CONTACTS 
0201 - Kaiser Medical Clinic, Oakland, CA                                                                                                                                 O-00000847 0804
020101 - Ms. V. Shim, MD; Surgeon                                                                                                                                         O-00000847 0804
020102 - Surgery Department

SUBJECTS
2nd-Opinion Meeting Referral Surgeon at Kaiser Oakland on Criteria f
Patient History 2nd Opinion #2 Submitted to Surgeon in Oakland Print
2nd-Opinion #2 Meeting Referral Surgeon at Kaiser Oakland on Criteri

1505 -
1505 -    ..
1506 - Summary/Objective
1507 -
150701 - Follow up ref SDS 18 0000. ref SDS 17 0000.
150702 -
150703 - The surgeon made a careful, thorough examination, ref SDS 0 AY5N, and
150704 - indicated that Millie is ready for mastectomy surgery. ref SDS 0 9U8G
150705 - The doctor discussed the role of experience performing surgery on a
150706 - patient with IBC in determining alignment and amount of tissue to
150707 - remove. ref SDS 0 FM5J  The 2nd opinion will also propose removing
150708 - additional lymph nodes in the left axilla. ref SDS 0 T23M   Surgery on
150709 - both breasts is not recommended to reduce chances of relapse, and for
150710 - patient convenience. ref SDS 0 NT9G  The doctor's 2nd opinion will
150711 - recommend mastectomy surgery for Millie's patient profile, ref SDS 0
150712 - XG5J, and explain a curative treatment model for stage III metastatic
150713 - cancer that is limited to regional disease. ref SDS 0 F49H
150714 -
150715 -
150716 -
150717 -
150718 -
150719 -
150720 -
150722 -  ..
1508 -
1509 -
1510 - Background
1511 -
1512 -
151201 - Patient History Submitted to Surgeon in Oakland
151202 -
151203 - Follow up ref SDS 19 0001.
151204 -
151205 - The doctor indicated understanding that initial presentation was IBC
151206 - in 2003, and asked how this was discovered, noting that often IBC is
151207 - overlooked, because symptoms are similar to more common diagnoses.
151208 - Millie explained the initial diagnosis was a tumor with infiltrating
151209 - carcinoma on the left breast, reported in patient history on 020306.
151210 - ref SDS 20 RQ5M  IBC was diagnosed two (2) years later after relapse
151211 - on 040517. ref SDS 20 FS6K
151213 -  ..
151214 - Millie asked if the doctor had reviewed patient history, and discussed
151215 - background with the surgeon in Walnut Creek, mentioned on 050824 by
151216 - the Advice Nurse, as standard practice for referrals at Kaiser?
151217 - ref SDS 22 HX98
151219 -  ..
151220 - The doctor today seemed to indicate efforts for collaboration with the
151221 - Walnut Creek office on patient history, reflecting prior reports on
151222 - 050329. ref SDS 15 X76K
151224 -  ..
151225 - Millie submitted a printed summary of patient history listed in the
151226 - record on 050812. ref SDS 20 0000  Doctor-patient partnership to
151227 - collaborate on preparing for the meeting today was reported yesterday.
151228 - ref SDS 22 0001
151230 -  ..
151231 - During the meeting today, the doctor asked questions on background,
151232 - and advised that accurate patient history aids assessment of diagnosis
151233 - and treatment plans.  The practice of asking the patient questions to
151234 - learn medical history aligns with experience in this case meeting at
151235 - UCSF on 041018, ref SDS 9 QZ4F, and, also, at Stanford Cancer Center,
151236 - shown by the record the next day on 041019. ref SDS 10 4Q4G
151238 -  ..
151239 - The doctor briefly thumbed through the 30 or so pages of background,
151240 - and commented that this is a complex case.  The doctor further noted
151241 - that summarizing patient history is a lot of hard work that saves the
151242 - doctor a lot of time finding critical details and "connecting the
151243 - dots" to quickly and accurately understand complex case history.
151245 -  ..
151246 - At the end of the meeting, the doctor opened patient history and
151247 - bookmarked the case study in the web browser computer program.  The
151248 - title...
151249 -
151250 -                   Millie's Patient History
151251 -
151252 - ...was assigned for ease in finding organizational memory that can be
151253 - retrieved quickly when needed.  The doctor opened several links from
151254 - the summary to find specific issues in the case study on 050812.
151255 - ref SDS 20 0000  The doctor further opened links from descriptions of
151256 - events to learn the full story in original sources, e.g., diagnosis of
151257 - IBC. ref SDS 20 MD5J  The doctor also used the "Back" button in the
151258 - web browser to navigate from the record of particular events, back to
151259 - the case study for finding other points of interest.
151261 -  ..
151262 - The doctor indicated that precision access to patient history
151263 - facilitates getting things done quickly and correctly.  This fits the
151264 - case study showing people care about accuracy when cognitive overhead
151265 - is reduced to volition, reported on 041014. ref SDS 4 GN7J
151267 -  ..
151268 - The doctor will submit a draft 2nd opinion to get feedback prior to
151269 - making distribution of a final version to avoid prior problems of
151270 - omissions and error working with Kaiser, UCSF, and Stanford, reported
151271 - on 041209. ref SDS 11 LO5L
151272 -
151273 -
151274 -
151275 -
151276 -
151277 -
1513 -

SUBJECTS
Purpose Meeting Objectives for 2nd Opinion #2 Examination Kaiser Int

2203 -
220401 -  ..
220402 - Purpose and Objectives for Examination Today
220403 - Summary of Patient History Explained During the Meeting
220404 -
220405 - Briefly...
220406 -
220407 - On 020208 the patient initially complained of lumps on the left breast
220408 - and under the left arm during an examination by the gynolcologist.  A
220409 - biopsy showed cancer, reported to the patient on 020306. ref SDS 20
220410 - UF4J
220412 -  ..
220413 - On 020312 a lumpectomy was performed on the left breast, and lymph
220414 - nodes were removed.  Neoadjuvant chemotherapy and radiation treatment
220415 - occurred during 2002.  The patient received no treatment during 2003;
220416 - red rash on the left breast, and discomfort under the left axilla were
220417 - reported episodically beginning in 2003. ref SDS 20 NJ5F  Relapse was
220418 - diagnosed in 040318; IBC was diagnosed on 040614. ref SDS 20 MD5J  The
220419 - patient responded well to treatment on the Avastin and Taxol trial
220420 - protocol.  On 041103 a CT scan reported pulmonary emboli.  On 041104
220421 - the patient was removed from treatment. ref SDS 20 VZ4I  On 050104
220422 - treatment resumed with AC. ref SDS 20 T35J  IBC worsened.  On 050329
220423 - treatment was changed to Taxotere and capecitabine (Xeloda).
220424 - ref SDS 20 SK7K  The patient recovered, and on 050727 the surgeon at
220425 - Kaiser in Walnut Creek said the patient is ready for surgery.  On
220426 - 050729 the primary care physician in Oncology asked for a date to
220427 - schedule surgery. ref SDS 20 RM6F  On August 19, 2005 the patient
220428 - received Taxotere chemotherapy to begin the 7th cycle of treatment,
220429 - and has one more week of supplemental treatment with capecitabine
220430 - (Xeloda) to complete the 7th cycle. ref SDS 21 0001  Chemotherapy has
220431 - now been paused pending decision and performance of surgery, as
220432 - planned by primary care physician on 050729. ref SDS 20 T35I
220434 -  ..
220435 - This meeting was scheduled on 050805, ref SDS 18 V15F, following up
220436 - discussion with the patient on 050729, ref SDS 17 V15F, and previously
220437 - planned on 050727 for referral by the surgeon in Kaiser's Walnut Creek
220438 - hospital to obtain a 2nd opinion. ref SDS 16 O85O
220440 -  ..
220441 - The purpose of the examination is to obtain a 2nd opinion on...
220442 -
220443 -    1.  Criteria for determining patient is ready for surgery,
220444 -        primarily related to establishing there has been sufficient
220445 -        recovery from IBC. ref SDS 0 G28J
220447 -         ..
220448 -    2.  Criteria for deciding to have mastectomy on both breasts to
220449 -        reduce chances of relapse and provide tissue for skin grafts,
220450 -        on the left breast, and for patient convenience to avoid
220451 -        prostheses. ref SDS 0 NT9G
220453 -         ..
220454 -    3.  Surgery tasks and issues that may arise performing a mastectomy
220455 -        on patients with IBC that are different from performing the
220456 -        procedure on patients without IBC. ref SDS 0 FM5J
220458 -         ..
220459 -    4.  Criteria for the patient to approve surgery, also, discussed on
220460 -        050727. ref SDS 0 JS4H
220461 -
220462 -
220463 -
220464 -
220465 -
220466 -
2205 -

SUBJECTS
Criteria Surgery Mastectomy IBC Biopsy Not Necessary for Surgery CA
Examination 2nd Opinion #2 Showed Patient Ready for Surgery Mastecto

3304 -
330501 -  ..
330502 - Criteria for Determining Patient Ready for Mastectomy Surgery
330503 - Examination Shows IBC Regresses No Visible Evidence of Cancer
330504 - 2nd Opinion to Report Patient Meets Criteria for Mastectomy Surgery
330505 -
330506 - Follow up ref SDS 16 YY7F.
330507 -
330508 - This is the first examination of the patient in Kaiser's Oakland
330509 - office.  Prior to making the examination, the doctor was not familiar
330510 - with patient history, see above, ref SDS 0 V15F; extensive experience
330511 - treating IBC patients aided the examination today.
330513 -  ..
330514 - Criteria for determining patient ready for mastectomy surgery was
330515 - discussed on 050727. ref SDS 16 OV5H
330517 -  ..
330518 - Today the doctor carefully examined both breasts by visualization and
330519 - touch, and commented that coloration appears substantially the same
330520 - Skin texture is similarly supple and soft on both breasts.  The left
330521 - breast has small areas of slight stiffness and flushness, possibly
330522 - from reaction to radiation or from IBC.  The nipple has no evident
330523 - contortion.  The doctor indicated finding no evidence of inflammation
330524 - common to IBC patients.  These findings align with examination on
330525 - 050727 by the surgeon in Kaiser's Walnut Creek office. ref SDS 16 YY7F
330527 -  ..
330528 - The doctor examined the right and left axilla by firmly pressing
330529 - fingers into and around these areas.  The doctor asked the patient for
330530 - any feelings of discomfort.  Millie reported no discomfort under
330531 - either arm.  Millie reports slight differences from feeling the left
330532 - axilla compared to the right, but also notes that there is no pain or
330533 - other discomfort that has previously existed sporadically since
330534 - February 2002, as shown in the case study on 040517. ref SDS 7 OW3I
330535 - The doctor commented there is nothing by feel that distinguishes right
330536 - from left conditions.
330538 -  ..
330539 - The doctor commented that the patient is ready for surgery to perform
330540 - a mastectomy.  This analysis aligns with the record of examination by
330541 - the surgeon in Kaiser's Walnut Creek office, reported on 050727,
330542 - ref SDS 16 OV5H, addressing the first issue for consideration in this
330543 - 2nd opinion referral, per above. ref SDS 0 HU9M
330545 -  ..
330546 - The doctor related having treated many IBC patients with mastectomy
330547 - surgery.  The doctor advised that Millie's condition is well within
330548 - criteria that have yielded successful mastectomy surgery on other
330549 - patients.
330551 -  ..
330552 - The doctor noted that observing normal breast coloration (i.e.,
330553 - regression of inflammation) is a primary factor in determining when
330554 - an IBC patient is ready for surgery, as discussed on 050727.
330555 - ref SDS 16 TN4Q
330557 -  ..
330558 - The doctor, also, cited patient history showing no evidence of distant
330559 - metastasis, based on the case study submitted today that lists...
330560 -
330561 -           Initial presentation............ 020321, ref SDS 20 OR56
330562 -           PET test........................ 020603, ref SDS 20 FP9N
330563 -           PET test........................ 030109, ref SDS 20 P94H
330564 -           CT test......................... 030220, ref SDS 20 O64F
330565 -           CT test......................... 041230, ref SDS 20 KU4G
330566 -           CT test......................... 050422, ref SDS 20 L26N
330567 -           CT test......................... 050610, ref SDS 20 M85O
330569 -  ..
330570 - The doctor indicated that these test diagnostics showing no distant
330571 - metastasis, together with visual examination today are sufficient to
330572 - determine sufficient recovery from IBC for a successful surgery.  This
330573 - does not guarantee surgery will eliminate the chance of cancer
330574 - returning.  The doctor feels this history makes Millie a good
330575 - candidate for mastectomy surgery at this time.
330577 -  ..
330578 - The doctor indicated that another needle biopsy on the left breast,
330579 - similar to the procedure performed on 040419 that discovered IBC,
330580 - ref SDS 5 789F, is not needed to determine that IBC has improved
330581 - enough for the patient to benefit from surgery.  This seems to align
330582 - with analysis of the surgeon in Kaiser's Walnut Creek office during
330583 - the meeting on 050727. ref SDS 16 SZ6M  During the meeting today, the
330584 - doctor cited biopsy on breast tissue from surgery will evaluate for
330585 - remaining cancer cells, per below. ref SDS 0 JS4H
330586 -
330587 -     [On 050920 Doctor Grissom 2nd opinion proposes thin full thickness
330588 -     surgical biopsies with suture closure (rather than punch biopsy)
330589 -     to test for IBC and help determine scope of surgery. ref SDS 25
330590 -     XL7P
330592 -  ..
330593 - There was no express discussion today of CA 15-3, also, cited on
330594 - 050727. ref SDS 16 YK6K  This issue may be addressed in the 2nd
330595 - opinion.
330596 -
330597 -
330598 -
330599 -
330600 -
3307 -

SUBJECTS
Experience Treating IBC Not Critical for Performing Mastectomy Scope

3803 -
380401 -  ..
380402 - Experience Not Critical for Performing Mastectomy on IBC Patient
380403 - Scope of Surgery Standard Mastectomy and Remove Additional Lymph Nodes
380404 - Lymph Nodes Remove from Left Axilla; Supraclavicular Not Considered
380405 -
380406 - Follow up ref SDS 16 QJ3Q, ref SDS 17 Z45N.
380407 -
380408 - The doctor today seemed to advise that mastectomy surgery for IBC
380409 - patients is essentially the same for patients without IBC.  Patient
380410 - history of inflammation having spread during this past March above the
380411 - breast toward the neck, discussed previously on 050324, ref SDS 14
380412 - WH5L, does not change surgical alignment and the amount of tissue to
380413 - be removed relative to a standard mastectomy, now that inflammation
380414 - has regressed, as discussed on 050727. ref SDS 16 JV5F
380416 -  ..
380417 - There was an understanding from the meeting today that experience
380418 - treating IBC patients is not a major factor in success of mastectomy
380419 - surgery on patients suffering from IBC.  The doctor will list in the
380420 - 2nd opinion specific issues that may relate to mastectomy for IBC
380421 - patients, based on experience performing this procedure in other IBC
380422 - cases, following up on review with the surgeon in Kaiser's Walnut
380423 - Creek office on 050727. ref SDS 16 QJ3Q
380424 -
380425 -     [On 050907 Kaiser referral draft 2nd opinion does not confirm
380426 -     understandings on requirements for experience to perform
380427 -     mastectomy surgery on patient with IBC. ref SDS 23 EW8H
380429 -      ..
380430 -     [On 050908 Kaiser referral does not address follow up request on
380431 -     requirements for experience to perform a successful mastectomy
380432 -     surgery on a patient with IBC. ref SDS 24 NG5K
380434 -  ..
380435 - The doctor plans to propose in the 2nd opinion written report
380436 - consideration to remove additional lymph nodes under the left arm, as
380437 - a precaution to reduce the likelihood of future relapse.  The doctor
380438 - explained this can be accomplished during the mastectomy surgery,
380439 - because the left axillary will be exposed and so subject to
380440 - examination, and surgery, if warranted, during the primary procedure.
380442 -  ..
380443 - There was no discussion today of Doctor Laio's recommendation reviewed
380444 - on 040309 to remove lymph nodes in the supraclavicular region that
380445 - were found by a biopsy to be infected with cancer. ref SDS 3 HD5N
380446 -
380447 -
380448 -
380449 -
380450 -
3805 -

SUBJECTS
Mastectomy Both Breasts Recommend Against Surgery to Remove 2 Breast

4103 -
410401 -  ..
410402 - Scope Surgery Avoid Remove 2 Breasts Reduce Chances Relapse
410403 - Mastectomy Both Breasts Skin Grafts Healthy Tissue Unnecessary
410404 -
410405 - Follow up ref SDS 16 NT9G.
410406 -
410407 - The doctor recommends against removing both breasts, discussed
410408 - previously with the patient on 050729. ref SDS 17 4Y6H  The reasoning
410409 - seems to reflect reliance on published studies.  The doctor further
410410 - noted that a very recent study may suggest some statistical
410411 - therapeutic benefit from reducing the chance for cancer to infect the
410412 - 2nd (here, the right) breast.  There was discussion of patient
410413 - convenience, as presented previously on 050727. ref SDS 16 NT9G  The
410414 - doctor will address scope of surgery in the 2nd opinion.
410415 -
410416 -     [On 050907 doctor's 2nd opinion draft cites rising complications
410417 -     from prophylactic mastectomy with Millie's patient profile,
410418 -     primarily citing age. ref SDS 23 WU4M
410419 -
410420 -
410421 -
410422 -
410423 -
410424 -
410425 -
410426 -
4105 -

SUBJECTS
Criteria Approve Surgery for Extending Quality of Life Patient Decis
Criteria Patient Approve Surgery Mastectomy Pathology Report on Tiss

4804 -
480501 -  ..
480502 - Criteria for Patient to Approve Surgery Reduce Chances of Relapse
480503 - Mastectomy Pathology Report on Tissue Removed Indicates Cancer Status
480504 -
480505 - Follow up ref SDS 16 VL4O.
480506 -
480507 - Delay submitting patient history, discussed above, ref SDS 0 BL8N,
480508 - prevented consideration during the meeting of prior analysis on
480509 - benefits of mastectomy surgery in this case, as discussed previously
480510 - on 050727. ref SDS 16 VL4O
480512 -  ..
480513 - The 2nd opinion report can address risks of surgery for IBC patients,
480514 - with respect to longevity and quality of life, previously discussed on
480515 - 050727. ref SDS 16 T15N
480517 -      ..
480518 -     [On 050908 Kaiser referral does not address request for risk
480519 -     analysis of surgery for Millie's patient profile. ref SDS 24 YO6I
480521 -  ..
480522 - The doctor clearly recommended today that mastectomy is the best
480523 - course for the patient at this time, and cited a benefit not
480524 - previously considered.  The doctor indicated today that a biopsy on
480525 - tissue removed during a mastectomy operation could show no cancer
480526 - activity, consistent with CT testing, which has never identified
480527 - cancer in the left breast, per the study above. ref SDS 0 JA4H
480528 -
480529 -     [On 050907 2nd opinion draft does not seem to mention benefits of
480530 -     biopsy on tissue from mastectomy surgery demonstrating no further
480531 -     cancer. ref SDS 23 WU9K
480533 -      ..
480534 -     [On 050908 Kaiser referral does not address request for risk
480535 -     analysis of surgery for Millie's patient profile. ref SDS 24 YO6I
480537 -  ..
480538 - Biopsy findings of no cancer in the left breast would support the
480539 - prospect of a curative treatment model.  Even if cancer is found in
480540 - the biopsy of the left breast, this might also support a curative
480541 - model, based on the objective of surgery to remove infected tissue
480542 - mass.
480544 -  ..
480545 - Previously, on 040419 a needle biopsy procedure was performed that did
480546 - not remove the breast, and it revealed cancer had relapsed, reported
480547 - on 040429. ref SDS 6 F66N  Earlier today, the doctor seemed to say
480548 - that a needle biopsy is not necessary, ref SDS 0 T14L, since a more
480549 - severe treatment will yield tissue for a biopsy.
480550 -
480551 -
480552 -
480553 -
480554 -
480555 -
480556 -
480557 -
4806 -

SUBJECTS
Curative Treatment Model Stage III Not Stage IV Metastatic Cancer Re
Criteria Approve Surgery for Extending Quality of Life Patient Decis

6304 -
630501 -  ..
630502 - Stage III Regional Cancer Presents Chance for Curative Treatment
630503 -
630504 - The doctor explained that metastatic cancer can be diagnosed with
630505 - regional disease, which has occurred in Millie's case, as shown by
630506 - patient history...
630507 -
630508 -           Initial presentation............ 020321, ref SDS 20 ED3K
630509 -           Lymph nodes supraclavicular..... 040318, ref SDS 20 YC5W
630511 -  ..
630512 - The doctor further explained that practice in Kaiser's Oakland office
630513 - stages regional metastasis for breast cancer at level III.  There was
630514 - discussion of patient history on 040614 showing Millie was staged at
630515 - level IV. ref SDS 20 MD5J, based on diagnosis of IBC on relapse.
630516 - ref SDS 8 SZ3I  The doctor called a colleague during the meeting and
630517 - asked about staging.  This discussion was approximately 30 seconds or
630518 - less.  The doctor feels that impression in this case after initial
630519 - diagnosis of IBC supports level IV staging; subsequent patient history
630520 - 18 months later may now support stage III.  The doctor, also, noted
630521 - that staging, per se, is a semantical guide, since patients are
630522 - monitored closely and treated at Kaiser according to progression of
630523 - symptoms in all cases.
630525 -  ..
630526 - The doctor emphasized several times during the meeting that Millie's
630527 - condition of regional metastatic disease appears conducive to a
630528 - curative treatment model, based on experience in the Oakland office.
630530 -  ..
630531 - Pursuing a cure for cancer patients was reviewed recently on 041210.
630532 - ref SDS 12 NQ9J
630533 -
630534 -     [On 051010 Doctor Grissom explains proposal for very wide
630535 -     mastectomy presents treatment model for cure based on Millie's
630536 -     patient history. ref SDS 26 GW5K
630538 -      ..
630539 -     [On 051007 case study purpose of mastectomy surgery cure, local
630540 -     control, palliation. ref SDS 27 F25H
630541 -
630542 -
630543 -
630544 -
630545 -
630546 -
630547 -
630548 -
6306 -