THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: August 26, 2005 09:30 AM Friday;
Millie meeting at Kaiser in Oakland for 2nd opinion on surgery.
2...Patient History Submitted to Surgeon in Oakland
3...Purpose and Objectives for Examination Today
4...Summary of Patient History Explained During the Meeting
5...Criteria for Determining Patient Ready for Mastectomy Surgery
6...Examination Shows IBC Regresses No Visible Evidence of Cancer
7...2nd Opinion to Report Patient Meets Criteria for Mastectomy Surgery
8...Experience Not Critical for Performing Mastectomy on IBC Patient
9...Scope of Surgery Standard Mastectomy and Remove Additional Lymph Nodes
10...Lymph Nodes Remove from Left Axilla; Supraclavicular Not Considered
11...Scope Surgery Avoid Remove 2 Breasts Reduce Chances Relapse
12...Mastectomy Both Breasts Skin Grafts Healthy Tissue Unnecessary
13...Criteria for Patient to Approve Surgery Reduce Chances of Relapse
14...Mastectomy Pathology Report on Tissue Removed Indicates Cancer Status
15...Stage III Regional Cancer Presents Chance for Curative Treatment
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0201 - Kaiser Medical Clinic, Oakland, CA O-00000847 0804
020101 - Ms. V. Shim, MD; Surgeon O-00000847 0804
020102 - Surgery Department
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 - ..
1506 - Summary/Objective
150701 - Follow up ref SDS 18 0000. ref SDS 17 0000.
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
150722 - ..
1510 - Background
151201 - Patient History Submitted to Surgeon in Oakland
151203 - Follow up ref SDS 19 0001.
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...
151250 - Millie's Patient History
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
Purpose Meeting Objectives for 2nd Opinion #2 Examination Kaiser Int
220401 - ..
220402 - Purpose and Objectives for Examination Today
220403 - Summary of Patient History Explained During the Meeting
220405 - Briefly...
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...
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
Criteria Surgery Mastectomy IBC Biopsy Not Necessary for Surgery CA
Examination 2nd Opinion #2 Showed Patient Ready for Surgery Mastecto
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
330506 - Follow up ref SDS 16 YY7F.
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...
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
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.
Experience Treating IBC Not Critical for Performing Mastectomy Scope
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
380406 - Follow up ref SDS 16 QJ3Q, ref SDS 17 Z45N.
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
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
Mastectomy Both Breasts Recommend Against Surgery to Remove 2 Breast
410401 - ..
410402 - Scope Surgery Avoid Remove 2 Breasts Reduce Chances Relapse
410403 - Mastectomy Both Breasts Skin Grafts Healthy Tissue Unnecessary
410405 - Follow up ref SDS 16 NT9G.
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.
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
Criteria Approve Surgery for Extending Quality of Life Patient Decis
Criteria Patient Approve Surgery Mastectomy Pathology Report on Tiss
480501 - ..
480502 - Criteria for Patient to Approve Surgery Reduce Chances of Relapse
480503 - Mastectomy Pathology Report on Tissue Removed Indicates Cancer Status
480505 - Follow up ref SDS 16 VL4O.
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
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.
Curative Treatment Model Stage III Not Stage IV Metastatic Cancer Re
Criteria Approve Surgery for Extending Quality of Life Patient Decis
630501 - ..
630502 - Stage III Regional Cancer Presents Chance for Curative Treatment
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...
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
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
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