THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: April 29, 2004 02:45 PM Thursday;
Millie meeting with the surgeon on biopsy redness problem.
2...Skin Cancer Diagnosed from Biopsy Masectory Treatment Prescribed
3...Breast Skin Cancer May be Different from Original Breast Tumor
4...Pathology Lab Study Differences in Cancer to Evaluate Scope of Problem
5...Scope of Problem Evaluate Pathology Lab Study Differences in Cancer
6...Chemotherapy Required to Treat Redness Prior to Masectomy Surgery
7...Masectomy Surgery Following Chemotherapy Treat Redness 4 - 6 Months
8...Written Recommendations on Treatment from Tumor Board Requested
9...Tumor Board Notified New Findings Written Recommendations Requested
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Biopsy Taken Redness Left Breast Examined by the Surgeon
Masectory Treatment Prescribed Diagnose Skin Cancer Breast from Biop
Breast Cancer in the Skin Diagnosed from Biopsy Taken on 040419
1105 - ..
1106 - Summary/Objective
110701 - Follow up ref SDS 11 0000.
110703 - The biopsy taken on 040419 shows the redness problem is a form of skin
110704 - cancer that can only be treated with a masectomy. the surgeon
110705 - has discussed these findings with the doctor. ref SDS 0 F66N
110706 - Surgery will be performed after 4 - 6 months of treatments that will
110707 - reduce the redness, which means shrink the cancer in the skin.
110708 - ref SDS 0 SD7F the surgeon feels the current skin cancer
110709 - problem may not have been caused by the prior tumor, because pathology
110710 - reported surgery had achieved "clear margins." ref SDS 0 J757 She
110711 - feels further study is needed to understand the scope of the problem,
110712 - ref SDS 0 9H7M, and will advise the doctor that Millie wants
110713 - written report from the Tumor Board showing what was reviewed,
110714 - findings, analysis and proposed treatment plan. ref SDS 0 9H7M
110716 - [On 040517 the pathology report on the biopsy diagnoses metastatic
110717 - Carcinoma involving dermal lymphmatics consistent with
110718 - inflammatory carcinoma of the breast. ref SDS 15 8R6M
110724 - ..
1110 - Discussion
111101 - Skin Cancer Diagnosed from Biopsy Masectory Treatment Prescribed
111103 - The surgeon initially related having talked to the doctor about
111104 - results of the biopsy taken on 040419. ref SDS 11 789F She asked if
111105 - the doctor has talked to Millie about this?
111107 - ..
111108 - Millie advised that she has not talked to the oncologist.
111110 - [On 040504 the doctor talks to Millie on results of biopsy.
111111 - ref SDS 14 WR62
111113 - ..
111114 - The surgeon then said that she was very sorry to say the biopsy taken
111115 - on 040419 at the Kaiser hospital in Martinez, ref SDS 11 789F, shows
111116 - that red rash originally reported on 030109, ref SDS 6 KW5F, again on
111117 - 030606, ref SDS 7 7C6W, and more recently on 040318, ref SDS 9 IM6J,
111118 - has been diagnosed by pathology to be cancer, and this may require
111119 - that Millie have a mastectomy.
111121 - [On 040504 the doctor described the new problem as inflammatory
111122 - disease. ref SDS 14 UR6M
111124 - ..
111125 - [On 040517 the pathology report on the biopsy was submitted to the
111126 - patient during a meeting; review after the meeting showed the
111127 - report diagnoses metastatic Carcinoma involving dermal lymphmatics
111128 - consistent with inflammatory carcinoma of the breast. ref SDS 15
111129 - 6T5G Research indicated that IBC is a very serious form of
111130 - cancer. ref SDS 15 6M9H
111132 - ..
111133 - [On 040614 the doctor proposed not asking the Tumor Board to
111134 - revise findings and recommendations based on evidence available
111135 - prior to the hearing on 040419, but not submitted, and then
111136 - confirmed by a new diagnosis of IBC, until after a few months to
111137 - assess response to treatment on the Avastin and Taxol chemothrapy
111138 - trial protocol. ref SDS 16 4R59
111140 - ..
111141 - [On 051027 surgeon reports biopsy on mastectomy surgery finds
111142 - "funny stuff," which was later determined to diagnose DCIS, which
111143 - research on the Internet indicates has raises diagnostic and
111144 - treatment issues. ref SDS 23 HB4M
111146 - ..
111147 - The doctor offered that Millie's active life of exercise, work and
111148 - involvement that maintains strength, positive attitude and forward
111149 - focus are important factors of recovery. The primary care physician
111150 - has previously noted the same factors.
111152 - [On 051021 after 18 months of treatment biopsy on 051012
111153 - negative for inflammatory carcinoma. ref SDS 22 544N
Distant Metastasis Skin Cancer Breast Different from Original Cancer
120401 - ..
120402 - Breast Skin Cancer May be Different from Original Breast Tumor
120403 - Pathology Lab Study Differences in Cancer to Evaluate Scope of Problem
120404 - Scope of Problem Evaluate Pathology Lab Study Differences in Cancer
120406 - The surgeon feels that cancer found in the pathology report could be a
120407 - different type from the prior cancer, and so may indicate that cancer
120408 - is occurring elsewhere in body, an example is the lung, mentioned by
120409 - Doctor Liao on 040303. ref SDS 8 Y158 As a result, the surgeon will
120410 - contact the pathology lab this afternoon, and ask for a study
120411 - comparing the recent biopsy with the original biopsy taken by the
120412 - doctor on 020312, ref SDS 3 BL83, to determine if the current problem
120413 - is a different type of cancer.
120415 - ..
120416 - The surgeon explained that this could be a different type of cancer
120417 - because her prior work removing the original tumor, first on 020312,
120418 - ref SDS 3 Q78M, achieved "clear margins" indicating cancer was fully
120419 - removed at that time, reported on 020405, ref SDS 4 QV8I, and
120420 - explained again on 020408. ref SDS 5 0001 The doctor feels the skin
120421 - cancer now diagnosed could therefore be a manifestation of other
120422 - problems. She will ask the pathlogy lab to address this issue.
120424 - [On 040517 the pathology report on the biopsy diagnoses metastatic
120425 - Carcinoma involving dermal lymphmatics consistent with
120426 - inflammatory carcinoma of the breast. ref SDS 15 8R6M
Meeting Doctor Riley-Paull to Examine Recovery from Surgery on 02032
Schedule Masectomy Surgery Following Chemotherapy Treat Redness 4 -
140501 - ..
140502 - Chemotherapy Required to Treat Redness Prior to Masectomy Surgery
140503 - Masectomy Surgery Following Chemotherapy Treat Redness 4 - 6 Months
140505 - The surgeon explained that the current treatment regimine of
140506 - chemotherapy and Avastin will be needed for 4 - 6 months to reduce
140507 - cancer in the breast, so that there is enough healthy skin that can be
140508 - stitched together to cover the surgical wound. After chemotherapy has
140509 - reduced redness in the breast, a masectomy will then be performed
140510 - probably during a week off, at the end of a 3 week chemotherapy
140511 - treatment cycle, in August or September. The surgeon said that
140512 - radiation may be given after surgery and more chemotehrapy, as
140513 - occurred after the first surgery in 2002, and depending on the amount
140514 - of radiation previously given to the breast area the first time.
140516 - ..
140517 - The surgeon will coordinate with the primary care physician on follow
140518 - up examinations to monitor progress and schedule surgery. This plan
140519 - fits the model presented on 040419 of relying on team care for notice
140520 - to perform cross-departmental examinations that ensure quality care.
140521 - ref SDS 11 XU75
140523 - [On 040504 the doctor plans to consult with surgeon on when the
140524 - patient is ready for a masectomy in 4 - 6 months. ref SDS 14 MG8G
140526 - ..
140527 - [On 040504 reported research done 3 weeks later that indicates
140528 - typically masectomy is common treatment for inflammatory breast
140529 - cancer and is performed after treatment with chemotherapy.
140531 - ..
140532 - [On 040517 doctor examination indicates redness may be declining
140533 - as a result of the 1st three (3) chemotherapy treatments, that
140534 - includes Avastin in a drug trial. ref SDS 15 735H
140536 - ..
140537 - [On 040517 research indicates chemotherapy, surgery, more chemo,
140538 - and then radiation again is a common treatment regimine for IBC.
140539 - ref SDS 15 YM3M
140541 - ..
140542 - [On 040517 Tumor Board minutes discuss planning for surgery, and
140543 - possibly further radiation. ref SDS 15 5O4F
140545 - ..
140546 - [On 040614 doctor explains dilemma patient faces difficult
140547 - decision on having surgery or staying on Avastin trial; requires
140548 - more data, but PET scan tests not approved. ref SDS 16 ER9I
140550 - ..
140551 - [On 040812 doctor indicates patients with IBC need not be treated
140552 - with surgery for IBC. ref SDS 17 T75L
140554 - ..
140555 - [On 041210 doctor proposes surgery to treat IBC; case study
140556 - reviews history considering surgery for Millie. ref SDS 18 ZV5J
140558 - ..
140559 - [On 050107 surgeon examines worsening biopsy wound; will advise
140560 - primary care physician that IBC must be largely cured before
140561 - surgery can be considered for a masectomy on the left breast to
140562 - contain the spread of cancer. ref SDS 19 UM6I
140564 - ..
140565 - [On 050204 doctor asks for results of meeting with surgeon on
140566 - 050107, which cited reasoning today for deferring surgery until
140567 - IBC cleared with chemotherapy. ref SDS 20 NE3L
140569 - ..
140570 - [On 050311 the doctor has not seen the report nor talked to the
140571 - surgeon, ref SDS 21 UH3O; doctor calls surgeon asks for another
140572 - examination to report on performing surger to remove pockets of
140573 - resistance to chemotherapy. ref SDS 21 XQ41
Tumor Board Notified New Findings Written Recommendations Requested
150401 - ..
150402 - Written Recommendations on Treatment from Tumor Board Requested
150403 - Tumor Board Notified New Findings Written Recommendations Requested
150405 - The surgeon feels that Millie presents a complex patient profile that
150406 - requires careful analysis. The tumor board should be notified that
150407 - pathology report shows findings of new cancer, along with results from
150408 - the bone scan today, ref SDS 13 DJ5K, and such other tests that will
150409 - aid diagnosis, and then issue a written report to the patient showing
150410 - what was reviewed, who was consulted, what findings and conclusions
150411 - were reached, and what further diagnostics and treatment should be
150412 - considered, including analysis for performing a masectory after the
150413 - current red rash problem recedes.
150415 - [On 061020 primary care physician feels that patient profile
150416 - has too many issues for a 5-year medical case of secondary
150417 - inflammatory breast cancer (IBC), cellulitus, lymphedema,
150418 - pulmonary embolism, broken finger. ref SDS 24 MO4K
150420 - ..
150421 - The surgeon will call the doctor this afternoon and convey
150422 - Millie's request for a copy of the report issued by the Tumor Board.
150424 - [On 040517 primary care physician submitted pathology report on
150425 - biopsy; subsequent review shows findings metastatic Carcinoma
150426 - involving dermal lymphmatics consistent with inflammatory
150427 - carcinoma of the breast. ref SDS 15 8R6M
150429 - ..
150430 - [On 040517 received record of Tumor Board hearing; there was no
150431 - consideration of biopsy finding IBC. ref SDS 15 MB7G
150433 - ..
150434 - We reviewed the tenuousness of communication and analysis performed
150435 - solely through verbal discussion. Complexity from examining many
150436 - patients and interacting with colleagues and other staff on wide
150437 - ranging issues of administration, management, pathology, diagnosis and
150438 - prescribing treatment inherently overwhelm the biology of human span
150439 - of attention. During the 15 minutes or so when a doctor sees a
150440 - patient, matters that seem clear and complete in the moment, can
150441 - easily become confused and fade from the mind minutes later while
150442 - seeing other patients and dealing with other matters that busy the
150443 - mind of a top physician. In addition, personalities and authority can
150444 - significantly influence the way facts are understood, conveyed and
150445 - acted upon, where people are pursuaded by rhetoric and respect for, or
150446 - fear of, authority to ignore the record, correlations, impications and
150447 - nuance in order to protect personal standing, resulting in error,
150448 - loss, crisis and calamity. See, for example, Andy Grove's remarks on
150449 - experience at Intel showing that mental maps are awfully forgiving of
150450 - ambiguity, when people fail to invest time for writing, and instead
150451 - rely on remembing verbal commentary, reviewed on 980307. ref SDS 1
150452 - 3668
150454 - ..
150455 - the surgeon feels that writing things down helps maintain
150456 - clarity and comprehension in the medical record that can guide,
150457 - supplment and confirm verbal discussion. This practice aligns with
150458 - Kaiser's guidelines for an effective doctor and patient partnership,
150459 - reviewed at Kaiser on 990625, ref SDS 2 4185, and calling out to
150460 - confirm accuracy of communications. ref SDS 2 3960
150462 - ..
150463 - the surgeon seemed to strongly support getting a second opinion
150464 - in Millie's case, concurring with the doctor's discussion on
150465 - 040318, ref SDS 9 AW6M, and with research at that time showing
150466 - advantage of getting a 2nd opinion. ref SDS 9 8U4M
150468 - ..
150469 - A question posed by the record is whether to delay treatment
150470 - based on history of deferring action after notice on 030606 of
150471 - redness in combination with rising CA 15-3 and other factors
150472 - noted by the doctor? ref SDS 7 NE6F
150474 - ..
150475 - Another question is the scope of the problem, and whether in
150476 - addition to treating the breast, there are other matters that
150477 - need early attention in conjunction with chemotherapy?
150479 - ..
150480 - Conceivably, the timing of the treatments is optimal, and
150481 - nothing further can be done but to wait for further
150482 - manifestations of distant metastasis to occur.
150484 - ..
150485 - The issue with the breast does not seem to fit the criteria for
150486 - distant metastasis.