The CAMDEN Study

Cancer and Medication, Diet, Exercise and Nature

Comprehensive Breast Cancer Survey

Version: A Nov. 2017

Survivors of five or more years.

About the Undergraduate Investigator: Jordan Turner is a pre-medical Biology student at the
University of Wisconsin Milwaukee and Baylor 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 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.

Must be living with stage IV or metastatic disease for at least 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) Please list any general areas where there may be cancer in the body:

(7a) Please list any other chronic diseases that you were diagnosed with (and the year of
diagnosis):

Medications:
(1b) Please indicate whether you 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 within five years prior to diagnosis (and
indicate how long you have been taking each):

(3b) Please list the medications and supplements taken within five years after diagnosis (and
indicate how long you have been taking each).

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

(5b) Have you taken statin medications within five years after diagnosis (and indicate how long
you have been taking them and specific which ones):

(6b) Have you taken Metformin, Glucophage XR, Carbophage SR, Riomet, Fortamet, Glumetza,
Obimet, Gluformin, Dianben, Diabex, Diaformin, Siofor, or Roimet within five years prior to
diagnosis (and indicate how long you have been taking them and specify which ones):
(7b) Have you taken Metformin, Glucophage XR, Carbophage SR, Riomet, Fortamet, Glumetza,
Obimet, Gluformin, Dianben, Diabex, Diaformin, Siofor, or Roimet within five years after
diagnosis (and indicate how long you have been taking them and specify which ones):

(8b) What kind of surgery did you have for your cancer (mastectomy, lumpectomy, etc)?

Lifestyle:

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

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

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

(4c) Please indicate the degree to which you exercised post-diagnosis in terms of hours per
week?

(5c) How often did you consume alcohol pre-diagnosis (and indicate the amount in ounces per
day):
(6c) How often do you consume alcohol post-diagnosis (and indicate the amount in ounces per
day):

(7c) How often have you used tobacco products prior to diagnosis (and specify which ones):

(8c) How often do you use tobacco products post-diagnosis (and specify which ones):

(9c) How often have you used marijuana (legally or otherwise) prior to diagnosis (and specify
how used):

(10c) How often do you use marijuana (legally or otherwise) post-diagnosis (and specify how
used):

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

(12c) Please list any over-the-counter approved or unapproved supplements (not prescriptions)
that you consumed post-diagnosis:
(13c) Please indicate if or how often you prayed or meditated within five years prior to
diagnosis?

(14c) Please indicate if or how often you 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:

THANK YOU for completing this comprehensive research survey.

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

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