CONTACTS 

SUBJECTS
Medical Management Review Delayed Due to Complications Diagnosis IBC

1403 -
1403 -    ..
1404 - Summary/Objective
1405 -
140501 - Follow up ref SDS 3 0000, ref SDS 2 0000.
140502 -
140508 - On 040504 the doctor asked to submit correspondence through Rosalie.
140509 - ref SDS 2 6H44
140511 -  ..
140512 - On 040517 the doctor submitted a document which later turned out to be
140513 - a pathology report which contained a new diagnosis of inflammatory
140514 - breast cancer (IBC). ref SDS 3 6T5G  Research found that IBC is a more
140515 - serious condition that requires expedited treatment. ref SDS 3 6M9H
140517 -  ..
140518 - There is a meeting set for 040614 where the doctor will review
140519 - progress in the case toward maintaining Millie in the Avastin trial.
140521 -  ..
140522 - During this meeting, issues in the record on 040517 can be discussed
140523 - to clarify if Kaiser has diagnosed IBC, based on research at that
140524 - time, ref SDS 3 S79G, and a work plan is needed to take timely action.
140525 - ref SDS 3 5Q5L
140527 -  ..
140528 - Tumor Board work product should also be reviewed. ref SDS 3 F751
140530 -  ..
140531 - Submitted ref DIT 1 0001 to Rosalie, asking that she forward to the
140532 - doctor, and which says the following...
140533 -
140534 -    1.  Dear Rosalie,
140536 -         ..
140537 -        We visited briefly with the doctor in the Chemotherapy
140538 -        Clinic on 040504, ref SDS 2 6H44, and at that time the doctor
140539 -        asked that you facilitate communication by forwarding this
140540 -        letter to him. ref DIT 1 0001
140542 -         ..
140543 -    2.  Thanks very much for your support.  The following is for the
140544 -        doctor, but may relate to your work as well monitoring
140545 -        participants in the Avastin trial. ref DIT 1 PI6M
140547 -         ..
140548 -    3.  Dear Doctor,
140550 -         ..
140551 -        In our meeting on 040504 we planned to discuss strengthening
140552 -        medical management, based on Kaiser's work to apply technology
140553 -        for a "paperless" medical chart, and related tasks. ref DIT 1
140554 -        CF7G  Some folks summarize this as "Knowledge Management."  You
140555 -        mentioned that term during our visit on 040504. ref SDS 2 0001
140568 -         ..
140569 -    5.  Since we met on 040504, new circumstances require focusing on
140570 -        helping Millie, ref DIT 1 MN9K, and so the prior agenda must be
140571 -        set aside, as follows...
140577 -         ..
140578 -    6.  In our meeting on 040517, you submitted a pathology report that
140579 -        seems to diagnose inflammatory breast cancer (IBC).  Because of
140580 -        dynamics during the meeting, ref DIT 1 FP4F, there wasn't time
140581 -        on 040517 to consider implications of this new information.
140582 -        Subsequent review following the meeting seems to indicate that
140583 -        Millie now faces a very significant challenge. ref SDS 3 6M9H
140585 -         ..
140586 -    7.  Hopefully, this analysis is incorrect. ref DIT 1 MQ5G
140588 -         ..
140589 -    8.  When we meet on Monday, you can clarify the situation.  Millie
140590 -        has great confidence in your leadership and expertise, and
140591 -        wants very much to be an effective partner in managing
140592 -        treatment. ref DIT 1 KR5J
140594 -         ..
140595 -    9.  Assuming, IBC has been diagnosed, ref DIT 1 0U5O, we would like
140596 -        to go down the list of issues in the letter on 040517.
140597 -        ref SDS 3 S79G and perhaps formulate a work plan, also listed
140598 -        in that record. ref SDS 3 5Q5L
140600 -         ..
140601 -   10.  This can all be done online using the new system you
140602 -        demonstrated on 040504 -- we don't have to print a bunch of
140603 -        paper. ref DIT 1 UJ6N
140605 -         ..
140606 -   11.  As noted in the record on 040517, there has been some good
140607 -        news. ref DIT 1 BM3I
140609 -         ..
140610 -   12.  Millie says the lumps in her neck have all but disappeared.  We
140611 -        both feel the red rash on the breast has begun to subside, and
140612 -        the skin seems more normal, rather than "thickened."  Not
140613 -        sure about the lump under the arm.  The last CA 15-3 test
140614 -        showed a slow down in the rise from 10 to only 8.  In any case
140615 -        this record may suggest that the present course is the best
140616 -        course. ref DIT 1 CQ3L
140617 -
140618 -            [On 040614 the doctor examines the neck, and concurs there
140619 -            has been significant reduction in swelling of lymph nodes.
140620 -            ref SDS 5 R76I
140622 -             ..
140623 -            [On 040614 doctor examines left breast and reports redness
140624 -            has reduced further. ref SDS 5 735H
140626 -         ..
140627 -   13.  Millie wants this case re-submitted to the Tumor Board with the
140628 -        IBC issue, the bone scan results, and an updated CA 15-3,
140629 -        hopefully showing a decline or at least continued slow down in
140630 -        the rise. ref DIT 1 RR4J  Millie wants a PET scan for another
140631 -        perspective on the scope of the problem.  If the PET scan
140632 -        confirms prior feelings that the problem is limited to the
140633 -        neck, the breast and maybe under the left arm, then these
140634 -        indicators taken together may support the Tumor Board endorsing
140635 -        the current treatment under the new diagnosis of IBC.
140636 -
140637 -            [On 040614 the doctor recommends against PET scan test to
140638 -            evaluate scope of problem. ref SDS 5 HG5G
140640 -             ..
140641 -            [On 040614 CA 15-3 rises to 70, the doctor orders another
140642 -            CA 15-4 blood test. ref SDS 5 GL5N
140644 -         ..
140645 -   14.  Kaiser should submit information on standard treatment for IBC,
140646 -        and how that is thought to compare with the current regimen.
140647 -        ref DIT 1 SC5K
140649 -         ..
140650 -   15.  Kaiser should then coordinate with Stanford, Cal, or some other
140651 -        local Cancer Center, ref DIT 1 FE5O, where IBC is treated
140652 -        routinely, for backup review of the case, as you discussed on
140653 -        040318. ref SDS 1 AW6M
140655 -         ..
140656 -   16.  There has, also, been some less happy news.  Hopefully, this is
140657 -        related to side effects of treatment, and so is generally
140658 -        normal, rather than a flag that disease is progressing.
140659 -        ref DIT 1 UQ6J
140661 -         ..
140662 -   17.  Beginning about a week ago, Millie is definitely feeling more
140663 -        tired. ref DIT 1 NS6O
140665 -         ..
140666 -   18.  Possibly we over extended on exercise, taking several 7 mile
140667 -        walks around town, but she has done a lot of that, so it is
140668 -        quite unusual for her to get tired and spend the day in bed.
140669 -        ref DIT 1 NW7I  She also had another bout of coughing through
140670 -        the night due to a scratchy throat.  This episode was not as
140671 -        severe as the one reported to you on 040517, and thought to be
140672 -        allergy related. ref SDS 3 RZ4I
140674 -  ..
140675 - This reports experience of complications and problems beginning on
140676 - 040607. ref SDS 4 MP6J
140678 -  ..
140679 - Millie's letter to the doctor continues...
140680 -
140681 -   19.  Still, I had to help her sit up to sleep in bed to avoid stuff
140682 -        backing up in her throat.  The next day she was okay, but I
140683 -        thought about taking her for emergency treatment that night.
140684 -        ref DIT 1 PC8I
140686 -         ..
140687 -   20.  Again, you have done a terrific job under all the
140688 -        circumstances.  Your leadership of the clinic shines through in
140689 -        the professionalism, teamwork and cooperation of the staff.
140690 -        ref DIT 1 XD8O
140692 -         ..
140693 -   21.  If you have time to review the record on 040517, ref SDS 3
140694 -        0001, please submit any corrections you feel can be rolled back
140695 -        into the record to ensure accurate, useful organizational
140696 -        memory for guiding the work. ref DIT 1 4E9J
140698 -             ..
140699 -            [On 040614 the doctor reported his computer was down, so he
140700 -            was not able to review pending issues from the prior
140701 -            meeting on 040517. ref SDS 5 S79G
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