THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: October 18, 2004 09:00 AM Monday;
UCSF meeting for 2nd opinion Millie.
2...2nd Opinion Requested on IBC Distant Metastasis Surgery Avastin Trial
3...2nd Opinion Metastasis, Surgery, Ending Treatment
4...CA 15-3 Cancer Marker Documented Requested Verify Accuracy Conversation
5...CA 15-3 Not Relied Upon by UCSF for Patient Status
6...Patient History Not Available on UCSF Med School Computer
7...Case Studies for Chronology of Patient History Not Reviewed
8...IBC Status Not Determined from Clinical Examination
9...Delayed Treatment IBC Does Not Impact Health Recovery in this Case
10...PET Test Not Recommended to Determine Scope of Problem
11...Surgery Not Needed for IBC when Metastatic Cancer Diagnosed
12...Out of Capsule Lymph Nodes Recurrance in Neck Drive Diagnosis
13...Metastatic Cancer Stage III Requires Continued Chemotheapy No Surgery
14...Patient Strong Response to Treatment Fortunate
15...Continue Treatment and Switch Promptly When Disease Progresses
16...UCSF Sponsors New Drug Trials May Help Millie When Cancer Progresses
17...Tired Cough Breathing Difficult Could Signal Cancer in Lungs
18...Shortness of Breath Fatigue Cough Clearing Throat May be Lung Cancer
19...Lung Cancer May Explain Symptoms Fatigue Shortness of Breath Cough
20...Avastin Protocol Randomized Phase III Trial as First-line Therapy
21...Written Report Pending and Medical Records Returned
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2nd Opinion Verify Scope of Problem and Treatment Planning Tumor Boa
2nd Opinion Requested from UCSF, Stanford, UC Davis Cancer Centers
UCSF Meeting Doctor Benz 2nd Opinion
1305 - ..
1306 - Summary/Objective
130701 - Follow up ref SDS 29 0000, ref SDS 27 0000.
130703 - The doctor made a good review of pathology and test documents.
130704 - ref SDS 0 EN63 He concurs with Kaiser's analysis that recurrence in
130705 - the neck under all of patient risk factors indicate metastic cancer.
130706 - The doctor feels that surgery is not an option, and there is no
130707 - prospect for ending treatments. ref SDS 0 EO3Y All of the films and
130708 - slides were returned to the patient. The doctor plans to dictate a
130709 - report. ref SDS 0 O64L
130711 - ..
130712 - Mil submitted email to Sheridan asking that she pass along thanks to
130713 - the doctor for expedited review on short notice. Thanked Sheridan for
130714 - her efforts as well.
130716 - [On 041018 follow up letter submitting the record. ref SDS 31 0001
130718 - ..
130719 - [On 041117 received 2nd opinion report from Doctor Benz at UCSF
130720 - cancer center. ref SDS 34 6L9O
130725 - ..
1310 - Background
131101 - 2nd Opinion Requested on IBC Distant Metastasis Surgery Avastin Trial
131103 - Follow up ref SDS 29 0184.
131105 - Medical Records delivered.......... 041015, ref SDS 29 0184
131106 - Patient Information submitted...... 011012, ref SDS 25 G63W
131107 - Issues on 2nd Opinion submitted.... 011002, ref SDS 20 K138
131108 - Case studies IBC................... 011002, ref SDS 20 Y29R
131110 - ..
131111 - Current Condition....
131113 - CA 15-3 - 39 lowest in 3 years..... 041014, ref SDS 28 2N5J
131114 - CT test no evidence cancer......... 041005, ref SDS 22 NL4N
131115 - Bone scan test no evidence cancer.. 040713, ref SDS 17 L34N
131117 - ..
131118 - Prior to meeting with Doctor Benz, we asked the receptionist about
131119 - visiting with Sheridan Tinker to verify Doctor Benz was able to access
131120 - the case studies, planned when we visited last Friday, 041015, to
131121 - deliver the medical records. ref SDS 29 NW58 The receptionist said
131122 - that Sheridan did not come into the office today, which conflicted
131123 - with Sheridan's letter on 041012 advising that she would meet with us
131124 - today. ref SDS 25 N25Y
131126 - ..
131127 - The receptionist used Millie's credit card to process payment for the
131128 - visit today in the amount of $600, as agreed during the call with
131129 - Sheri on 041012.
131135 - ..
1314 - 1000
131501 - The doctor came into the examination and appoligized for being late
131502 - for the 0930 meeting, explaining he was reviewing the extensive
131503 - medical record received from Kaiser, and delivered to UCSF this past
131504 - Friday. ref SDS 29 0184
CA 15-3 Not Used UCSF Cancer Center Cancer Marker Assess Response Tr
240401 - ..
240402 - 2nd Opinion Metastasis, Surgery, Ending Treatment
240403 - CA 15-3 Cancer Marker Documented Requested Verify Accuracy Conversation
240405 - The doctor summarized the purpose of the meeting based on Millie's
240406 - letter to UCSF dated 041002, which had been printed and was fastened
240407 - into the patient file folder used by the doctor throughout the meeting
240408 - today. The doctor read from the letter...
240410 - 1. I need to make a decision on whether to continue, stop and
240411 - have a mastectomy, or simply to stop treatment altogether
240412 - on the grounds that diagnostics using CT scans have not
240413 - identified distant metastasis, and show that all tumors
240414 - have been significantly reduced or been eliminated. A
240415 - complicating factor seems to be that if I opt for surgery,
240416 - then I can no longer get treatment with Avastin, even if
240417 - the evidence shows the treatment is effective. So, there
240418 - is a dilemma, and I need guidance on resolving it.
240419 - ref SDS 20 Y25R
240421 - ..
240422 - 2. I would like a physician to review the case history to see
240423 - if anything has been overlooked that might indicate distant
240424 - metastasis. Kaiser had the case reviewed by a "Tumor
240425 - Board" in April. Their report did not seem comprehensive
240426 - nor offer helpful guidance. The Tumor Board made no
240427 - finding on distant metastasis; the attending physician
240428 - feels that lumps in the neck, which are symptoms of IBC,
240429 - establish metastasis. I want a 2nd opinion. ref SDS 20 Y27U
240431 - ..
240432 - UCSF practice verifying the purpose of meeting by citing the patient's
240433 - letter requesting 2nd opinion consultation, ref SDS 0 LX3U, fits the
240434 - model of leadership required for good management by being prepared to
240435 - work productively, presented by Covey, reviewed on 921205. ref SDS 1
240436 - 5940 On 960205 study reported that people waste 70% of the day in
240437 - unproductive meetings because the purpose of meeting is unclear, and
240438 - nobody invests time to be prepared to work effectively. ref SDS 3
240439 - 5902
240441 - ..
240442 - Millie noted today that the most recent CA 15-3 cancer marker has
240443 - dropped to 39, which is within the normal range, reported on 041007,
240444 - ref SDS 24 2N5J, for the first time since March of 2002.
240446 - ..
240447 - The doctor said that he reviewed Kaiser's report for the blood test on
240448 - 041007 and it shows results for CA 15-3 are "in lab." He asked if
240449 - Kaiser has published an updated version of the report showing results
240450 - for CA 15-3? Doctor Benz explained that UCSF best practices for
240451 - quality control of communications strives to rely on documentation
240452 - from original sources to authenticate accuracy of conversation in the
240453 - meeting today. The gist of story on Millie's condition can be derived
240454 - from discussion during the meeting, but issuing a 2nd opinon requires
240455 - authority on file to verify accuracy.
240457 - [On 060815 Doctor explained that getting the gist of the story
240458 - is good enough for another 2nd opinion. ref SDS 48 YK6N
240460 - ..
240461 - UCSF practice relying on documentation to authenticate accuracy of
240462 - conversation aligns with management standards for traceability to
240463 - original sources, reviewed on 950721. ref SDS 2 1740 This seems to
240464 - conflict with Kaiser's report on 040812 that accuracy of medical
240465 - practice is less precise than engineering, and therefore errors and
240466 - omissions in tests are not important to diagnosis and treatment.
240467 - ref SDS 18 LQ5L
240469 - ..
240470 - [On 041019 Doctor Guardino demonstrated importance of accuracy
240471 - in health care by requiring an aide to check the record for
240472 - verification on the date of a pathology report on IBC, rather
240473 - than rely on assurances in conversation. ref SDS 32 BV92
240475 - ..
240476 - [On 041230 primary care physician asked patient for reasons
240477 - chemotherapy regimine was changed to another drug, illustrating
240478 - importance of timely, accurate records. ref SDS 39 XQ84
240480 - ..
240481 - The doctor asked that Millie notify Kaiser to submit an updated report
240482 - to UCSF for the blood test on 041007 showing CA 15-3 39.
240484 - ..
240485 - Millie advised that this has been done.
240487 - ..
240488 - Document review on 041014 to prepare for the meeting today showed that
240489 - the version of the report for the blood test on 041007 did not have
240490 - results from the lab on CA 15-3. ref SDS 27 SR7I The nurse in the
240491 - Infusion Clinic at Kaiser reported later in the day that CA 15-3 had
240492 - dropped to 39. Since this is a dramatic change in the cancer marker,
240493 - reaching normal for the first time in over a year, Millie asked the
240494 - nurse to print the test report on 041007 that corrects the omission in
240495 - the documents Kaiser assembled for 2nd opinion review. ref SDS 28 2N5J
240498 - ..
240499 - CA 15-3 Not Relied Upon by UCSF for Patient Status
240501 - Millie handed Kaiser's latest report showing CA 15-3 39 to Doctor
240502 - Benz.
240504 - ..
240505 - The doctor looked at the report showing CA 15-3 has dropped to normal
240506 - for the first time in 3 years. Doctor Benz commented that UCSF does
240507 - not rely on CA 15-3, and so the report is not significant for analysis
240508 - of Millie's condition. The doctor indicated that dramatic change in
240509 - CA 15-3 can signal progression of disease or response to treatment;
240510 - however, patients can have serious cancer disease while CA 15-3
240511 - remains low for a long time, and as a result, UCSF does not use CA
240512 - 15-3 to evaluate patient status. This aligns with primary care
240513 - physician on 030508 advising that 25% rise in CA 15-3 does not signal
240514 - concern about recurrent disease, on grounds representing that ASCO
240515 - does not recommend CA 15-3 to diagnose breast cancer. ref SDS 8 M28G
240517 - ..
240518 - [On 041019 CA 15-3 not used for cancer marker at Stanford
240519 - Cancer Center. ref SDS 32 Y15N
240521 - ..
240522 - [On 070328 cancer biomarkers, like CA 15-3, technology rapidly
240523 - advancing for diagnosis and treatment. ref SDS 51 0001
240525 - ..
240526 - [On 070406 UCSF submits results blood tests showing CA 15-3 has
240527 - dropped to near normal range with cetuximab treatments provided
240528 - by UCSF within a clinical study. ref SDS 52 EQ6I
240531 - ..
240532 - On 030220 research indicates ASCO guidance indicates CA 15-3 helps
240533 - identify recurrent disease. ref SDS 7 SZ4G The primary care
240534 - physician in the Oncology Department at Kaiser in Walnut Creek
240535 - commented on 030508 that steady rise of CA 15-3 did not support
240536 - patient concerns about relapse. ASCO guidance was cited which seems
240537 - to recommend CA 15-3 to assess relapse. ref SDS 8 M28G On 040517 rise
240538 - of CA 15-3 was discussed in a document submitted on the Tumor Board
240539 - "minutes" as indicating failed treatment in this case. ref SDS 14 4R59
Doctor Notes Medical Chart Typically Sparse Illegible Not Effective
Medical Chart Illegible Sparse Handwritten Notes Cryptic Unreadable
2nd Opinion Medical Records Review Organize to Facilitate 2nd Opinio
350601 - ..
350602 - Patient History Not Available on UCSF Med School Computer
350603 - Case Studies for Chronology of Patient History Not Reviewed
350605 - The doctor did an excellent job understanding pathology, diagnosis,
350606 - and treatment history based on documents from Kaiser. He explained
350607 - that doctor's progress notes in the medical chart reporting patient
350608 - history on examinations, and work up for diagnosis and treatment plans
350609 - are sparce, illegible, and disconnected from chronology and context,
350610 - and so are typically not reviewed to prepare 2nd opinions, becasue it
350611 - takes too much time to figure out what was intended, reflecting review
350612 - on 041014. ref SDS 27 W78K This conflicts with Kaiser's Healthwise
350613 - Handbook calling for review of patient history in the Medical Chart to
350614 - diagnose and prescribe treatment, reported on 990625. ref SDS 5 TD5S
350616 - ..
350617 - Millie's primary care physician citied similar problems on 040227 to
350618 - explain difficulty finding patient history on medical tests.
350619 - ref SDS 11 8874
350621 - [On 070221 computers at the VA provide a "miracle" giving doctor's
350622 - instant access to legible patient history with a few clicks.
350623 - ref SDS 50 HH5N
350625 - ..
350626 - Previously, on 990912 national reporting cited illegible handwritting,
350627 - ref SDS 6 0900, causes failed communication which increases medical
350628 - mistakes. ref SDS 6 0960 On 041013 Kaiser was credited by the
350629 - Enterprise Architect at Boeing for leading in applying Knowledge
350630 - Management to improve medical practice. ref SDS 26 W14V
350632 - [On 041019 Doctor Guardino demonstrated importance of accuracy in
350633 - health care by requiring an aide to check the record for
350634 - verification on the date of a pathology report on IBC, rather than
350635 - rely on assurances in conversation. ref SDS 32 BV92
350637 - ..
350638 - [On 041130 written work plan submitted by Kaiser illigible,
350639 - conflicts with Breast Cancer Treatment Guidelines for Patients on
350640 - page 52. ref SDS 35 9V71
350642 - ..
350643 - [On 041230 primary care physician asked patient for reasons
350644 - chemotherapy regimine was changed to another drug, illustrating
350645 - importance of timely, accurate records in the patient medical
350646 - chart. ref SDS 39 XQ84
350648 - ..
350649 - Doctor Benz indicated that Millie's work on 041014 to prepare for the
350650 - meeting today by placing tabs in Kaiser's documentation, ref SDS 27
350651 - VA9J, was very helpful for saving time finding relevant reports on
350652 - imaging and biopsy tests. The doctor used the reports tabbed by
350653 - Millie on 041014 to construct a rough time line on patient case
350654 - history.
350656 - ..
350657 - The doctor advised he needs the chronology of patient history on
350658 - discovery of IBC, and details about the onset of original disease. He
350659 - explained that the chronology submitted to UCSF on 041002, ref SDS 20
350660 - K138, could not be accessed from his computer here at the UCSF Med
350661 - School, nor at his regular office. As a result, he never saw patient
350662 - history, despite coordination by Sheridan to facilitate review, per
350663 - above, ref SDS 0 LW5V, and despite the patient driving 60 miles
350664 - several days ago to provide an orientation to facilitate the doctor's
350665 - access to the record for working intelligently, reported on 041016,
350666 - ref SDS 29 NW58, and frustrating planning on 971021. ref SDS 4 3636
350668 - [On 050212 Doctor Kim could not find details of patient history
350669 - in the medical chart stored by Kaiser's computer knowledge base
350670 - in time for emergency treatment; relied on personal memory of
350671 - medicated patient traumatized by fairly dangerous condition for
350672 - relevant facts over the past three (3) years. ref SDS 41 VC8H
350674 - ..
350675 - [On 050414 John Maloney cites UCSF for using Knowledge
350676 - Management in medical practice, ref SDS 43 LX7F, with
350677 - "earth-shattering achievements" over the past 10 years.
350678 - ref SDS 43 JY5Y
350680 - ..
350681 - [On 060809 UCSF willing to try again to use SDS technology for
350682 - saving time accessing medical records on patient history.
350683 - ref SDS 47 I73H
350685 - ..
350686 - We offered to power up the notebook computer to show the chronology
350687 - during the meeting, but the doctor was late for another meeting, and
350688 - didn't have time. Since the doctor had other commitments, we did not
350689 - take time during the meeting to resolve access problems with UCSF's
350690 - technical staff, so that the doctor could review case studies on the
350691 - Internet that show the chronology of patient history. On 041004 the
350692 - new patient coordinator, Sheridan, recommended that patients visit the
350693 - UCSF web site for information on doctors and services. ref SDS 21 WO4R
350694 - This was restated last week on 041212. ref SDS 25 MQ4J Doctors should
350695 - have equal access to websites for patient information, as planned by
350696 - Sheriden in her letter on 041212. ref SDS 25 3Y5L
350698 - ..
350699 - The doctor spent an hour so asking a great many detailed questions to
350700 - manually construct a chronology of patient history. He asked Millie
350701 - when symptoms began many years ago, the date of the first operation,
350702 - and the date of re-excission for clear margins, dates of chemotherapy,
350703 - and changes in the protocol from AC to Taxotere, when radiation was
350704 - performed, when the red rash first appeared, how prominent symptoms
350705 - seemed at the time, how severe, and how long breast coloration lasted,
350706 - when axillary lumps appeared, what image testing showed, and how CA
350707 - 15-3 cancer marker varied with discovery of IBC? The doctor made
350708 - extensive notations to his case sheet, based on momentary
350709 - recollections by the patient of events in 2002 and 2003. He drew
350710 - arrows to connect disparate markings in his notes; he crossed some
350711 - things out, and added notations to reflect evolving understanding from
350712 - discussion with Millie clarifying points about chronology.
350714 - ..
350715 - At one point, while questioning Millie, and thumbing through Kaiser's
350716 - many documents, they all slipped from his lap and scattered in a
350717 - jumble on the floor. All three (3) of us bent over to pick up the
350718 - papers, and put them back in order. Took about 5 minutes. The doctor
350719 - apologized and commented that Millie has a very complex medical
350720 - history that takes time and concentration to absorbe and connect
350721 - related parts of many documents for comprehensive understanding.
350723 - [On 041117 Doctor's 2nd opinion error in chronology saying
350724 - re-excission was on 040327. ref SDS 34 OS8Y
350726 - ..
350727 - [On 041117 Doctor's 2nd opinion shows complexity of patient
350728 - history. ref SDS 34 OS9R
350730 - ..
350731 - [On 060815 Doctor explained that getting the gist of the story is
350732 - good enough for another 2nd opinion. ref SDS 48 YK6N
350734 - ..
350735 - [On 071006 Paula in Kaiser's MCRC business unit discovered that
350736 - Knowledge Management practices using SDS records online
350737 - expedites handling documents and facilitates understanding
350738 - complex issues. ref SDS 54 EX8K
350740 - ..
350741 - Doctor Benz commented that secondary IBC is a rare disease. Symptoms
350742 - change over time, and this complicates diagnosis. He asked how long
350743 - ago the redness in the left breast was least severe?
350745 - [On 061020 primary care physician feels patient profile has too
350746 - many issues for a 5-year medical case of secondary inflammatory
350747 - breast cancer (IBC), cellulitus, lymphedema, pulmonary embolism,
350748 - broken finger. ref SDS 49 MO4K
350750 - ..
350751 - Millie recalled the most severe condition was in March, April, and
350752 - May. Since treatment started with Taxol and Avastin on 040420, there
350753 - has been improvement. Today the condition is better than at any time
350754 - since IBC disease was diagnosed on 040614, and observed this year in
350755 - March, reported on 040318. ref SDS 13 IM6J
350759 - ..
350760 - IBC Status Not Determined from Clinical Examination
350762 - The doctor examined Millie, including her head.
350764 - ..
350765 - The doctor indicated he cannot determine from clinical examination if
350766 - the IBC disease is breaking up in the left breast, because he has only
350767 - a single point of reference. He would need several visits to offer an
350768 - opinion of the IBC condition in the left breast.
350770 - ..
350771 - Doctor Benz described the condition of the left breast observed during
350772 - the examination as showing slight coloration compared to the right
350773 - breast that is not infected.
350775 - [On 041019 Doctor Guardino at Stanford Medical Center described
350776 - slight redness in left breast compared to right breast.
350777 - ref SDS 32 TX93
350779 - ..
350780 - [On 041117 2nd opinion report from Doctor Benz at UCSF cancer
350781 - center confirms findings that left breast shows "areas of" of peau
350782 - d'orange..." ref SDS 34 OO8O
350786 - ..
350787 - Delayed Treatment IBC Does Not Impact Health Recovery in this Case
350789 - The doctor seemed to say that delayed treatment from 021209 until
350790 - 040420 impacts patient survival and health.
350792 - ..
350793 - There was not enough time today for Doctor Benz to clarify when
350794 - delayed treatment impacts the patient. For example, the lump under
350795 - the arm got progressively worse for several years. Redness of the
350796 - left breast got worse over 14 months. When lumps occurred in the
350797 - neck, there was a report on 040318 that treatment was needed
350798 - immediately. ref SDS 13 8R6M Why is treatment needed immediately for
350799 - one symptom of IBC, lumps in the neck, but not for two other symptoms,
350800 - redness of left breast, and lumps under the left arm, especially
350801 - following a year of treatment for these specific areas? Why a biopsy
350802 - and immediate treatment for lumps in the neck, but no biopsy for lumps
350803 - under the arm, and no biopsy for worsening redness of the breast? Is
350804 - this supported by the literature?
Surgery Not Effective for Millie's Pataient Profile to Treat IBC Doc
380401 - ..
380402 - PET Test Not Recommended to Determine Scope of Problem
380403 - Surgery Not Needed for IBC when Metastatic Cancer Diagnosed
380404 - Out of Capsule Lymph Nodes Recurrance in Neck Drive Diagnosis
380405 - Metastatic Cancer Stage III Requires Continued Chemotheapy No Surgery
380407 - The doctor indicated that cancerous lymph nodes in the neck, the onset
380408 - of IBC, and earlier the out of capsule finding in the pathology on
380409 - lymph nodes under the arm, reported 020312, all indicate that Millie
380410 - has stage III metastatic cancer. The doctor also mentioned her2/neu,
380411 - and estrogen negative are further signs of metastasis.
380413 - [On 041117 2nd opinion received from Doctor Benz does not mention
380414 - stage III cancer. ref SDS 34 B48N
380416 - ..
380417 - The doctor commented that at one time standard treatment for IBC was
380418 - chemotherapy, surgery, radiation and more chemotherapy, as shown in
380419 - research reported on 040517. ref SDS 14 JK8L He further indicated
380420 - that surgery is not an effective option for Millie's patient profile.
380421 - No criteria was presented to support this opinion, which, however,
380422 - seems consistant with comment by the primary care physician in the
380423 - Oncology Department during a meeting at Kaiser on 040812. ref SDS 18
380424 - SE61 Doctor Benz further indicated there is no path nor realistic
380425 - prospect for leaving treatment. He said unfortunately there is no
380426 - cure for, nor recovery from. metastic cancer that continually mutates
380427 - to resist treatment, as related by the priary care physician at Kaiser
380428 - on 030606. ref SDS 9 N27L Doctor Benz further said that Millie's
380429 - cancer will therefore likely relapse, also, discussed previously at
380430 - Kaiser on 030606. ref SDS 9 NE4G
380432 - [On 041019 Doctor Guardino indicated surgery may be effective
380433 - after progress recovering from IBC occurs. ref SDS 32 TX96
380435 - ..
380436 - [On 041117 2nd opinion from Doctor Benz confirms understanding of
380437 - recommending against a surgical solution in Millie's case, and
380438 - does not offer a basis for this opinion. ref SDS 34 OU5P
380440 - ..
380441 - [On 041209 2nd opinion received from Stanford says that surgery
380442 - may be possible after regression of inflammatory breast condition
380443 - and does not describe criteria for determining sufficient
380444 - regression. ref SDS 37 SN97
380446 - ..
380447 - [On 041210 doctor proposes surgery to treat IBC; case study
380448 - reviews history considering surgery for Millie. ref SDS 38 ZV5J
380450 - ..
380451 - [On 050324 research yielded a professional comment that IBC is not
380452 - always inoperable, which seems to present a bias against surgery
380453 - that may align with Doctor Benz at UCSF. ref SDS 42 TN76
380455 - ..
380456 - [On 050324 research indicates metastatic cancer involving regional
380457 - lymph nodes, diagnosed on 040318, ref SDS 13 8R6M, may be operable
380458 - to reduce chances of relapse, which is different from "distant
380459 - metastasis," that surgery cannot cure, but may play a palliative
380460 - role, ref SDS 42 O84N, further explained from research on 050712.
380461 - ref SDS 44 B65G
380463 - ..
380464 - [On 050712 research indicates surgery can be a treatment option
380465 - for stage III cancer, and is generally not attempted for stage IV
380466 - cancer patients, who instead receive palliative treatment.
380467 - ref SDS 44 B65G
380469 - ..
380470 - This aligns with an article last year received on 031010 explaining
380471 - that 50% of breast cancer patients relapse within two (2) years.
380472 - ref SDS 10 IM6N
380474 - [On 041019 Doctor Guardino at Stanford cited similar perspective.
380475 - ref SDS 32 TX9P
380477 - ..
380478 - [On 041117 UCSF 2nd opinion discusses relapse for metastatic
380479 - cancer. ref SDS 34 OU5V
380481 - ..
380482 - The doctor asked if PET scans have been done?
380484 - ..
380485 - Millie related there have been two PET scans, and these were submitted
380486 - to UCSF on 041015. There was discussion about advantage of having
380487 - another PET scan to understand the scope of the problem?
380489 - ..
380490 - The doctor indicated that testing for cancer with PET technology was
380491 - important in some situations, and noted that in Millie's case, when
380492 - the patient experiences physical symptoms, this is a good time to
380493 - consider treatment, rather that try PET scans, based on his theory
380494 - that metastatic cancer has occurred, and treatment must thereafter be
380495 - continuous.
380497 - ..
380498 - The doctor related that about 10 years ago Millie might have been
380499 - treated with bone marrow transplants, but this has not proven
380500 - effective, and nothing else has yet been developed to recover from
380501 - metastatic disease.
380503 - ..
380504 - The doctor seemed to further indicate that the original out of
380505 - capsule condition established metastatic disease, and that IBC was
380506 - only one manifestation. If IBC had not occurred, then cancer would
380507 - have emerged elsewhere under Doctor Benz's theory and experience.
380511 - ..
380512 - Patient Strong Response to Treatment Fortunate
380513 - Continue Treatment and Switch Promptly When Disease Progresses
380514 - UCSF Sponsors New Drug Trials May Help Millie When Cancer Progresses
380516 - The doctor noted that medical records show Millie has been fortunate
380517 - by responding favorably to the current treatment, which does not often
380518 - occur for patients with her condition, and that she should therefore
380519 - remain on the Avastin drug trial until there is evidence of greater
380520 - harm than benefit, either progression of disease, or when side effects
380521 - become intollerable. The doctor recommended that treatment should be
380522 - continuous while symptoms of cancer are still present. He will
380523 - recommend in his 2nd opinion report other chemotherapies, including
380524 - possible new drug trials sponsored by UCSF to maintain effectiveness
380525 - of continuous treatment for IBC.
380527 - [On 041019 Doctor Guardino at Stanford recommends continuing
380528 - Avastin trial protocol. ref SDS 32 HX5H
380530 - ..
380531 - [On 041104 Kaiser reports dramatic improvement patient CA 15-3
380532 - cancer marker drops to normal for 1st time in 2 years, ref SDS 33
380533 - GJ5M; CT test shows no evidence of cancer pathology, ref SDS 33
380534 - Q49F; Kaiser ends treatment of IBC on Taxol Avastin trial due to
380535 - discovery of pulmonary emboli in a CT test, ref SDS 33 N438; plans
380536 - switch to new treatment for IBC as soon as possible. ref SDS 33
380537 - WT60
380539 - ..
380540 - [On 041117 received 2nd opinion report from Doctor Benz at UCSF
380541 - and recommending continuing with the Avastin trial, ref SDS 34
380542 - OU4U, and further suggesting follow on treatment with
380543 - capecitabine, another form of liposomal anthracycline known as
380544 - Doxil, or combinations in couplets involving such agents as
380545 - Gemzar. ref SDS 34 OU5V
380547 - ..
380548 - [On 041117 UCSF 2nd opinion Doctor Benz says to contact colleague,
380549 - Doctor Rugo, on participating in new UCSF drug trials for breast
380550 - cancer. ref SDS 34 OV3T
380552 - ..
380553 - [On 041130 primary care physician recommends continuous treatment
380554 - for IBC, after discovery that patient must end treatment on
380555 - Avastin trial due to side effects of pulmonary emboli. ref SDS 36
380556 - Y66F
380558 - ..
380559 - The doctor noted that most likely, cancer will return, but in the
380560 - meantime getting weekly treatments does not present a significant
380561 - impairment to daily life. He asked how treatments are being tolerated
380562 - in the form of 40%, 60%, 90% of normal activity?
380564 - ..
380565 - Millie offered that the effect of treatments at this time is about 70%
380566 - of normal activity. An example is that walking around Lafayette
380567 - reservoir 3 - 5 times a week, has been cut back to about once every
380568 - few months, since treatments began in April. On the other hand, she
380569 - still goes to exercise class about 3 times a week, rather than 5 - 6
380570 - times prior to treatments beginning in April.
380574 - ..
380575 - Tired Cough Breathing Difficult Could Signal Cancer in Lungs
380576 - Shortness of Breath Fatigue Cough Clearing Throat May be Lung Cancer
380577 - Lung Cancer May Explain Symptoms Fatigue Shortness of Breath Cough
380579 - Millie asked about persistent fatigue, clearing of throat, cough,
380580 - heavy chest, and shortness of breath, for example when walking up
380581 - stairs at home. This was first reported to Kaiser on 040517,
380582 - ref SDS 14 RZ4I, and has become progressively worse, reported a few
380583 - weeks ago on 041005. ref SDS 22 RZ4I On 040812 Kaiser reviewed
380584 - correlations with pulmonary emboli associated with the Taxol/Avastin
380585 - drug trial. ref SDS 18 MG4G Medication was prescribed for a sore
380586 - throat from coughing, but was not effective. Primary care physician
380587 - prescribed an inhaler to relieve shortness of breath. This has
380588 - worked, but Millie had to stop using it because the inhaler made her
380589 - unable to talk.
380591 - ..
380592 - Doctor Benz commented that Millie's fatigue, coughing, throat
380593 - clearing, and breathing problems may be caused by blood clots that
380594 - have occurred in some patients treated with the Avastin Taxol drug
380595 - trial. The doctor, also, discussed potential for cancer to have moved
380596 - into the lungs, which aligns with Doctor Laio's comments at Kaiser on
380597 - 040303. ref SDS 12 SO3F
380599 - ..
380600 - During the meeting at Kaiser on 041005, the primary care physician
380601 - noted that CT tests do not show lung problems that explain chronic
380602 - cough, heavy chest, shortness of breath, and fatigue, ref SDS 22 OG3I,
380603 - and so the patient has nothing to worry about. ref SDS 22 OG5L
380605 - ..
380606 - Doctor Benz concurred there may be nothing to worry about. He said
380607 - mistakes are caused by the dynamics of complex biology at low levels
380608 - of detail. Different situations can have similar initial
380609 - consequences, which lead to diagnosis mistakes. Doctor Benz indicated
380610 - that cardiopulmonary problems are often not visible with typical
380611 - medical imaging, like CT tests. If the analyst is looking for signs
380612 - of breast cancer, investigation of other problems, like lung and heart
380613 - disorders, might be overlooked, and so requires increased scrutiney in
380614 - order to avoid complications of compound issues.
380616 - ..
380617 - The doctor feels correlation between Millie's rising symptoms of
380618 - pulmonary embolism for 6 months, concurrent with treating her cancer
380619 - using bevacizumab chemotherapy, which has published accounts of death
380620 - from pulmonary embolism, should be further investigated to avoid a
380621 - serious mistake. He feels CT tests should be ordered with
380622 - instructions to look for pulmonary embolism.
380624 - ..
380625 - Millie asked the doctor to include this issue in the 2nd opinion UCSF
380626 - publishes for follow up guidance at Kaiser.
380628 - ..
380629 - [On 041104 Kaiser reports blood clots found in CT test on 041028
380630 - caused coughing and heavy chest conditions due to pulmonary emboli
380631 - side effects of Avastin chemotherapy; patient removed from clincal
380632 - trial, and all treatment was stopped. ref SDS 33 N43I
380634 - ..
380635 - [On 041117 2nd opinion received from Doctor Benz cites problem of
380636 - persistant cough, heavy chest, and difficult breathing being
380637 - investigated by Kaiser. ref SDS 34 OT5Q
380639 - ..
380640 - [On 050104 patient resumes treatment of IBC, condition worsens.
380641 - ref SDS 40 0001
380643 - ..
380644 - [On 070510 UCSF maintains that until cardiopulmonary problems rise
380645 - to visibility using CT tests without thin slice spiral CT
380646 - technology, doctors and patients have nothing to worry about.
380647 - ref SDS 53 KD84
380652 - ..
380653 - Avastin Protocol Randomized Phase III Trial as First-line Therapy
380655 - The doctor asked about the Avastin protocol, which was submitted with
380656 - the record on 040517, citing the meeting at Kaiser when the Consent
380657 - form was signed, ref SDS 13 DK63, and provided to UCSF in the letter on
380658 - 041002 requesting a meeting. ref SDS 20 Y29R
380660 - [On 041018 Millie submitted this for UCSF records. ref SDS 31 L36Q
380665 - ..
380666 - Written Report Pending and Medical Records Returned
380668 - The doctor advised he has not consulted the primary care physician,
380669 - nor with anyone from Kaiser on this case.
380671 - ..
380672 - The doctor will dictate an opinion for distribution within a week or
380673 - so.
380675 - [On 041117 received 2nd opinion report from Doctor Benz at UCSF
380676 - cancer center. ref SDS 34 6L9O
380678 - ..
380679 - The doctor returned all of the films and pathology slides requested in
380680 - UCSF's letter on 041006, and delivered to UCSF this past Friday.
380681 - ref SDS 29 0184
380683 - ..
380684 - The doctor seemed to indicate that imaging scan documents were not
380685 - reviewed, and none of the bloot test reports were examined, and would
380686 - not be needed to prepare his opinion, which reduced the work on 041014
380687 - to assemble the record into a training drill.
380689 - ..
380690 - Consideration might therefore be made to save time and cost, and to
380691 - reduce aggravation expending efforts on assembling records, reported
380692 - on 041014, ref SDS 27 0001, which are not needed. For example, a
380693 - doctor might make an initial review, then, if more is needed, request
380694 - specific scans and slides, rather than force a lot of people to expend
380695 - a lot of effort assemblng a lot of records that are simply handed back
380696 - to the patient unopened. Maybe there is no good answer to this, but
380697 - it is clearly cost factor.
380699 - [On 041019 Doctor Guardino at Stanford reviewed all of the CT
380700 - scans. ref SDS 32 ER8O
380702 - ..
380703 - [On 050826 applied experience from using medical records for the
380704 - 1st 2nd opinion to order a reduced set of medical records for the
380705 - 2nd opinion #2. ref SDS 45 668F
380707 - ..
380708 - [On 060725 applied experience today for another request that UCSF
380709 - offer 2nd opinion, by providing patient history with links to
380710 - relevant documents. ref SDS 46 QS4X
380712 - ..
380713 - [On 060821 for 3rd 2nd opinion submitted to UCSF very small number
380714 - of documents in a "packet" assembled by
380715 - Advice Nurse at Kaiser.