CONTACTS 

SUBJECTS
Meeting Progress Beginning 8th Treatment Cycle Avastin Trial with Ta

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 52 0000, ref SDS 51 0000.
040502 -
040503 - Dramatic changes today.  An analyst reported finding pulmonary
040504 - embolism in the CT test last night.  The doctor feels this explains
040505 - chronic cough, heavy chest, and shortness of breath the past 6 months.
040506 - ref SDS 0 RZ4I  Kaiser canceled chemotherapy treatment today, and
040507 - ended all treatments on the Avastin Taxol trial that has been
040508 - effective in recent months recovering from inflammatory breast cancer
040509 - (IBC), because Avastin has been associated with side effects of
040510 - pulmonary emboli. ref SDS 0 N438  Consideration to continue treatment
040511 - with Taxol, which has proven effective, and stop only Avastin in order
040512 - to maintain momentum toward recovery, were deferred until the primary
040513 - care physician returns from vacation. ref SDS 0 Q59K  Examination
040514 - today shows progress recovering from IBC with the current treatment.
040515 - Terrific news of CA 15-3 cancer marker dropped to normal for the first
040516 - time in 2 years, ref SDS 0 GJ5M; previously swelled lymph nodes are no
040517 - longer pathologic, according to the CT test. ref SDS 0 Q49F  The
040518 - doctor feels continuous treatment of IBC is essential, which aligns
040519 - with 2nd opinions from UCSF and from Stanford. ref SDS 0 6T5G  The
040520 - doctor indicated Kaiser will develop a new treatment plan in 2 weeks,
040521 - after the primary care physician returns from vacation. ref SDS 0 WT60
040522 - In the meantime, the doctor significantly changed the prescription for
040523 - Coumadin; dosage is increased by 400%, and the period of treatment is
040524 - extended to a lifetime. ref SDS 0 N455  This was a lot to absorb in 30
040525 - minutes.
040526 -
040527 -        [On 041117 2nd opinion received from Doctor Benz at UCSF.
040528 -        ref SDS 58 ZO6L
040530 -         ..
040531 -        [On 041130 meeting with primary care physician develop work
040532 -        plan on resuming treatment. ref SDS 59 0001
040534 -         ..
040535 -        [On 041209 2nd opinion received from Doctor Guardino at
040536 -        Stanford. ref SDS 60 0001
040537 -
040538 -
040539 -
040540 -
040542 -  ..
0406 -
0407 -
0408 - Discussion
0409 -
040901 - Agenda Progress Review Begin 8th Cycle Avastin Trial with Taxol
040902 -
040903 - Follow up ref SDS 52 SM6M, ref SDS 51 SM6M.
040904 -
040905 - The meeting today was regularly scheduled for starting the 8th cycle
040906 - of the protocol on the Avastin drug trial.
040908 -  ..
040909 - The primary care physician and oncologist is on vacation, so Millie
040910 - met with another doctor on the oncology team, following up the meeting
040911 - on 041059 starting the 7th cycle of the trial. ref SDS 52 SM6M  This
040912 - meeting further follows up meetings at UCSF on 041018, ref SDS 55
040913 - 0001, and the next day at Stanford on 041019. ref SDS 56 0001
040918 -  ..
040919 - Millie created an agenda on the marking board...
040920 -
040921 -        CA 15-3 Diagnostic Test.................... ref SDS 0 GJ5M
040922 -        CT Test report............................. ref SDS 0 NL4N
040923 -        Coughing, heavy chest, breathing
040924 -        issues continue............................ ref SDS 0 RZ4I
040925 -        Lumps under arm............................ ref SDS 0 MW8J
040926 -        Lumps in neck smaller...................... ref SDS 0 8R6M
040927 -        Breast redness mastectomy surgery
040928 -        schedule................................... ref SDS 0 6T5G
040929 -
040930 -
040931 -
040932 -
040933 -
040934 -
040935 -
0410 -

SUBJECTS
CA 15-3 Cancer Marker Dramatic Reversal Drops to Normal 39 Recovery

1203 -
120401 -  ..
120402 - CA 15-3 Cancer Marker Dramatic Reversal Dropping to Normal 39
120403 - Recovery Progress CA 15-3 Cancer Marker Drops from 49 to 39 Normal
120404 -
120405 - Follow up ref SDS 52 087J, ref SDS 51 087J.
120406 -
120407 - Blood test on 041007 shows CA 15-3 suddenly dropped dramatically to
120408 - 39, which is the high end of normal, ref SDS 53 2N5J; and is cited
120409 - again the following week on 041014. ref SDS 54 2N5J
120411 -           ..
120412 -          041007......... 39............... 041104, ref SDS 0 087J
120413 -          040923......... 49 H............. 041006, ref SDS 52 087J
120414 -          040908......... 44 H............. 040909, ref SDS 51 087J
120415 -          040825......... 47 H............. 040812, ref SDS 51 087J
120416 -          040811......... 42 H............. 040812, ref SDS 48 087J
120417 -          040728......... 43 H............. 040729, ref SDS 46 2N5J
120418 -          040712......... 47 H............. 040713, ref SDS 44 087J
120419 -          040614......... 55 H............. 040615, ref SDS 43 PX6X
120420 -          040517......... 78 H............. 040601, ref SDS 39 2N5J
120421 -          040311......... 70 H............. 040318, ref SDS 28 SM6M
120422 -          040205......... 60 H............. 040211, ref SDS 25 SM6M
120423 -          031201......... 62 H............. 031205, ref SDS 23 SM6M
120424 -          030912......... 66 H............. 030915, ref SDS 22 SM6M
120425 -          030708......... 68 H............. 030710, ref SDS 20 SM6M
120426 -          030503......... 54 H............. 030508, ref SDS 18 SM6M
120427 -          030403......... 45 H............. 030508, ref SDS 18 SM6M
120428 -          030215......... 46 H............. 030220, ref SDS 17 5E6L
120429 -          030106......... 37 H............. 030109, ref SDS 16 SM6M
120430 -          021202......... 41 H?............ 021204, ref SDS 14 SP5G
120431 -          021111......... 36 H?............ 021113, ref SDS 13 Y65I
120432 -          021023......... 33 H?............ 021023, ref SDS 12 SQ5I
120433 -          020930......... 33 H?..29........ 021002, ref SDS 11 SQ5I
120434 -          020917......... 36 H?............ 020924, ref SDS 10 SQ5I
120435 -          020717......... 59 H?............ 020726, ref SDS 9 YN5K
120436 -          020629......... 75 H ............ 020705, ref SDS 8 UX6I
120437 -          020608........  67 H ............ 020614, ref SDS 6 0001
120438 -          020603........ 108 H ............ 020607, ref SDS 5 X67F
120439 -          020511........ 117 H ............ 020603, ref SDS 4 PJ4J
120440 -          020419......... 81 H ............ 020430, ref SDS 3 7N5H
120441 -          020321......... 85 H ............ 020405, ref SDS 2 6T8K
120442 -
120443 -
120444 -
120446 -  ..
1205 -
1206 -
1207 - Analysis
1208 -
120801 - CA 15-3 Cancer Marker Drop Attributed to Treatment
120802 - Patient Responds to Treatment CA 15-3 Reverses and Drops to 39 Normal
120803 -
120804 - Follow up ref SDS 52 GJ5M, ref SDS 51 GJ5M.
120805 -
120806 - Because of a new problem, pulmonary emboli, reviewed below,
120807 - ref SDS 0 RZ4I, the doctor did not discuss dramatic improvement in CA
120808 - 15-3 cancer marker, suddenly reversing direction from prior 24 months,
120809 - and dropping from 49 to 39, which is the high end of "normal,"
120810 - reported on 041007. ref SDS 53 2N5J  The last time the patient had an
120811 - even near normal CA 15-3 test was over 2 years ago on 021023, after
120812 - treatment with Taxotere. ref SDS 12 SQ5I
120814 -  ..
120815 - Favorable response to treatment shown by improvement in CA 15-3 aligns
120816 - with steady improvement in image testing and clinical examinations
120817 - found during the past few months, e.g., on 041005, ref SDS 52 MW8J,
120818 - and further helps resolve prior dilemma from conflicting rise in CA
120819 - 15-3, also, reported on 041005. ref SDS 52 GJ5M
120821 -  ..
120822 - There was no consideration today of whether Taxol or Avastin was the
120823 - primary agent in affecting improvements.
120824 -
120825 -
120826 -
120827 -
120828 -
1209 -

SUBJECTS
CT Test Shows Pulmonary Emboli Blood Clots Millie Must End Treatment
CT Test No Evidence of Active Cancer Similar to Prior Test

1404 -
140501 -  ..
140502 - CT Scan No Active Cancer New Problem Pulminary Emboli Blood Clots
140503 - Pulminary Emboli New Problem Blood Clots CT Scan No Active Cancer
140504 - Blood Clots Pulminary Emboli New Problem CT Scan No Active Cancer
140505 -
140506 - Follow up ref SDS 52 NL4N, ref SDS 47 H85S.
140507 -
140508 - The doctor submitted a report on the CT test performed last night on
140509 - 041103, and following up the test on 040921, which was received during
140510 - a meeting with the doctor on 041005. ref SDS 52 NL4N
140512 -  ..
140513 - This was an emergency test, performed a month ahead of schedule.
140514 - Millie received a call from Kaiser yesterday afternoon about 1400
140515 - saying the doctor suddenly ordered an immediate CT test for last night
140516 - at 2000 on the same day.  This changed past practice ordering work
140517 - several weeks prior to the actual test.  The CT test yesterday was
140518 - approximately 1.5 months since the previous test on 040921, which is
140519 - significantly advanced and out of sequence specified for the
140520 - Avastin/Taxol chemotherapy drug trial requiring CT tests every 3
140521 - months, reported on 040402. ref SDS 30 HS45
140523 -  ..
140524 - Significantly expediting the CT test yesterday signaled an emergency
140525 - of some kind, which was not disclosed by Kaiser.
140527 -  ..
140528 - On 041018 Millie presented chronic symptoms of pulmonary embolism to
140529 - Doctor Benz at UCSF for 2nd opinion, ref SDS 55 LX96, as planned in
140530 - the meeting at Kaiser on 041005. ref SDS 52 H46M
140532 -                ..
140533 -               [On 041117 Doctor Benz reported in a 2nd opinion that
140534 -               Kaiser is "investigating" patients chronic symptoms of
140535 -               cough, shortness of breath, heavy chest, and fatigue;
140536 -               possibily Kaiser advanced the CT test to "investigate"
140537 -               for pulmonary emboli at the suggestion of Doctor Benz,
140538 -               which is otherwise not explained. ref SDS 58 OT5Q
140540 -  ..
140541 - This further complements prior tests listed on 040416 reporting on the
140542 - CT test that set a baseline for the Avastin trial.
140543 -
140544 -              Prior Tests
140545 -
140546 -              040921 reported on 041005.............. ref SDS 52 NL4N
140547 -              040710 reported on 040811.............. ref SDS 47 DU9I
140548 -              040410 reported on 040416.............. ref SDS 33 HX4K
140549 -              040307 reported on 040318.............. ref SDS 29 LK5L
140550 -              031031 reported on 031205.............. ref SDS 24 IG9K
140551 -              030626 reported on 030710.............. ref SDS 21 AL6N
140552 -              030428 reported on 030508.............. ref SDS 19 LK5L
140554 -  ..
140555 - CT test dated 041103 shows....
140556 -
140557 -       Patient
140564 -        ..
140565 -       68/F Radiology Report               Exam  1 of 1
140566 -       Page 1
140568 -        ..
140569 -       CT scan of the neck, chest, abdomen and pelvis (digital)
140571 -        ..
140575 -        ..
140576 -       History
140578 -        ..
140579 -       H/o metastatic breast CA.  Pt is on ataxon avastin.
140581 -        ..
140582 -       Findings
140584 -        ..
140585 -       Technique:  Standard CT scan of the neck, chest, abdomen and
140586 -       pelvis protocol following intravenous and oral contrast.
140588 -        ..
140589 -       Comparison:   040921
140591 -        ..
140592 -       Neck
140594 -        ..
140595 -       The visualization portions of the intracranial structures
140596 -       demonstrate no evidence for abnormal enhancement.  The
140597 -       visualized ethmoid, sphenoid and maxillary sinuses are clear.
140599 -        ..
140600 -       The upper cervical region is limited in evaluation due to
140601 -       metallic artifacts from dental amalgam.
140603 -        ..
140604 -       There are subcentimeter lymph nodes anterior and posterior to
140605 -       the internal juglar veins bilaterally.  None are larger than 1
140606 -       cm in short axis and not patholgic based on size criteria.
140607 -       There are also subcentimeter lyjmph nodes in the spinal
140608 -       accessory spaces bilaterally.
140610 -        ..
140611 -       There is a subcentimeter low density lesion in the right
140612 -       thyroid, probably of no clinical significance.
140614 -  ..
140615 - Pulmonary Emboli Finding
140616 -
140617 -
140618 -       Chest
140619 -
140620 -       Since the previous exam, there are now filling defects within
140621 -       the primary branches of the right upper lobe and right lower
140622 -       lobe pulmonary arteries consistent wtih pulmonary emboli.  A
140623 -       small hiatal hernia is identified.  There is abnormal contour of
140624 -       the left breast with skin thickening.  A Port-A-Cath is seen in
140625 -       the right upper chest.
140627 -  ..
140628 - Analyst called the doctor today and warned about severe conditions in
140629 - findings of pathology report, as shown below. ref SDS 0 RZ4I
140630 -
140631 -            [On 061012 CT test on 060930 shows pulmonary embolism
140632 -            recurrence, ref SDS 84 294Q; current conditions seems less
140633 -            severe than on 041103, ref SDS 84 7E7G, except new finding
140634 -            of enlarged right ventricle presents new problem of heart
140635 -            disorder. ref SDS 84 7E5L
140637 -             ..
140638 -            [On 081105 Millie notified that primary care physician
140639 -            orders Muga test for heart damage prior to starting
140640 -            sunitinib clinical study that has some heart related side
140641 -            effects. ref SDS 89 WO72
140643 -  ..
140644 - Why was there no call on 021218 to alert the doctor in similar fashion
140645 - about findings in PET scan test report of regional symptoms for IBC,
140646 - evident from the record on 030109? ref SDS 16 L66M
140648 -  ..
140649 - Why, as well, was the doctor not alerted by the analyst for the CT
140650 - test report on 030626 of findings with language that warns about
140651 - possible new cancer that correlates to findings of symptoms, received
140652 - on 030710? ref SDS 20 VM7I
140654 -             ..
140655 -            [On 041230 CT test on 041217 says pulmonary emboli is no
140656 -            longer visualized. ref SDS 64 PW3K
140658 -  ..
140659 - CT test report continues...
140660 -
140661 -       There is subcentimeter mediastinal and axillary lymph nodes,
140662 -       none of which are pathologic based on size criteria.
140663 -
140664 -            [On 041230 CT test on 041217 shows lymph nodes swelled to
140665 -            maximum 15 x 13 mm, and described as not pathologic by size
140666 -            criteria. ref SDS 64 PW3K
140668 -        ..
140669 -       Images in the lung windows show subcentimeter pulmonary nodules
140670 -       on image #34, #35 and #43, within the right middle lobe and
140671 -       right lower lobe.  There are increased interstitial markings in
140672 -       the left upper lobe and lingui which may be due to therapeutic
140673 -       changes.
140675 -  ..
140676 - When the analyst takes the trouble to list a particular image, this
140677 - suggests the findings may of interest to the patient's doctor.
140679 -  ..
140680 - CT test report continues...
140681 -
140682 -       Abdomen and Pelvis
140684 -        ..
140685 -       The liver is remarkable for a 1.4 cm simple cyst at the dome.
140687 -  ..
140688 - This representation repeats the error in the test report received on
140689 - 040811. ref SDS 47 WW68
140691 -  ..
140692 - Why doesn't the report say "unchanged" or "stable" to compare with
140693 - prior tests, as set out in tests dated 040921 and received on 041005,
140694 - ref SDS 52 RX5K, and the test on 040307 and received on 040318?
140695 - ref SDS 28 VZ5Z  Without notice of stable condition, this appears to
140696 - be a new item of concern to the patient and the oncologist.
140698 -  ..
140699 - CT test report continues...
140700 -
140701 -       The gallbladder, pancreas, and adrenal glands are normal in
140702 -       appearance.
140704 -        ..
140705 -       The spleen contains punctate calcifications and represents old
140706 -       granulomatous disease.  There is heavy calcification of the
140707 -       spleenic artery.
140709 -  ..
140710 - What is significance of "heavy calcification of the spelnic artery"?
140712 -  ..
140713 - Does not sound good.
140715 -  ..
140716 - CT test report continues...
140717 -
140718 -       The kidneys show symmetrical excretion of contrast bilaterally.
140719 -       There are subcentimeter low density lesions in the mid pole of
140720 -       both kidneys (image #78, #80) and in the lower pole of the left
140721 -       on image #87.
140723 -  ..
140724 - When the analyst takes the trouble to list a particular image, this
140725 - suggests the findings may be of interest for analysis and continued
140726 - scrutiny.
140728 -  ..
140729 - CT test report continues...
140730 -
140731 -       There is no evidence for abdominal or pelvic lymphadenopathy.
140732 -       The uterus is absent.  No free fluit.  The urinary bladder
140733 -       appears within normal limits.
140734 -
140735 -       The bony structures show no evidence for metastatic bone
140736 -       disease.
140738 -        ..
140739 -       Impression
140740 -
140741 -       1.  Since 040921 there are filling defects within the pulmonary
140742 -           arteries representing pulmonary emboli.  Findings were left
140743 -           on voicemail for Doctor Kaufman.
140745 -            ..
140746 -       2.  Shotty lymph nodes in the neck and chest.  none are
140747 -           pathologic by size criteria.
140749 -            ..
140750 -           IA
140752 -            ..
140753 -           S Chan MD
140755 -            ..
140756 -           DD 041104  DT  041104  DJH
140757 -
140758 -
140759 -
140760 -
140761 -
140762 -
140763 -
1408 -

SUBJECTS
Pulmonary Emboli Blood Clots CT Test Findings Millie Ends Treatment

2803 -
280401 -  ..
280402 - Pulmonary Emoboli Ends Taxol Avastin Trial Dilemma Need Treatment
280403 - Coughing Clearing Throat Shortness Breath Diagnosed Pulmonary Emboli
280404 - Cumadin Lifelong Treatment 4 MG Blood Clot Found in One CT Scan Test
280405 -
280406 - Follow up ref SDS 52 RZ4I, ref SDS 51 RZ4I.
280407 -
280408 - Kaiser called yesterday, and ordered an emergency CT test for Millie
280409 - performed late last night, ref SDS 0 SW4F, implementing UCSF 2nd
280410 - opinion to investigate rising symptoms of pulmonary embolism, reported
280411 - on 041018. ref SDS 55 GH4O
280413 -  ..
280414 - During the meeting this morning, the doctor advised that he received
280415 - an emergency call from the CT test analyst, as shown in the report,
280416 - ref SDS 0 RC47, who gave an alert that the emergency CT test last
280417 - night on 041103, per above, ref SDS 0 NL4N, shows pulmonary embolism,
280418 - per above. ref SDS 0 QP6S
280420 -  ..
280421 - The radiologist calling the attending physician on observing life
280422 - threatening conditions in a CT test, as occurred with PE today, shows
280423 - Millie could have benefited from similar alert that 3-symptoms of IBC
280424 - were identified in the CT test on 021218, so that Millie could have
280425 - received treatment in time to prevent spread of disease in January
280426 - 2003, rather than delay treatment until May of 2004. ref SDS 0 C95F
280428 -  ..
280429 - The doctor said that pulmonary embolism is a major change in Millie's
280430 - patient profile.  Millie cannot get treatment today, and cannot
280431 - continue in the Taxol bevacizumab (Avastin) trial, that has shown good
280432 - results recovering from IBC, per below, ref SDS 0 6T5G, because blood
280433 - clots and pulmonary emboli are side effects of Avastin that can cause
280434 - death quickly.
280436 -                ..
280437 -               [On 041117 Doctor Benz reported in a 2nd opinion that
280438 -               Kaiser is "investigating" patient's chronic symptoms
280439 -               suggests Kaiser may have advanced the CT test to
280440 -               "investigate" for pulmonary emboli, at the suggestion of
280441 -               Doctor Benz, which is otherwise not explained.
280442 -               ref SDS 58 OT5Q
280444 -                ..
280445 -               [On 060722 research indicates CT testing commonly
280446 -               overlooks pulmonary emboli. ref SDS 79 MH5M
280448 -                ..
280449 -               [On 060722 case study shows Millie is high risk for
280450 -               pulmonary emobli but still difficult to diagnose, and to
280451 -               implement Kaiser's risk management policy to reduce risk
280452 -               of recurrenct, ref SDS 79 6G6O, which has 45% chance of
280453 -               death. ref SDS 79 BI5J
280455 -                ..
280456 -               [On 060722 wicked problems commonly occur in medical
280457 -               practice, illustrated by Millie's patient history.
280458 -               ref SDS 79 346F
280460 -                ..
280461 -               [On 061012 CT test on 060930 shows pulmonary embolism
280462 -               recurrence, ref SDS 84 294Q; current conditions seems
280463 -               less severe than on 041103, ref SDS 84 7E7G, except new
280464 -               finding of enlarged right ventricle presents new problem
280465 -               of heart disorder. ref SDS 84 7E5L
280467 -                ..
280468 -               [On 061230 UCSF indicates Millie can be treated with
280469 -               bevicizumab (Avastin) in another trial combined with
280470 -               abraxane, despite patient history suffering pulmonary
280471 -               embolism on Taxoter Avastin drug trial. ref SDS 86 TV5G
280473 -  ..
280474 - On 040402 the protocol nurse, Rosalie, reviewed side effects for
280475 - Millie's signature to participate in the Avastin trial protocol.  At
280476 - that time, she discussed all of the 50 or so side effects, which
280477 - includes pulmnary emboli, coughing, heavy chest, fatigue, shortness of
280478 - breath, etc.  She seemed to indicate that nose bleeds are the most
280479 - likely side effect. ref SDS 30 V77O
280481 -                ..
280482 -               [On 041230 CT test on 041217 shows no visualization of
280483 -               pulmonary emboli. ref SDS 64 PW3K
280485 -  ..
280486 - The doctor explained today that chronic fatigue, heaviness in the
280487 - chest, persistent difficulty clearing her throat, cough, and worsening
280488 - shortness of breath Millie has experienced beginning on 040517,
280489 - ref SDS 37 RZ4I, are caused by a blood clot in the lungs, called
280490 - pulmonary embolism, based on reports from the CT test taken last
280491 - night, per above. ref SDS 0 QP6S  The doctor indicated pulmonary
280492 - emboli can cascade into complications, including death, if not treated
280493 - promptly.
280495 -                ..
280496 -               [On 041130 meeting with doctor patient reports coughing
280497 -               symptoms continue. ref SDS 59 RZ4I
280499 -                ..
280500 -               [On 041210  meeting with doctor patient reports coughing
280501 -               symptoms are improved. ref SDS 61 6L5L
280503 -                ..
280504 -               [On 041211 coughing worsens, spitting up blood; very
280505 -               concerned. ref SDS 63 SE5O
280507 -                ..
280508 -               [On 041230 meeting with doctor patient reports pulmonary
280509 -               emboli symptoms decline; coughing, heavy chest,
280510 -               shortness of breath have significantly improved.
280511 -               ref SDS 64 RZ4I
280513 -                ..
280514 -               [On 050729 Coumadin treatments continued as a precaution
280515 -               without evidence of pulmonary emboli. ref SDS 72 RZ4I
280517 -                ..
280518 -               [On 050729 patient again reports difficult breathing,
280519 -               heavy chest that supported diagnosis for pulmonary
280520 -               emboli and prescription of Coumadin; xrays ordered; CT
280521 -               test does not indicate pulmonary emboli; doctor cites
280522 -               drop in physical fitness due to lack of exercise caused
280523 -               by side effects of chemotherapy. ref SDS 72 JV63
280525 -                ..
280526 -               [On 050922 Doctor Bailey recommends hypercoagulable
280527 -               state work up for genetic and acquired disposition for
280528 -               blood clots, risk assessment pulmonary emobli in
280529 -               connection with mastectomy surgery. ref SDS 73 XD9X
280531 -                ..
280532 -               [On 051007 patient removed from treatment for blood
280533 -               clots based on ending treatment with chemotherapy drug
280534 -               Avastin a year earlier, and in order to remove concerns
280535 -               about blood clots that make surgery high risk.
280536 -               ref SDS 74 EQ7K
280538 -                ..
280539 -               [On 060714 oldest son hospitalized again with pulmonary
280540 -               emboli. ref SDS 78 8S6I
280542 -                ..
280543 -               [On 060722 oldest son reports doctors performed tests
280544 -               and found genetic cause of blood clots that will require
280545 -               continuing treatment. ref SDS 79 3D9T
280547 -                ..
280548 -               [On 061012 CT test on 060930 shows pulmonary embolism
280549 -               recurrence, ref SDS 84 294Q; current conditions seems
280550 -               less severe than on 041103, ref SDS 84 7E7G, except new
280551 -               finding of enlarged right ventricle presents new problem
280552 -               of heart disorder. ref SDS 84 7E5L
280554 -  ..
280555 - The doctor advised that Kaiser has determined from a single CT test
280556 - report today finding pulmonary embolism, ref SDS 0 QP6S, that Millie
280557 - requires treatment with a blood thinner, and because she is a cancer
280558 - patient, Kaiser policy requires treatments to continue for the rest of
280559 - her life, because high risks of death from recurrence.
280560 -
280561 -     [On 070510 UCSF maintains that until cardiopulmonary problems rise
280562 -     to visibility using CT tests without thin slice spiral CT
280563 -     technology, doctors and patients have nothing to worry about.
280564 -     ref SDS 88 KD84
280566 -  ..
280567 - Since symptoms were reported on 040517, a month after Millie started
280568 - the Avastin trial on 040420, and since symptoms steadily worsened for
280569 - 6 months, what accounts for delayed diagnosis of pulmonary emboli that
280570 - requires lifetime treatment?  Under this record, if pulmonary emboli
280571 - tracked the record of symptoms, then Millie was at risk for the past 6
280572 - months?  During that time she had 2 CT tests.  The test on 040710 was
280573 - reviewed on 040811, and does not mention pulmonary emboli. ref SDS 47
280574 - WV66  The test on 040921 was received from Kaiser on 041005, and,
280575 - also, does not mention pulmonary emboli, but does say the lungs are
280576 - clear. ref SDS 52 WV5W
280578 -  ..
280579 - CT testing on the Avastin trial is scheduled for 3 month intervals,
280580 - reported on 040402. ref SDS 30 HS45
280581 -
280582 -     [On 050204 pulmonary emboli symptoms end, and CT test reported on
280583 -     041230 shows no visualization of blood clots, ref SDS 64 RZ4I;
280584 -     doctor continues treatment with Coumadin under Kaiser's policy
280585 -     treating cancer patients diagnosed with pulmonary emboli for life.
280586 -     ref SDS 67 S34I
280588 -      ..
280589 -     [On 050422 CT test continues to show no evidence pulmonary emboli,
280590 -     and patient has had no symptoms for 5 months; Coumadin treatment
280591 -     continued under Kaiser's policy for risk management of cancer
280592 -     patients. ref SDS 69 RZ4I
280594 -      ..
280595 -     [On 051007 primary care physician cites Kaiser policy for cancer
280596 -     patients diagnosed with pulmonary emboli to get Coumadin treatment
280597 -     for life. ref SDS 74 QG5H
280599 -      ..
280600 -     [On 051007 patient removed from treatment for blood clots
280601 -     based on ending treatment with chemotherapy drug Avastin a
280602 -     year earlier, and in order to remove concerns about blood
280603 -     clots that make surgery high risk. ref SDS 74 EQ7K
280605 -      ..
280606 -     [On 060722 Millie's son treated for recurrence pulmonary emboli,
280607 -     his doctor performed tests that identified genetic disposition for
280608 -     pulmonary emboli. ref SDS 79 3D9T
280610 -      ..
280611 -     [On 060722 "wicked problems" reviewed based on Millie's experience
280612 -     of delayed diagnosis and treatment for pulmonary emboli.
280613 -     ref SDS 79 WF56
280615 -      ..
280616 -     [On 060722 research 10% pulmonary emboli patients have recurrence,
280617 -     and 45% of those who suffer recurrence die, indicating high risk
280618 -     that supports continuing treatments to avoid recurrence.
280619 -     ref SDS 79 BI5J
280621 -      ..
280622 -     [On 060722 research indicates CT testing missed diagnosis of
280623 -     pulmonary emboli. ref SDS 79 MH5M
280625 -      ..
280626 -     [On 061002 Millie diagnosed with recurrence pulmonary emboli;
280627 -     requires treatment again with Lovenox to relieve blood clots, then
280628 -     continuing treatment with Coumadin to prevent recurrence.
280629 -     ref SDS 81 JK7J
280631 -  ..
280632 - The doctor advised that Millie must treat herself with Lovenox by a
280633 - needle-shot twice a day (every 12 hours) for a week to reduce blood
280634 - clots.  After initial week of self-administered treatments.
280636 -  ..
280637 - The doctor further explained that the Kaiser Coagulation Control
280638 - Clinic will plan and coordinate continuing treatments with a blood
280639 - thinner medication, called Coumadin, to prevent recurrence of
280640 - pulmonary embolism.  As noted, above, since Millie is a cancer
280641 - patient, Kaiser's protocol requires that Millie get warfarin
280642 - (Coumadin) treatments for the rest of her life. ref SDS 0 4Y9G
280644 -  ..
280645 - Coumadin (Warfarin) in 4 mg pills taken once a day is a blood thinner.
280647 -  ..
280648 - These treatments do not disolve the current blood clots.  The blood
280649 - clots are expected to disolve themselves in several weeks to a month
280650 - or so.
280652 -  ..
280653 - Prescription todya taking warfarin (Coumadin) 4 mg per day to prevent
280654 - further blood clots significantly changes previous prescription by the
280655 - primary care physician on 040819, for Millie to take Coumadin in 1 mg
280656 - pills to reduce the risk of blood clots associated with using a port
280657 - catheter to administer Avastin chemotherapy, and which supplemented
280658 - the use of heparin for that purpose. ref SDS 49 PQ9R
280660 -  ..
280661 - Changing prescription for Coumadin from 1 mg on 040819, ref SDS 49
280662 - PQ9R, to 4 mg today, and removing the patient from the Avastin trial
280663 - that has shown favorable results, further amends analysis by the
280664 - primary care physician on 040812, that treatment to prevent pulmonary
280665 - embolism (blood clots) was not needed in Millie's case, ref SDS 48
280666 - 1E8O, despite family history concerning her mother, who died at age
280667 - 40, and last year her son, hospitalized with pulmonary edema, as
280668 - further related by the protocol nurse on 040819. ref SDS 49 PI42
280670 -      ..
280671 -     [On 051007 Coagulation Treatment Clinic pauses Coumadin treatments
280672 -     for pulmonary emboli until after surgery. ref SDS 74 RZ4I  Primary
280673 -     care physician orders treatments for Millie ended because
280674 -     pulmonary emboli is a side effect of Avastin chemotherapy, which
280675 -     ended for Millie a year ago, and she has had no further symptoms
280676 -     of pulmonary emboli. ref SDS 74 XN7K
280678 -      ..
280679 -     [On 051025 Gloria called Millie and said the doctor has not
280680 -     notified the Coagulation Control clinic to end treatments with
280681 -     Coumadin; Gloria coordinating to complete the record on notice
280682 -     requirements. ref SDS 75 DI9H
280684 -      ..
280685 -     [On 051026 Gloria reported that the primary care physician changed
280686 -     the prescription on 051007 for ending Coumadin treatment, and
280687 -     ordered treatments resumed for pulmonary emboli, as required by
280688 -     Kaiser's guidance because Millie is a stage IV cancer patient.
280689 -     ref SDS 76 PO7J
280691 -      ..
280692 -     [On 051121 primary care physician ended Coumadin treatment for
280693 -     pulmonary emboli, and called the Anticoagulant Clinic in Martinez
280694 -     to confirm this change. ref SDS 77 RZ4I
280696 -      ..
280697 -     [On 060722 article on treatment for pulmonary emboli supports
280698 -     Kaiser's protocol to first treat acute coagulation to relieve
280699 -     blood clots, and then treat the patient with Coumadin (Warfarin)
280700 -     on a continuing basis. ref SDS 79 IS5L
280702 -      ..
280703 -     [On 060722 research 10% pulmonary emboli patients have recurrence,
280704 -     and 45% of those who suffer recurrence die, indicating high risk
280705 -     that supports continuing treatments to avoid recurrence.
280706 -     ref SDS 79 BI5J
280708 -      ..
280709 -     [On 061002 Millie diagnosed with recurrence pulmonary emboli;
280710 -     requires treatment again with Lovenox to relieve blood clots, then
280711 -     continuing treatment with Coumadin to prevent recurrence.
280712 -     ref SDS 81 JK7J
280714 -      ..
280715 -     [On 061004 Coagulation Treatment Clinic advised Millie to take
280716 -     Coumadin concurrent with Lovenox rather than after a week of
280717 -     treatment with Lovenox. ref SDS 82 X94S
280719 -      ..
280720 -     [On 061006 Millie's letter to doctor confirms instructions to take
280721 -     Coumadin concurrent with Lovenox, despite conflicts with prior
280722 -     prior practice, and standard practice in published guidance.
280723 -     ref SDS 83 OP69
280725 -  ..
280726 - Millie is to get a blood test today, and will get tested once a week
280727 - for a month or so to develop a profile that establishes the amount of
280728 - cumadin she needs to maintain a safe, stable blood counts for INR.
280729 - Kaiser has a specialized team for managing blood clot issues, and they
280730 - will contact Millie to schedule the program.
280732 -  ..
280733 - The doctor prepared an order for Millie to get blood drawn today in
280734 - the laboratory for testing and adjusting Coumadin treatments.
280736 -  ..
280737 - The doctor prepared a prescription to begin Coumadin treatment today.
280739 -  ..
280740 - Millie explained that, rather than get blood drawn from the lab, she
280741 - would get this done in the chemotherapy clinic in order to use the
280742 - port catheter installed on 040419, ref SDS 34 PPSW, that avoids harm
280743 - caused by conventional needle procedures, reported on 040318.
280744 - ref SDS 28 CO3G
280746 -  ..
280747 - The doctor insisted that blood draws once a week to test progress on
280748 - Coumadin therapy must be done in the laboratory with conventional
280749 - needle methods rather than use the port installed to avoid harm caused
280750 - by this method.  He feels that blood drawn through a port does not
280751 - yield a valid test.
280753 -  ..
280754 - Millie reviewed Kaiser's record showing 6 months experience beginning
280755 - in April 2004 getting blood drawn once a week to test for getting
280756 - chemotherapy treatment in the Avastin trial has not demonstrated
280757 - problems getting valid blood test results.  The primary care physician
280758 - prescribed a port catheter implant for Millie to avoid severe trauma
280759 - to her right arm, which is the only place needle punctures can be
280760 - done, due to cancer on her left side, reported on 040318 1615.
280761 - ref SDS 28 CO3G
280763 -  ..
280764 - The proposal today for getting multiple labs, with blood drawn for
280765 - testing INR in the right arm, and blood drawn for testing everything
280766 - else through the port appears conflicting with Doctor Johnson's order
280767 - on 040318. ref SDS 28 OF7H
280769 -  ..
280770 - Doctor Kaufman remained adamant today that the only way to draw blood
280771 - every week for testing Coumadin progress is with a conventional
280772 - needle.
280774 -  ..
280775 - After meeting with the doctor and with Rosalie, we went to the
280776 - pharmacy on the 2nd floor to fill the prescription for Coumadin.
280778 -  ..
280779 - Then we went to the laboratory on the 1st floor, where blood was drawn
280780 - with a needle from Millie's right arm, per the doctor's order.
280781 -
280782 -
280783 -
280784 -
280785 -
280786 -
280787 -
2808 -

SUBJECTS
Lumps Under Left Arm Less Severe Continue Improvement Prior Examinat

3003 -
300401 -  ..
300402 - Lumps Under Arm Seem Less Severe Today
300403 -
300404 - Follow up ref SDS 52 MW8J, ref SDS 51 MW8J.
300405 -
300406 - Millie commented that the lump under the left arm seems to have
300407 - disappeared, except for scar tissue; there is no discomfort nor
300408 - awareness of a difference between right and left axilla, reflecting
300409 - improvement reported during the meeting at Kaiser on 041005.
300410 - ref SDS 52 MW8J
300412 -  ..
300413 - The doctor examined the lump under the left arm, and noted finding no
300414 - evidence of cancer, consistent with the CT test taken yesterday, on
300415 - 041103, and reported above. ref SDS 0 QP74
300416 -
300417 -
300418 -
300419 -
3005 -

SUBJECTS
Lumps in Neck Left Side No Evidence Swelling Indicating Cancer Reced
Lumps Neck Seem to Have Become Softer Smaller Suggest Possible Favor

3704 -
370501 -  ..
370502 - Lumps in Neck No Evidence of Swelling Indicating Cancer Receded
370503 -
370504 - Follow up ref SDS 52 8R6M, ref SDS 51 8R6M.
370505 -
370506 - The doctor examined Millie's neck by pressing his fingers along the
370507 - left side where were lumps were previously swelled.  He concurred with
370508 - analysis of CT test last night on 041103, ref SDS 0 5F44, and with the
370509 - report on 041005 citing prior findings of no evidence that lymph nodes
370510 - are swelled, ref SDS 52 8R6M, which previously signaled alarm for
370511 - cancer, reported on 040309. ref SDS 27 0001
370512 -
370513 -
370514 -
370515 -
370516 -
3706 -

SUBJECTS
Avastin Taxol Trial Ends Avoid Blood Clots Pulmonary Emboli Coumadin
Examination Slight Coloration Redness Breast Requires Continued Trea
Dilemma Treatment with Taxol and Avastin for IBC Ended to Avoid Harm

5105 -
510601 -  ..
510602 - Inflammatory Breast Cancer (IBC) Requires Aggresive Treatment
510603 - Redness Breast Coloration Slight Shows Continuous Treatment Needed
510604 -
510605 - Follow up ref SDS 52 6T5G, ref SDS 51 6T5G.
510607 -  ..
510608 - The doctor advised that the primary care physician told him about
510609 - Millie having IBC.  He said that her patient history of slow response
510610 - to treatment in 2002, secondary IBC diagnosed in 2004, and now
510611 - pulmonary embolism diagnosed today presents a very complex case,
510612 - discussed further below, ref SDS 0 F47L, including treatment options.
510613 - ref SDS 0 Q59K
510615 -  ..
510616 - The doctor examined Millie and found slight coloration in the left
510617 - breast, indicating IBC has not been completely cured, which aligns
510618 - with findings at UCSF by Doctor Benz on 041018, ref SDS 55 V18I, and
510619 - the next day at Stanford by Doctor Guardino on 041019. ref SDS 56 TX93
510621 -  ..
510622 - The doctor asked what caused the nearly healed wound on the left
510623 - breast?
510625 -  ..
510626 - Millie explained work on 040419 by the surgeon performing a punch
510627 - biopsy, leading to a pathology report received from Kaiser on 040517
510628 - that showed inflammatory carcinoma, ref SDS 37 6T5G, which was later
510629 - diagnosed on 040614 as IBC. ref SDS 42 6T5G  For many months, the
510630 - wound was pussy, and would not heal.  About a month or so ago
510631 - treatments with Taxol and Avastin began to heal the wound.  A few
510632 - weeks ago on 041018 Doctor Benz at UCSF observed a poorly healed punch
510633 - biopsy.  The following day on 041019 Doctor Guardino made the same
510634 - finding.
510636 -         ..
510637 -        [On 041117 Doctor Benz's 2nd opinion mentions "poorly healed
510638 -        punch biopsy" in the left breast, reporting examination 041018.
510639 -        ref SDS 58 OT6R
510641 -         ..
510642 -        [On 041209 Doctor Guardino's 2nd opinion mentions "poorly
510643 -        healed punch biopsy" in the left breast, reporting examination
510644 -        on 041019. ref SDS 60 O23X
510646 -  ..
510647 - Examination today following treatment on 041021, ref SDS 57 9P6U,
510648 - shows continued improvement recovering from IBC in the left breast
510649 - under the Taxol Avastin chemotherapy trial, consistent with
510650 - improvement in CA 15-3 cancer marker falling to normal, ref SDS 0
510651 - GJ5M, and by the CT test citing no pathologic findings.  The doctor
510652 - commented that the wound is now almost fully healed, with only slight
510653 - scabbiness remaining.  He feels improvement signals that IBC is being
510654 - treated effectively.
510655 -
510656 -     [On 041230 after removal from treatment on 041104, IBC shows
510657 -     worsening progression. ref SDS 64 025H
510659 -  ..
510660 - The doctor advised that, because an analyst report shows a finding in
510661 - the CT test last night of pulmonary emboli, per above, ref SDS 0 RZ4I,
510662 - Millie cannot get treatment previously scheduled for today, after this
510663 - meeting, and further, that Millie can no longer get further treatments
510664 - with on Avastin Taxol trial, because blood clots and bleeding are side
510665 - effects, reported by Rosalie on 040318, ref SDS 28 UO3H, and because
510666 - the manufacturer of Avastin, Genentec, issued an announcment on 040812
510667 - of heightened risk of death from pulmonary emobolism. ref SDS 48 MG4G
510669 -        ..
510670 -       Taxol side effect is bleeding. ref OF 2 UK88
510672 -        ..
510673 -       Avastin side effect is pulmonary embolism. ref OF 2 CE39
510675 -  ..
510676 - Some patients are higher risk for this combination of side effects,
510677 - and Kaiser has now determines that Millie falls within this group.
510679 -  ..
510680 - This ends the dilemma of conflict between having surgery to treat IBC,
510681 - or continuing with Avastin Taxol trial posed by the primary care
510682 - physician on 040614, ref SDS 42 JK8L, reviewed again on 040812,
510683 - ref SDS 48 K47I, and most recently on 041005. ref SDS 52 N23N
510684 -
510685 -     [On 041210 doctor proposes surgery to treat IBC; case study
510686 -     reviews history considering surgery for Millie. ref SDS 62 ZV5J
510688 -  ..
510689 - A new dilemma is presented today because ending treatment conflicts
510690 - with analysis by the primary care physician and oncologist on 040812
510691 - showing treatment must continue until symptoms of IBC are eliminated.
510692 - ref SDS 48 CT9J  Additionally, recent 2nd opinions from UCSF on
510693 - 041018, ref SDS 55 LX7L, and the next day at Stanford on 041019, both
510694 - recommend continuous treatment. ref SDS 56 HX5H  Originally, the
510695 - surgeon at Kaiser disclosed on 040429 that the patient must be treated
510696 - for the breast to heal sufficiently to enable successful surgery.
510697 - ref SDS 36 SD7F
510698 -
510699 -     [On 041230 after removal from treatment on 041104, IBC shows
510700 -     worsening progression. ref SDS 64 025H
510702 -      ..
510703 -     [On 050104 Kaiser resumed treatment for Millie. ref SDS 66 407N
510705 -      ..
510706 -     [On 050204 CA 15-3 67 rise continues with over 2 month delay in
510707 -     treatment, not arrested by AC treatment. ref SDS 67 087J
510709 -      ..
510710 -     [On 050311 IBC worsens inflammation spreads, cancer blisters
510711 -     appear on left breast; CA 15-3 88 continues rise. ref SDS 68 025H
510713 -      ..
510714 -     [On 050727 IBC subsides, conditions improve; dilemma finally
510715 -     resolved after switching to treatment with Taxotere and
510716 -     capecitabine (Xeloda). ref SDS 71 YY7F
510718 -      ..
510719 -     [On 060123 Millie notifies Kaiser another extended delay in
510720 -     treatment occurring with rising CA 15-3 again. ref SDS 87 J94L
510722 -  ..
510723 - Discussed whether there might be an error in the CT test, in light of
510724 - past glitches, e.g., reported on 040318, ref SDS 28 ZE5O, and the fact
510725 - that symptoms of cough, heavy chest, shortness of breath have existed
510726 - for 6 months, beginning on 040517, ref SDS 37 RZ4I, without blood
510727 - clots being reported in CT tests?  Does this suggest prior tests were
510728 - analysed incorrectly?  Would it help to cross check test results prior
510729 - to drastic change that ends treatment at a time when the patient shows
510730 - favorable response?  Has this already been done?
510731 -
510732 -     [On 061020 primary care physician advised that CT tests for
510733 -     pulmonary embolism are different from CT tests for cancer, and so
510734 -     have to be expressly requested with the order for the test.
510735 -     ref SDS 85 S56G
510737 -  ..
510738 - The doctor noted that verification of testing is not a common practice
510739 - at Kaiser.
510740 -
510741 -
510742 -
510743 -
5108 -

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

6803 -
680401 -  ..
680402 - Dilemma Need Treatment Pulmonary Emoboli Ends Taxol Avastin Trial
680403 - Complex Patient History Conflicting Treatment Requirements Dilemma
680404 - Treatment Dilemma Deferred Until After Primary Care Physician Vacation
680405 -
680406 - Discussed options to accomplish regularly scheduled treatment for
680407 - complex patient profile, per above. ref SDS 0 6T5G
680409 -  ..
680410 - Rather than stop treatment altogether that has proven effective, as
680411 - reported today, ref SDS 0 GJ5M, can risk of pulmonary embolism (blood
680412 - clots), also, reported today, ref SDS 0 N438, be avoided, by reducing
680413 - the dose of Avastin?  Alternatively, can treatment be stopped only
680414 - with Avastin, and continue with Taxol, possibly combined with another
680415 - agent, like capecitabine, as recommended by UCSF in a letter to
680416 - Kaiser, received on 041117? ref SDS 58 OU6S  Doctor Benz noted patient
680417 - response to taxanes, supported by the record on 020628 reporting
680418 - cancer marker CA 15-3 improved dramatically following treatment with
680419 - Taxotere. ref SDS 7 ND4I  Taxol alone, or with another agent, may
680420 - help maintain momentum of recovery with CA 15-3 cancer marker down to
680421 - normal for the first time in 2 years, ref SDS 0 GJ5M, and with a CT
680422 - test that lists no signs of distant metastasis? ref SDS 0 Q49F
680424 -  ..
680425 - Doctor Kaufman plans to schedule a follow up meeting in two (2) weeks
680426 - when the primary care physician returns from vacation.  He feels
680427 - Millie needs to start treatment of IBC, as soon as possible in order
680428 - to prevent cancer from cascading out of control, per examination this
680429 - morning. ref SDS 0 6T5G
680431 -         ..
680432 -        [On 041230 doctor considers resuming treatment with Taxol, and
680433 -        elects to treat with Adriamycin and Cytoxin in order to qualify
680434 -        for a new trial with capacitabine. ref SDS 64 2V85
680436 -         ..
680437 -        [On 050520 dose of Xeloda (capecitabine) was reduced 25% to
680438 -        continue treatment with Taxotere and Xeloda, while reducing
680439 -        side effects. ref SDS 70 887S
680441 -  ..
680442 - Millie asked why she cannot get treatment already scheduled for today
680443 - with Taxol, Taxotere or some other agent rather than wait on the
680444 - vacation schedule?
680446 -  ..
680447 - The doctor noted Millie's patient history presents a complex dilemma
680448 - that should be deferred for analysis until the primary care physician
680449 - returns from vacation, following prior precedent on 040517.
680450 - ref SDS 37 SM6M  In the meantime, Millie cannot get chemotherapy to
680451 - treat IBC for at least the next two (2) weeks.
680453 -         ..
680454 -        [On 061020 primary care physician feels patient profile has too
680455 -        many issues for a 5-year medical case of secondary inflammatory
680456 -        breast cancer (IBC), cellulitus, lymphedema, pulmonary
680457 -        embolism, broken finger. ref SDS 85 MO4K
680459 -  ..
680460 - This new dilemma can be submitted to the Tumor Board for comment, and
680461 - to UCSF and Stanford for follow up on 2nd opinions.
680462 -
680463 -        [On 041130 the doctor indicated submitting the case to the
680464 -        tumor board would be embarrassing, and requested the patient
680465 -        withdraw the demand for review. ref SDS 59 YR8F
680467 -  ..
680468 - When we left the meeting with the doctor, the Protocol Nurse, Rosalie,
680469 - talked to Millie briefly in the halllway, and indicated that Kaiser
680470 - wants to continue CT testing to monitor Millie's progress for the
680471 - Avastin trial.  She also wants Millie to do a quality of life survey.
680473 -  ..
680474 - Millie said that things are a little confusing today.  She asked
680475 - Rosalie to contact her later about ancillary matters.
680476 -
680477 -
680478 -
680479 -
680480 -
680481 -
680482 -
680483 -
680484 -
680485 -
680486 -
6805 -