<p>¡Vida! Educational Series </p><p>Update on Breast Cancer</p><p>September 13, 2012 Location: ______</p><p>General Information Survey </p><p>1- I am a: (please circle all that apply) Other ______Breast cancer survivor Relative of a breast cancer survivor Caregiver of a breast cancer survivor CPG (Community Partner Group) Lay health worker/ promoter Health care professional______2- My residence is in city/town: ______county: ______zip code: ______3- My health insurance is: (please circle all that apply) AHCCCS PCAP Private (please specify) (HMO/ PPO) ______Other______No health insurance Medicare ______4- Age ______Gender ______5- Race/ Ethnicity: (please circle all that apply) Native American Pacific Islander Caucasian Mixed race Asian African American Other ______6- How did you hear about this session? ______7- As a result of viewing this presentation, will you? (circle all that apply): Seek medical care Yes No Share the information with others, if yes, who:______Yes No Change your practice Yes No Other: ______Before viewing the session: My knowledge about this topic is: (circle only one answer) none at all very little somewhat a lot</p><p>Please answer these questions before viewing this session: A-An example of targeted therapy for breast cancer is: chemotherapy radiation therapy trastuzumab surgery</p><p>B- Benefit of chemotherapy is best predicted by: Estrogen sensitivity Progesterone sensitivity Normal MammaPrint results High risk Oncotype DX results</p><p>C- Radiation therapy: circle all that apply improves survival after breast cancer decreases breast cancer recurrence locally prevents distant metastases always produces radiation pneumonitis</p><p>______After viewing the session: My knowledge about this topic is: (circle only one answer) 1 ¡Vida! Educational Series </p><p> none at all very little somewhat a lot</p><p>Please answer these questions after viewing this session:</p><p>A-An example of targeted therapy for breast cancer is: chemotherapy radiation therapy trastuzumab surgery</p><p>B- Benefit of chemotherapy is best predicted by: Estrogen sensitivity Progesterone sensitivity Normal MammaPrint results High risk Oncotype DX results</p><p>C- Radiation therapy: circle all that apply improves survival after breast cancer decreases breast cancer recurrence locally prevents distant metastases always produces radiation pneumonitis</p><p>2 ¡Vida! Educational Series </p><p>AFTER VIEWING THE SESSION PLEASE COMPLETE THIS SURVEY</p><p>Sponsored by the University of Arizona College of Medicine at the Arizona Health Sciences Center</p><p>ATP – CLINICAL CARE CONFERENCE SERIES GRAND ROUNDS TEACHING EVALUATION</p><p>YOUR NAME (please print): DEGREE / JOB TITLE:</p><p>TODAY’S DATE: 9/13/12 ARIZONA TELEMEDICINE PROGRAM SITE AFFILIATION:</p><p>STATUS: STUDENT  FELLOW  FACULTY  HOUSE OFFICER  OTHER </p><p>PROGRAM TITLE: Update on Breast Cancer SPEAKER: Ana Maria Lopez, MD,MPH,FACP</p><p>STRONGL NO STRONGL Y DISAGREE OPINION AGREE Y DISAGREE AGREE</p><p>This topic is of interest to me 1 2 3 4 5 This topic is relevant to my practice and will ultimately improve patient 1 2 3 4 5 care</p><p>I learned new information 1 2 3 4 5 The teaching techniques were conducive to learning 1 2 3 4 5 The speaker was prepared and informative 1 2 3 4 5 The educational objectives were met 1 2 3 4 5 I would not have been able to attend a lecture on this topic if it had not 1 2 3 4 5 been available via the ATP</p><p>What other topics would you like to see addressed?</p><p>Did you feel there was a bias toward any particular product or company? Yes____ NO _____ If yes, please explain:</p><p>COMMENTS:</p><p>3 ¡Vida! Educational Series </p><p>THANK YOU</p><p>You may submit the completed forms in any of the following ways:</p><p>Via fax: (520) 626- 6252 Attn: Bettina Hofacre</p><p>Via mail: University of Arizona Cancer Center Attn: Bettina Hofacre 1515 N. Campbell Ave Tucson, AZ 85724 </p><p>Via e-mail to: [email protected]</p><p>If you have any questions please contact:</p><p>Bettina Hofacre at (520) 626-3265</p><p>4</p>