THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net



Date: Fri, 19 Aug 2005 09:27:07 -0700

08 02 04 61 05081901




Ms. Sheridan L. Tinker
New Patient Coordinator
Admissions
University of California San Francisco
Medical Center
Carol Franc Buck Breast Care Center
1600 Divisadero, Second Floor
San Francisco, CA 94115
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Subject:   2nd Opinion Surgery on IBC ***********

Dear Sheri,

Doctor Benz examined Millie last year on Oct 18, and wrote an opinion to assist the oncologist at Kaiser in managing Millie's care. Kaiser eventually implemented recommendations in UCSF's 2nd opinion. After some ups and downs, Millie has made a strong recovery, and now needs further guidance on whether to have surgery, being discussed by Kaiser.
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Doctor Benz 2nd opinion indicated that UCSF could provide further comment, as needed. Millie wants UCSF's comment now, because Doctor Benz stated in his 2nd opinion letter that there was no role for surgery, based on her condition at that time. A 2nd opinion from Stanford said there might be a role for surgery after regression of inflammation. Therefore, Millie wants further review of the surgery option based "full" regression of inflammation that has subsequently occurred at this time, after implementing Doctor Benz's treatment ideas, as reported by the surgeon at Kaiser on July 27, 2005.
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You were very effective last year scheduling support by UCSF and in coordinating to transmit the doctor's opinion, so I am hopeful you can work your magic again and find a doctor with experience treating IBC to comment on Millie's case.
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Schedule - Millie's primary care physician at Kaiser indicated in a meeting on July 29 that surgery after mid-September is the time frame. We need input prior to that, because Millie will have to make a decision. She wants an opinion letter, like Doctor Benz issued last year, to help guide her decision, as well as input that might further support Kaiser in prescribing treatment, including surgery.
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Millie may not need to come in for a visit, because the record is very detailed in this case. She is available for examination, if needed, until August 27, when she leaves for Chicago, and returns on Sep 8.
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Since this is vacation time, it may be hard to get people involved on short notice. Doctor Benz would be perfect, since he has already worked on the case, and Kaiser has implemented his earlier recommendations. However, if Doctor Benz is not available another doctor with experience treating IBC patients should be okay.
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If UCSF needs additional payment for this follow up project, please let me know the details.
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You can forward this letter to your doctor candidates for consideration of following issues....
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Background...

A complete chronology of patient history with diagnostic test reports is listed in the record on August 12, 2005, and with precision links to original sources.
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Millie is currently being treated at Kaiser, originally diagnosed in February, 2002, and treated with surgery (lumpectomy), then drugs and radiation during 2002. There was no treatment during 2003. On June 14, 2004 Millie was diagnosed with IBC; symptoms may have appeared as early as December 2002. Within the past few weeks, Millie's condition has improved markedly following six (6) cycles of Taxotere and capecitiabine (Xeloda), as recommended by Doctor Benz. On August 19 (today) she will start another cycle, then treatments will be paused for surgery, if she decides to proceed. Side effects are beginning to impact tolerance for treatment, so a break is timely, as discussed with the primary care physician on July 29, 2005.
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On November 4, Millie was removed from treatment with the Avastin trial due to pulmonary emboli. On January 4, 2005 treatment resumed with AC, implementing recommendations in a 2nd opinion by Doctor Guardino at Stanford, and as shown in a treatment plan developed on December 20, 2004. On March 29, 2005 after 4 cycles of AC, Kaiser changed the treatment to Taxotere and capecitabine (Xeloda), implementing recommendations in the UCSF 2nd opinion. At that time CA 15-3 elevated to 100, inflammation had spread toward the neck, and cancer blisters had appeared on the left breast. Six (6) cycles of Taxotere and capecitabine yielded marked improvement, leading the primary care physician to ask the surgeon at Kaiser to schedule a mastectomy.
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The surgeon on two (2) occasions indicated limited experience performing mastectomy with IBC, and noted that IBC is a very rare disease affecting less than 1% of breast cancer patients.
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Criteria for when IBC patient is ready for surgery.

On July 27, the surgeon indicated that Millie is ready for surgery based on visual observation that prior severe inflammation has fully regressed, where the left breast now looks like the right breast. CA 15-3 has dropped from over 100 to below 37, the lowest point in 4 years of treatment. On the date of the examination, CA 15-3 bounced back to 46. There are two pending tests which will be reported today, and another CA 15-3 blood test was taken this morning in connection with routine testing for Coumadin treatment. These additional "dots" may show a positive or negative pattern. (see chronology of patient history for updates)
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Another question is the scope of surgery. Millie has discussed having both breasts removed, as much for personal convenience to avoid the bother of protheses, but also to provide a source of healthy tissue for the left breast. Since inflammation extended toward the neck above the breast for a few weeks prior to starting treatment with Taxotere and capecitiabine at the end of March, the surgeon has indicated there is an issue of how much of the breast and surrounding tissue to remove.
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Details of this discussion with the surgeon are shown in the record of patient history for July 27, 2005.
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Finally, Millie wants comment on whether surgery will do more good than harm, based on excellent analysis by the surgeon on July 27. Since at this time there is no evidence of distant metastasis, and only regional metastasis seems to be involved, would an operation increase the chances of longevity and quality of life.
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Mil is very grateful for Doctor Benz and the work at UCSF that assisted her in recovery from a difficult situation this past March. If we don't get a chance to work with the doctor and your team again, just want to commend the professionalism and high standard of care.
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Please call or reply to let me know progress on working this project.

Thanks.

Sincerely,



Rod Welch
rodwelch@pacbell.net
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Post Script

Last year Doctor Benz had trouble accessing links, and this caused problems developing a case history for his analysis. He did an excellent job under the circumstances, but we want to facilitate review this time around. Typically, when you click a link, if it opens a blank page, it means your browser "timed out" going through the UCSF firewall. Click the "Refresh" or "Reload" button on the browser, and that should give you instant, precision access into patient history. This will save a lot of time. ..
Copy to:
  1. ***** Millie, ******************.com