CONTACTS 

SUBJECTS
Meeting Doctor Examine Patient Tumor Board Review Develop New Treatm

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 70 0000. ref SDS 63 0000.
040502 -
040503 - The doctor was pleased that CA 15-3 cancer marker has dropped to
040504 - normal for the first time in 2 years. ref SDS 0 GJ5M  Continuing
040505 - symptoms of cough, heavy chest, and shortness of breath caused by
040506 - pulmonary emboli should subside after stopping treatment with Avastin,
040507 - and increasing Coumadin treatments 400%. ref SDS 0 RZ4I  A new problem
040508 - of pain in the right hip and knee will be evaluated today with an xray
040509 - in order to rule out distant metastasis. ref SDS 0 GN8K  The wound
040510 - from the biopsy in the left breast has suddenly worsened.  Treatment
040511 - with antibiotics was prescribed; follow up examination in two (2)
040512 - weeks. ref SDS 0 6T5G  Continuing coloration in the left breast shows
040513 - IBC requires timely treatment to maintain progress on improvement.
040514 - ref SDS 0 025H  Second opinions from UCSF and Stanford support timely
040515 - treatment. ref SDS 0 5X4J  Taxol without Avastin was considered for
040516 - resuming treatment immediately and avoiding side effects of pulmonary
040517 - emboli.  Treatment was deferred in order for the Protocol Nurse to
040518 - look for new chemotherapy trials. ref SDS 0 028N  The doctor discussed
040519 - factors to consider for a new work plan replacing the prior regimine
040520 - of Avastin and Taxol. ref SDS 0 028N  Discussed preparing a written
040521 - treatment plan and submission to the Tumor Board for support in
040522 - sorting out a complex case. ref SDS 0 YR8F
040524 -      ..
040525 -     [On 041202 Millie hospitalized in emergency room with elevated
040526 -     temperature and severely elevated inflammation of left breast,
040527 -     ref SDS 75 0001, which was successfully treated as expected
040528 -     reaction to antibiotics. ref SDS 75 RC92
040530 -      ..
040531 -     [On 041209 2nd opinion received from Doctor Guardino at
040532 -     Stanford. ref SDS 76 0001
040534 -      ..
040535 -     [On 041210 new chemotherapy trial found and prescribed for Millie.
040536 -     ref SDS 77 CF9F
040538 -      ..
040539 -     [On 041221 Rosalie advises Millie cannot participate in the new
040540 -     chemotherapy trial to treat cancer, because she only had two (2)
040541 -     treatments previously with Adriamycin (AC) and Cytoxan, and the
040542 -     protocol requires patients to have had four such treatments.
040543 -     ref SDS 79 E66I
040545 -      ..
040546 -     [On 041230 doctor prescribes chemotherapy treatment recommended by
040547 -     Doctor Guardino in Stanford's a 2nd opinion. ref SDS 80 IM5H
040549 -      ..
040550 -     [On 041230 doctor develops comprehensive treatment plan during
040551 -     discussion, which is reported in the record. ref SDS 80 LU6K
040553 -      ..
040554 -     [On 050311 examination shows new cancer sores on left breast.
040555 -     ref SDS 83 UA8N
040556 -
040557 -
040559 -  ..
0406 -
0407 -
0408 - Discussion
0409 -
040901 - Agenda Planning Scheduling Resumption of New Treatment for IBC
040902 -
040903 - Follow up ref SDS 70 SM6M, ref SDS 63 SM6M.
040904 -
040905 - The meeting today was scheduled to develop a work plan for resuming
040906 - chemotherapy to treat IBC, as soon as possible, recommended by a
040907 - doctor during a meeting at Kaiser on 041104. ref SDS 70 WT60  A new
040908 - treatment plan is needed, because at that time on 041004 Kaiser
040909 - abruptly cancelled treatments for Millie on the bevacizumab and Taxol
040910 - clinical trial because a finding in a CT test report of pulmonary
040911 - embolism was attributed to Avastin (bevacizumab). ref SDS 70 N438
040912 - Additionally, the primary care physician and oncologist was
040913 - vacationing on 041104 so Millie met with another doctor on the
040914 - oncology team, who deferred work on resuming treatments for the lead
040915 - oncologist handling Millie's case.  Kaiser scheduled today as the
040916 - earliest date to work this new problem.
040918 -  ..
040919 - Millie created an agenda on the marking board...
040920 -
040921 -        CA 15-3 normal best report 2 years......... 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 disappeared................ ref SDS 0 MW8J
040926 -        Lumps in neck disappeared.................. ref SDS 0 8R6M
040927 -        Breast redness punch biopsy
040928 -        worsening schedule treatment............... ref SDS 0 6T5G
040929 -        Treatment plan IBC urgent.................. ref SDS 0 025H
040930 -        Tumor board review......................... ref SDS 0 YR91
040931 -
040932 -
040933 -
040934 -
040935 -
040936 -
0410 -

SUBJECTS
CA 15-3 Cancer Marker Dramatic Reversal Drops to Normal 39 Recovery
CA 15-3 Cancer Marker Normal 39 No Change from 041104 Relying on Tes

1104 -
110501 -  ..
110502 - CA 15-3 Cancer Marker Dramatic Reversal Dropping to Normal 39
110503 - Recovery Progress CA 15-3 Cancer Marker Drops from 49 to 39 Normal
110504 -
110505 - Follow up ref SDS 70 087J, ref SDS 63 087J.
110506 -
110507 - There were no blood tests since the report on 041007 showing CA 15-3
110508 - suddenly dropped dramatically to 39, which is the high end of normal,
110509 - ref SDS 64 2N5J; and cited again later on 041014. ref SDS 66 2N5J
110510 -
110511 -     [On 041210 CA 15-3 rises above normal again to 43. ref SDS 77 087J
110513 -           ..
110514 -          041007......... 39............... 041104, ref SDS 70 087J
110515 -          040923......... 49 H............. 041006, ref SDS 63 087J
110516 -          040908......... 44 H............. 040909, ref SDS 62 087J
110517 -          040825......... 47 H............. 040812, ref SDS 59 087J
110518 -          040811......... 42 H............. 040812, ref SDS 59 087J
110519 -          040728......... 43 H............. 040729, ref SDS 57 2N5J
110520 -          040712......... 47 H............. 040713, ref SDS 55 087J
110521 -          040614......... 55 H............. 040615, ref SDS 54 PX6X
110522 -          040517......... 78 H............. 040601, ref SDS 50 2N5J
110523 -          040311......... 70 H............. 040318, ref SDS 38 SM6M
110524 -          040205......... 60 H............. 040211, ref SDS 36 SM6M
110525 -          031201......... 62 H............. 031205, ref SDS 34 SM6M
110526 -          030912......... 66 H............. 030913, ref SDS 33 SM6M
110527 -          030708......... 68 H............. 030710, ref SDS 31 SM6M
110528 -          030503......... 54 H............. 030508, ref SDS 28 SM6M
110529 -          030403......... 45 H............. 030403, ref SDS 28 SM6M
110530 -          030215......... 46 H............. 030220, ref SDS 27 5E6L
110531 -          030106......... 37 H............. 030109, ref SDS 26 SM6M
110532 -          021202......... 41 H?............ 021204, ref SDS 23 SP5G
110533 -          021111......... 36 H?............ 021113, ref SDS 22 Y65I
110534 -          021023......... 33 H?............ 021023, ref SDS 21 SQ5I
110535 -          020930......... 33 H?..29........ 021002, ref SDS 20 SQ5I
110536 -          020917......... 36 H?............ 020924, ref SDS 19 SQ5I
110537 -          020717......... 59 H?............ 020726, ref SDS 18 YN5K
110538 -          020629......... 75 H ............ 020705, ref SDS 17 UX6I
110539 -          020608........  67 H ............ 020614, ref SDS 16 0001
110540 -          020603........ 108 H ............ 020607, ref SDS 15 X67F
110541 -          020511........ 117 H ............ 020603, ref SDS 14 PJ4J
110542 -          020419......... 81 H ............ 020430, ref SDS 12 7N5H
110543 -          020321......... 85 H ............ 020405, ref SDS 11 6T8K
110544 -
110545 -
110546 -
110548 -  ..
1106 -
1107 -
1108 - Analysis
1109 -
110901 - CA 15-3 Cancer Marker Drop Attributed to Treatment
110902 - Patient Responds to Treatment CA 15-3 Reverses and Drops to 39 Normal
110903 -
110904 - Follow up ref SDS 70 GJ5M, ref SDS 63 GJ5M.
110905 -
110906 - The doctor noted improvement in CA 15-3 cancer marker.  The drop from
110907 - 49 to 39 was reported on 041007, ref SDS 64 2N5J, and is the best
110908 - report in 2 years since the CA 15-3 test on 021023, after treatment
110909 - with Taxotere. ref SDS 21 SQ5I  The doctor expressed disappointment
110910 - about ending treatment with Avastin and Taxol that achieved very
110911 - favorable results, reported on 041104. ref SDS 70 XN6O
110913 -  ..
110914 - The doctor orders another CA 15-3 blood test to update the last test
110915 - on 041104, and in light of new developments with biopsy wound on the
110916 - left breast suddenly woresning, per below. ref SDS 0 6T5G
110917 -
110918 -        [On 041202 attending physician included CA 15-3 in blood test
110919 -        for patient work up, ref SDS 75 4Q49, for treatment in
110920 -        emergency room with elevated temperature and severe
110921 -        inflammation of left breast, ref SDS 75 0001, which was
110922 -        successfully treated as expected reaction to antibiotics,
110923 -        ref SDS 75 RC92;
110925 -         ..
110926 -        [On 041210 CA 15-3 rises to 43 after 6 weeks without treatment.
110927 -        ref SDS 77 GJ5M
110928 -
110929 -
110930 -
110931 -
110932 -
1110 -

SUBJECTS
CT Test Shows Pulmonary Emboli Blood Clots Millie Must End Treatment
CT Test No Evidence Cancer Similar to Prior Test Lymph Nodes Not Pat
CT Test 041103 Previously Received at Kaiser on 041104 Printed Revie

1405 -
140601 -  ..
140602 - CT Scan No Active Cancer New Problem Pulminary Emboli Blood Clots
140603 - Pulminary Emboli New Problem Blood Clots CT Scan No Active Cancer
140604 - Blood Clots Pulminary Emboli New Problem CT Scan No Active Cancer
140605 -
140606 - Follow up ref SDS 70 NL4N, ref SDS 63 NL4N.
140607 -
140608 - For discussion during the meeting today, the doctor printed a copy of
140609 - the report for the CT test performed on 041103, and reviewed last
140610 - month on 041104, ref SDS 70 NL4N, showing no pathlogic nodes by size
140611 - criteria. ref SDS 70 Q49F
140612 -
140613 -
140614 -
140615 -
140616 -
1407 -

SUBJECTS
Cough Heavy Chest Shortness of Breath Symptoms Pulmonary Emboli Cont

2203 -
220401 -  ..
220402 - Pulmonary Emoboli Ends Taxol Avastin Trial Dilemma Need Treatment
220403 - Coughing Heavy Chest Shortness Breath Diagnosed Pulmonary Emboli
220404 - Cumadin Lifelong Treatment 4 MG Blood Clot Found in One CT Scan Test
220405 -
220406 - Follow up ref SDS 70 RZ4I, ref SDS 63 RZ4I.
220407 -
220408 - The doctor asked how Millie is feeling?
220410 -  ..
220411 - Millie reported coughing, heavy chest, and shortness of breath
220412 - continue unchanged.
220414 -  ..
220415 - The doctor indicated symptoms should begin to decline as a result of
220416 - blood clot disipating naturally after ending treatments on the trial
220417 - for Avastin, reported on 041104. ref SDS 70 RZ4I  He indicated that
220418 - increasing the dosage of Coumadin (Warfarin) 400% from 1 mg prescribed
220419 - on 040819, ref SDS 60 PQ9R, up to 4 mg pills prescribed 3 weeks ago on
220420 - 041104, ref SDS 70 Q57K, helps avoid further pulmonary emboli (blood
220421 - clots) which cause symptoms of cough, heavy chest, and shortness of
220422 - breath.
220424 -      ..
220425 -     [On 041210  meeting with doctor patient reports coughing symptoms
220426 -     are improved. ref SDS 77 6L5L
220428 -      ..
220429 -     [On 041211 coughing worsens, spitting up blood; very concerned.
220430 -     ref SDS 78 SE5O
220432 -      ..
220433 -     [On 041230 meeting with doctor patient reports pulmonary emboli
220434 -     symptoms decline; coughing, heavy chest, shortness of breath have
220435 -     significantly declined. ref SDS 81 898Y
220436 -
220437 -
220438 -
2205 -

SUBJECTS
Knee Hip Discomfort Xray Ordered to Rule Out Distant Metastasis

2503 -
250401 -  ..
250402 - Knee Hip Discomfort Xray Ordered to Rule Out Distant Metastasis
250403 -
250404 - Millie reported a new problem of pain in right hip and in the right
250405 - knee.
250407 -  ..
250408 - The doctor explained this is most likey arthritis-related, based on
250409 - prior testing that has found normal age related gradual degernation in
250410 - joints.  He ordered xrays to ensure that distant metastatis has not
250411 - begun to occur.
250413 -  ..
250414 - After the meeting, and after visiting with Rosalie, per below, we
250415 - went to the Imaging Department on the basement floor, and got the
250416 - xray of Mil's right hip and right knee.
250417 -
250418 -    [On 041210 xray shows no distant metastatis; there is some slight
250419 -    arthritis, which can be treated with Glucosimine and Chondroitin.
250420 -    ref SDS 77 5M8N
250421 -
250422 -
250423 -
250424 -
250425 -
2505 -

SUBJECTS
Lumps Under Left Arm No Examination Patient Reports Favorable Condit

2703 -
270401 -  ..
270402 - Lumps Under Arm Seem Less Severe Today
270403 -
270404 - Follow up ref SDS 70 MW8J, ref SDS 63 MW8J.
270405 -
270406 - Millie reported no evident renewal of activity under the left arm;
270407 - there is no discomfort, and no increase in lumpiness, reflecting
270408 - favorable examination on 041130, and the CT test on 041103, reviewed
270409 - during the meeting on 041104. ref SDS 70 MW8J
270411 -  ..
270412 - The doctor made no examination on this matter.
270413 -
270414 -
270415 -
270416 -
270417 -
270418 -
270419 -
270420 -
2705 -

SUBJECTS
Neck Lumps Left Side No Examination Patient Reports Favorable Condit

3303 -
330401 -  ..
330402 - Lumps in Neck No Evidence of Swelling Indicating Cancer Receded
330403 -
330404 - Follow up ref SDS 70 8R6M, ref SDS 63 8R6M.
330405 -
330406 - There was no examination of the neck, because of favorable
330407 - examinations and testing the past few months, reported on 041104.
330408 - ref SDS 70 8R6M
330409 -
330410 -
330411 -
330412 -
330413 -
330414 -
3305 -

SUBJECTS
Wound Punch Biopsy Left Breast Suddenly Worsens from Nearly Healed t
Wound Punch Biopsy Left Breast Suddenly Worsens from Nearly Healed t

4004 -
400501 -  ..
400502 - Wound Punch Biopsy Suddenly Worsens Treated with Antibiotics
400503 - Inflammatory Breast Cancer (IBC) Requires Aggresive Treatment
400504 - Redness Breast Coloration Slight Shows Continuous Treatment Needed
400505 - Dilemma Need Treatment Pulmonary Emoboli Ends Taxol Avastin Trial
400506 -
400507 - Follow up ref SDS 70 6T5G, ref SDS 63 6T5G.
400508 -
400509 - The doctor asked about progress recovering from IBC in the left
400510 - breast?
400512 -  ..
400513 - Millie advised that the wound from the punch biopsy taken on 040419
400514 - has suddenly worsened, after being nearly healed on 041104.
400515 - ref SDS 70 RH4J  The wound now requires a bandage to contain dripping.
400517 -  ..
400518 - The doctor examined Millie's left breast.  He concurred there is a
400519 - festering condition in marked contrast to findings on 041104, and
400520 - examinations by Doctor Benz on 041018, and reported in a 2nd opinion
400521 - as "incompletely healed," received on 041117. ref SDS 71 OT6R
400522 - Similarly, on 041019 Doctor Guardino at Stanford described a "poorly"
400523 - healed biopsy site. ref SDS 68 TX93
400525 -  ..
400526 - The doctor initially diagnosed Cellulitis that compounds inflammation
400527 - from IBC on the left breast.
400529 -  ..
400530 - The doctor took a skin tissue sample from the wound for analysis in
400531 - the lab to verify diagnosis.
400533 -  ..
400534 - The doctor further prescribed antiobiotics based on penicillin to
400535 - treat Cellulitis, and the doctor ordered a CA 15-3 lab to also test
400536 - for rising IBC by updating prior results on 041104, per above.
400537 - ref SDS 0 GJ5M
400539 -  ..
400540 - The doctor will see Millie again on 041210 1500 to examine progress
400541 - treating the sore on the left breast with antibiotics.
400542 -
400543 -     [On 041201 Millie concerned red rash spreads significantly on left
400544 -     breast. ref SDS 74 0001  Writes letter to Kaiser notifying of
400545 -     sudden increase in IBC symptoms, and asks if this is an expected
400546 -     reaction to antibiotics that heals the wound from the punch
400547 -     biopsy. ref SDS 74 RO7Q
400549 -      ..
400550 -     [On 041202 Millie hospitalized in emergency room with elevated
400551 -     temperature and severely elevated inflammation of left breast,
400552 -     ref SDS 75 0001, which was successfully treated as expected
400553 -     reaction to antibiotics for cellulitis. ref SDS 75 RC92
400555 -      ..
400556 -     [On 041202 lab report on tissue sample taken today, ref SDS 0
400557 -     HT7G, was reported by Emergency Room doctor to find cellulitis.
400558 -     ref SDS 75 4Q94
400560 -      ..
400561 -     [On 041210 recovery of wound from punch biopsy slow; prescription
400562 -     renewed. ref SDS 77 6T5G
400564 -      ..
400565 -     [On 041230 antibiotics prescription terminated for failure to heal
400566 -     wound from punch biopsy. ref SDS 81 2V58
400567 -
400568 -
400569 -
400570 -
4006 -

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

5306 -
530701 -  ..
530702 - Slight Coloration Left Breast Infected IBC Needs Immediate Treatment
530703 - Holiday from Chemotherapy Conflicts with Need for Immediate Treatment
530704 -
530705 - The doctor noted that examination still shows some redness coloration
530706 - that indicates continued presence of IBC in the left breast,
530707 - consistent with examination on 041104, ref SDS 70 GL4K, which
530708 - determined treatment must resume as soon as possible for local control
530709 - to recover from IBC, and essential for deciding on further surgery.
530710 - ref SDS 70 WT60
530711 -
530712 -     [On 041201 Millie concerned red rash spreads significantly on left
530713 -     breast. ref SDS 74 0001  Writes letter to Kaiser notifying of
530714 -     sudden increase in IBC symptoms, and asks if this is an expected
530715 -     reaction to antibiotics to heal the punch biopsy. ref SDS 74 RO7Q
530717 -      ..
530718 -     [On 041202 Millie hospitalized in emergency room with elevated
530719 -     temperature and severely elevated inflammation of left breast,
530720 -     ref SDS 75 0001, which was successfully treated as expected
530721 -     reaction to antibiotics. ref SDS 75 RC92
530723 -  ..
530724 - The doctor discussed taking a chemotherapy "holiday."
530726 -  ..
530727 - Patients gain strength, and the immune system recovers from
530728 - debilitating effects of constant treatment, experienced by the patient
530729 - the past few months, and reported for example, on 040812. ref SDS 59
530730 - K47I  In this case, Millie's last treatment was on 041021, ref SDS 69
530731 - 0001, because the 1st treatment for the 8th cycle was scheduled for
530732 - 041104, but on that date, Kaiser stopped treatments due to concern
530733 - about pulmonary emboli. ref SDS 70 RZ4I  This is already a 5 week
530734 - "holiday," and by the time another treatment can be given, even if
530735 - scheduled today, the "holiday" will be up to 6 weeks.
530737 -  ..
530738 - Millie explained that she has been on a "holiday" from treatment since
530739 - 041021, ref SDS 69 EB7J; and is concerned that delaying treatment will
530740 - lose control of the cancer, cited by Doctor Kaufman during the meeting
530741 - at Kaiser on 041104. ref SDS 70 WT60  Millie wants to resume treatment
530742 - today in order to optimize chances of recovery.
530743 -
530744 -     [On 050729 planning another break from chemotherapy after evident
530745 -     success of treatment with Taxotere capecitabine (Xeloda), and
530746 -     possible surgery in Sepbember 2005. ref SDS 90 Z26O
530748 -  ..
530749 - The doctor noted that pausing treatment requires balancing complex
530750 - issues.  Advantages have to be weighed against risks of cancer
530751 - cascading out of control, discussed below, ref SDS 0 Y66F, and
530752 - previously on 030606.  Each patient is different and there are many
530753 - factors to consider for achieving local control. ref SDS 30 ED8H
530754 -
530755 -        [...below, the doctor prepared a decision flow chart that
530756 -        illustrates complexity treating Stage IV cancer. ref SDS 0 CV9I
530758 -         ..
530759 -        [On 041210 doctor proposes surgery to treat IBC; case study
530760 -        reviews history considering surgery for Millie. ref SDS 77 ZV5J
530761 -
530762 -
530763 -
530764 -
5308 -

SUBJECTS
2nd Opinions UCSF Stanford Synthesize Recommendations Adopt Continuo
Multi-agent Treatments Couplets Capecitabene-Taxotere Rejected to Pr

6604 -
660501 -  ..
660502 - Capecitabine-Taxotere Couplets Rejected to Preserve Future Options
660503 - 2nd Opinions Synthesize Adopt Recommendations Continuous Treatment
660504 - Multi-agent Treatments Avoid Couplets Prolong Effective Chemotherapy
660505 - Couplets Avoid Multi-agent Treatment Extend Effectiveness Chemotherapy
660506 -
660507 - The doctor reported receiving the 2nd opinion from Doctor Benz
660508 - following examination at UCSF on 041018. ref SDS 67 0001
660510 -  ..
660511 - Today, the doctor explained a practice of synthesizing ideas from 2nd
660512 - opinions.  He proposed treatment with capecitabine mentioned in Doctor
660513 - Benz's report, received on 041117, ref SDS 71 OU5V, but further noted
660514 - a preference to avoid couplets, contrary to the Benz report suggesting
660515 - Gemzar-Taxotere or capecitabine-Taxotere combinations. ref SDS 71 OU6S
660516 - The doctor explained that not combining chemotherapy drugs preserves
660517 - treatment options for the future, considered further below in
660518 - discussing the treatment plan. ref SDS 0 FY5F
660519 -
660520 -     [On 041230 treatment plan synthesizes recommendations from
660521 -     Stanford and from UCSF in 2nd opinions. ref SDS 80 XQ72
660523 -      ..
660524 -     [On 050329 doctor prescribes treatment with Taxotere and
660525 -     capecitiabine (Xeloda). ref SDS 84 FP57
660527 -      ..
660528 -     [On 050913 doctor objects that 2nd opinions delay mastectomy
660529 -     surgery for patient with secondary IBC, history of relapse, and
660530 -     pulmonary emboli. ref SDS 93 G44O
660532 -      ..
660533 -     [On 061208 doctor objects to multi-agent, couplets combining
660534 -     chemotherapy drug treatments. ref SDS A1 HS5O
660536 -      ..
660537 -     [On 061218 doctor repeats generalization about using single agent
660538 -     treatments to avoid exhausing drugs to treat Millie, without
660539 -     listing available drugs for IBC, and conflicting with patient
660540 -     history prescribing double-agent treatments. ref SDS A2 JU7J
660541 -
660542 -
660543 -
660544 -
660545 -
6606 -

SUBJECTS
Immediate Treatment Essential Avoid Cancer Cascading Out of Control

7103 -
710401 -  ..
710402 - Cascading Out of Control Avoided Timely Treatment IBC
710403 - Timely Treatment Avoid Cancer Cascading Out of Control
710404 -
710405 - The doctor indicated that resuming treatment immediately is essential
710406 - to avoid losing control of IBC in the left breast, cited above
710407 - describing a "cascade" effect, ref SDS 0 EV7M, and recommended
710408 - previously after examination on 041104, ref SDS 70 WT60, when
710409 - treatment with the Taxol and Avastin trial ended abruptly due to
710410 - discovery of pulmonary embolism attributed to Avastin, also, reported
710411 - on 041104. ref SDS 70 N438  Immediate resumption of treatment helps
710412 - meet requirements for continuous regimine of chemotherapy recommended
710413 - by Doctor Benz during the meeting at UCSF on 041018, ref SDS 67 LX7L,
710414 - and confirmed in the Doctor's 2nd opinion received on 041117.
710415 - ref SDS 71 OU4U  Doctor Guardino at Stanford, also, supports
710416 - continuous treatment, reported on 041019. ref SDS 68 HX5H
710417 -
710418 -     [On 050311 examination shows new cancer sores on left breast,
710419 -     indicating worsening disease. ref SDS 83 UA8N
710421 -      ..
710422 -     [On 060809 patient letter to Kaiser reports concern about
710423 -     experience treating IBC to provide timely treatment before disease
710424 -     spins out of control. ref SDS 98 C89J
710425 -
710426 -
710427 -
710428 -
7105 -

SUBJECTS
Treatment IBC Deferred to Search for New Chemotherapy Drug Trial Imm

7403 -
740401 -  ..
740402 - Search for New Chemotherapy Drug Trial Defers Treatment IBC
740403 - Treatment IBC Deferred to Search for New Chemotherapy Drug Trial
740404 - Taxol without Avastin or Reduced Dose Enables Immediate Treatment
740405 -
740406 - Millie asked to resume treatment immediately with Taxotere, which was
740407 - effective in 2002; or with Taxol, which was effective with bevacizumab
740408 - the past 6 months, or start treatment with capacitabine and Taxotere,
740409 - recommended by Doctor Benz in UCSF 2nd opinion, discussed today, per
740410 - above. ref SDS 0 5X4J
740412 -  ..
740413 - The doctor advised that rather than begin treatment immediately with
740414 - established chemotherapies recommended by UCSF 2nd opinion, per above,
740415 - ref SDS 0 Y66F, the protocol nurse, Rosalie, will look for more
740416 - clinical trials of new drugs.  The doctor indicated that drug trials
740417 - are the best treatment for Millie's patient profile, discussed
740418 - previously on 040318, ref SDS 38 DG4X, and that new drugs increase
740419 - effectiveness of treatments after cancer mutates, also, noted on
740420 - 040318. ref SDS 38 DG6L  Requirements to change treatments when
740421 - disease progresses due to mutated cancer cells was presented on
740422 - 030606. ref SDS 30 N27L
740424 -  ..
740425 - Evidence that cancer has mutated and was progressing seems unclear in
740426 - the record of Millie's patient history.  Recent 2nd opinion review
740427 - indicated findings that the patient was responding to treatment.  On
740428 - 041117 UCSF recommended in a 2nd opinion continuing the current
740429 - treatment, ref SDS 71 OU9U; Doctor Benz also noted liklihood of
740430 - eventual progression. ref SDS 71 OU5P  On 041019 Doctor Guardino at
740431 - Stanford made similar recommendations. ref SDS 68 HX5H
740433 -  ..
740434 - Delaying treatment of inflammatory breast cancer (IBC) occurred
740435 - previously on 040318 when antibiotics were prescribed to treat
740436 - Cellulitus because inflammation in the left breast was observed,
740437 - ref SDS 38 PY5H, which later was found by biopsy on 040419 to be IBC.
740438 - Treatment for Cellulitis was ended a few weeks later on 040402 when
740439 - there was no progress clearing inflammation.  Chemotherapy started on
740440 - 040420 eventually brought improvement causing IBC rash to subside.
740441 - ref SDS 41 IM6J  At that time, on 040318 IBC had not yet been
740442 - diagnosed, so urgency may not have been supported by the record.  IBC
740443 - was subsequently reported on 040517, and diagnosed a month later on
740444 - 040614 by Kaiser, and this diagnosis was supported by UCSF, and by
740445 - Stanford, who indicate continuous treatment is essential.
740447 -  ..
740448 - Since treatment was unexpectedly interrupted on 041104, treatment
740449 - could resume immediately with Taxol and a reduced dose of Avastin; or,
740450 - alternatively, not including Avastin, since it may have caused
740451 - pulmonary emboli.  Taxol has proven over the past few months to be at
740452 - least partially responsible for improvement in favorable response
740453 - treating IBC, as discussed during the meeting at Kaiser on 041104.
740454 - ref SDS 70 Q59K  Another option for single agent treatment now being
740455 - recommended by Kaiser, per above, ref SDS 0 5X4J, would be to try
740456 - Taxotere chemotherapy again, since this was very effective in 2002,
740457 - reported by the doctor in a meeting on 021206. ref SDS 24 694H
740459 -  ..
740460 - The doctor noted there are many possibilities for treatment.
740461 -
740462 -     [...below, the doctor discussed a limited number of drugs for
740463 -     treating breast cancer. ref SDS 0 763L
740464 -
740465 -     [On 041230 doctor considers resuming treatment with Taxol, and
740466 -     elects to treat with Adriamycin and Cytoxin in order to qualify
740467 -     for a new trial with capacitabine. ref SDS 80 2V85
740469 -  ..
740470 - The decision was taken to defer starting treatment until Rosalie can
740471 - investigate availability new chemotharapy drug trials.  He expects to
740472 - have some ideas in time for the next meeting on 041210 scheduled this
740473 - morning to evaluate antibiotics prescribed for the worsening wound
740474 - from the punch biopsy, per above. ref SDS 0 WL5K  Consideration of
740475 - starting treatment immediately with Taxol, or Taxotere, already
740476 - approved for Millie based on past history of effective application,
740477 - and to run concurrent with investigations for new drug trials, was not
740478 - discussed, perhaps due to protocol qualifying factors to participate
740479 - in trials.
740480 -
740481 -     [On 041201 Rosalie calls Millie to discuss trial for a new
740482 -     chemotherapy treatment using capecitabine. ref SDS 74 4P9L
740484 -      ..
740485 -     [On 041210 new chemotherapy trial found and prescribed for Millie.
740486 -     ref SDS 77 CF9F
740488 -      ..
740489 -     [On 041221 Rosalie advises Millie cannot participate in the new
740490 -     chemotherapy trial to treat cancer, because she only had two (2)
740491 -     treatments previously with Adriamycin (AC) and Cytoxan, and the
740492 -     protocol requires patients to have had four such treatments.
740493 -     ref SDS 79 E66I
740495 -      ..
740496 -     [On 041230 worsening IBC symptoms; treatment prescribed based on
740497 -     Stanford 2nd opinion recommending Adriamycin/Cytoxan chemotherapy
740498 -     which Kaiser believed would qualify Millie for referral to
740499 -     clinical trial with capecitabine recommended by UCSF. ref SDS 80
740500 -     IM5H
740502 -      ..
740503 -     [On 050311 examination shows new cancer sores on left breast.
740504 -     ref SDS 83 UA8N
740505 -
740506 -
740507 -
740508 -
740509 -
740510 -
7406 -

SUBJECTS
Written Work Plan Treatment Work Up Patient Requests to Study Refine
Tumor Board Review Work Plan Treatment Work Up Patient Requests to S

AD04 -
AD0501 -  ..
AD0502 - Written Work Plan Resisted Reliance Verbal Presentation
AD0503 - Work Plan and Tumor Board Review Requested to Analyse Complex Case
AD0504 - Tumor Board Resolve Dilemma Treatment Plan After Major Change in Case
AD0505 -
AD0506 - Millie requested a written treatment plan listing chemotherapy agents
AD0507 - in the order of priority, and with Kaiser's analysis of the case in
AD0508 - relation to 2nd opinions from UCSF, and from Stanford.
AD0510 -  ..
AD0511 - There was further discussion on submitting a work plan for analysis
AD0512 - and comment by the Kaiser Tumor Board, following up the last hearing
AD0513 - on 040416, received and discussed with the doctor on 040517,
AD0514 - ref SDS 48 F77M  Follow up review by the Tumor Board was proposed by
AD0515 - the doctor on 040614, ref SDS 53 4R59, and was discussed again during
AD0516 - the last meeting at Kaiser to help resolve dilemmas fashioning a new
AD0517 - plan that replaces prior treatment with Taxol and Avastin. ref SDS 70
AD0518 - Q59K
AD0520 -             ..
AD0521 -            [On 050913 patient requests "Time Out" diliberation through
AD0522 -            Tumor Board review and joint meeting for collaboration
AD0523 -            using Kaiser's team care practice to assess 2nd opinions
AD0524 -            and plan treatment options, including consideration for
AD0525 -            major surgery, ref SDS 93 6W4L; Kaiser advised there is not
AD0526 -            enough time to implement Kaiser's requirements for "Time
AD0527 -            Out." ref SDS 93 6W52
AD0529 -  ..
AD0530 - The doctor advised that a written treatment plan for the patient is
AD0531 - unnecessary, because he has made a verbal explanation during the
AD0532 - meeting today.  Reliance on memory of verbal representations aligns
AD0533 - with research on 950426 showing executive training teaches reliance on
AD0534 - conversation. ref SDS 4 8849  Study on 020504 shows widespread
AD0535 - resistance to written confirmation of verbal representations called
AD0536 - out by standards and regulations. ref SDS 13 NS6F  On 040614 the
AD0537 - doctor explained practice to avoid written communications confirming
AD0538 - understandings in meetings and calls, and advised at that time that
AD0539 - patients call the advise nurse on treatment matters, and should work
AD0540 - with Kaiser through conversation. ref SDS 53 O53O
AD0541 -
AD0542 -            [...below, the doctor notes that written analysis and
AD0543 -            planning, and support by the Tumor Board are unnecessary
AD0544 -            overkill because Millie's case is too simple. ref SDS 0
AD0545 -            763L
AD0547 -             ..
AD0548 -            [On 041230 doctor explains comprehensive treatment plan
AD0549 -            during meeting; cites dilemma because treatment plan was
AD0550 -            not written down, so could not verify accuracy of critical
AD0551 -            details need to avoid damage to patient's heart,
AD0552 -            ref SDS 80 XQ84; collaboration through doctor-patient
AD0553 -            partnership yields written analysis that saves time for the
AD0554 -            doctor. ref SDS 80 LU6K
AD0556 -             ..
AD0557 -            [On 050311 review solution for team care practice to get
AD0558 -            feedback from colleagues using a written record under the
AD0559 -            doctor-patient partnership. ref SDS 82 PB8N
AD0561 -             ..
AD0562 -            [On 050414 Knowledge Management cited at work in medical
AD0563 -            practice for many years; Kaiser leader on implementation.
AD0564 -            ref SDS 85 AG4I
AD0566 -             ..
AD0567 -            [On 050520 the doctor began capturing a legible record on
AD0568 -            Kaiser's computer, and disclosed Kaiser's plans to equip
AD0569 -            patient examination rooms with ergonomic work stations for
AD0570 -            efficiently investing intellectual capital. ref SDS 86 HX6J
AD0572 -             ..
AD0573 -            [On 050728 fear of accountability at GE shows common
AD0574 -            resistance to avoid writing for accurate communication.
AD0575 -            ref SDS 89 AO66
AD0577 -             ..
AD0578 -            [On 050913 primary care physician objects to reading
AD0579 -            written record of patient history, asks patient to verbally
AD0580 -            recall from memory details of 2nd opinions on
AD0581 -            considerations for major, high risk surgery. ref SDS 93
AD0582 -            KP9F
AD0584 -             ..
AD0585 -            [On 051121 Kaiser email support for doctor/patient
AD0586 -            partnership communication. ref SDS 94 V25O
AD0588 -             ..
AD0589 -            [On 060428 doctor submitted via electronic transmission
AD0590 -            (email) full report for PET scan test on 060414; enabled
AD0591 -            being prepared to facilitate a productive meeting; Millie
AD0592 -            is doctor's only patient who requests medical reports to be
AD0593 -            prepared for effective meetings. ref SDS 95 W54F
AD0595 -             ..
AD0596 -            [On 060821 Doctor Benz at UCSF objected to written record
AD0597 -            of patient history, asks patient to explain from memory.
AD0598 -            ref SDS 99 F65F
AD0600 -             ..
AD0601 -            [On 080110 UCSF reports doctors do not have enough time to
AD0602 -            prepare written analysis for annual review of patient
AD0603 -            progress to evaluate diagnosis and treatment plans.
AD0604 -            ref SDS A3 BF66
AD0606 -  ..
AD0607 - The doctor further said that submission of the case to the Tumor Board
AD0608 - is unnecessary, because patient history is too simple for review,
AD0609 - discussed further below. ref SDS 0 763L
AD0610 -
AD0611 -            [On 050727 due diligence using the Tumor Board for
AD0612 -            collaboration on planning masectomy to treat IBC which is
AD0613 -            very rare, and so practioners typically have limited
AD0614 -            experience with this procedure. ref SDS 88 R36H
AD0616 -             ..
AD0617 -            [On 050913 primary care physician rejects request for joint
AD0618 -            planning meeting for collaboration using Kaiser's team care
AD0619 -            practice to assess 2nd opinions and plan treatment options,
AD0620 -            including consideration for major surgery. ref SDS 93 G95J
AD0622 -  ..
AD0623 - Written planning that confirms verbal understandings, and, also,
AD0624 - review for expanding span of attention and correction of mistakes have
AD0625 - both been long resisted in all professional fields....
AD0626 -
AD0627 -        1.  Good management unnecessary
AD0628 -            overkill........................ 890324, ref SDS 1 X74I
AD0630 -             ..
AD0631 -        2.  Accuracy takes too much
AD0632 -            time for people trying to
AD0633 -            expedite, collaborate, and
AD0634 -            get along with everybody........ 890809, ref SDS 2 0880
AD0636 -             ..
AD0637 -        3.  Feel good management doesn't
AD0638 -            worry about accuracy............ 911123, ref SDS 3 1331
AD0640 -             ..
AD0641 -        4.  Executive training teaches
AD0642 -            work by conversation, people
AD0643 -            do not have enough time for
AD0644 -            accuracy........................ 950426, ref SDS 4 7730
AD0646 -             ..
AD0647 -        5.  Article reports study
AD0648 -            showing successful CEO's
AD0649 -            confirm understandings
AD0650 -            in writing after meetings
AD0651 -            but many CEO's resist
AD0652 -            good management................. 990625, ref SDS 7 4914
AD0653 -
AD0655 -  ..
AD0656 - Some authorities say writting to confirm verbal understandings
AD0657 - improves the work.....
AD0658 -
AD0659 -        1.  Andy Grove at Intel argues that
AD0660 -            written analysis of communication
AD0661 -            in meetings is essential to
AD0662 -            avoid mistakes caused by
AD0663 -            ambiguity of mental maps........ 980307, ref SDS 5 3668
AD0665 -             ..
AD0666 -        2.  Article in Fortune reported
AD0667 -            study showing successful
AD0668 -            CEO's confirm understandings
AD0669 -            in writing to avoid
AD0670 -            mistakes........................ 990625, ref SDS 7 1024
AD0672 -  ..
AD0673 - Millie noted today that a major change and setback in patient care
AD0674 - occurred on 041104, when Kaiser suddenly ended treatment with Taxol
AD0675 - and Avastin, which was achieving progress controlling cancer in the
AD0676 - left breast, and related symptoms under the left arm, and on the left
AD0677 - side of the neck, consistent with IBC.  Ending treatment that had
AD0678 - demonstrated positive results on the grounds that Avastin caused side
AD0679 - effects of pulmonary emboli in the patient based on a CT test report,
AD0680 - ref SDS 70 N438, was not followed up with continuing Taxol treatments,
AD0681 - which may have been the prime cause of improvement on the Avastin
AD0682 - Taxol trial, based on patient strong response to treatments with
AD0683 - Taxotere in 2002. ref SDS 70 Q59K
AD0685 -         ..
AD0686 -        [On 061020 primary care physician feels patient profile has too
AD0687 -        many issues for a 5-year medical case of secondary inflammatory
AD0688 -        breast cancer (IBC), cellulitis, lymphedema, pulmonary
AD0689 -        embolism, broken finger. ref SDS A0 MO4K
AD0691 -  ..
AD0692 - Previously, on 020726 the doctor submitted this case to the Tumor
AD0693 - Board to resolve a complex treatment dilemma when CA 15-3 tests
AD0694 - fluctuated unexpectedly. ref SDS 18 MO37  Similarly, today, the Tumor
AD0695 - Board can help resolve the dilemma cited on 041104 where treatment has
AD0696 - been stopped with Avastin to avoid pulmonary emboli, but can continue
AD0697 - with Taxol, or with Taxol and a reduced dose of Avastin, to satisfy
AD0698 - requirements for immediate treatment, recommended in the meeting at
AD0699 - Kaiser on 041104, and noted by the doctor today, ref SDS 0 Y66F, which
AD0700 - further aligns with 2nd opinions from UCSF and Stanford that indicate
AD0701 - continuous treatment is needed to recover from IBC. ref SDS 70 F47L
AD0702 - The Tumor Board can prepare a written report, like the report from
AD0703 - UCSF received on 041117, ref SDS 71 OU6S, and the report due Stanford
AD0704 - for the meeting on 041019. ref SDS 68 0001
AD0705 -
AD0706 -        [On 041209 received written report from Stanford with 2nd
AD0707 -        opinion recommending continuous treatments. ref SDS 76 XS4I
AD0709 -         ..
AD0710 -        [On 050913 primary care physician rejects request for joint
AD0711 -        planning meeting for collaboration using Kaiser's team care
AD0712 -        practice to assess 2nd opinions and plan treatment options,
AD0713 -        including consideration for major surgery. ref SDS 93 G95J
AD0715 -  ..
AD0716 - Written work plans citing patient history, treatment scenarios, and
AD0717 - written opinions from the Tumor Board enable the doctor and the
AD0718 - patient to study, research, and refine planning toward deciding follow
AD0719 - up action, as shown in the record on 040517. ref SDS 48 4R59  Written
AD0720 - work plans demonstrate application of Kaiser's Breast Cancer Treatment
AD0721 - Guidelines for Patients on page 52.  Written work plans can be linked
AD0722 - to written test reports, which are commonly more reliable than
AD0723 - conversation for complex analysis, illustrated by work on 041104.
AD0724 - ref SDS 70 NL4N
AD0726 -  ..
AD0727 - An example of reliance on written records for accurate analysis
AD0728 - occurred on 041019 during the meeting at Stanford Medical Center for a
AD0729 - 2nd opinion.  At that time, Doctor Guardino asked an aide to leave the
AD0730 - examination room and check the record from the patient's medical chart
AD0731 - submitted by Kaiser for the date of a CT test, rather than rely on
AD0732 - guessing from personal memory that occurs in conversation. ref SDS 68
AD0733 - BV92
AD0735 -         ..
AD0736 -        [On 041230 the doctor discussed Stanford's report during a
AD0737 -        meeting at Kaiser. ref SDS 81 IM5H
AD0739 -         ..
AD0740 -        [On 041230 doctor explains comprehensive treatment plan during
AD0741 -        meeting; cites dilemma because treatment plan was not written
AD0742 -        down, so could not verify accuracy of critical details need to
AD0743 -        avoid damage to patient's heart, ref SDS 80 XQ84; collaboration
AD0744 -        through doctor-patient partnership yields written analysis that
AD0745 -        saves time for the doctor. ref SDS 80 LU6K
AD0747 -         ..
AD0748 -        [On 041230 doctor develops comprehensive treatment plan during
AD0749 -        discussion, which is reported in the record. ref SDS 80 LU6K
AD0751 -  ..
AD0752 - The doctor commented that written analysis and Tumor Board review are
AD0753 - unnecessary overkill because this case has become a simple matter of
AD0754 - progressing routinely through a limited number of drugs (see list
AD0755 - below, ref SDS 0 FY5F) for treating Millie's patient profile of triple
AD0756 - negative status, shown by biopsy on 020321. ref SDS 21 LA7O  Objection
AD0757 - to written plans, analysis, and records of communications was
AD0758 - presented previously on 020402. ref SDS 10 KG4H  The doctor requested
AD0759 - verbal communications on 040614 and asked the patient not to submit
AD0760 - written confirmation. ref SDS 53 O53O (see also above, ref SDS 0 8P8F)
AD0762 -         ..
AD0763 -        [...below, the doctor presents a list of drugs for Millie's
AD0764 -        patient profile. ref SDS 0 FY5F
AD0766 -         ..
AD0767 -        [...below, Kaiser's Breast Cancer Treatment Guidelines helps
AD0768 -        interpret the doctor's list. ref SDS 72 UB4H
AD0770 -         ..
AD0771 -        [On 050913 primary care physician rejects request for joint
AD0772 -        planning meeting for collaboration using Kaiser's team care
AD0773 -        practice to assess 2nd opinions and plan treatment options,
AD0774 -        including consideration for major surgery. ref SDS 93 G95J
AD0776 -         ..
AD0777 -        [On 061020 primary care physician feels patient profile has
AD0778 -        too many issues for a 5-year medical case of secondary
AD0779 -        inflammatory breast cancer (IBC), cellulitis, lymphedema,
AD0780 -        pulmonary embolism, broken finger. ref SDS A0 MO4K
AD0782 -  ..
AD0783 - Doctor Benz supports this analysis in part noting in a 2nd opinion
AD0784 - received a few weeks ago on 041117...
AD0785 -
AD0786 -        Given the total lack of hormonal responsiveness, there is no
AD0787 -        point to the use of endocrine therapy, nor would she be a
AD0788 -        candidate for Herceptin, given the HER-2/neu negativity.
AD0789 -        However, other small molecule kinase inhibitors as part of a
AD0790 -        protocol would certainly be warranted if she were eligible for
AD0791 -        such studies. ref SDS 71 OU6W
AD0793 -            ..
AD0794 -           [On 050907 Doctor Shim at Kaiser in Oakland recommends
AD0795 -           retesting for status change that could have a huge impact on
AD0796 -           expanding treatment options. ref SDS 92 TX6J
AD0798 -  ..
AD0799 - Doctor Benz's reference to prospects for a trial protocol suggests
AD0800 - that despite limited treatments options, there remain opportunities to
AD0801 - find and evaluate for effective treatment.
AD0803 -         ..
AD0804 -        [On 050414 Knowledge Management cited at work in medical
AD0805 -        practice for many years; Kaiser leader on implementation.
AD0806 -        ref SDS 85 AG4I
AD0808 -         ..
AD0809 -        [On 050520 the doctor began capturing a legible record on
AD0810 -        Kaiser's computer, and disclosed Kaiser's plans to equip
AD0811 -        patient examination rooms with ergonomic work stations for
AD0812 -        efficiently investing intellectual capital. ref SDS 87 R35L
AD0813 -
AD0814 -
AD0815 -
AD0816 -
AD0817 -
AD0818 -
AD09 -

SUBJECTS
Rough Sketch Handwritten Illegible Diagram for Treatment Plan Lists

AI03 -
AI0401 -  ..
AI0402 - Chemotherapy Limited Number of Drugs for Treating Cancer
AI0403 - Options Chemotherapy Therapy for Cancer Treatment Work Plan
AI0404 - Rough Sketch Lists Limited Chemotherapies for Treatment Work Up Plan
AI0405 -
AI0406 - The doctor used an ink pen to draw on the sanitation tissue covering
AI0407 - the patient examination table a rough sketch listing available
AI0408 - chemotherapy drugs for breast cancer. (see interpretation below,
AI0409 - ref SDS 0 OK8L, and, also, the list of drugs for treating breast
AI0410 - cancer in a Kaiser publication, ref SDS 0 9V63)  The sketch looks like
AI0411 - a work flow diagram shown in Kaiser's "Breast Cancer Treatment
AI0412 - Guidelines for Patients" on page 52 that sets work up required for
AI0413 - Stage IV patients.  The doctor set Stage IV for Millie on 040614, due
AI0414 - to diagnosis of IBC on recurrance, ref SDS 53 SZ3I  IBC is not
AI0415 - expressly discussed on page 52 of the Breast Cancer Treatment
AI0416 - Guidelines.
AI0418 -  ..
AI0419 - The doctor did not clarify if this list is for patients with triple
AI0420 - negative (ER/PR/HER2) status, per above, ref SDS 0 763L, and diagnosis
AI0421 - of secondary IBC delayed for 18 months, reported on 040614.
AI0422 - ref SDS 53 6T6G
AI0424 -  ..
AI0425 - The doctor's diagram indicates the following matrix but with work flow
AI0426 - arrows added..........
AI0428 -         ..
AI0429 -        S         IBC             Chems        Toxins      Targeted
AI0430 -
AI0431 -                 Avast???  PE                               H.....
AI0432 -                                                            ......
AI0433 -       UC                         Tax....
AI0434 -                                  Ge?z...
AI0435 -                          AC      Nun...
AI0436 -                                  ..... CPPD??      Cl... ...
AI0437 -       TB                         Xel....
AI0438 -                                  CMF
AI0439 -
AI0441 -                                   ..
AI0442 -                                  x   O
AI0443 -                                      |
AI0444 -                                  x   O
AI0445 -                                      |
AI0446 -                                  x   O
AI0447 -                                      |
AI0448 -                                  x   O
AI0450 -  ..
AI0451 - The doctor tore off the marked segment of sanitation tissue and handed
AI0452 - it to the patient for a work plan.  While preparing the drawing the
AI0453 - doctor's narrative was spoken too quickly to absorb.  Patient history
AI0454 - enables some interpretation and inferrence for creating this record.
AI0455 -
AI0456 -     [...below, Kaiser's Breast Cancer Treatment Guidelines helps
AI0457 -     interpret the doctor's sketch. ref SDS 0 UB4H
AI0459 -  ..
AI0460 - The doctor's explanation seemed to relate this listing of treatments
AI0461 - to the earlier discussion on strategy to prescribe chemotherapy drugs
AI0462 - individually, rather than in couplets, in order to stretch out the
AI0463 - time treatments can be given as drugs reach a level where side effects
AI0464 - cannot be tolerated by the patient, ref SDS 0 5X4J, which was
AI0465 - previously discussed on 030606. ref SDS 30 JP7G
AI0466 -
AI0467 -     [On 041230 doctor clarifies options for continuing treatment.
AI0468 -     ref SDS 80 2R7G
AI0470 -      ..
AI0471 -     [On 050329 doctor prescribes treatment with Taxotere and
AI0472 -     capecitiabine (Xeloda). ref SDS 84 FP57
AI0474 -      ..
AI0475 -     [On 050907 Doctor Shim at Kaiser in Oakland recommends retesting
AI0476 -     for status change that could have a huge impact on expanding
AI0477 -     treatment options. ref SDS 92 TX6J
AI0478 -
AI0479 -
AI0480 -
AI0481 -
AI0482 -
AI0483 -
AI0484 -
AI05 -

SUBJECTS
Illegible Writing Communication Failure Medical Mistakes Treatment P

AV03 -
AV0401 -  ..
AV0402 - Treatment Plan Work Up Prepare from Initial Rough Sketch
AV0403 - Written Work Plan Illegible Support Formal Treatment Plan
AV0404 - Illegible Sketch Useful for Preparing Formal Treatment Plan
AV0405 -
AV0406 - The meaning of the drawing is unclear.  It fits a record of illegible
AV0407 - writings reported on 041014 reviewing notes of examinations that are
AV0408 - filed in the patient medical chart, ref SDS 65 W78K  Previously, on
AV0409 - 990912 illegible handwritting was cited, ref SDS 8 0900, that makes
AV0410 - communication difficult, causing medical mistakes. ref SDS 8 0960  On
AV0411 - 041018, Doctor Benz at the UCSF Cancer Center indicated the problem of
AV0412 - poor legibility occurs often in medical practice. ref SDS 67 EN63
AV0413 - Today, receipt of a roughly sketched drawing could be used for "mental
AV0414 - pointers" to prepare a work plan with flow chart technology, like
AV0415 - Visio.  The doctor's hand sketch is similar to work product prepared
AV0416 - by an architect or engineer, and handed to a CAD technician, along
AV0417 - with guidance and follow up to verify alignment with objectives,
AV0418 - requirements, and commitments.  This might fit the model of the
AV0419 - doctor-patient partnership called out in Kaiser's Healthwise Handbook,
AV0420 - reviewed on 990625. ref SDS 6 0806
AV0421 -
AV0422 -        [On 041230 doctor clarifies options for continuing treatment.
AV0423 -        ref SDS 80 2R7G
AV0425 -         ..
AV0426 -        [On 041230 doctor develops comprehensive treatment plan during
AV0427 -        discussion, which is reported in the record. ref SDS 80 LU6K
AV0429 -         ..
AV0430 -        [On 050520 the doctor began capturing a legible record on
AV0431 -        Kaiser's computer, and disclosed Kaiser's plans to equip
AV0432 -        patient examination rooms with ergonomic work stations for
AV0433 -        efficiently investing intellectual capital. ref SDS 87 R35L
AV0435 -         ..
AV0436 -        [On 050819 pharmacist handwritten record of patient report on
AV0437 -        side effects illegible, incomplete, following industry practice
AV0438 -        to avoid compliance with standards for accuracy. ref SDS 91
AV0439 -        A15O
AV0441 -  ..
AV0442 - Interpretation of Kaiser's Work Plan received today...
AV0443 -
AV0444 -     S   - may relate to the 2nd opinion from Stanford Cancer Center.
AV0445 -    UC   - may relate to the 2nd opinion from UCSF Cancer Center
AV0446 -    TB   - has no evident meaning.
AV0448 -    ..
AV0449 -   IBC   - acronym for inflammatory breast cancer, which has been
AV0450 -           common to the case since research reported on 040517.
AV0451 -           ref SDS 48 6M9H
AV0453 -    ..
AV0454 -   Avast - likely implies with question marks a diagramatic
AV0455 -           representation that IBC has been treated with Avastin, which
AV0456 -           has now been stopped, and there is now a question of which
AV0457 -           treatment to try next - best interpretation of doctor's
AV0458 -           writing.
AV0459 -
AV0460 -    PE   - following the question marks is unknown.
AV0462 -    ..
AV0463 -   Chems - seems to be a category of drugs and so may stand for
AV0464 -           "Chemotherapies," i.e., a list of drug treatments that can
AV0465 -           be used for Millie's condition.
AV0467 -            ..
AV0468 -    AC   - has an arrow pointing from the top of the list of drugs, and
AV0469 -           so may be an afterthought adding AC to the top of the list
AV0470 -           of available chemotherapies; there is another line drawn
AV0471 -           from the "S" to AC, which has stood for Adriamycin and
AV0472 -           Cytoxan used to treat Millie, shown on 020405, ref SDS 11
AV0473 -           6SWS  This could reflect that Stanford recommended trying
AV0474 -           Adriamycin and Cytoxyn (AC) again, reported in the record on
AV0475 -           041019 when Millie had a meeting at Stanford. ref SDS 68
AV0476 -           BV6K
AV0477 -
AV0478 -               [On 041209 Stanford's 2nd opinion recommends trying AC
AV0479 -               again. ref SDS 76 SN88
AV0481 -                ..
AV0482 -               [On 041230 the doctor propses adopting Stanford's
AV0483 -               recommendation to try AC as the next treatment for
AV0484 -               Millie. ref SDS 81 IM5H
AV0486 -            ..
AV0487 -   Tax.. - this is the only chemotherapy that is written with
AV0488 -           sufficient legibility to assume it means Taxotere.  It could
AV0489 -           mean Taxol, but the remaining markings look closer to
AV0490 -           Taxotere.  Since Taxotere is common to case history, e.g.,
AV0491 -           on 041117 recommended by UCSF in combination with
AV0492 -           capecitabine, ref SDS 71 OU6S, and previously prescribed for
AV0493 -           Millie on 020603 to replace AC, ref SDS 14 WO4O, there is
AV0494 -           strong liklihood that "Taxotere" was intended to be
AV0495 -           conveyed.
AV0496 -
AV0497 -               [On 050520 capecitabine Taxotere dramatic improvement
AV0498 -               after 2 cycles of treatment the spread and severity of
AV0499 -               inflamation, and the firmness of skin have all receded
AV0500 -               to near normal, CA 15-3 drops to 65; side effects of
AV0501 -               peeling, blistering feet reduce level of treatment by
AV0502 -               25%. ref SDS 87 887S
AV0504 -                ..
AV0505 -               [On 060428 Navelbine proposed by doctor consideration of
AV0506 -               treatment that complements previously effective
AV0507 -               combination of capecitabine and Taxotere in the event of
AV0508 -               relapse. ref SDS 95 K36G
AV0510 -            ..
AV0511 -           The remainder of the handwritten list is not legible.
AV0512 -
AV0514 -  ..
AV0515 - Kaiser publishes a patient booklet with requirements for patient work
AV0516 - up that presents a legible list of commonly prescribed treatments for
AV0517 - cancer...
AV0519 -          ..
AV0520 -         Work Up Kaiser Breast Cancer Patient Treatment Planning
AV0521 -         Breast Cancer Treatment Guidelines for Patients
AV0522 -         Version IV September 2002
AV0523 -
AV0525 -  ..
AV0526 - This Kaiser publication was not reviewed during the meeting, nor cited
AV0527 - in Kaiser's work plan document submitted today, per above. ref SDS 0
AV0528 - FY5F  The Breast Cancer Treatment Guidelines has detailed requirements
AV0529 - for work ups to plan treatment based on patient staging levels.
AV0530 - Nothing along these lines has been submitted to the patient, nor were
AV0531 - any "work ups" found in the medical records received from Kaiser on
AV0532 - 041014 in connection with obtaining 2nd opinions at that time.
AV0533 - ref SDS 65 PF7I
AV0535 -  ..
AV0536 - Page 19 in Kaiser's Breast Cancer guidelines has a list under a
AV0537 - heading that has words that seem related to the illegible sketch
AV0538 - received today from the doctor, per above. ref SDS 0 9V71  Kaiser's
AV0539 - booklet lists...
AV0541 -          ..
AV0542 -         Drugs Commonly Used to Treat Breast Cancer
AV0543 -
AV0544 -         Generic               Brand
AV0545 -
AV0546 -         Cyclophosphamide      Cytoxan
AV0547 -         Docetaxel             Taxotere
AV0548 -         Doxorubicin           Adriamycin
AV0549 -         Epirubicin            Ellence
AV0550 -         Pacltaxel             Taxol
AV0551 -         Tamoxifen             Nolvadex
AV0552 -         Toremifen             Fareston
AV0553 -         Trastuzumab           Herceptin
AV0554 -
AV0555 -            [On 060808 research added following to Kaiser's list...
AV0556 -            ref SDS 97 SX5F
AV0558 -          ..
AV0559 -         vinorelbine           Navelbine
AV0560 -         gemcitabine           Gemzar)
AV0561 -         capecitabine          Xeloda
AV0563 -  ..
AV0564 - Capecitabine (Xeloda), gemcitabine, and Doxil were all proposed by
AV0565 - Doctor Benz in a 2nd opinion received on 041117. ref SDS 71 OU5V
AV0567 -  ..
AV0568 - Research on the Internet explains Doxil...
AV0569 -
AV0570 -              http://www.atdn.org/simple/doxil.html
AV0571 -
AV0572 -            [On 060428 Navelbine proposed by doctor consideration of
AV0573 -            treatment that complements previously effective
AV0574 -            combination of capecitabine and Taxotere in the event of
AV0575 -            relapse. ref SDS 95 K36G
AV0577 -             ..
AV0578 -            [On 060711 planning treatment of relapse, indicates there
AV0579 -            is an expanded list of cancer treatments for IBC, which
AV0580 -            requires review. ref SDS 96 834N
AV0582 -  ..
AV0583 - Another list is described....
AV0585 -          ..
AV0586 -         Chemotherapy regimens containing two or more drugs
AV0587 -
AV0588 -         CMF     Cyclophosphamide
AV0589 -                 methotrexate
AV0590 -                 fluorouracil
AV0591 -
AV0592 -         CAF     Cyclophosphamide
AV0593 -                 Doxorubicin
AV0594 -                 fluorouracil
AV0596 -          ..
AV0597 -         AC      Doxorubicin
AV0598 -                 Cyclophosphamide
AV0600 -          ..
AV0601 -         AC+Paclitaxel    Doxorubicin
AV0602 -                          Cyclophosphamide
AV0603 -                          Paclitaxel
AV0605 -          ..
AV0606 -         A CFM            Doxorubicin followed by
AV0607 -                          Cyclophosphamide
AV0608 -                          methotrexate
AV0609 -                          fluorouracil
AV0611 -          ..
AV0612 -         CEF              Cyclophosphamide
AV0613 -                          Epirubicin
AV0614 -                          Fluorouracil
AV0616 -  ..
AV0617 - On 041117 Doctor Benz 2nd opinion UCSF, ref SDS 71 OU5V, proposed
AV0618 - following combination...
AV0619 -
AV0620 -         TX               Docetaxel (Taxotere)
AV0621 -                          Capecitabine (Xeloda)
AV0623 -          ..
AV0624 -         GX               Gemcitabine (Gemzar)
AV0625 -                          Capecitabine (Xeloda)
AV0627 -          ..
AV0628 -         Doxil            liposomal
AV0629 -                          anthracycline
AV0631 -          ..
AV0632 -         NX               Vinorelbine (Navelbine)
AV0633 -                          Capecitabine (Xeloda)
AV0634 -
AV0635 -                  [On 060711 a patient tried combining Navelbine and
AV0636 -                  Xeloda. ref SDS 96 FE3O
AV0637 -
AV0639 -      ..
AV0640 -     [On 050520 Taxotere capecitabine dramatic improvement after 2
AV0641 -     cycles of treatment the spread and severity of inflamation, and
AV0642 -     the firmness of skin have all receded to near normal, CA 15-3
AV0643 -     drops to 65; side effects of peeling, blistering feet reduce level
AV0644 -     of treatment by 25%. ref SDS 87 887S
AV0646 -      ..
AV0647 -     [On 050907 Doctor Shim at Kaiser in Oakland recommends retesting
AV0648 -     for status change that could have a huge impact on expanding
AV0649 -     treatment options. ref SDS 92 TX6J
AV0651 -      ..
AV0652 -     [On 060428 Navelbine proposed by doctor consideration of
AV0653 -     treatment that complements previously effective
AV0654 -     combination of capecitabine and Taxotere in the event of
AV0655 -     relapse. ref SDS 95 K36G
AV0656 -
AV0657 -
AV0658 -
AV0659 -
AV07 -

SUBJECTS
Doctor Asks Patient to Withdraw Request for Tumor Board Review becau

AX03 -
AX0401 -  ..
AX0402 - Complex Case Many Treatment Options Tumor Board Can Aided Analysis
AX0403 - Kaiser's Work Up Not Effective for Treatment Planning Complex Case
AX0404 -
AX0405 - Overall, the rendering received from Kaiser today is not an effective
AX0406 - work plan.  The number of drugs for breast cancer seems to extend
AX0407 - beyond Kaiser's list.  For example, today, the doctor planned to defer
AX0408 - treatment in order to investigate new drug trials that may expand the
AX0409 - number of treatment options. ref SDS 0 024F  Additionally, Doctor
AX0410 - Benz's 2nd opinion received on 041117 lists capecitabine, liposomal,
AX0411 - anthracycline, ref SDS 71 OU5V, and, also, Gemzar, ref SDS 71 OU6S,
AX0412 - which are not on Kaiser's work plan received today nor in Kaiser's
AX0413 - Breast Cancer Treatment Guidelines.  During the meeting on 041104,
AX0414 - decision on treatment was expressly deferred for analysis by primary
AX0415 - care physician to resolve complex dilemmas in this case. ref SDS 70
AX0416 - Q54O
AX0418 -         ..
AX0419 -        [On 041230 doctor clarifies options for continuing treatment.
AX0420 -        ref SDS 80 2R7G
AX0422 -         ..
AX0423 -        [On 041230 doctor develops comprehensive treatment plan during
AX0424 -        discussion, which is reported in the record. ref SDS 80 LU6K
AX0426 -         ..
AX0427 -        [On 050414 Knowledge Management cited at work in medical
AX0428 -        practice for many years; Kaiser leader on implementation.
AX0429 -        ref SDS 85 AG4I
AX0431 -         ..
AX0432 -        [On 050520 the doctor began capturing a legible record on
AX0433 -        Kaiser's computer, and disclosed Kaiser's plans to equip
AX0434 -        patient examination rooms with ergonomic work stations for
AX0435 -        efficiently investing intellectual capital. ref SDS 87 R35L
AX0437 -  ..
AX0438 - The approximate 25 nodes in the doctor's rough sketch of a decision
AX0439 - matrix, ref SDS 0 FY5F, as well as shown in Kaiser's Breast Cancer
AX0440 - Treatment Guidelines on page 52, ref SDS 0 UB4H, both suggest
AX0441 - significant complexity in forming a treatment plan, as the doctor
AX0442 - oberserved initially in considering a chemotherapy "holiday," per
AX0443 - above. ref SDS 0 Y660  The Tumor Board can provide help considering
AX0444 - opportunities and risks in tailoring treatment up based on a complex
AX0445 - patient history.
AX0447 -      ..
AX0448 -     [On 050907 Doctor Shim at Kaiser in Oakland recommends retesting
AX0449 -     for status change that could have a huge impact on expanding
AX0450 -     treatment options. ref SDS 92 TX6J
AX0452 -  ..
AX0453 - The doctor strongly indicated that Millie's condition and treatment
AX0454 - issues are so simple that submission to a Tumor Board would cause
AX0455 - embarassment, and as a result he requested that the patient not puruse
AX0456 - Tumor Board support.  This appears to change the prior recommendation
AX0457 - on 040614 to seek follow up review by the Tumor Board when change
AX0458 - occurs in patient condition, ref SDS 53 4R59, as occurred on 041104,
AX0459 - ref SDS 70 N43I, and discussed further today. ref SDS 0 YR91
AX0461 -  ..
AX0462 - Millie agreed to withdraw the request for a written opinion from the
AX0463 - Tumor Board.
AX0464 -
AX0465 -     [On 041210 new chemotherapy trial found and prescribed for Millie.
AX0466 -     ref SDS 77 CF9F
AX0468 -      ..
AX0469 -     [On 041221 Rosalie advises Millie cannot participate in the new
AX0470 -     chemotherapy trial to treat cancer, because she only had two (2)
AX0471 -     treatments previously with Adriamycin (AC) and Cytoxan, and the
AX0472 -     protocol requires patients to have had four such treatments.
AX0473 -     ref SDS 79 E66I
AX0474 -
AX0475 -
AX0476 -
AX0477 -
AX0478 -
AX0479 -
AX0480 -
AX0481 -
AX0482 -
AX0483 -
AX05 -