THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: March 24, 2005 04:00 PM Thursday; Rod Welch

Millie meeting at Kaiser to evaluate breast surgery.

1...Summary/Objective
2...Biopsy Wound Healing Significantly Again After Getting Treatment
3...IBC Worsens Spreading Beyond Breast Toward Neck New Cancer Sores
4...Pockets of Resistance to Chemotherapy Require Treatment with Surgery
5...Surgery for Masectomy Waiting for Chemotherapy to Heal IBC
6...Treatment Loop Chemo Needs Surgery and Surgery Waiting for Chemo
7...Complex Surgery Need Recovery IBC for Incision into Healthy Skin
8...Dilemma Chemo Needs Surgery Surgery Waiting for Chemo Treatment Loop
....3...Criteria for Surgery to Perform Masectomy on IBC Patient
....4...Criteria to Approve Surgery for Extending Quality of Life
........Experience Performing Surgery on IBC Patients Rare Disease
........Skin Grafts to Avoid Restoring Surgery with Infected Tissue
........Masectomy Evaluate Surgery for IBC 2nd Opinion Recommended
........Tumor Board Review to Set Criteria on Surgery to Treat IBC
........2nd Opinion Recommended to Evaluate Surgery for IBC Masectomy
9...Research Criteria on Surgery for Masectomy to Reduce Chance of Relapse
........Metastatic Cancer Regional Lymph Nodes May be Operable
........Regional Metastasis May be Operable Not Distant Metastasis
........Surgery Criteria Metastatic Sites within Regional Lymph Nodes
........IBC Not Always Inoperable Indicates Surgery is Not Common


..............
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CONTACTS 

SUBJECTS
Biopsy Wound Healing Significantly Again After Getting Treatment Sur
Meeting Surgeon Evaluate Masectomy Left Breast Requested by Primary

0704 -
0704 -    ..
0705 - Summary/Objective
0706 -
070601 - Follow up ref SDS 29 0000. ref SDS 25 0000.
070602 -
070603 - The examination evaluated prospects for masectomy on referral from the
070604 - primary care physician in the Oncology Department, and follows up a
070605 - prior visit on January 7.  Chemotherapy treatments since January 7
070606 - have partially healed the wound from the biopsy taken on 040419.
070607 - ref SDS 0 WI6K  There is otherwise observable advance of disease.
070608 - Inflammation spread above the breast since January 7. ref SDS 0 YY7F
070609 - There was discussion about "pockets of resistance" to chemotherapy,
070610 - cited by Oncology. ref SDS 0 GK9M  Criteria for sufficient recovery
070611 - from IBC to permit surgery needs more work; possibly UCSF and Stanford
070612 - can follow up opinions from visits in October 2004. ref SDS 0 OV5H
070613 - Research on the Internet yielded an email address where inquiries
070614 - might, also, be made, ref SDS 0 QJ5H, and, also, suggest a role for
070615 - surger with metastatic cancer limited to regional involvement of lymph
070616 - nodes, as in this case. ref SDS 0 TN76  However, with disease now
070617 - spreading, there is no evident boundary for surgery, and there is not
070618 - sufficient healthy tissue on the breast to close a surgical wound.
070619 - ref SDS 0 WH5L  Options were considered to work around a "treatment
070620 - loop." Oncology calls for surgery to complement chemotherapy, and
070621 - Surgery wants a site cleared of disease with chemotherapy. ref SDS 0
070622 - WH5L  The surgeon indicated limited experience treating IBC patients.
070623 - ref SDS 0 QJ3Q  The surgeon will schedule additional review and
070624 - recommended getting more opinions, including collaboration and due
070625 - diligence through the Tumor Board. ref SDS 0 O85O
070626 -
070627 -     [On 050727 follow up examination by surgeon shows IBC has suddenly
070628 -     and miraculously healed completely after 5 treatments with
070629 -     Taxotere and capecitabine, ref SDS 37 YY7F, considerations for
070630 -     surgery relate to scope of masectomy, ref SDS 37 JV5F, and unique
070631 -     factors for IBC patients, ref SDS 37 QJ3Q, and to advisability for
070632 -     extending quality of life. ref SDS 37 VL4O
070633 -
070634 -
070635 -
070636 -
070638 -  ..
0707 -
0708 -
0709 - Progress
0710 -
071001 - Biopsy Wound Healing Significantly Again After Getting Treatment
071002 -
071003 - Follow up ref SDS 24 IS5N.
071004 -
071005 - The surgeon examined Millie's left breast in accordance with request
071006 - by the Oncologist on 050311, ref SDS 28 XQ41, and following up
071007 - examination of the biopsy wound on 050107. ref SDS 24 IS5N
071008 - Previously, the surgeon met with the patient on 040429 to present
071009 - results of a biopsy showing cancer, ref SDS 9 0001, performed earlier
071010 - by the surgeon on 040419 to evaluate inflammation (redness) observed
071011 - on the left breast. ref SDS 7 789F
071013 -         ..
071014 -    1.  The surgeon was pleased and surprised to observe the wound from
071015 -        the punch biopsy taken on 040419, ref SDS 7 XU52, finally shows
071016 -        some healing after three (3) treatments with Adriamycin Cytoxan
071017 -        (AC) (the 3rd on 050225, ref SDS 26 0001), compared to the
071018 -        examination on 050107, when the wound was "messy," ref SDS 24
071019 -        778O, and further reversing worsening conditions reported on
071020 -        041230. ref SDS 22 6T5G and previously on 041210 when the
071021 -        primary care physician indicated that surgery may be required
071022 -        to treat IBC in the left breast. ref SDS 19 ZV5J
071023 -
071024 -            [On 050727 follow up examination by surgeon shows biopsy
071025 -            wound fully healed after 4 treatments with Taxotere and
071026 -            capecitabine. ref SDS 37 WI6K
071027 -
071028 -
071029 -
071030 -
071031 -
071032 -
0711 -

SUBJECTS
IBC Worsens Spreading Beyond Breast Toward Neck New Cancer Sores Dil

1703 -
170401 -  ..
170402 - IBC Worsens Spreading Beyond Breast Toward Neck New Cancer Sores
170403 - Pockets of Resistance to Chemotherapy Require Treatment with Surgery
170404 -
170405 - Follow up ref SDS 24 6W6O.
170406 -
170407 -    2.  The surgeon noted expanding inflammation (red rash) compared to
170408 -        the examination of the left breast on 050107. ref SDS 24 UM6I
170409 -        Skin texture seems thicker and markedly more firm than the
170410 -        right breast.  Disease now reaches above the breast toward the
170411 -        neck, worse than on 050107, ref SDS 24 UM6I, and several new
170412 -        cancer sores, observed initially on 050311 by the primary care
170413 -        physician, ref SDS 28 UA8N, indicate worsening inflammatory
170414 -        breast cancer (IBC).  There was no discussion of rising CA 15-3
170415 -        now above 80, reported on 050311. ref SDS 28 087J  There were
170416 -        no diagrams prepared nor pictures taken to preserve an accurate
170417 -        memory on the spread of disease in order to guide the scope of
170418 -        surgery, which the doctor noted is critical to successful
170419 -        mastectomy for IBC conditions, during the meeting on 050107.
170420 -        ref SDS 24 UM6I
170422 -         ..
170423 -        Diagrams and pictures proposed to determine boundaries of
170424 -        future surgery, discussed below. ref SDS 0 0347
170425 -
170426 -            [On 050520 dramatic improvement after 2 cycles of treatment
170427 -            with Taxotere and Xeloda. ref SDS 32 025H
170429 -             ..
170430 -            [On 050727 surgeon examination finds left breast fully
170431 -            healed and ready for surgery after treatment with Taxotere
170432 -            and capecitabine. ref SDS 37 YY7F
170434 -         ..
170435 -        Millie asked about primary care physician concerns in the
170436 -        meeting on 050311 that the left breast may have "pockets" of
170437 -        resistance to treatment by chemotherapy, and therefore requires
170438 -        a surgical solution. ref SDS 28 PA4N
170439 -
170440 -
170442 -  ..
170443 - Surgery for Masectomy Waiting for Chemotherapy to Heal IBC
170444 - Treatment Loop Chemo Needs Surgery and Surgery Waiting for Chemo
170445 - Complex Surgery Need Recovery IBC for Incision into Healthy Skin
170446 - Dilemma Chemo Needs Surgery Surgery Waiting for Chemo Treatment Loop
170447 -
170448 -
170449 -        The surgeon explained again today that, until IBC is cleared
170450 -        from the breast with chemotherapy, masectomy surgery cannot be
170451 -        performed to prevent cancer from relapsing as occurred on
170452 -        041230, because spread of IBC toward the neck, per above,
170453 -        ref SDS 0 YY7F, presents a complex problem of finding a
170454 -        physical location on the body for making an incision to remove
170455 -        infected tissue, and further there is not enough healthy skin
170456 -        on the breast to the close the wound from surgery.  The surgeon
170457 -        cited prior analysis on 050107, ref SDS 24 UM6I, which in turn
170458 -        relied on examination and review of the case previously on
170459 -        040429. ref SDS 9 SD7F
170460 -
170461 -            [...see below surgeon has performed mastectomy surgery on a
170462 -            patient with IBC possibly once 5 years ago. ref SDS 0 QJ44
170464 -             ..
170465 -            [...see below research does not yield guidance on criteria
170466 -            for when a patient is ready for surgery and how to set
170467 -            physical boundaries of the procedure. ref SDS 0 QJ5H
170469 -             ..
170470 -            [On 050401 Millie and Pam met with Doctor Choi who
170471 -            recommended against surgery at this time; there was no
170472 -            evident discussion on criteria that establish level of
170473 -            recovery where surgery can be performed. ref SDS 31 PPSU
170475 -         ..
170476 -        Millie noted that analysis today presents a complex dilemma to
170477 -        break out of an evident "treatment loop."  Surgery is waiting
170478 -        for chemotherapy to achieve completely healthy tissue, and
170479 -        Oncology says surgery is needed to overcome "pockets of
170480 -        resistance" to chemotherapy, described in the Oncology
170481 -        department on 050311. ref SDS 28 PA4N
170482 -
170483 -            [On 050727 follow up examination by surgeon shows IBC has
170484 -            suddenly and miraculously healed completely after 5
170485 -            treatments with Taxotere and capecitabine, ref SDS 37 YY7F,
170486 -            considerations for surgery relate to scope of masectomy,
170487 -            ref SDS 37 JV5F, and unique factors for IBC patients,
170488 -            ref SDS 37 QJ3Q, and to advisability for extending quality
170489 -            of life. ref SDS 37 VL4O
170491 -             ..
170492 -            [On 061020 primary care physician feels patient profile has
170493 -            too many issues for a 5-year medical case of secondary
170494 -            inflammatory breast cancer (IBC), cellulitus, lymphedema,
170495 -            pulmonary embolism, broken finger. ref SDS 45 MO4K
170496 -
170497 -
170498 -
170499 -
170500 -
1706 -

SUBJECTS
Criteria Surgery Masectomy IBC Spreading Above Breast Will Biopsy De

2203 -
220401 -         ..
220402 -    3.  Criteria for Surgery to Perform Masectomy on IBC Patient
220403 -
220404 -        On 050311 the primary care physician in Oncology seemed to
220405 -        expect the Surgery Department to present criteria for deciding
220406 -        when to perform surgery in the event that chemotherapy fails.
220407 -        ref SDS 28 PB4N
220409 -         ..
220410 -        Background on considerations to perform surgery for a masectomy
220411 -        is summarized on 041210. ref SDS 19 ZV5J
220412 -
220413 -            [...below, surgeon will collaborate with primary care
220414 -            physician to present criteria pending review to determine
220415 -            when patient is ready for surgery and whether this is a
220416 -            good risk for the patient to take. ref SDS 0 QQ4N
220418 -             ..
220419 -            [...see below for research on the Internet. ref SDS 0 QJ5H
220421 -         ..
220422 -        What criteria will inform Surgery that the patient is ready for
220423 -        a masectomy, i.e., what conditions establish "successful"
220424 -        chemotherapy for sufficient recovery in a case of IBC?
220425 -
220426 -                [On 050401 Doctor Choi did not discuss criteria for
220427 -                when surgery can be performed on a patient recovering
220428 -                from IBC. ref SDS 31 RS5L
220430 -                 ..
220431 -                [On 050610 window of opportunity for surgery to perform
220432 -                masectomy after switching treatments to Taxotere and
220433 -                capecitabine (Xeloda), and dramatic recovery from IBC
220434 -                after 3 treatments; doctor calls for follow up
220435 -                examination to schedule masectomy surgery, ref SDS 34
220436 -                XQ41; did not discuss criteria for surgery, ref SDS 34
220437 -                2J72, listed on 050324. ref SDS 0 O16N
220439 -             ..
220440 -        a.  Will another biopsy be taken to establish IBC has been
220441 -            fully or sufficiently treated to permit successful surgery,
220442 -            based on experience using biopsy on 040419 to discover IBC
220443 -            after other measures had failed? ref SDS 7 789F
220444 -
220445 -                [On 050727 patient wants to avoid another slow healing
220446 -                biopsy experience; surgeon indicated another biopsy is
220447 -                not needed for determining patient is ready for
220448 -                mastectomy surgery. ref SDS 37 SZ6M
220450 -                 ..
220451 -                [On 050826 referral surgeon in Kaiser's Oakland office
220452 -                indicated a needle punch biopsy as performed on 040419
220453 -                to discover IBC is not helpful determining IBC has
220454 -                recovered sufficiently for a successful mastectomy.
220455 -                ref SDS 38 T14L
220457 -                 ..
220458 -                [On 050920 Doctor Grissom 2nd opinion proposes thin
220459 -                full thickness surgical biopsies with suture closure
220460 -                (rather than punch biopsy) to test for recovery from
220461 -                IBC and help determine scope of surgery. ref SDS 39
220462 -                XL7P
220464 -                 ..
220465 -                [On 050923 the surgeon at Kaiser in Walnut Creek agrees
220466 -                to perform biopsies to determine complete response to
220467 -                treatment for local disease. ref SDS 40 SZ6M
220469 -                 ..
220470 -                [On 051012 4 biopsies were taken during minor surgery
220471 -                at Kaiser in Walnut Creek. ref SDS 42 DG6J
220473 -                 ..
220474 -                [On 051006 Gloria called with the Kaiser Coagulation
220475 -                Clinic in Martinez, and related Millie should stop
220476 -                taking Coumadin to prepare for minor biopsy surgery on
220477 -                051012. ref SDS 41 YV6I
220479 -                 ..
220480 -                [On 051012 biopsies on left breast taken at Kaiser to
220481 -                further evaluate recovery from IBC. ref SDS 42 DG6J
220483 -                 ..
220484 -                [On 051018 Millie notified of favorable results from skin
220485 -                biopsies, no evidence of cancer. ref SDS 43 QN3I
220487 -             ..
220488 -        b.  Will the surgeon look at CA 15-3, now very elevated above
220489 -            100, but if this drops to normal, how long before surgery
220490 -            can be performed - a week, a month...?  On 040812 the
220491 -            primary care physician discussed needing several reports
220492 -            for a month or more consistently below the "normal" value
220493 -            of 39. ref SDS 12 CT9J
220494 -
220495 -                [On 050708 CA 15-3 dropped below 39 to 37 for the first
220496 -                time in 4 years. ref SDS 35 2N5J
220498 -                 ..
220499 -                [On 050727 surgeon found CA 15-3 had increased to 46.
220500 -                ref SDS 37 YK6K
220502 -             ..
220503 -        c.  If coloration clears from the breast, and normal to near
220504 -            normal texture is achieved compared with the healthy right
220505 -            breast, will this signal surgery can be safely performed?
220506 -
220507 -                [On 050727 follow up examination by surgeon shows IBC
220508 -                has suddenly and miraculously healed completely after 5
220509 -                treatments with Taxotere and capecitabine, ref SDS 37
220510 -                YY7F, considerations for surgery relate to scope of
220511 -                masectomy, ref SDS 37 JV5F, and unique factors for IBC
220512 -                patients, ref SDS 37 QJ3Q, and to advisability for
220513 -                extending quality of life. ref SDS 37 VL4O
220515 -             ..
220516 -        d.  How will effects of coloration and texture change caused by
220517 -            radiation treatments, noted by primary care physician on
220518 -            040402, ref SDS 6 8T5O, and cited previously in CT test
220519 -            report on 030710, ref SDS 4 GJ69, be distinguished from IBC
220520 -            symptoms in order to permit surgery to proceed?
220522 -             ..
220523 -        e.  In that case, how will the boundary of surgery for removing
220524 -            the breast be established?  Will surgery extend above the
220525 -            breast to remove areas observed today with inflammation and
220526 -            coloration extending toward the neck? ref SDS 0 YY7F
220527 -            Should the doctor prepare diagrams and take photographs to
220528 -            record maximum spread of disease for guiding surgical
220529 -            removal of infected tissue? also cited above. ref SDS 0
220530 -            YY7F
220532 -             ..
220533 -        f.  How will boundaries of surgery to clear IBC be
220534 -            distinguished from boundaries of red rash observed 041202
220535 -            following reaction to antibiotcs? ref SDS 16 415Y
220536 -
220537 -                [On 050727 follow up examination by surgeon addressed
220538 -                considerations for scope of surgery. ref SDS 37 JV5F
220540 -                 ..
220541 -                [On 051012 biopsies taken to help establish limits of
220542 -                mastectomy surgery. ref SDS 42 UM8O
220544 -                 ..
220545 -                [On 061020 photographs discussed to determine
220546 -                measurable disease required for treatment at UCSF in
220547 -                clinical study of new cancer drugs. ref SDS 45 JQ3J
220549 -                 ..
220550 -                [On 070130 photographs planned to determine measureable
220551 -                disease treating Millie with drug trial in clinical
220552 -                study at UCSF. ref SDS 46 M661
220554 -             ..
220555 -        g.  Does IBC present issues that benefit from experience by the
220556 -            surgeon in assessing scope and accomplishing particular
220557 -            surgical details that are different and so not commonly
220558 -            considered in performing masectomy surgery on patients who
220559 -            do not have IBC, as discussed further below? ref SDS 0 F14N
220561 -             ..
220562 -            Does it help for a surgeon who has not performed masectomy
220563 -            on an IBC patient to consult with a surgeon who has done
220564 -            say 5 - 10 such cases, i.e., in relation to issues d and
220565 -            e. ref SDS 0 JS6N
220566 -
220567 -                [On 050727 follow up examination by surgeon addressed
220568 -                investigating unique factors for IBC patients.
220569 -                ref SDS 37 QJ3Q
220570 -
220571 -
220572 -
220573 -
2206 -

SUBJECTS
Criteria Approve Surgery for Extending Quality of Life Where Researc

2703 -
270401 -         ..
270402 -    4.  Criteria to Approve Surgery for Extending Quality of Life
270403 -
270404 -        The study on 041210 considered factors for surgery. ref SDS 19
270405 -        657F  Objective to extend longevity and quality of life has
270406 -        been previously considered in a study reported on 041230.
270407 -        ref SDS 22 P19O
270409 -             ..
270410 -        a.  What factors in patient history have proven conducive to
270411 -            treating IBC with surgery in light of research on 040517
270412 -            indicating mastectomy can increase chances for cancer to
270413 -            recur, when cancer spreads beyond the breast? ref SDS 10
270414 -            YM3M  How does this relate to the patient profile in this
270415 -            case, shown below, ref SDS 0 M54Q, and to recommendations
270416 -            against surgery by Doctor Benz at UCSF in an opinion
270417 -            received on 041117, ref SDS 13 OU5V, and further where
270418 -            primary care physician proposes surgery on 050311 to treat
270419 -            "areas of resistance to chemotherapy" in left breast,
270420 -            ref SDS 28 XQ41, and further where Doctor Guardino at
270421 -            Stanford cites possibility of surgery, if regression of
270422 -            inflammation occurs? ref SDS 17 SN97  Does Kaiser have data
270423 -            on patients with conditions similar to Millie; is there
270424 -            published guidance on benefits of masectomy surgery for
270425 -            Millie's patient profile as follows...
270426 -
270427 -                    [On 050610 primary care physician discusses surgery
270428 -                    after regression of inflammation occurs in the left
270429 -                    breast. ref SDS 34 XQ41
270430 -
270431 -            1.  Age 69 generally good health, weight normal, 40 years
270432 -                exercise regular and vigorous (until about a year ago,
270433 -                when chemo treatments proscribed exercise), non-smoker,
270434 -                social drinker.
270436 -                 ..
270437 -            2.  CT testing for 4 years shows no evidence of distant
270438 -                metastasis.
270439 -
270440 -                    [On 050610 history of CT tests, including recent
270441 -                    report on 050530. ref SDS 34 NL4N
270443 -                 ..
270444 -            3.  Metastatic disease involving regional lymph nodes
270445 -                by criteria...
270446 -
270447 -                a.  Out of capsule under left arm, and other cancer
270448 -                    factors reported on 020321. ref SDS 1 6Q6J
270449 -
270450 -                    Case history of recurring cancer swelling under
270451 -                    left arm, reported on 040517. ref SDS 10 OW3I
270453 -                     ..
270454 -                b.  Cancerous lymph nodes discovered on left side of
270455 -                    neck reported on 040318. ref SDS 5 8R6M
270457 -                     ..
270458 -                c.  Research today seems to suggest IBC is not always
270459 -                    inoperable, and that some patients present with
270460 -                    metastatic cancer with regional disease involving
270461 -                    lymph nodes, per below. ref SDS 0 TN76
270462 -
270463 -                        [On 051121 primary care physician finds patient
270464 -                        has no evidence of disease (NED) based on
270465 -                        estensive testing with biopsy, PET, CA 1503;
270466 -                        prognosis is for future relapse due to
270467 -                        diagnosis of metastatic cancer, and therefore
270468 -                        mastectomy surgery on 051021 was palliation for
270469 -                        furture relapse. ref SDS 44 LH7M
270471 -                 ..
270472 -            4.  IBC was not original diagnosis; patient was first
270473 -                treated with surgery to remove a tumor on 020212; after
270474 -                treatment with AC then switching to Taxotere, then
270475 -                radiation, and more Taxotere, treatment was ended in
270476 -                December 2002, reported on 031206, ref SDS 2 SM6M; on
270477 -                030109 symptoms of IBC were reported. ref SDS 3 KW5F
270478 -                On 040614 patient was diagnosed with IBC, ref SDS 11
270479 -                6T5G, after starting treatment on the Avastin trial on
270480 -                040420. ref SDS 8 9Z5J
270482 -             ..
270483 -        b.  What benefits are expected for longevity and quality of
270484 -            life from a surgical solution to perform a masectomy, as
270485 -            the core objective of treatment, shown in the study on
270486 -            041230? ref SDS 22 XV7M
270488 -             ..
270489 -        c.  What risks flow from masectomy surgery with Millie's
270490 -            patient profile, ref SDS 0 YW6M, that give pause to
270491 -            approving surgery in this case, cited by Doctor Benz at
270492 -            UCSF in a 2nd opinion received on 041117? ref SDS 13 OU5P
270493 -
270494 -
270495 -
270496 -
270497 -
270498 -
270499 -
270500 -
270501 -
2706 -

SUBJECTS
Experience Performing Surgery Limited Maybe 1 about 5 Years Ago on I
Surgery Scope 2 Breasts Remove Evaluate Criteria for Masectomy Left

3604 -
360501 -         ..
360502 -        Experience Performing Surgery on IBC Patients Rare Disease
360503 -        Skin Grafts to Avoid Restoring Surgery with Infected Tissue
360504 -
360505 -        Millie asked about resolving the dilemma of a "treatment loop"
360506 -        discussed today, per above, ref SDS 0 WH5L, by removing both
360507 -        breasts and using skin from the healthy right breast to close
360508 -        the wound from a masectomy on the left breast.  Another
360509 -        possibility would be to graft skin from another part of the
360510 -        body, say the leg, to close the wound.  Might this procedure
360511 -        reduce risk in closing a masectomy wound with tissue infected
360512 -        by IBC, discussed by the surgeon today, per above, ref SDS 0
360513 -        WH5L, and also addressing the primary care physician's
360514 -        objectives on 050311 to treat "pockets of resistance" to
360515 -        chemotherapy with surgery? ref SDS 28 PA4N
360517 -         ..
360518 -        For example, research on 040517 indicated that on rare
360519 -        occasions skin grafts are needed to heal wounds from masectomy
360520 -        surgery. ref SDS 10 VW5F  Perhaps this is such an occasion.
360522 -         ..
360523 -        The surgeon indicated today not having performed this type of
360524 -        surgery.
360525 -
360526 -            [On 050329 primary care physician advised that examination
360527 -            today was performed by the most experienced surgeon at the
360528 -            Kaiser Walnut Creek hospital and clinic. ref SDS 30 YV95
360530 -         ..
360531 -        Millie asked how many surgeries have been performed on patients
360532 -        with IBC, and what has been the track record, e.g., 8 out of 10
360533 -        successful in the past year; 2 out of 10 successful in the past
360534 -        5 years?  What experience is available for criteria to guide a
360535 -        decision on when the patient has recovered sufficiently from
360536 -        IBC to enable surgery, per above, ref SDS 0 O16N, under the
360537 -        doctor's reasoning during the meeting on 040429, ref SDS 9
360538 -        SD7F, and what are the chances for success?  Any lessons
360539 -        learned from past surgery on IBC patients, per criteria listed
360540 -        above? ref SDS 0 YW6O
360542 -         ..
360543 -        The surgeon indicated having performed a surgery once in the
360544 -        past 5 years that may have been similar to Millie's condition
360545 -        of IBC.  This aligns with research on 040517 that found IBC is
360546 -        a rare disease affecting about 1% of cancer patients.
360547 -        ref SDS 10 TO7L
360548 -
360549 -            [On 050329 primary care physician disclosed that the
360550 -            examination today was performed by a lead surgeon with as
360551 -            much or more experience than other surgeons at the Kaiser
360552 -            Walnut Creek hospital. ref SDS 30 XQ41
360554 -             ..
360555 -            [On 050727 the surgeon confirmed limited experience
360556 -            treating IBC patients because IBC occurs in less than 1% of
360557 -            breast cancer patients; indicated that Kaiser in Walnut
360558 -            Creek, CA sees maybe 1 IBC patient a year. ref SDS 37 YK78
360559 -
360560 -
360561 -
360562 -
360563 -
3606 -

SUBJECTS
Masectomy Evaluate Surgery for IBC 2nd Opinion Tumor Board Review No
Mastectomy Evaluate Surgery for IBC 2nd Opinion Tumor Board Review t
Tumor Board Review Work Plan Treatment Work Up Patient Requests to S
Tumor Board Team Care Communication Collaboration Due Diligence Chal
Stanford Offers Additional Consultation as Needed 2nd Opinion

5907 -
590801 -         ..
590802 -        Masectomy Evaluate Surgery for IBC 2nd Opinion Recommended
590803 -        Tumor Board Review to Set Criteria on Surgery to Treat IBC
590804 -        2nd Opinion Recommended to Evaluate Surgery for IBC Masectomy
590805 -
590806 -        To address limited experience treating IBC patients, per above,
590807 -        ref SDS 0 QJ3Q, the surgeon suggested getting other opinions on
590808 -        criteria for surgery to treat IBC with "pockets of resistance"
590809 -        to chemotherapy, and drawing on advice from the tumor board in
590810 -        this case to resolve the dilemma of a treatment loop shown by
590811 -        the record today, per above. ref SDS 0 WH5L
590813 -         ..
590814 -        Millie agreed.
590816 -         ..
590817 -        Doctor Benz at UCSF Cancer Center proposed in a letter received
590818 -        on 041117 to provide additional consultation on future trial
590819 -        protocols, ref SDS 13 OV3T, that supplements 2nd opinion based
590820 -        on an examination performed on 041018.  Similarly, Doctor
590821 -        Guardino in the Cancer Center at Stanford Medical Center
590822 -        offered additional consultation at the end of the 2nd opinion
590823 -        received on 041209. ref SDS 17 HS6L
590825 -         ..
590826 -        The surgeon will schedule a meeting with another doctor at
590827 -        Kaiser to examine the left breast for a determination of
590828 -        criteria on when surgery will have a good chance of succeeding.
590829 -
590830 -            [On 050401 Millie and Pam met with Doctor Choi who
590831 -            recommended against surgery at this time; there was no
590832 -            evident discussion on criteria that establish level of
590833 -            recovery where surgery can be performed. ref SDS 31 PPSU
590835 -         ..
590836 -        The surgeon will visit with the primary care physician to
590837 -        collaborate and coordinate review by the Tumor Board that draws
590838 -        on Kaiser's expertise for criteria on when to perform surgery.
590839 -        This hearing will supplement the hearing on 040416 that
590840 -        discussed surgery, reported in the meeting between the doctor
590841 -        and the patient on 040517. ref SDS 10 F77M
590842 -
590843 -            [On 050727 due diligence, collaboration, communication and
590844 -            Team Care are planned for evaluating surgical solution to
590845 -            Millie's patient profile, ref SDS 37 PF7O; for some reason
590846 -            analysis of the case through the Tumor Board process has
590847 -            not made progress at Kaiser. ref SDS 37 R36H
590849 -         ..
590850 -        The surgeon will submit a written report on the meeting today
590851 -        that clarifies understandings on the work plan to address
590852 -        pending issues.
590853 -
590854 -            [On 050329 the primary care physician had not seen a report
590855 -            from the surgeon on the meeting today, and cited a hectic
590856 -            schedule. ref SDS 30 XQ41
590857 -
590858 -
590859 -
590860 -
590861 -
590862 -
5909 -

SUBJECTS
Metastatic Cancer Regional and Distant Metastasis Very Different Reg
Research Criteria on Surgery for Masectomy to Reduce Chance of Relap

7104 -
710501 -  ..
710502 - Research Criteria on Surgery for Masectomy to Reduce Chance of Relapse
710503 -
710504 - Research on the Internet addresses requirements for criteria to assess
710505 - when surgery can be performed on a patient with IBC, per above,
710506 - ref SDS 0 OV5H, and further supports the surgeon's comments today on
710507 - treating IBC with chemotherapy before surgery. ref SDS 0 WH5L  This
710508 - research complements work on 040517 developing background on IBC.
710509 - ref SDS 10 6M9H and further. ref SDS 10 L17O
710511 -         ..
710512 -        [On 050712 further research for natural remedies to supplement
710513 -        medical treatments. ref SDS 36 4P62
710515 -         ..
710516 -        [On 050712 research types of breast surgery for masectomy.
710517 -        ref SDS 36 J46O
710519 -  ..
710520 - Nearly every authority indicates that surgery is not an appropriate
710521 - treatment for IBC.  There is an exception, but no criteria is shown
710522 - for when surgery can be performed, and the scope of removal when
710523 - disease has spread, per above. ref SDS 0 WH5L
710525 -  ..
710526 - One authority says in part...
710527 -
710528 -        Journal of Clinical Oncology, Vol 23, No 16 (June 1), 2005:
710529 -        pp. 3860-3862; 2005 American Society of Clinical Oncology
710530 -        DOI: 10.1200/JCO.2005.05.294
710531 -
710532 -                http://www.jco.org/cgi/content/full/23/16/3860
710534 -         ..
710535 -        CORRESPONDENCE
710537 -         ..
710538 -        In Reply
710540 -         ..
710541 -        George Somlo
710543 -         ..
710544 -        Division of Medical Oncology and Therapeutics Research, City
710545 -        of Hope Comprehensive Cancer Center, Duarte, CA
710546 -
710548 -         ..
710549 -        Metastatic Cancer Regional Lymph Nodes May be Operable
710550 -        Regional Metastasis May be Operable Not Distant Metastasis
710551 -        Surgery Criteria Metastatic Sites within Regional Lymph Nodes
710552 -        IBC Not Always Inoperable Indicates Surgery is Not Common
710553 -
710554 -
710555 - Solmo continues...
710556 -
710557 -        Next, I would like to address comments regarding treatment and
710558 -        outcome. Inflammatory breast carcinoma is not always
710559 -        inoperable, although we agree that a surgeon's willingness and
710560 -        ability to perform an operation does not mean that such
710561 -        approach should be encouraged. While up-front surgery is not
710562 -        the current recommendation in the management of inflammatory
710563 -        breast cancer, lack of familiarity with neoadjuvant strategies
710564 -        and inflammatory carcinomatous presentation, especially in our
710565 -        earlier cases, did lead to the occasional primary surgical
710566 -        intervention followed by adjuvant chemotherapy.
710568 -         ..
710569 -        Our patient population was somewhat heterogeneic both from the
710570 -        biologic and treatment point of view, but we did not include
710571 -        any patient with metastatic sites beyond regional lymph nodes.
710573 -  ..
710574 - This presentation indicating IBC is not always inoperable, suggests
710575 - that surgery is an exception for treatment of IBC, and so supports
710576 - authorities who discourage surgery for treatment in Millie's case,
710577 - e.g., primary care physician in Oncology Department at Kaiser on
710578 - 040812, ref SDS 12 SE61, supported by Doctor Benz at UCSF in a 2nd
710579 - opinion received on 041117. ref SDS 13 OU5P  Doctor Guardino at
710580 - Stanford indicated only that surgery might be useful for Millie, in a
710581 - 2nd opinion received on 041209. ref SDS 17 SN97
710583 -             ..
710584 -            [On 050712 research indicates surgery can be a treatment
710585 -            option for stage III cancer, and is generally not attempted
710586 -            for stage IV cancer patients, who instead receive
710587 -            palliative treatment. ref SDS 36 B65G
710589 -             ..
710590 -            [On 051121 primary care physician finds patient has no
710591 -            evidence of disease (NED) based on estensive testing with
710592 -            biopsy, PET, CA 1503; prognosis is for future relapse due
710593 -            to diagnosis of metastatic cancer, and therefore mastectomy
710594 -            surgery on 051021 was palliation for furture relapse.
710595 -            ref SDS 44 LH7M
710597 -  ..
710598 - Millie's condition may fit the criteria of not having "metastatic
710599 - sites beyond regional lymph nodes," ref SDS 0 O84N, based on the
710600 - meeting with the primary care physician at Kaiser on 040812.
710601 - ref SDS 12 LQ5M  Earlier on 020321 the doctor submitted excerpts from
710602 - the AJCC Cancer Staging Handbook, which mentions Regional Lymph Nodes,
710603 - ref SDS 1 6Q6N, as distinct from a local site for tumor, ref SDS 1
710604 - ON5I, and further distinct from distant metastatis. ref SDS 1 6R5X
710606 -  ..
710607 - We still need guidance on when IBC has recovered sufficiently for
710608 - surgery, and how far the surgery should extend toward the neck.
710610 -  ..
710611 - There is an email address...
710612 -
710613 -                   gsomlo@coh.org
710614 -
710615 - ...for the author.  May be able to get criteria for when to perform
710616 - surgery.
710617 -
710618 -
710620 -  ..
710621 - Another site....
710622 -
710623 -       Inflammatory Breast Cancer
710624 -       Help Website - Surgery
710625 -
710626 -              http://www.ibchelp.org/mrm.html
710627 -
710628 - ...discusses surgery, but not criteria for when surgery can be
710629 - performed.
710630 -
710631 -
710632 -
710633 -
710634 -
710635 -
710636 -
710637 -
710638 -
710639 -
7107 -