Breast Cancer Risk Assessment & Prevention

Please be aware this program is usually covered by insurance, however, you may be responsible for a copay. If your insurance requires a referral, you will need to obtain one from your doctor.

To determine if this program is appropriate for you please answer a few brief questions.

Please complete the assessment below to determine if this program is appropriate for you. If you are eligible, a referral specialist will contact you within two business days to gather more detailed information.

Contact Information

Are you the patient? *

Have you ever been seen at Roswell Park Cancer Institute?


Has this individual ever been seen at Roswell Park Cancer Institute?

Would you like to join our mailing list?

Patient's Contact Information
Eligibility

Do youDoes the patient have a history of breast cancer?

Do youDoes the patient have a lump in yourhis/her breast?

Do youDoes the patient have an abnormal mammogram?

Do youDoes the patient have a history of LCIS or ADH on breast biopsy?

LCIS = Lobular Carcinoma In Situ, a benign (not cancer) condition
ADH = Atypical Ductal Hyperplasia, a benign (not cancer) condition
If yes, ELIGIBLE

Have youHas the patient had radiation treatment to yourthe chest for Hodgkin Lymphoma?

If yes, ELIGIBLE
Must answer yes to the following question and at least one in the box bellow.

Does cancer run in yourthe patient's family?

Is there a family history of ovarian cancer?

Has a parent, sibling or child of the patient's ever been diagnosed with breast cancer?

Select all that apply:

Have at least two of the patient's aunts/uncles/grandparents/first cousins ever been diagnosed with breast cancer?

Select all that apply:

Does anyone in yourthe patient's family have a mutation in any of these genes?

Have youHas the patient had a mammogram within the last year?

When was yourthe patient's last mammogram?