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.


1. First Name *
Your answer
2. Your Facebook Name *
Your answer
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?
Your answer
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?
Your answer
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.
Your answer
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 *
MM
/
DD
/
YYYY
11. Date of diagnosis with resistance mutation
MM
/
DD
/
YYYY
12. What was your age at initial diagnosis with lung cancer? *
Your answer
13. Where are you located? *
Your answer
14. Where are you treated? *
Your answer
15. What is your stage of cancer? *
Your answer
16a. What was your first line of treatment? *
Your answer
16b. When did you begin your first line of treatment? *
MM
/
DD
/
YYYY
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. *
Your answer
17a. What was your second line of treatment? (Leave blank if still on 1st line)
Your answer
17b. When did you begin your second line of treatment? (Leave blank if still on 1st line)
MM
/
DD
/
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.
Your answer
18a. What was your third line of treatment? (Leave blank if still on 1st or 2nd line)
Your answer
18b. When did you begin your third line of treatment? (Leave blank if still on 1st or 2nd line)
MM
/
DD
/
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.
Your answer
19. Please describe any additional treatments.
Your answer
20a. Have you ever been in a clinical trial?
20b. If "yes", which trial or trials have you been in?
Your answer
21. Any other details you would like to share with the group?
Your answer
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