If you are a woman younger than 45 who has been diagnosed with breast cancer, we want to hear from you in order to help other young breast cancer survivors like you in the future. The survey takes about 10 minutes, is voluntary and you can stop taking it at any time. All results are anonymous.

If you would like further information on the researchers conducting the study, how the study is being assessed, to what agencies the results will be reported, and more, please go to this link: Click Here

If you live in Louisiana, and have been contacted by the Louisiana Tumor Registry (LTR) at LSU Health New Orleans School of Public, please enter the four digit identification (ID) number on the letter and paper survey sent to you by LTR in the space below. If you do not live in Louisiana or did not receive such a letter and survey, please disregard.

Were you contacted by the Louisiana Tumor Registry (LTR) at LSU Health Sciences Center New Orleans to participate in the survey?


In what state do you live?


1. I do not have the energy I used to

How much have each of the following applied to you at any time since your breast cancer diagnosis?

2. I have difficulty planning activities because of the cancer or its treatments

How much have each of the following applied to you at any time since your breast cancer diagnosis?

3. I find that the cancer or its treatments keep me from working

How much have each of the following applied to you at any time since your breast cancer diagnosis?

4. I find that cancer or its treatments interfere with my ability to work

How much have each of the following applied to you at any time since your breast cancer diagnosis?

5. I find that my clothes do not fit

How much have each of the following applied to you at any time since your breast cancer diagnosis?

6. I am embarrassed to show my body to others because of my illness

How much have each of the following applied to you at any time since your breast cancer diagnosis?

7. I am uncomfortable with the changes in my body

How much have each of the following applied to you at any time since your breast cancer diagnosis?

8. I frequently feel anxious

How much have each of the following applied to you at any time since your breast cancer diagnosis?

9. I frequently feel overwhelmed by my emotions and feelings about the cancer

How much have each of the following applied to you at any time since your breast cancer diagnosis?

10. I have difficulty sleeping

How much have each of the following applied to you at any time since your breast cancer diagnosis?

11. I have difficulty concentrating

How much have each of the following applied to you at any time since your breast cancer diagnosis?

12. I have difficulty remembering things

How much have each of the following applied to you at any time since your breast cancer diagnosis?

13. I have difficulty asking friends or relatives to do things for me

How much have each of the following applied to you at any time since your breast cancer diagnosis?

14. I worry about whether the cancer is progressing

How much have each of the following applied to you at any time since your breast cancer diagnosis?

15. I worry about not being able to care for myself

How much have each of the following applied to you at any time since your breast cancer diagnosis?

16. I do not feel sexually attractive

How much have each of the following applied to you at any time since your breast cancer diagnosis?

17. I have financial problems

How much have each of the following applied to you at any time since your breast cancer diagnosis?

18. Have you looked for work since your breast cancer diagnosis?


19. I have difficulty finding a new job since I have had cancer

How much have each of the following applied to you at any time since your breast cancer diagnosis?

Are you single and not in a significant relationship?


20. I have difficulty meeting potential dates

How much have each of the following applied to you at any time since your breast cancer diagnosis?

21. I have difficulty telling a date about the cancer or its treatment

How much have each of the following applied to you at any time since your breast cancer diagnosis?

22. I am afraid to initiate a sexual relationship with someone

How much have each of the following applied to you at any time since your breast cancer diagnosis?

23. Do you want to be pregnant at any point in the future?


24. I worry about not being able to get pregnant

How much have each of the following applied to you at any time since your breast cancer diagnosis?

25. I worry about the effects pregnancy will have on breast cancer

How much have each of the following applied to you at any time since your breast cancer diagnosis?

26. I worry about the effects cancer treatment will have on pregnancy

How much have each of the following applied to you at any time since your breast cancer diagnosis?

27. Have you ever discussed fertility issues associated with breast cancer with a healthcare provider?


28. I worry about experiencing premature menopause

How much have each of the following applied to you at any time since your breast cancer diagnosis?

29. Have you ever discussed the relationship between breast cancer and menopause with a healthcare provider?


30. I am interested in genetic testing for the two breast cancer susceptibility genes (BRCA1 and BRCA2)

How much have each of the following applied to you at any time since your breast cancer diagnosis?

31. Have you ever discussed genetic testing for breast cancer with a healthcare provider?


32. I worry about my family members having a higher risk of breast cancer becuase of my breast cancer diagnosis

How much have each of the following applied to you at any time since your breast cancer diagnosis?

33. I have problems with sexual intimacy since my breast cancer diagnosis

How much have each of the following applied to you at any time since your breast cancer diagnosis?

34. I worry about my breast cancer spreading

How much have each of the following applied to you at any time since your breast cancer diagnosis?

35. I worry my breast cancer might come back

How much have each of the following applied to you at any time since your breast cancer diagnosis?

36. Have you attended a breast cancer support group since being diagnosed with breast cancer?


37. Prior to this survey, have you ever visited www.SurviveDAT.org, www.SurviveAL.org or www.SurviveMISS.org?


Please indicate what category describes your racial background


Clicking on the “agree” button below indicates that:
  • You are a young breast cancer survivor (less than 45 years old at the time of breast cancer diagnosis)
  • You are at least 18 years of age
  • You have voluntarily agreed to participate
  • You have read all the information associated with this survey
If you do not wish to participate, please decline participation by clicking on the “disagree” button.

ELECTRONIC CONSENT: Please select your choice below.

Thank you very much for your participation. If you have any questions, please contact Lisa Smith at (855) 394‐4032 (toll‐free) or (504) 568‐5848.

SurviveDAT is dedicated to enhancing the health and wellness of young breast cancer survivors in Louisiana. Our goal is to address the unique needs of these survivors through an online resource that includes an extensive list of community programs, support groups and services available locally and nationally. For more information, please visit WWW.SURVIVEDAT.ORG.

Contact Information:
Study Coordinator, Lisa Smith: 855-394-4032 (toll-free) or 504-568-5848
Principal Investigator, Donna Williams: 504-568-5875

If you are emotionally distressed or upset and feel you need assistance right now, please contact the American Cancer Society at 1‐800‐227‐2345 or visit www.cancer.org, day or night, for information and support.