Dificultades: Barreras hacia la comprensión

Before completing this brief survey, you must provide your informed consent below. Please read the information below: After you review the information below, you will be asked whether or not you voluntarily agree to participate in the study. The survey should take no more than 5 minutes to complete.

________________________________________________________________ University of North Carolina-Chapel Hill

Written Consent to Participate in a Research Study Adult Participants: Oncologists

Social Behavioral Form

________________________________________________________________ Consent Form Version Date: March, 11 2014

Title of Study: Understanding racial disparities in the diffusion of Oncotype DX in breast cancer Principal Investigator: Megan Roberts

UNC-Chapel Hill Department: Health Policy and Management Phone number: 717.448.3247

Co-Investigators: Morris Weinberger, Stephanie Wheeler, Katie Reeder-Hayes, Stacie Dusetzina, Michaela Dinan

Funding Source and/or Sponsor: CCEP Pre-Doctoral Fellowship, UNC Lineberger Comprehensive Cancer Center, Megan Roberts

Study Contact telephone number: 717.448.3247 Study Contact email: [email protected]

________________________________________________________________ Information about this study

The purpose of this study is to understand how oncologists use Oncotype DX testing to help make treatment decisions for breast cancer patients. We will interview breast medical and surgical

oncologists about this topic. For this study, we are interested in what you think about the benefits and challenges of Oncotype DX testing for providing care to women with breast cancer.

If you decide to participate, you will be one of up to 20 oncologists in this research study. Your involvement will include completing a short (~5 minute) survey and participating in a 30-minute telephone interview. With your permission, the interview will be audiotaped, and the interviewer will take notes on the discussion so that the research team can learn about your thoughts on this topic. Possible benefits from being in this study

Your participation in this study will increase our understanding of how Oncotype DX may be used to improve cancer care for women with breast cancer. You will be offered a $100 VISA gift card for taking part in this study.

Possible risks from being in this study

The risks and discomforts related to this study are minimal. We will take great care to protect the confidentiality of the information you provide. The audio recordings and notes from the interview will be kept confidential, which means that the information will be kept in a secure, password-protected computer that will be accessed only by the principal investigator of the study team. All data will be de-identified.

You will not be mentioned by name in any reports, articles or presentations that result from this study. In the event of publication of this research we will not disclose any personally identifiable information. Your contact information will be kept confidential as required by law and will be kept in a separate, secured file. Your name and address will only be used to send you the $100 VISA gift card. Federal Privacy Regulations provide safeguards for privacy, security, and authorized access. Except when

required by law, you will not be identified by name, address, telephone number, or any other direct personal identifier disclosed outside of the University of North Carolina.

For UNC employees ONLY

Taking part in this research is not a part of your University duties, and refusing will not affect your job. You will not be offered or receive any special job-related consideration if you take part in this

research.

Withdrawing from the Study

You can withdraw from this study at any time, without penalty. The investigators also have the right to stop your participation at any time.

What if you have questions about this study?

You have the right to ask and have answered, any questions you may have about this research. If you have questions, complaints, concerns, or if a research-related injury occurs, you should contact the researchers listed on the first page of this form.

What if you have questions about your rights as a research participant?

All research on human volunteers is reviewed by a committee that works to protect your rights and welfare. If you have questions or concerns about your rights as a research subject, or if you would like to obtain information or offer input, you may contact the Institutional Review Board at 919-966- 3113 or by email to [email protected].

- - -

Title of Study: Understanding racial disparities in the diffusion of Oncotype DX in breast cancer Principal Investigator: Megan Roberts

Participant’s Agreement:

Do you voluntarily agree to participate in this research study? [Drop down menu] YES, NO

Please complete the following brief survey: 1. What is your gender?

a.

b.

2. What is your age? ________________

3. What is your race/ethnicity? (circle all that apply) a. White b. Black c. Asian d. Hispanic e. Native American f. Other_______________________________ 4. What is your role in patient care?

a. Medical Oncologist b. Surgical Oncologist

5. How many years have you been in practice since completing training (all residency and fellowship training)? ________________

6. Among my peers, I am usually the first to try out new medical technologies for clinical care (including screening technologies, new diagnostic and prognostic tests, and therapeutics) <strongly disagree, disagree, somewhat disagree, neither agree or disagree, somewhat agree, agree ,strongly agree>

In order for us to better understand the patient population that you serve, please estimate the following:

7. Approximately what percent of your patients are insured by Medicaid? ______% 8. Approximately what percent of your patients have no insurance? _____%

9. In terms of your patients’ racial/ethnic background, approximately what percent of your patients are (these figures should add to 100%):

a. White ________%

b. Black ________%

c. Hispanic ________%

d. Other ________%

10. Estimate the percentage of your patients who have breast cancer __________________% 11. Estimate how many total breast cancer patients that you see in an average week?

__________________ per week

12. Estimate the percentage of your breast cancer patients that are hormone receptor positive?__________________%

In order for us to better understand the practice in which you serve, please estimate the following about your practice setting:

13. Describe your practice setting: (select all that apply) a. Public b. Private c. Academic Affiliated d. Non-Academic Affiliated e. Urban f. Rural g. Suburban

14. How many other providers in your practice treat breast cancer patients? __________________ 15. In a given month, estimate how many times you order Oncotype DX for your patients.