EGFR Resisters Community
Welcome to the entry point for the EGFR Resisters Community! Our intended membership: lung cancer patients with EGFR driven mutations. Caregivers are also welcome to join the group.

Please fill out this form to tell us about your cancer experience. This information will be shared with members of the group. There is also a "Closed" group on Facebook - "EGFR Resisters Lung Cancer Patient Group" - that you can search for and ask to join. This link tells you about Facebook privacy settings for groups. https://www.facebook.com/help/220336891328465

Please - one entry per person with EGFR+ lung cancer. Caregivers should complete this form only if the person with EGFR+ lung cancer will NOT be completing the form.

Under no circumstances will the spreadsheet collecting this information be shared directly with anyone else. It is not collected under research protocols and thus not useful as is to researchers. We can use it to sort out information and answer questions about our members, for ourselves and for the medical and research communities.

We are committed to holding our members' information in confidentiality. We are relying on Google and Facebook security systems to protect the information we collect, and we are relying on each other not to copy and republish information that members may share with each other. We cannot guarantee total data security with 100% confidence. If at any point you would like to remove your data from the form, please let us know and we will do so as quickly as possible.

If you have any questions or need us to update your information, email us at egfrresisters@gmail.com.



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1. First Name *
2. Your Facebook Name *
3. Are you the patient or a caregiver? *
4. Is your cancer EGFR positive? *
5a. If yes, which base mutation do you have? *
5b. If "Other", what is your base EGFR mutation?
6. Have you become resistant to any EGFR targeted treatment drugs? *
7a. If yes, which ones?
7b. If "Other", which other drug(s) are you resistant to?
8a. Which resistance mutations have  you developed? Choose as many as applicable. *
Required
8b. If "Other", please list resistance mutation(s) not on the list.
9. Have you had a Next Generation Sequencing test from a tissue biopsy? (Such as a Foundation One test) *
9. Have you had a Next Generation Sequencing test  from a blood biopsy? (Such as a Guardant test) *
10. Date of diagnosis with EGFR mutation *
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11. Date of diagnosis with resistance mutation
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12. What was your age at initial diagnosis with lung cancer? *
13. Where are you located? *
14. Where are you treated? *
15. What is your stage of cancer? *
16a. What was your first line of treatment? *
16b. When did you begin your first line of treatment? *
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16c. Why did you stop this first line of treatment? (Where did you progress? Or did you stop for another reason?) Enter "Have not stopped" if still on 1st line. *
17a. What was your second line of treatment? (Leave blank if still on 1st line)
17b. When did you begin your second line of treatment? (Leave blank if still on 1st line)
MM
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DD
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YYYY
17c. Why did you stop this second line of treatment? (Where did you progress? Or did you stop for another reason?) Enter "Have not stopped" if still on 2nd line.
18a. What was your third line of treatment? (Leave blank if still on 1st or 2nd line)
18b. When did you begin your third line of treatment? (Leave blank if still on 1st or 2nd line)
MM
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DD
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YYYY
18c. Why did you stop this third line of treatment? (Where did you progress? Or did you stop for another reason?) Enter "Have not stopped" if still on 3rd line.
19. Please describe any additional treatments.
20a. Have you ever been in a clinical trial?
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20b. If "yes", which trial or trials have you been in?
21. Any other details  you would like to share with the group?
Submit
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