the amount in
ounces per day):

(7c) How often did the individual use tobacco products before diagnosis (and specify which
ones)?

(8c) How often did the individual use tobacco products after diagnosis (and specify which
ones)?

(9c) How often did the individual use marijuana (legally or otherwise) prior to diagnosis (and
specify how used):

(10c) How often did the individual use marijuana (legally or otherwise) after diagnosis (and
specify how used):

(11c) Please list any over-the-counter approved or unapproved supplements (not prescriptions)
that the individual consumed within five years prior to diagnosis?
(12c) Please list any over-the-counter approved or unapproved supplements (not prescriptions)
that the individual consumed within five years after diagnosis?

(13c) Please indicate if or how often the patient prayed or meditated within five years prior to
diagnosis?

(14c) Please indicate if or how often the patient prayed or meditated within five years post-
diagnosis?

I agree to provide this information willingly and for the sole purpose of scientific research. The
data found herein may be published as a cumulative review and will not use identifying features.
Please date and sign below:

Please specify your relationship to the individual:

THANK YOU for completing this comprehensive research survey.

Scan or email results to jordan_turner1@baylor.edu or mail via USPS to:

Jordan Turner
ATNN: Cancer Research
19 Park View Lane
Watertown, WI 53094