CONTACTS 

SUBJECTS
Patient Comments 2nd Opinion Draft Received from Kaiser Internal Ref

0903 -
0903 -    ..
0904 - Summary/Objective
0905 -
090501 - Follow up ref SDS 34 0000. ref SDS 33 0000.
090502 -
090503 -
090504 -
090505 -
090507 -  ..
0906 -
0907 -
0908 - Progress
0909 -
090901 - Submitted ref DIT 1 0001 to Veronica with comments on 2nd opinion #2
090902 - draft Kaiser internal referral received on 050907. ref SDS 34 C16S
090903 -
090904 -    1.  Very sound analysis in your 2nd opinion, and thanks for timely
090905 -        efforts in Millie's case. ref DIT 1 0001
090907 -         ..
090908 -    2.  If time permits, there is a detailed review listed in the
090909 -        record on 050907, ref SDS 34 0001, with issues you might
090910 -        consider. ref DIT 1 JI6F
090912 -         ..
090913 -    3.  To expedite your time, ref DIT 1 GQ6M, here are a few key
090914 -        points....
090916 -         ..
090917 -    4.  This is entirely a professional matter, so I leave it to your
090918 -        discretion in pointing out the 2nd opinion draft makes several
090919 -        comments that testing indicates Millie has not been diagnosed
090920 -        with "metastatic disease." ref DRP 1 868N  Notice, however,
090921 -        that the biopsy report from the original surgery on 020312, and
090922 -        received on 020321, expressly discussed metastatic cancer,
090923 -        ref SDS 3 4U8X, and similar constructions are used in various
090924 -        CT reports. ref DIT 1 F47F  A key point is that none of the
090925 -        testing reports nor anything else in Mil's patient history
090926 -        cites "distant metastasis," so your recommendations are solidly
090927 -        based.  You can see original sources in the record on 050907.
090928 -        ref SDS 34 555G
090929 -
090930 -            [...see below Veronica discusses this issue; plans to
090931 -            change final version to say "no distant metastatic
090932 -            disease." ref SDS 0 1W9L
090934 -             ..
090935 -            [On 050909 request revised final version of 2nd opinion.
090936 -            ref SDS 35 TX4W
090938 -             ..
090939 -            [On 050909 Veronica says final draft changed "no metastatic
090940 -            disease" to no "distant metastatic disease." ref SDS 35
090941 -            5A9G
090943 -             ..
090944 -            [On 050909 final draft received; still says CT and bone
090945 -            scan tests show no metastatic disease. ref SDS 35 JX7S
090946 -
090948 -         ..
090949 -    5.  I only mention this because I don't want your opinion to "get
090950 -        off on the wrong foot" with the primary care provider, Doctor
090951 -        Johnson, who regularly says Mil has metastatic cancer.  A
090952 -        simple work around is to say "...patient history shows
090953 -        metastatic cancer with regional disease, and there is no
090954 -        evidence of distant metastasis."  This still supports the
090955 -        curative treatment model you propose with a surgery component.
090956 -        Again, I realize I am "out of my league" on this subject and so
090957 -        only offer an informational comment. ref DIT 1 9G8N
090959 -         ..
090960 -    6.  The 2nd opinion draft does not discuss the issue of experience
090961 -        in performing mastectomy surgery on an IBC patient, noted in
090962 -        review yesterday on 050907, ref SDS 34 FM5J, for not confirming
090963 -        discussions at Kaiser in Oakland on 050826. ref SDS 33 FM5J
090964 -        Investigating the experience factor was the main reason for a
090965 -        referral by the surgeon in the Walnut Creek office, reported on
090966 -        050727. ref SDS 25 O85O  If you feel this should not be
090967 -        discussed in the 2nd opinion document, per se, maybe we can
090968 -        talk about it when you have time.  The surgeon in Walnut Creek
090969 -        has said on several occasions she has never done a mastectomy
090970 -        on a patient with IBC. ref SDS 25 QJ3Q  This may be irrelevant,
090971 -        or there may be advantages having the work performed by someone
090972 -        who has experience treating IBC patients.  If so, Millie should
090973 -        be informed in advance.  We very much like Doctor Riley-Paul
090974 -        and would love to have her do the work, if experience treating
090975 -        IBC with mastectomy is not a factor.  Again, we can talk about
090976 -        this if you feel discussion is more useful in this situation.
090977 -        ref DIT 1 TE9O
090978 -
090979 -            [...see below Kaiser referral does not address patient's
090980 -            request for requirements on experience to perform a
090981 -            successful mastectomy surgery on a patient with IBC.
090982 -            ref SDS 0 NG5K
090984 -         ..
090985 -    7.  Finally, can you discuss risks and benefits of surgery on
090986 -        longevity and quality of life, and the same if Millie decides
090987 -        not to have surgery, also, discussed with the surgeon at Kaiser
090988 -        on 050727. ref SDS 25 VL4O  Doctor Benz at UCSF last October
090989 -        said in a 2nd opinion received on 041117 that there is no role
090990 -        for surgery in Millie's case. ref SDS 16 OU5P  Doctor Johnson
090991 -        in the Walnut Creek has commented both ways at different times.
090992 -        It could be that last October Mil was not ready for surgery,
090993 -        but now she is and so we should go ahead.  If we could get some
090994 -        of the reasoning and factors that support a decision either
090995 -        way, this would be a big help.  If you prefer to discuss it,
090996 -        rather than do a write up, that's fine. ref DIT 1 RK5M
090997 -
090998 -            [...see below, Kaiser referral does not address request for
090999 -            risk analysis of surgery for Millie's patient profile.
091000 -            ref SDS 0 YO6I
091002 -         ..
091003 -    8.  Everything else is great in the 2nd opinion! ref DIT 1 DV3J
091004 -
091005 -
091006 -
091008 -  ..
0911 -
0912 -
0913 - 2138
0914 -
091401 - Received ref DRT 1 0001 from Veronica responding to the letter this
091402 - morning, per above. ref SDS 0 08GF
091403 -
091404 -    1.  I see your point - but in oncology community (medical oncology
091405 -        as well as surgical oncology), true definition of metastatic
091406 -        disease is distant metastasis.  I will try to clarify it before
091407 -        I make it final now. ref DRT 1 0001
091409 -  ..
091410 - Veronica addresses the recommendation to change the 2nd opinion by not
091411 - saying the patient does not have metastatic cancer, per above.
091412 - ref SDS 0 LJ3X
091413 -
091414 -            [On 050909 request revised final version of 2nd opinion.
091415 -            ref SDS 35 TX4W
091417 -             ..
091418 -            [On 050909 Veronica says final draft changed "no metastatic
091419 -            disease" to no "distant metastatic disease." ref SDS 35
091420 -            5A9G
091422 -             ..
091423 -            [On 050909 final draft received; still says CT and bone
091424 -            scan tests show no metastatic disease. ref SDS 35 JX7S
091426 -  ..
091427 - Veronica does not address...
091428 -
091429 -    1.  The purpose of the 2nd opinion to investigate the importance of
091430 -        experience performing mastectomy surgery on an IBC patient,
091431 -        discussed at Kaiser in Walunt Creek on 050727, ref SDS 25 QJ3Q,
091432 -        and again at Kaiser in Oakland on 050826, ref SDS 33 FM5J, and
091433 -        which is requested in the letter this morning, per above.
091434 -        ref SDS 0 LJ6S
091436 -         ..
091437 -    2.  Risks and benefits of surgery, also requested in the letter
091438 -        this morning, ref SDS 0 LJ7Y, and discussed previously at
091439 -        Kaiser in Walnut Creek on 050727, ref SDS 25 VL4O, and also at
091440 -        the Oakland office on 050826. ref SDS 33 GT5K
091441 -
091442 -
091443 -
091444 -
091445 -
0915 -

SUBJECTS
Cure Goal Treatment No Evidence Distant Metastasis Patient Stage III
Curative Treatment Model Stage III Not Stage IV Metastatic Cancer Re
Criteria Approve Surgery for Extending Quality of Life Patient Decis

3105 -
3106 - 2157
310701 -  ..
310702 - Retest Biopsy for Changing Status Expand Treatment Options
310703 - Treatment Options May Be Expanded Retest for Status Change
310704 - Test Status Change Possible Huge Improvement Treatment Options
310705 - Stage III Regional Cancer Presents Chance for Curative Treatment
310706 -
310707 - Follow up ref SDS 34 F49H, ref SDS 33 F49H.
310708 -
310709 - Received ref DRT 2 0001 from Veronica following up her first letter
310710 - received earlier this evening, per above. ref SDS 0 1W9L
310712 -  ..
310713 - Veronica says...
310714 -
310715 -    1.  I looked at your comments -
310717 -         ..
310718 -    2.  To test for ER, PR, and HER-2, ask the WCR path to test skin
310719 -        biopsy that was done in 2004, not FNA(fine needle
310720 -        aspiration)from the neck. ref DRT 2 6M5M
310722 -  ..
310723 - Veronica seems to be saying she reviewed the SDS record on 050907,
310724 - which was cited in the letter to her this morning, per above,
310725 - ref SDS 0 LI6Y, and reviews her 1st draft.  In this letter she
310726 - comments further to clarify her recommendation for retesting Millie's
310727 - status. ref SDS 34 AE6P
310729 -  ..
310730 - Saying to...
310731 -
310732 -        ...test skin biopsy that was done in 2004, not FNA(fine needle
310733 -        aspiration)from the neck.
310734 -
310735 - ...requires further clarification, because there were two (2) taken in
310736 - 2004 besides the FNA biopsy taken from the neck on 040303.
310737 -
310738 -     [On 050909 submitted letter asking Veronica to clarify which
310739 -     biopsy she wants to retest. ref SDS 35 435L
310740 -
310741 -
310742 -
310743 -
310744 -
310745 -
310746 -
310747 -
310748 -
310749 -
310750 -
3108 -