Pre-Registration

Precision Therapy For Advanced Prostate Cancer

Knowledge is the Best Defense Against Prostate Cancer

Men with metastatic hormone (castrate) resistant prostate cancer may be eligible to participate in the Dream Team “Precision Therapy for Advanced Prostate Cancer” treatment and clinical trial program. Those men interested in this program should provide their information in the form below. It is understood that this pre-registration is not a commitment by you to participate in the program, or, a commitment by the program team that you meet the eligibility criteria. Your information will be reviewed by the program team and you will be contacted directly on follow-up procedures.

Name*
Email Address*
Phone Number*
Address
City*
State*, Zip
Are you a survivor with recurrent prostate cancer?*
Yes     No
If Yes, What year were you diagnosed?
Your age when diagnosed?
PSA and Gleason Score When Diagnosed?
PSA:    Gleason Score :
Your Primary Treatment(s):
(check all that apply):

Surgery   External Beam Radiation   Proton Beam   Seed Implants   Radiation   Hormone Therapy   Chemotherapy   Provenge   Xtandi   Xgeva   Zytiga   Other  
What year did you first have a recurrence of prostate cancer?
What treatments have you undergone for the recurrence?
(check all that apply):

Surgery   External Beam Radiation   Proton Beam   Seed Implants   Radiation   Hormone Therapy   Chemotherapy   Provenge   Xtandi   Xgeva   Zytiga   Other  
What is your current PSA level?
PSA:   
Has your doctor told you that you have metastatic hormone resistant prostate cancer?
Yes    No
Has the metastases (cancer spread) been located?
Where:   
Have you participated in any other clinical trials?
Describe:






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