CONTACTS 

SUBJECTS
Meeting the doctor Begin 5th Cycle Avastin Trial Late Brief Meet   04

0503 -
0503 -    ..
0504 - Summary/Objective
0505 -
050501 - Follow up ref SDS 44 0000. ref SDS 40 0000.
050502 -
050503 - The doctor had limited time for the examination to start the next
050504 - cycle on the Avastin trial. ref SDS 0 RO5I  Good news was significant
050505 - drop in CA 15-3 cancer marker that is now near the target level of 39.
050506 - ref SDS 0 087J  Review of CT test aligns with favorable CA 15-3
050507 - indicating favorable response to treatment. ref SDS 0 T761  Several
050508 - conflicts between CT test reports does not require reconciliation for
050509 - accurate diagnosis and treatment planning. ref SDS 0 LQ5L  At this
050510 - time the only evidence of distant metastasis are lumps in the neck,
050511 - that are symptoms of IBC, which are no longer evident from clinical
050512 - examination. ref SDS 0 LQ5M  Side effects are beginning to accumulate,
050513 - ref SDS 0 RZ4I, and Genentec, who manufacturers Avastin, disclosed
050514 - increased risk of blood clots; the doctor explained family history
050515 - of blood clot problems does not prevent continued participation in the
050516 - Avastin trial because the patient has no personal history of blood
050517 - clot problems. ref SDS 0 W35K  The doctor advised the patient has
050518 - difficult decision whether to have surgery or continue in the Avastin
050519 - trial that causes side effects.  He recommended against submitting the
050520 - matter to the Tumor Board for analysis to resolve the dilemma.
050521 - ref SDS 0 T75L
050522 -
050523 -     [On 040909 continued improvement reported prior to starting 6th
050524 -     cycle Avastin trial. ref SDS 50 0001
050525 -
050526 -
050527 -
050528 -
050530 -  ..
0506 -
0507 -
0508 - Progress
0509 -
050901 - Meeting Truncated Delay 30 Minutes Not Enough Time for Agenda
050902 -
050903 - Follow up ref SDS 44 RO5I.
050904 -
050905 - The doctor was late to the meeting, and explained his schedule is
050906 - backed up today, so we only had a few minutes for examination prior to
050907 - starting the 5th cycle of the Avastin trial, as called out in the
050908 - consent reviewed on 040318. ref SDS 25 P13J  The doctor's regular
050909 - examination room was being used by another doctor, so we met in a room
050910 - at the end of the hall at the opposite end from the reception area.
050912 -  ..
050913 - There were no marking instruments, so we could not set out an agenda.
050914 -
050915 -
050916 -
050917 -
050918 -
050919 -
0510 -

SUBJECTS
CA 15-3 Cancer Marker 47 Drops from 55 Consistent with CT Testing Sh
CA 15-3 Cancer Marker 47 drops from 55 Continuing Trend Shows Respon
CA 15-3 70 Rises from 60 Reversing Trend of Past 6 Months
CA 15-3 Cancer Marker 78 Rises from 70 Indicating Potential Cancer A
CA 15-3 Cancer Marker 42 Drops from 54 Reversing Previous Rise Indic

1907 -
190801 -  ..
190802 - Recovery Progress CA 15-3 Cancer Marker Drops to 43 from 54
190803 - CA 15-3 Cancer Marker Continues Falling Consistent with Treatment Plan
190804 -
190805 - Follow up ref SDS 44 087J, ref SDS 40 087J.
190806 -
190807 - CA 15-3 blood test on 040728 shows another significant drop to 43 from
190808 - 54, and the test yesterday on 040811 shows a slight drop to 42.
190810 -           ..
190811 -          040811......... 42 H............. 040812, ref SDS 0 087J
190812 -          040728......... 43 H............. 040729, ref SDS 46 2N5J
190813 -          040712......... 54 H............. 040713, ref SDS 45 2N5J
190814 -          040628......... 47 H............. 040713, ref SDS 44 087J
190815 -          040614......... 55 H............. 040615, ref SDS 43 PX6X
190816 -          040517......... 78 H............. 040601, ref SDS 37 2N5J
190817 -          040311......... 70 H............. 040318, ref SDS 25 SM6M
190818 -          040205......... 60 H............. 040211, ref SDS 22 SM6M
190819 -          031201......... 62 H............. 031205, ref SDS 21 SM6M
190820 -          030912......... 66 H............. 030915, ref SDS 20 SM6M
190821 -          030708......... 68 H............. 030710, ref SDS 19 SM6M
190822 -          030503......... 54 H............. 030508, ref SDS 18 SM6M
190823 -          030403......... 45 H............. 030508, ref SDS 18 SM6M
190824 -          030215......... 46 H............. 030220, ref SDS 17 SM6M
190825 -          030106......... 37 H............. 030109, ref SDS 16 SM6M
190826 -          021202......... 41 H...39........ 021204, ref SDS 14 SP5G
190827 -          021111......... 36 H?............ 021113, ref SDS 13 Y65I
190828 -          021023......... 33 H?............ 021023, ref SDS 12 SQ5I
190829 -          020930......... 33 H?..29........ 021002, ref SDS 11 SQ5I
190830 -          020917......... 36 H?............ 020924, ref SDS 10 SQ5I
190831 -          020717......... 59 H?............ 020726, ref SDS 9 YN5K
190832 -          020629......... 75 H ............ 020705, ref SDS 8 UX6I
190833 -          020608........  67 H ............ 020614, ref SDS 7 0001
190834 -          020603........ 108 H ............ 020607, ref SDS 6 X67F
190835 -          020511........ 117 H ............ 020603, ref SDS 5 PJ4J
190836 -          020419......... 81 H ............ 020430, ref SDS 4 7N5H
190837 -          020321......... 85 H ............ 020405, ref SDS 3 6T8K
190838 -
190839 -
190840 -
190842 -  ..
1909 -
1910 -
1911 - Analysis
1912 -
191201 - CA 15-3 Cancer Marker Consistently Below 39 Shows Treatment Effective
191202 -
191203 - Follow up ref SDS 44 GJ5M, ref SDS 40 GJ5M.
191204 -
191205 - The doctor discussed implications of CA 15-3 history, which has
191206 - reached a low point of 42, per above, ref SDS 0 087J, in relation to
191207 - other favorable test and clinical examination data, toward ending
191208 - treatments in order to eliminate rising side effects, per below.
191209 - ref SDS 0 K47I
191210 -
191211 -
191212 -
191213 -
191214 -
191215 -
191216 -
1913 -

SUBJECTS
Avastin Side Effect New Evidence Increased Risk Pulmonary Emboli Blo

2903 -
290401 -  ..
290402 - Avastin Side Effect New Evidence Increased Risk Blood Clots
290403 - Coughing Heaviness in Chest Side Effect Taxol and Avastin Trial
290404 - Blood Clots Severe Problem Avastin Treatments Announced by Genentec
290405 -
290406 - Follow up ref SDS 44 RZ4I, ref SDS 41 RZ4I.
290407 -
290408 - Millie advised that side effects of nose bleeds, coughing, heaviness
290409 - in the chest, fatigue, and shortness of breath climbing stairs at
290410 - home, reported on 040517, ref SDS 33 RZ4I, continue with varying
290411 - severity.  Cough medicine has reduced the problem of a sore throat
290412 - from difficulty clearing her thoat with excessive coughing, similar to
290413 - the report on 040713. ref SDS 44 RZ4I  Low energy has reduced daily
290414 - exercise that has been a lifestyle for 30 years.
290415 -
290416 -    [On 041005 Millie reported continuing nose bleeds, cough, heavy
290417 -    chest. ref SDS 51 RZ4I
290419 -     ..
290420 -    [On 041210 nose bleed side effects subside after ending
290421 -    treatment with bevacizumab. ref SDS 60 FL8G
290423 -  ..
290424 - Below, Millie asks about ending chemotherapy to reduce side effects,
290425 - based on tests showing positive response to treatment; Doctor explains
290426 - difficult dilemma, and considers PET scan test for additional data to
290427 - facilitate decision making. ref SDS 0 K47I
290429 -  ..
290430 - Millie asked about reports in the news that Genentec has disclosed
290431 - severe side effects of bevacizumab (Avasin) chemotherapy, which seem
290432 - related to symptoms experienced the past few months after starting
290433 - treatment on the clinical study drug trial, reported on 040517.
290434 - ref SDS 33 RZ4I
290436 -  ..
290437 - The doctor explained that Kaiser is familiar with reports of increased
290438 - risk for blood clots in the lungs from participating in the drug trial
290439 - for bevacizumab.  Pulmonary embolism is a blood clot problem that may
290440 - relate to fatigue and breathing issues Millie has experienced.  It is
290441 - listed in the protocol consent forms, ref OF 2 CE39, which Millie
290442 - received from Kaiser on 040318, ref SDS 25 UO3H, and later signed
290443 - after explanation of side effects on 040402, though there is no record
290444 - explaining pulmonary embolism, nor that blood clots in the lungs are a
290445 - high risk of causing death, SDS 26 HS9X, as related in recent news
290446 - reporting.
290448 -  ..
290449 - After starting treatment with bevacizumab on 040420, on 040517, Millie
290450 - reported symptoms of fatigue, difficulty breathing, and chronoc cough.
290451 - ref SDS 33 RZ4I  Kaiser advised there was nothing to worry about
290452 - because symptoms were likely a reaction to an allergy, ref SDS 33
290453 - AY5K, and that pre-treatment drugs controlled allergic reaction to a
290454 - tolerable level. ref SDS 33 V64M  A month later, on 040614 the doctor
290455 - consulted with the protocol nurse on Millie's rising problems.  He
290456 - advised that rising fatigue, heavy chest, chronic cough, and shortness
290457 - of breath were nothing to worry about because loss of fitness occurs
290458 - with chemotherapy. ref SDS 40 R433
290460 -  ..
290461 - Today, Millie related family history of her mother dying at age 40
290462 - from blood clot conditions due to coronary thrombosis.  Last year
290463 - Millie's son, age 49, was hospitalized and treated for shortness of
290464 - breath from climbing stairs at home due to blood clots.  The diagnosis
290465 - was pulmonary edema, and was treated with Coumadin for a number of
290466 - months.  Millie's son is currently off treatment.
290468 -             ..
290469 -            [On 101029 1733 son hospitalized painful breathing,
290470 -            possible diagnosis lung cancer, lymphoma??? ref SDS 75 X06U
290472 -  ..
290473 - Millie's younger son, also, had blood clot problems in connection
290474 - with complications from a knee operation. reported on 971107.
290475 - ref SDS 1 0073
290477 -  ..
290478 - The doctor advised that Millie has nothing to worry about based on CT
290479 - testing performed 040710, and received from Kaiser yesterday, 070811.
290480 - ref SDS 47 H85S  The doctor cited test findings...
290481 -
290482 -            Again noted is scar tissue in the left lung apex.  There is
290483 -            a 2 mm nodule in the right middle lobe just anterior to the
290484 -            major fissure (image #37), unchanged.  There are no other
290485 -            pulmonary nodules.  Heart size is normal.  There is no
290486 -            pericardial or pleural effusion. ref SDS 47 WW68
290488 -  ..
290489 - The primary care physician noted that since Millie has no personal
290490 - history being diagnosed with blood clot problems, the fact that
290491 - Millie's mother, and Millie's two (2) adult sons have had related
290492 - conditions does not present risk for Millie continuing chemotherapy
290493 - with bevacizumab (Avastin), based on recent reports of patients dying
290494 - from blood clots caused by treatment in the clinical study drug trial
290495 - for bevacizumab.
290496 -
290497 -     [On 040819 protocol nurse, Rosalie, says Millie is not at risk for
290498 -     blood clot problems on the Avastin trial with symptoms of fatigue,
290499 -     heavy chest, shortness of breath, and cough, and despite family
290500 -     history of blood clot problems in the lungs, ref SDS 49 PI42;
290501 -     Coumadin prescribed in dose of 1 mg to reduce risk of blood clots
290502 -     caused by the port catheter for chemotherapy treatments.
290503 -     ref SDS 49 OX77
290505 -      ..
290506 -     [On 041104 pulmonary embolism diagnosed by CT scan, Millie removed
290507 -     from cancer treatment with bevacizumab (Avastin) clinical drug
290508 -     trial, ref SDS 56 RZ4I; because symptoms of heavy chest, shortness
290509 -     of breath, fatigue, cough attributed can quickly cascade causing
290510 -     death, ref SDS 56 N43I; Kaiser policy requires cancer patients
290511 -     diagnosed with pulmonary emboli get treatment for life,
290512 -     ref SDS 56 4Y9G, Coumadin increased from 1 mg to 4 mg, and
290513 -     preceeded with Lovenox treatments. ref SDS 56 N455
290515 -      ..
290516 -     [On 051007 doctor ends treatment with Coumadin (warfarin) for
290517 -     pulmonary embolism, ref SDS 67 RZ4I, a year after ending treatment
290518 -     with bevacizumab. ref SDS 67 XN7K
290520 -      ..
290521 -     [On 060714 oldest son hospitalized again with pulmonary emboli.
290522 -     ref SDS 69 8S6I
290524 -      ..
290525 -     [On 060722 oldest son reports doctors performed tests and found
290526 -     genetic cause of blood clots that will require continuing
290527 -     treatment. ref SDS 70 3D9T
290529 -      ..
290530 -     [On 060724 notified Kaiser of new information on family history of
290531 -     blood clot problems. ref SDS 71 NL5Q
290533 -      ..
290534 -     [On 060726 letter from Arlette says Kaiser received this notice
290535 -     and forwarded to the primary care physician. ref SDS 72 0001
290537 -      ..
290538 -     [On 061002 Millie diagnosed with recurrence pulmonary emboli;
290539 -     requires treatment again with Lovenox to relieve blood clots, then
290540 -     continuing treatment with Coumadin to prevent recurrence.
290541 -     ref SDS 73 JK7J
290542 -
290543 -
290544 -
290545 -
2906 -

SUBJECTS
Meeting with Doctor about Lump in left breast and Under Left Arm Cau
Swelling Left Side Under Left Arm Likely Caused by Draining Lymph No
Symptom New Lump Under Arms where Cancer Surgery Performed on 020312
Pea-like Cluster and Firmness Indicates Cancerous Lumps Not Present
Lumps Under Left Arm Smaller Demonstrate Favorable Response to Treat

3607 -
360801 -  ..
360802 - Lumps Under Arm Seem Less Severe Today
360803 -
360804 - Follow up ref SDS 44 MW8J, ref SDS 42 MW8J.
360805 -
360806 - Millie reported the lump under her left arm seems to be getting
360807 - smaller, continuing prior report of response to treatment, and
360808 - consistant with the doctor's analysis of testing today, per below.
360809 - ref SDS 0 T761
360811 -  ..
360812 - The doctor did not make an examination.
360813 -
360814 -     [On 040909 examination found lump under the arm getting smaller.
360815 -     ref SDS 50 MW8J
360816 -
360817 -
360818 -
360819 -
3609 -

SUBJECTS
Lumps Neck Nearly Gone Clinical Examination Doctor Confirms No Other

4203 -
420401 -  ..
420402 - Lumps in Neck Not Evident from Clinical Examination No Stiffness Pain
420403 - Metastatic Cancer Diagnosed Based on Lumps in Neck of IBC Patient
420404 -
420405 - Follow up ref SDS 44 8R6M, ref SDS 40 8R6M.
420406 -
420407 - Millie reported that swelled lumps in the neck seem to have
420408 - disappeared following treatment begun on 040420. ref SDS 29 9Z5J  She
420409 - cannot feel anything now in the area that was reported on 040211 that
420410 - had severe lumps, ref SDS 22 WP7L, and was diagnosed as cancer on
420411 - 040309. ref SDS 24 HD5N
420413 -  ..
420414 - The doctor did not make an examination.  He noted that Millie's report
420415 - today aligns with findings in the CT test on 040710, received on
420416 - 040811, discussed below, ref SDS 0 T761, confirming understandings
420417 - from the meeting on 040713 that, at this time, lumps in the neck on
420418 - the left side are the only evidence of metastatic cancer, ref SDS 44
420419 - X36J, along with lumps under the left arm, which both symptoms of
420420 - regional disease currently diagnosed as IBC in the left breast,
420421 - reported on 040517. ref SDS 33 S65H  The doctor further noted
420422 - favorable response to treatment for IBC with the Avastin Taxol trial.
420423 -
420424 -
420425 -
420426 -
4205 -

SUBJECTS
Redness Returns to Left Breast Diagnosed as Cellulitus Treated with
Breast Softer Change May Indicate Recovery from Trauma of Surgery
Diagnosis Changed from Cellulitus to Radiation Reaction Treated with
Cancer Treatment Delayed Cellulitus Diagnosed Treated with Antibioti
Breast Redness Returns to Left Breast Diagnosed as Cellulitus Treate
Breast Redness Diagnosis Changed from Cellulitus to Radiation Reacti
Biopsy Pathology Report Diagnosed Inflammatory Breast Cancer Submitt
Pathology Report on Biopsy Diagnosed Inflammatory Breast Cancer Subm
Inflammatory Breast Cancer Rare 1% of Cases Aggressive Spreads Quick
Treatment Chemotherapy Masectomy Surgery Radiation Initially Reduce   7
Treatment Chemotherapy Masectomy Radiation How Inflammatory Breast C
Time Not Enough for Examination to Evaluate Symptoms IBC Reduced Red
IBC Time Not Enough for Examination to Evaluate Symptoms Reduced Red

6315 -
631601 -  ..
631602 - Inflammatory Breast Cancer (IBC) Diagnosed Based on Pathology Report
631603 - Redness Breast Seems Less Severe; Skin Seems Softer after Treatments
631604 -
631605 - Follow up ref SDS 44 6T5G, ref SDS 40 6T5G.
631606 -
631607 - Due to limited time, there was no examination of left breast.
631609 -  ..
631610 - Millie reported further reduction of inflammation, and softening of
631611 - skin, indicating response to treatment, which aligns with the doctor's
631612 - comments on the CT testing, per below. ref SDS 0 T761
631613 -
631614 -
631615 -
631616 -
631617 -
631618 -
631619 -
6317 -

SUBJECTS
Medical Tests Conflicts CT Not Resolved Medical Practice Verify Accu

8103 -
810401 -  ..
810402 - CT Test Significant Improvement Decrease Axillary Lymphadenopathy
810403 -
810404 - Follow up ref SDS 47 H85S, ref SDS 44 LK5L.
810405 -
810406 - The doctor reviewed the CT test dated 040710, which was received from
810407 - Kaiser yesterday on 040811. ref SDS 47 X14J  The doctor noted
810408 - significant decrease in the size of swelled lymph nodes from findings,
810409 - and comparisons in the report, ref SDS 47 WV5W, that support
810410 - "impressions" saying....
810412 -         ..
810413 -        Interval improvement in the neck and bilateral axillary
810414 -        adenopathy. ref SDS 47 WW79
810416 -  ..
810417 - The doctor noted there is no other evidence of distant metastasis in
810418 - Kaiser's tests and analysis, which aligns with improved conditions
810419 - reported above....
810420 -
810421 -        CA 15-3 42, near normal.................... ref SDS 0 GJ5M
810422 -        Lump under left arm reduced................ ref SDS 0 MW8J
810423 -        Lumps in neck disappeared.................. ref SDS 0 8R6M
810424 -        Redness reduced left breast................ ref SDS 0 6T5G
810426 -       ..
810427 -      [On 050324 research indicates distinction between metastatic
810428 -      disease involving regional lymph nodes, which may be operable to
810429 -      reduce chances of relapse, and distant metastasis, which surgery
810430 -      cannot cure, but may play a palliative role, ref SDS 63 O84N,
810431 -      further explained from research on 050712. ref SDS 64 B65G
810432 -
810433 -
810435 -  ..
810436 - Engineering Precision Not Required for Medical Practice Accuracy
810437 - Conflicts Medical Tests CT Not Resolved with Precision
810438 - Medical Test Report Conflicts Not Resolved for Accuracy
810439 - Accuracy Medical Test Report Conflicts Not Resolved with Precision
810440 -
810441 - Millie asked about cancerous lymph nodes reported in a CT test on
810442 - 040410, which are not discussed in the follow up test dated 040710, as
810443 - shown in the record on 040811, when the report was submitted by
810444 - Kaiser? ref SDS 47 WW53  This seems similar to CT testing problems in
810445 - the record for 031205. ref SDS 21 GJ69
810446 -
810447 -        (...below, PET testing not approved by Kaiser to resolve
810448 -        conflicts in CT testing. ref SDS 0 7R9H)
810450 -  ..
810451 - The doctor thumbed through the patient medical chart.  He looked on
810452 - Kaiser's computer in the examination room.  He could not locate the
810453 - report for CT test on 040410, which was received from the doctor at
810454 - Kaiser during a meeting on 040416, ref SDS 28 HX4K, and is discussed
810455 - in the record on 040811 citing evident conflicts, ref SDS 47 WW3V,
810456 - which Millie asks about today.  Difficulty finding patient history on
810457 - medical tests was reported on 040318. ref SDS 25 ZE5O
810458 -
810459 -     [On 061024 case study medical practice computer access limited
810460 -     even with everything on the computer, people can't find details
810461 -     stored in parts of the computer (software modules) that are not
810462 -     frequently used. ref SDS 74 JD9L
810464 -  ..
810465 - The doctor related emphatically that medical practice does not have
810466 - the same standards of precision that are used in engineering to
810467 - reconcile differences and conflicts for errors and omissions that
810468 - guide accuracy of diagnosis and treatment.  The doctor said that
810469 - doctors do not have enough time to compare test reports for conflicts,
810470 - errors, and omissions.  The primary care physician, who visits
810471 - directly with patients expects specialists, who prepare reports, to
810472 - make accurate comparisons, and, if there are discrepancies, the
810473 - practice at Kaiser is to ignore them as irrelevant, otherwise they
810474 - would be in the report, since that is the job of the specialist.
810475 -
810476 -     [On 060126 medical analyst cannot find prior report for PET scan
810477 -     test on 051005 to make comparison and trend analysis with results
810478 -     of new test on 060120. ref SDS 68 LC7N
810480 -  ..
810481 - Previously, on 040402 the chemotherapy trial protocol nurse reported
810482 - that Kaiser has very high standards for precision, and that medical
810483 - records are audited to verify accuracy of diagnosis and treatment that
810484 - yield effective and predictable results. ref SDS 26 6E4K
810485 -
810486 -     [On 041018 Doctor Benz read from patient's letter to verify the
810487 -     scope and agenda for a 2nd opinion, ref SDS 53 LX3U, the doctor
810488 -     further requested written verification of CA 15-3 cancer
810489 -     marker, even though he also said that UCSF does not rely on
810490 -     this criteria, ref SDS 53 L16Q, all demonstrating importance of
810491 -     accuracy in medical practice illustrated by Rosalie's
810492 -     explanation of drug trial protocols, ref SDS 26 6E4K, however,
810493 -     the doctor then relied on asking questions to obtain patient's
810494 -     personal memory of events over 3 years to prepare a hurried,
810495 -     cursory, and erroneous chronology of patient history that
810496 -     ignored the written record submitted to UCSF. ref SDS 53 EN63
810498 -      ..
810499 -     [On 041019 Doctor Guardino demonstrated importance of accuracy
810500 -     in health care by requiring an aide to check the record for
810501 -     verification on the date of a pathology report on IBC, rather
810502 -     than rely on assurances in conversation. ref SDS 54 BV92
810504 -      ..
810505 -     [On 041021 errors in chemotherapy treatment by the Infusion Clinic
810506 -     illustrate requirement for high degree of precision following
810507 -     protocols. ref SDS 55 NG7B
810509 -      ..
810510 -     [On 041130 discussion at Kaiser on getting a written work
810511 -     plan and review by Tumor Board on treating the patient,
810512 -     ref SDS 58 YR8F, after major change in status due to
810513 -     pulmonary emboli ended participation in the Avasting Taxol
810514 -     trial. ref SDS 58 WL9M
810516 -      ..
810517 -     [On 041230 primary care physician asked patient for reasons
810518 -     chemotherapy regimine was changed to another drug, illustrating
810519 -     importance of timely, accurate records. ref SDS 61 XQ84
810520 -
810521 -
810522 -
810523 -
8106 -

SUBJECTS
IBC Surgery Masectomy Not Required Dilemma Surgery or Avastin Trial
Dilemma Patient Difficult Decision Surgery or Continue Avastin Trial
Surgery Dilemma Patient Difficult Decision Surgery or Continue Avast
Surgery Not Required IBC Masectomy Dilemma Surgery or Avastin Trial

8706 -
870701 -  ..
870702 - Dilemma Avastin Side Effects IBC Surgery Tumor Board Not Required
870703 - IBC Does Not Require Surgery Dilemma Surgery or Avastin Trial
870704 - Difficult Case Need CA 15-3 Below 39 to Support Conflicting CT Tests
870705 - Masectomy Preceded by Chemotherapy for Inflammatory Breast Cancer
870706 -
870707 - Follow up ref SDS 40 JK8L, ref SDS 33 JK8L.
870708 -
870709 - Millie asked if findings of.....
870710 -
870711 -    1.  CT test showing significant
870712 -        reduction in size of swelled lymph
870713 -        nodes......................................... ref SDS 0 T761
870715 -         ..
870716 -    2.  Lump under the arm swelling
870717 -        has reduced IAW CT test....................... ref SDS 0 MW8J
870719 -         ..
870720 -    3.  Lumps in neck have reduced
870721 -        IAW CT test................................... ref SDS 0 8R6M
870723 -         ..
870724 -    4.  Redness (inflammation) in left
870725 -        breast reduced................................ ref SDS 0 6T5G
870726 -
870727 - ....all seem to indicate a condition has been, or will soon be,
870728 - reached where ending chemotherapy to reduce side effects, and
870729 - surgery should be considered, as planned previously
870730 - on....
870731 -
870732 -        Surgeon.............................. 040429, ref SDS 31 SD7F
870733 -        Doctor............................... 040504, ref SDS 32 MG8G
870734 -        Research on IBC...................... 040517, ref SDS 33 YM3M
870735 -        Tumor Board.......................... 040517, ref SDS 33 F77M
870737 -  ..
870738 - The doctor indicated that treatment for IBC in Millie's case does not
870739 - require surgery to remove tissue that has proven susceptible to
870740 - cancer, and so Millie need not necessarily decide to have a
870741 - mastectomy.  The doctor feels Millie's case presents a significant
870742 - dilemma for patient and physician to decide on a course of treatment,
870743 - described previously on 040614. ref SDS 40 ER9I
870744 -
870745 -     [On 041018 Doctor Benz indicated that surgery is not an effective
870746 -     solution for Millie, and offered no criteria this determination.
870747 -     ref SDS 53 EO3Y
870749 -      ..
870750 -     [On 041019 Doctor Guardino indicated surgery may be effective
870751 -     after progress recovering from IBC occurs, and offered no criteria
870752 -     for evaluating progress. ref SDS 54 TX96
870754 -      ..
870755 -     [On 041117 2nd opinion from Doctor Benz confirms understanding of
870756 -     recommending against a surgical solution in Millie's case, and
870757 -     does not offer a basis for this opinion. ref SDS 57 OU5P
870759 -      ..
870760 -     [On 041209 2nd opinion received from Stanford says that surgery
870761 -     may be possible after regression of inflammatory breast condition
870762 -     and does not describe criteria for determining sufficient
870763 -     regression. ref SDS 59 SN97
870765 -      ..
870766 -     [On 041210 doctor proposes surgery to treat IBC; case study
870767 -     reviews history considering surgery for Millie. ref SDS 60 ZV5J
870769 -      ..
870770 -     [On 050311 doctor describes pockets of resistance to chemotharpy
870771 -     may require treatment with breast surgery, ref SDS 62 PA4N; calls
870772 -     surgeon to request examination and opinion. ref SDS 62 XQ41
870774 -      ..
870775 -     [On 050324 research yielded a professional comment that IBC is not
870776 -     always inoperable, ref SDS 63 TN76, which seems to present a bias
870777 -     against surgery that may align with Doctor Benz at UCSF, who
870778 -     discouraged surgery in a 2nd opinion received on 041117.
870779 -     ref SDS 57 OU5P
870781 -      ..
870782 -     [On 050712 research indicates surgery can be a treatment option
870783 -     for stage III cancer, and is generally not attempted for stage IV
870784 -     cancer patients, who instead receive palliative treatment.
870785 -     ref SDS 64 B65G
870787 -  ..
870788 - Millie asked if favorable response to treatment shown by consecutive
870789 - CA 15-3 reports slightly above the target range of 39, reported today,
870790 - per above, ref SDS 0 087J, indicate progress toward ending
870791 - chemotherapy treatments that severely sap her energy, and reduce
870792 - quality of life, per side effects, discussed above? ref SDS 0 RZ4I
870794 -  ..
870795 - The doctor said Millie's situation is a "difficult" dilemma
870796 - because CA 15-3 has fluctuated significantly indicating both cancer
870797 - activity and favorable response to the Avastin and Taxol chemotherapy,
870798 - which therefore indicates continuing with treatment. ref SDS 0 KV59
870799 -
870800 -     [On 041005 CA 15-3 rises to 49 illustrating dilemma of conflicting
870801 -     diagnostics. ref SDS 51 GJ5M
870803 -      ..
870804 -     [On 041014 CA 15-3 finally falls to normal at 39, the high-end of
870805 -     the normal range. ref SDS 52 HG9K
870807 -      ..
870808 -     [On 041104 dilemma resolved when CT test shows pulmonary emoboli
870809 -     (blood clots) attributed to Avastin chemotherapy treatment
870810 -     reported to cause death in some patients, and may have caused
870811 -     coughing, heavy chest, and shortness of breath, forced patient to
870812 -     end treatment with Avastin; presents new dilemma because leaving
870813 -     the Taxol and Avastin trial conflicts with requirement for
870814 -     continuous treatment to avoid symptoms of IBC to increase, and
870815 -     which had decreased under Taxol and Avastin. ref SDS 56 N43I
870817 -      ..
870818 -     [On 041130 doctor proposes taking chemotherapy holiday to recover
870819 -     from side effects; explains need to balance pausing treatment
870820 -     against allowing symptoms of IBC to cascade out of control.
870821 -     ref SDS 58 Y660
870823 -      ..
870824 -     [On 050729 planning another break from chemotherapy after evident
870825 -     success of treatment with Taxotere capecitabine (Xeloda), and
870826 -     possible surgery in Sepbember 2005. ref SDS 65 Z26O
870828 -  ..
870829 - There was discussion of getting another PET scan to evaluate the scope
870830 - of cancer, considered previously on 040614. ref SDS 40 HG4G  Can PET
870831 - scan testing help resolve conflicts in the CT tests, per above,
870832 - ref SDS 0 LQ5L, based on successful experience the doctor cited on
870833 - 020603 relying on PET scan test results to change the course of
870834 - treatment at that time? ref SDS 5 0001
870836 -  ..
870837 - The doctor recommended against a PET scan, as unnecessary duplication
870838 - of CT tests.  Millie indicated that PET scan tests are hard to endure
870839 - along with current side effects of chemotherapy, per above,
870840 - ref SDS 0 RZ4I, so she is not enthusiastic about more PET scan
870841 - diagnostic tests.
870843 -  ..
870844 - The doctor advised that side effects of weekly cancer treatments must
870845 - therefore be endured in order to reach a stable condition where CA
870846 - 15-3 is consistently below 39 for several months.  He seemed to
870847 - indicate that several months with CA 15-3 at about 30 would support
870848 - ending weekly treatments.
870849 -
870850 -     [On 040909 worsening side effects, plans confirmed to continue
870851 -     treatment until CA 15-3 reaches a normal range for several months,
870852 -     as criteria for changing treatment to reduce side effects.
870853 -     ref SDS 50 F17K
870855 -      ..
870856 -     [On 041014 CA 15-3 finally falls to normal at 39, the high-end of
870857 -     the normal range. ref SDS 52 HG9K
870859 -      ..
870860 -     [On 041104 dilemma resolved when CT test shows pulmonary emoboli
870861 -     (blood clots) attributed to Avastin chemotherapy treatment
870862 -     reported to cause death in some patients, and may have caused
870863 -     coughing, heavy chest, and shortness of breath, forced patient to
870864 -     end treatment with Avastin; presents new dilemma because leaving
870865 -     the Taxol and Avastin trial conflicts with requirement for
870866 -     continuous treatment to avoid symptoms of IBC to increase, and
870867 -     which had decreased under Taxol and Avastin. ref SDS 56 N43I
870869 -      ..
870870 -     [On 050729 about a year later, patient has approximate same
870871 -     position, struggling to achieve a stable condition, with CA 15-3
870872 -     providing one diagnostic as part of deciding to have surgery.
870873 -     ref SDS 65 VP4N
870875 -      ..
870876 -     [On 050819 CA 15-3 still unstable; went down to 37, then bounced
870877 -     back to 46, then dropped again to 39. ref SDS 66 TL6J
870879 -  ..
870880 - On 030508 the doctor reviewed ASCO comments on CA 15-3 to support
870881 - Kaiser's analysis that rise in CA 15-3 at that time does not suggest
870882 - relapse nor failure of treatment. ref SDS 18 M28G
870883 -
870884 -
870885 -
870886 -
8709 -

SUBJECTS
Tumor Board Re-hearing Consider New Evidence Major Change Patient Pr

A203 -
A20401 -  ..
A20402 - Tumor Board Doctor Recommends Against Re-hearing on IBC
A20403 -
A20404 - Follow up ref SDS 40 4R59, ref SDS 33 K48O.
A20405 -
A20406 - Millie asked if this is a good time to get help from the Tumor Board
A20407 - on solving treatment dilemmas posed by the doctor today, per above?
A20408 - ref SDS 0 T75L  On 040614 the doctor suggested deferring help from the
A20409 - Tumor Board on treating IBC until after getting experience from a few
A20410 - cycles of treatment on the Avastin trial. ref SDS 40 4R59  Kaiser now
A20411 - has experience from 4 cycles in Millie's case.
A20413 -  ..
A20414 - Can the Tumor Board offer guidance on diagnosing the cause of rising
A20415 - symptoms with cough, shortness of breath, heavy chest, always being
A20416 - tired, and correlations with public reports Avastin has caused deaths
A20417 - from pulmonary embolism, and Millie's family history of blood clot
A20418 - problems, per above? ref SDS 0 RZ4I
A20420 -  ..
A20421 - The doctor recommended against requesting additional input from the
A20422 - Tumor Board on the dilemma presented today, ref SDS 0 T75L, in order
A20423 - to supplement the Board's prior work.  The reasoning is unclear for
A20424 - Kaiser not getting support from the Tumor Board on treating IBC, and
A20425 - symptoms of pulmonary embolism, following experience on the Taxol and
A20426 - bevacizumab (Avastin) drug trial.
A20427 -
A20428 -     [On 040909 Millie notified Kaiser to make referral for a 2nd
A20429 -     opinion. ref SDS 50 AW6M
A20431 -      ..
A20432 -     [On 041005 since Millie's symptoms of pulmonary embolism are
A20433 -     worse, since Kaiser diagnoses worsening cough, nose bleed, and
A20434 -     shortness of breath is caused by poor fitness from lack of
A20435 -     exercise due fatigue from side effects of chemotherapy, and since
A20436 -     Kaiser failed to order 2nd opinion and a Tumor Board, Millier
A20437 -     ordered a 2nd opinion to assist the medical team. ref SDS 51 RZ4I
A20438 -
A20439 -
A20440 -
A20441 -
A20442 -
A20443 -
A20444 -
A20445 -
A205 -