THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: September 23, 2005 03:15 PM Friday;
Millie meeting at Kaiser to evaluate surgery for mastectomy to treat IBC
2...Agenda Review Findings 2nd Opinions Planning to Assess Mastectomy
3...IBC Symptoms Resolved Shown by Examination
4...Mastectomy Surgery Ready to Go After Chemotherapy Heals IBC
5...Examination Shows Regional Symptoms Cancer Left Breast Subside
6...2nd Opinions Not Presented by Surgeon Patient Submits for Review
7...Case Study Due Diligence Collaboration Team Care Communication
8...Collaboration Team Care Practice Chance Meeting in Hallway
9...Due Diligence Hallway Meeting Coordinate Team Practice for Surgery
10...Status Test for Change ER PR HER2/neu from Negative to Positive
11...Retest Biopsy 040419 for Status Change Increase Treatment Options
12...Treatment Options Expand Retest Status for ER PR HER2/neu Positive
13...PET Scan and Biopsy Tests Investigate Recovery from IBC
14...Criteria for Surgery to Perform Mastectomy on IBC Patient
15...Surgery Patient Ready Based on Criteria to Assess IBC Recovery
....2...Biopsy to establish the left breast is clear of disease,
....3...CA 15-3 criteria consistently below normal listed on
....4...Visual and palpation examination have been conducted over the
........Boundary Very Wide Mastectomy Biopsies Assess Scope
........Biopsies Set Boundaries Wide Mastectomy Reduce Risk Relapse
........Complex Criteria Scope Boundaries Mastectomy Aided by Biopsy
........Very Wide Mastectomy Biopsies Set Boundary Reduce Risk Relapse
....6...Experience Performing Very Wide Mastectomy
........Due Diligence Communicate Collaboration Leverage Experience
........Mastectomy Time Out Evaluate Treatment Options Secondary IBC
........Time Out Mastectomy Due Diligence IBC No Tumor Pulmonary Emboli
........Shared Decisions About Surgery
....7...Criteria to Approve Surgery for Extending Quality of Life
........Patient Decision to Have Surgery Consult with the Oncologist
........Regional Lymph Nodes Metastatic Cancer Surgery Close Call
........Surgery Close Call Regional Lymph Nodes Metastatic Cancer
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Meeting Agenda Surgeon Evaluate Mastectomy Left Breast Follow Up Requ
0403 - ..
0404 - Summary/Objective
040501 - Follow up ref SDS 41 0000. ref SDS 32 0000.
040503 - Surgeon pleased examination shows no signs of IBC, indicating local
040504 - control with chemotherapy. ref SDS 0 YY7F 2nd opinions were reviewed.
040505 - ref SDS 0 Z46K Surgeon concurs with PET scan testing to evaluate
040506 - distant metastasis, ref SDS 0 OV5H, and will schedule Millie for thin
040507 - skin biopsies to assess local recovery of IBC. ref SDS 0 SZ6M Surgeon
040508 - seemed to concur with objectives of "very wide mastectomy" to avoid
040509 - risks cited by Doctor Bailey of cutting into infected skin, and risks
040510 - that surgical wound will not heal. ref SDS 0 NT9G Scheduled meeting
040511 - with plastic surgeon to evaluate Doctor Grissom's proposal for
040512 - closure. ref SDS 0 F144 The surgeon proposed that, if PET and biopsy
040513 - tests find no evidence of disease, then the patient can be treated
040514 - with a standard mastectomy, and thereby avoid risks of closing a very
040515 - wide surgical wound. ref SDS 0 4G4L Surgeon claimed experience with
040516 - "very wide mastectomy" and in contemporaneous collaboration with
040517 - plastic surgeon, indicating local staff may be able to handle the
040518 - project. ref SDS 0 QJ3Q Kaiser's Healthwise Handbook provides a check
040519 - list to assess risks of surgery. ref SDS 0 O85O The doctor seemed to
040520 - indicate today that Millie has distant metastasis, based on the neck
040521 - biopsy in 2004, which may render considerations moot for local control
040522 - with surgery. ref SDS 0 VL4O Risks of surgery cited by Grissom and
040523 - Bailey were reviewed during the meeting today. ref SDS 0 KF6I Millie
040524 - decided to proceed with testing and then assess prospects of surgical
040525 - solution proposed by primary care physician based on the strength of
040526 - Kaiser's plan, and in relation to alternatives of debilitating side
040527 - effects from chemotherapy. ref SDS 0 G49M
040529 - [On 050927 received surgeon notes; review shows close alignment
040530 - with the record today. ref SDS 62 T14N
040532 - ..
040533 - [On 050928 submitted record of meeting today, and surgeon's notes
040534 - to consultants for comments. ref SDS 63 1J5J
040536 - ..
040537 - [On 050929 biopsies surgery scheduled for 051012 1600. ref SDS 65
040538 - 0001
040540 - ..
040541 - [On 051012 prepared letter requesting Kaiser implement
040542 - requirements for "Time Out" to perform due diligence with risk
040543 - analysis of mastectomy surgery proposal. ref SDS 69 6D4F
040547 - ..
0408 - Progress
040901 - Agenda Review Findings 2nd Opinions Planning to Assess Mastectomy
040903 - Follow up ref SDS 41 WI6K, ref SDS 32 WI6K.
040905 - The doctor came into the room and, after pleasantries, she asked
040906 - Millie what she thinks?
040908 - [On 051019 letter to Millie on filing notice for Kaiser to perform
040909 - due diligence cites "what do you think...) ref SDS 71 O26Q
040911 - ..
040912 - Millie commented that the meeting today was called by the primary care
040913 - physician in the Oncology Department, reported on 050913, and for the
040914 - purpose of scheduling mastectomy surgery during a "window of
040915 - opportunity" for accomplishing "local control." ref SDS 56 T646
040917 - ..
040918 - Millie asked what the surgeon thinks about performing surgery, based
040919 - on prior examinations and 2nd opinions. The following agenda was
040920 - proposed to guide discussions...
040922 - ..
040923 - Examination............................... ref SDS 0 YY7F
040924 - 2nd Opinions.............................. ref SDS 0 7K3J
040925 - PET and biopsy tests...................... ref SDS 0 OV5H
040926 - Scope and surgical boundaries............. ref SDS 0 NT9G
040927 - Plastic surgeon review.................... ref SDS 0 F144
040928 - Risk assessment and follow up............. ref SDS 0 VL4O
Examination Left Breast IBC Symptoms Resolved Inflammation Red Thick
2nd Opinion Submitted to Surgeon for Review Discussion During Examin
180501 - ..
180502 - IBC Symptoms Resolved Shown by Examination
180503 - Mastectomy Surgery Ready to Go After Chemotherapy Heals IBC
180504 - Examination Shows Regional Symptoms Cancer Left Breast Subside
180506 - Follow up ref SDS 41 YY7F, ref SDS 32 YY7F.
180508 - The surgeon examined Millie's left breast and commented that, after
180509 - eight (8) cycles with Taxotere and capecitabine (Xeloda), reported on
180510 - 050916, ref SDS 57 407N, and begun on 050329 to implement
180511 - recommendations by Doctor Benz at UCSF, ref SDS 33 FP57, inflammation
180512 - (redness) in the left breast is still completely eliminated by
180513 - visualization compared to the right breast, and further compared to
180514 - prior examinations on...
180516 - ..
180517 - 050727......................... ref SDS 41 YY7F
180518 - 050401......................... ref SDS 34 EY9J
180519 - 050324......................... ref SDS 32 YY7F
180520 - 050107......................... ref SDS 26 IS5N
180521 - 041209......................... ref SDS 19 O23T
180522 - 041117......................... ref SDS 14 OU5T
180523 - 040429......................... ref SDS 11 SD7F
180524 - 040419......................... ref SDS 10 XU4S
180526 - ..
180527 - Examination today indicates that recovery from IBC reported previously
180528 - by the surgeon on 050727, ref SDS 41 YY7F, has been maintained,
180529 - albeit while being treated with chemotherapy.
2nd Opinion Submitted to Surgeon for Review Discussion During Examin
2nd Opinions Meeting Doctor Riley-Paull Surgeon Evaluate Masectomy L
200501 - ..
200502 - 2nd Opinions Not Presented by Surgeon Patient Submits for Review
200504 - Follow up ref SDS 41 WH5L, ref SDS 32 WH5L.
200506 - ..
200507 - Background on considerations for surgery are summarized on 041210,
200508 - ref SDS 21 ZV5J, and case study to prevent disease from cascading out
200509 - of control to extend quality of life is reported on 041230.
200510 - ref SDS 24 XV7M
200512 - ..
200513 - Millie asked about 2nd opinions, discussed with the primary care
200514 - physician on 050913. ref SDS 56 T46F
200516 - ..
200517 - The surgeon advised that she has received and reviewed 2nd opinions in
200518 - this case. The surgeon indicated there was not enough time to bring
200519 - the 2nd opinions to the meeting with analysis to facilitate discussion
200520 - today.
200522 - ..
200523 - The surgeon asked Millie again what she thinks about everything based
200524 - on memory of 2nd opinions, recommendations from the primary care
200525 - physician, and from discussions with the surgeon back on 050727?
200526 - ref SDS 41 YY7F
200528 - [On 051019 letter to Millie on filing notice for Kaiser to perform
200529 - due diligence cites "what do you think...) ref SDS 71 O26Q
200531 - ..
200532 - Millie submitted printed copies of the three (3) opinions received in
200533 - this case...
200535 - 1. Doctor Shim in Kaiser's Oakland office recommended by the
200536 - surgeon, who filed a final opinion on 050909. ref SDS 53
200537 - 1O4I
200539 - ..
200540 - 2. Doctor Grissom recommended by UCSF, who filed a final
200541 - opinion received on 050920. ref SDS 59 PQ5S
200543 - ..
200544 - 3. Doctor Bailey recommended by UCSF, who filed a 2nd opinion
200545 - on 050920, and received on 050922. ref SDS 60 HP3H
200547 - ..
200548 - The surgeon looked briefly through these documents during the meeting,
200549 - and noted highlights added by the patient to facilitate discussion of
200550 - recommendations.
200552 - [...below Kaiser's Healthwise Handbook discusses 2nd opinions.
200553 - ref SDS 0 O85O
200555 - ..
200556 - Millie requested the doctor's comments on 2nd opinion findings and
200557 - recommendations in relation to the primary care physician's call to
200558 - the surgeon and leaving a message on 050913 saying to schedule Millie
200559 - for mastectomy surgery? ref SDS 56 T646
200561 - ..
200562 - The surgeon said that the patient must consent for Kaiser to perform
200563 - surgery, and asked again what Millie thinks about having a mastectomy?
200565 - [On 051019 letter to Millie on filing notice for Kaiser to perform
200566 - due diligence cites "what do you think...) ref SDS 71 O26Q
200568 - ..
200569 - Millie said that mastectomy surgery to achieve local control, and
200570 - reduce chances of distant metastasis, recommended by the primary care
200571 - physician, requires review to determine that favorable conditions for
200572 - a successful surgery are presented, especially in light of risks cited
200573 - in 2nd opinions, as reported by Doctor Bailey in the meeting with the
200574 - primary care physician on 050913. ref SDS 56 X584 and further citing
200575 - Doctor Grissom. ref SDS 56 X545
200577 - ..
200578 - The surgeon concurred that mastectomy surgery is high risk for
200579 - Millie's patient profile diagnosed with secondary IBC, multiple
200580 - relapse, and blood clot issues.
200582 - ..
200583 - Previously, on 050727 the surgeon cited prospect of microscopic cancer
200584 - cells likely remain after treatment that are not detectable with
200585 - tests. ref SDS 41 R34I This patient history increases possibility
200586 - that the wound from surgery will not heal, as occurred with the punch
200587 - biopsy taken on 040419, and noted by the surgeon was still not healed
200588 - on 050107 due to continuing IBC, despite good response on the Avastin
200589 - trial last year. ref SDS 26 IS5N Doctor Bailey indicates in a 2nd
200590 - opinion received yesterday on 050922 that pulmonary emboli presents a
200591 - risk of death to while the patient is off Coumadin for the operation.
200592 - ref SDS 60 6Z5Q
200594 - [...below, surgeon raises prospect of standard breast surgery
200595 - rather than very wide mastectomy, if PET and skin biopsies are
200596 - both negative for cancer. ref SDS 0 4G4L
200598 - ..
200599 - [...below, surgeon discusses risks cited in 2nd opinions.
200600 - ref SDS 0 VL4O
Collaboration Teamwork Failed Due Diligence Requirements Ignored Fam
470401 - ..
470402 - Case Study Due Diligence Collaboration Team Care Communication
470403 - Collaboration Team Care Practice Chance Meeting in Hallway
470404 - Due Diligence Hallway Meeting Coordinate Team Practice for Surgery
470406 - Follow up ref SDS 56 6W4L.
470408 - The surgeon reported having recently consulted with the primary care
470409 - physician on Millie's case (see below, ref SDS 0 LP6H).
470411 - ..
470412 - This was wonderful news resolving prior problems where the surgeon and
470413 - primary care physician have had continuing difficulty collaborating to
470414 - implement Kaiser's risk management requirements for due diligence,
470415 - reported on...
470417 - ..
470418 - 050913......................... ref SDS 56 6W4L
470419 - 050729......................... ref SDS 43 U24K
470420 - 050727......................... ref SDS 41 PF7O
470421 - 050329......................... ref SDS 33 XQ41
470422 - 050324......................... ref SDS 32 QQ4N
470423 - 050311......................... ref SDS 30 XQ41
470424 - 050204......................... ref SDS 27 UH3O
470425 - 050107......................... ref SDS 26 777K
470426 - 041230......................... ref SDS 24 UJ5M
470427 - 040419......................... ref SDS 10 XU75
470428 - 020726......................... ref SDS 3 YO6K
470430 - ..
470431 - [On 060809 advice nurse explains Kaiser's support for doctors
470432 - conferring to collaborate on providing good patient care.
470433 - ref SDS 77 NT8Y
470435 - ..
470436 - During the meeting on 040419 the surgeon explained Kaiser's team care
470437 - practice for cross-departmental examinations that provide redundancy
470438 - for quality care of diagnosis and treatment planning. ref SDS 10 XU75
470439 - This aligned with planning in the Oncology Department to obtain backup
470440 - from the Radiologist on assessment of Millie's progress, reported on
470441 - 020726. ref SDS 3 RQ9F
470443 - ..
470444 - During the meeting on 050913, Millie asked for a joint meeting with
470445 - the Oncologist and the Surgeon to facilitate collaboration, planning,
470446 - and coordiation performing due diligence on proposed complex surgical
470447 - procedure. ref SDS 56 6W4L
470449 - [On 051103 article reports complex patient care with multiple
470450 - doctors reduces the quality of medical care. ref SDS 75 EU35
470452 - ..
470453 - Millie recalled today that, when the doctor visited in the
470454 - Chemotherapy Clinic on 050916, he advised of having met with the
470455 - surgeon, following the meeting on 050913, when Millie submitted a
470456 - summary of preliminary findings from 2nd opinions. ref SDS 56 T46F At
470457 - that time, on 050913, the doctor did not have time to review the
470458 - summary, ref SDS 56 KJ4J; so, possibly this was discussed with the
470459 - surgeon in their follow on meeting mentioned by the doctor on 050916,
470460 - even though the doctor did not have time on 050916 to explain the
470461 - substance of meeting with the surgeon. ref SDS 57 PF3G
470463 - ..
470464 - Also, on 050913 the primary care physician strongly objected to due
470465 - diligence obtaining 2nd opinions that help the patient consider
470466 - invasive surgery proposed by Kaiser. ref SDS 56 5T4J
470468 - ..
470469 - Today, Millie asked the surgeon for results of meeting with the
470470 - primary care physician, per above? ref SDS 0 N45O Did this meeting
470471 - implement Kaiser requirements for due diligence to enable informed
470472 - consent by the patient and ensure the efficacy of invasive procedures,
470473 - cited in Kaiser's Healthwise Handbook, and implemented with steps
470474 - listed on a document titled "Time Out," reported on 050913?
470475 - ref SDS 56 Q94H
470477 - ..
470478 - The doctor said that she passed the primary care physician in the hall
470479 - on the way to the cafeteria, and they stopped and talked briefly about
470480 - Millie's case. She could not recall what was said. The doctor
470481 - recalled the day was pretty hectic; there was a lot happening so she
470482 - did not have time to make notes of the meeting, nor to send confirming
470483 - correspondence. The doctor said she has not received correspondence
470484 - from oncology confirming was discussed. She recalled today that the
470485 - primary care physician feels strongly about Millie getting a
470486 - mastectomy for local control, which aligns with the record of Millie
470487 - meeting with the primary care physician a week or so ago on 050913.
470488 - ref SDS 56 5T5N
470490 - [...see below presents patient profile is high risk for relapse
470491 - regardless of mastectomy for local control. ref SDS 0 O15H
470493 - ..
470494 - [On 050927 surgeon's notes cite purpose of mastectomy surgery
470495 - in Millie's case is local control only and will not improve
470496 - chances of avoiding distant metastasis nor increase longevity.
470497 - ref SDS 62 AK4T
470499 - ..
470500 - [On 051007 primary care physician presents purpose of standard
470501 - mastectomy is for palliation in the event of future relapse.
470502 - ref SDS 67 6A4N
Status Test for Change ER PR HER2/neu from Negative to Positive Trea
490401 - ..
490402 - Status Test for Change ER PR HER2/neu from Negative to Positive
490403 - Retest Biopsy 040419 for Status Change Increase Treatment Options
490404 - Treatment Options Expand Retest Status for ER PR HER2/neu Positive
490406 - Follow up ref SDS 51 AE6P.
490408 - The surgeon seemed to concur with Doctor Shim's recommendation to
490409 - retest prior biopsy tissue to check for changes in patient status that
490410 - could greatly expand treatment options, reported on 050907.
490411 - ref SDS 51 AE6P Doctor Bailey concurs in a 2nd opinion received on
490412 - 050922, ref SDS 60 XD4S, and reviewed today, per above. ref SDS 0 7J67
490413 - This was further presented to the primary care physician during a
490414 - meeting on 050913. No action action was taken at that time, perhaps
490415 - in reliance on the Surgery Department to order a retest. ref SDS 56
490416 - X546
490418 - ..
490419 - We reviewed Doctor Shim's proposal to test tissue from biopsy taken by
490420 - the surgeon on 040419, reported in a telecon call with Doctor Shim on
490421 - 040909. ref SDS 53 P58N
490423 - ..
490424 - Today, the surgeon commented that the biopsy on 040419 may not enough
490425 - tissue for retesting. She proposed a solution to test tissue from the
490426 - thin sliver skin biopsies of the left breast now planned to evaluate
490427 - recovery from IBC, and to help determine the diameter of mastectomy
490428 - surgery, per below. ref SDS 0 NT9G
490430 - ..
490431 - Previously, on 050912 Doctor Grissom commented during a 2nd opinion
490432 - meeting that testing for patient status change requires analysis of
490433 - pathology on a biopsy taken at a time when the patient has positive
490434 - disease. ref SDS 55 MX5N The biopsy on 040419 meets this requirement.
490435 - The goal of the new biopsies planned for next week is to find no
490436 - disease, and so this may not meet requirements for testing status
490437 - change.
490439 - ..
490440 - The surgeon said that a retest for status change will be ordered on
490441 - the biopsy taken 040419.
490443 - [On 050927 received surgeon notes; review shows no indications
490444 - ordering retest of the biopsy on 040419 for status change.
490445 - ref SDS 62 WV5O
490447 - ..
490448 - [On 051007 primary care physician planned to order retest of
490449 - biopsy for status change. ref SDS 67 KE5L
490451 - ..
490452 - [On 051022 surgeon reported retest was ordered with no record in
490453 - surgeon's notes received on 050927, and that results of retesting
490454 - have not been received; doctor following up to obtain results.
490455 - ref SDS 73 NE9J
490457 - ..
490458 - [On 051027 surgeon has not received results of retesting for
490459 - status change; will check with pathology department on finding
490460 - correct biopsy slide to test. ref SDS 74 964L
PET Scan Test Distant Metastasis and Left Breast Tumor Relapse Bilat
2nd Opinion Doctor Lisa Bailey Patient Notes from Meeting on 050909
2nd Opinion Doctor Nima Grissom Patient Notes from Meeting on 050912
580601 - ..
580602 - PET Scan and Biopsy Tests Investigate Recovery from IBC
580603 - Criteria for Surgery to Perform Mastectomy on IBC Patient
580604 - Surgery Patient Ready Based on Criteria to Assess IBC Recovery
580606 - Follow up ref SDS 41 OV5H, ref SDS 32 OV5H.
580608 - Background on considerations to perform surgery for a mastectomy is
580609 - summarized on 041210. ref SDS 21 ZV5J Today, the surgeon revised
580610 - recommendations on 050727, ref SDS 41 OV5H, and indicated that
580611 - mastectomy surgery requires additional work up for criteria from the
580612 - meeting on 050324. ref SDS 32 OV5H
580614 - 1. Distant metastasis should be further evaluated with a PET scan
580615 - test to support analysis by Doctor Shim received on 050909,
580616 - citing history of CT and prior PET tests. ref SDS 53 JX7S
580617 - Grissom recommends a PET scan test, reported on 050920.
580618 - ref SDS 59 XL7P Bailey, also, supports additional PET scan
580619 - test, see 050922. ref SDS 60 XD7U
580621 - ..
580622 - Bilateral mammogram test was also recommended, and this was
580623 - performed on 050922. ref SDS 61 0001
580625 - ..
580626 - Breast MRI test recommended by Doctor Bailey in a 2nd opinion
580627 - received yesterday on 050922, ref SDS 60 XD7U, was deferred
580628 - today until after other test results.
Biopsy Planning Evaluate IBC Recovery Patient Ready for Mastectomy S
630401 - ..
630402 - 2. Biopsy to establish the left breast is clear of disease,
630403 - criteria listed on 050324. ref SDS 32 OV8L, and discussed again
630404 - on 050727. ref SDS 41 SZ6M
630406 - ..
630407 - On 050920 Doctor Grissom in a 2nd opinion proposes thin full
630408 - thickness surgical biopsies with suture closure (rather than
630409 - punch biopsy) to test for IBC and help determine scope of
630410 - surgery. ref SDS 59 XL7P
630412 - ..
630413 - The surgeon concurred, and will schedule Millie for biopsy
630414 - surgery. There was discussion about how long and how many thin
630415 - skin biopsies should be taken in order to accomplish
630416 - objectives, including setting boundaries for surgery, per
630417 - below. ref SDS 0 JV5J Initially, the doctor proposed 1" long
630418 - tissue samples, then considered .5" samples. Three (3) biopsy
630419 - samples were discussed. The doctor decided to consider taking
630420 - 3 or 4 samples, and this will be finally determined based
630421 - progress during the procedure.
630423 - [On 050927 received surgeon's notes describing biopsies as
630424 - reasonable and feasible. ref SDS 62 EU67
630426 - ..
630427 - [On 050929 biopsies surgery scheduled for 051012 1600.
630428 - ref SDS 65 0001
630430 - ..
630431 - [On 051006 Gloria called with the Kaiser Coagulation Clinic
630432 - in Martinez, and related Millie should stop taking Coumadin
630433 - to prepare for minor biopsy surgery on 051012. ref SDS 66
630434 - YV6I
630436 - ..
630437 - [On 051012 4 biopsies were taken during minor surgery at
630438 - Kaiser in Walnut Creek. ref SDS 69 DG6J
630440 - ..
630441 - [On 051018 Millie notified favorable results from skin
630442 - biopsies, no evidence of cancer. ref SDS 70 QN3I
630444 - ..
630445 - The surgeon today explained background performing this
630446 - procedure, and concurred that this minor biopsy surgery would
630447 - help determine if IBC still exists in the breast, and thereby
630448 - help reduce risks of cutting through infected skin, which would
630449 - cause serious complications causing cancer to cascade out of
630450 - control, discussed in Doctor Bailey's opinion received on
630451 - 050922. ref SDS 60 XD8P
630453 - ..
630454 - On 050727 the patient wanted to avoid biopsy tests, because the
630455 - biopsy on 040419 took about 14 months to heal. ref SDS 41 SZ6M
630456 - Failure of the first biopsy to heal normally occurred because
630457 - the skin was infected with IBC. Currently planned biopsy tests
630458 - assess whether IBC has subsided sufficiently to contemplate a
630459 - surgical solution proposed by primary care physician on...
630461 - 050610............................ ref SDS 38 XQ41
630462 - 050729............................ ref SDS 43 BZ56
630463 - 050913............................ ref SDS 56 T46F
630465 - ..
630466 - If these new biopsies are negative for cancer, then unlike the
630467 - prior biopsy that did not heal due to cancer found on 040429,
630468 - ref SDS 11 C155, these new wounds should heal because there is
630469 - no cancer. In that case mastectomy surgery might be
630470 - considered, based on PET scan findings, and review by the
630471 - plastic surgeon on prospects for closing the wound. In any
630472 - case, if the small biopsy wounds will not heal this is a flag
630473 - to avoid the risks of a much larger mastectomy wound.
CA 15-3 45 Above Normal 39 Steady Below Alarm Level of 80 Aligns wit
670401 - ..
670402 - 3. CA 15-3 criteria consistently below normal listed on
670403 - 050324. ref SDS 32 K13M
670405 - ..
670406 - This was not discussed today.
670408 - ..
670409 - On 050913 recent history shows that CA 15-3 seems somewhat
670410 - stable at 45, which is above the nominal target of 39.
670411 - ref SDS 56 087J Analysis at that time on 050913 discusses
670412 - possible persistent cancer activity to account for persistent
670413 - diagnostic above normal. ref SDS 56 ST6G Generally, this
670414 - suggests caution about chances of cancer being under total
670415 - control, as related during the meeting with the surgeon on
670416 - 050727. ref SDS 41 YK6K
670418 - [On 051007 CA 15-3 holding steady at 45 which is 6 points
670419 - above the high end of normal; nothing in PET scan tests
670420 - indicates local, regional nor local cancer. ref SDS 67 S57K
Examination Visual Observe Skin Coloration Normal Redness Inflammati
710401 - ..
710402 - 4. Visual and palpation examination have been conducted over the
710403 - past few months. All indicate IBC has substantially subsided;
710404 - Bailey on 050909, and Grissom on 050912 report observing some
710405 - thickened skin slightly erythematous.
710407 - Surgeon Kaiser Walnut Creek..... 050923, ref SDS 0 YY7F
710408 - Bailey.......................... 050922, ref SDS 60 6Y7N
710409 - Grissom......................... 050920, ref SDS 59 XL4W
710410 - Primary care physician.......... 050913, ref SDS 56 M56N
710411 - Shim, Kaiser Oakland............ 050907, ref SDS 51 AE4V
710413 - ..
710414 - To differentiate observations of symptoms from actual IBC
710415 - infection, Bailey and Grissom propose PET testing, which was
710416 - ordered by PCP on 050913 and is currently scheduled to be
710417 - performed on 051005. ref SDS 56 T699 Grissom proposed
710418 - biopsies, per the record above. ref SDS 0 SZ6M Below, the
710419 - surgeon scheduled these biopsies. ref SDS 0 F13M
Mastectomy Surgery Left Breast Very Wide Reviewed 2nd Opinions for R
Surgeon Proposes Standard Mastectomy If Thin Skin Biopsies and PET S
770501 - ..
770502 - Boundary Very Wide Mastectomy Biopsies Assess Scope
770503 - Biopsies Set Boundaries Wide Mastectomy Reduce Risk Relapse
770504 - Complex Criteria Scope Boundaries Mastectomy Aided by Biopsy
770505 - Very Wide Mastectomy Biopsies Set Boundary Reduce Risk Relapse
770507 - Follow up ref SDS 41 NT9G.
770509 - ..
770510 - 5. Surgeon noted that mastectomy surgery in this case presents
770511 - high risks caused by complex criteria for setting boundaries
770512 - and scope of tissue removal, discussed previously on 050324,
770513 - ref SDS 32 0347, and again on 050727, ref SDS 41 JV5F Risks
770514 - can be managed to some degree by following 2nd opinion from
770515 - Doctor Grissom calling for thin skin biopsies reported on
770516 - 050920. ref SDS 59 GT3M
770518 - ..
770519 - These skin biopsies were added to patient diagnostic work up
770520 - planning, per above. ref SDS 0 4F5H
770522 - [On 051012 4 biopsies were taken during minor surgery at
770523 - Kaiser in Walnut Creek. ref SDS 69 DG6J
770525 - ..
770526 - The surgeon reviewed analysis on 050727, concurring today that
770527 - a very wide mastectomy is needed in this case to remove the
770528 - entire left breast previously irradiated and infected with IBC,
770529 - ref SDS 41 JV5F, so that the risk of relapse is reduced by
770530 - removing tissue that may still contain microscopic cancer cells
770531 - not detected by testing (see below, discussing risks of
770532 - mastectomy, ref SDS 0 KF6I). There was, also, discussion today
770533 - that the surgical wound from removing a wider area of skin to
770534 - avoid relapse can be closed with reconstructive surgery using a
770535 - DIEP flap or TRAM, as called out by Doctor Grissom in a 2nd
770536 - opinion on 050920. ref SDS 59 GT3M Doctor Bailey, also,
770537 - recommends in a 2nd opinion received on 050922 that for
770538 - mastectomy to be effective reducing the risk of relapse in this
770539 - case, surgery must remove a wide area of breast skin previously
770540 - radiated during the period July - September 2002, ref SDS 60
770541 - XD8P, and, which subsequently became infected by IBC, beginning
770542 - perhaps as early as 021218, based on PET scan test findings and
770543 - inflammation on the left breast observed by the primary care
770544 - physician on 030109, and later reported by the surgeon to have
770545 - spread beyond the breast observed during a meeting at Kaiser on
770546 - 050324. ref SDS 32 YY7F
770548 - [On 050927 the surgeon's notes for some reason do not
770549 - mention requirements for "very wide mastectomy to reduce
770550 - risk of relapse. ref SDS 62 AK5T
770552 - ..
770553 - [On 050928 plastic surgeon seems to propose very wide
770554 - mastectomy with standard closure. ref SDS 64 245N
770556 - ..
770557 - [On 051007 primary care physician objects to very wide
770558 - mastectomy and reconstruction for reducing risk of relapse
770559 - by removing skin previously infected with IBC, and instead
770560 - ordered a standard mastectomy for palliation strategy.
770561 - ref SDS 67 P64J
770563 - ..
770564 - [On 051019 prepared letter asking Kaiser to take Time Out
770565 - for performing due diligence requirements presenting risks
770566 - and benefits, ref SDS 71 DY5P, on the scope of mastectomy
770567 - surgery in this case. ref SDS 71 DZ56
770569 - ..
770570 - [On 051021 surgeon performed surgery and explained that a
770571 - very wide mastectomy was accomplished with standard closure
770572 - and without complications. ref SDS 72 MM6M
770574 - ..
770575 - [On 061020 primary care physician feels patient profile has
770576 - too many issues for a 5-year medical case of secondary
770577 - inflammatory breast cancer (IBC), cellulitus, lymphedema,
770578 - pulmonary embolism, broken finger. ref SDS 78 MO4K
770580 - ..
770581 - Does patient history of IBC occurring on relapse present risks
770582 - to traditional treatment of IBC with chemotherapy, standard
770583 - mastectomy surgery, chemotherapy, and radiation, reported on
770584 - 040517, ref SDS 12 XG7K; because the patient was previously
770585 - radiated in July and August, 2002, then in order to give more
770586 - radiation, called out by the Kaiser Tumor Board on 040416,
770587 - ref SDS 9 2U5V; the breast and surrounding tissue must be
770588 - replaced with plastic surgery; and additionally, since control
770589 - of IBC wavered during March 2005, when treatment was
770590 - interrupted for three (3) months and infection spread beyond
770591 - the breast, does this introduce risk determining the scope of
770592 - surgery that can only be resolved with very wide mastectomy,
770593 - which can be closed with plastic surgery? Are there other
770594 - considerations that require analysis to fully resolve this
770595 - issue?
770597 - [On 050927 this question is listed to follow up surgeon's
770598 - notes that propose standard mastectomy if testing shows no
770599 - disease, ref SDS 62 4G4F, citing doctor's comments today,
770600 - per below. ref SDS 0 4G4L
770602 - ..
770603 - The surgeon noted that the plastic surgeon might not agree to
770604 - perform this surgery due to high risks that a surgical wound
770605 - will not heal, as shown by experience with the punch biopsy
770606 - taken on 040419, and observed during the meeting with the
770607 - surgeon on 050107. ref SDS 26 IS5N Concerns by the plastic
770608 - surgeon are critical for assessing viability of this project,
770609 - including proposed work arounds, see below. ref SDS 0 4H48
770611 - ..
770612 - The surgeon will schedule a consultation with plastic surgeon
770613 - on staff in the Walnut Creek office.
770615 - [On 050928 meeting with plastic surgeon discusses plastic
770616 - surgery for primary closure, ref SDS 64 246G; three (3) new
770617 - risks were discussed for surgical solution, ref SDS 64
770618 - UM4I, plastic surgeon recommends standard closure for very
770619 - wide mastectomy until after clear margins are established.
770620 - ref SDS 64 245N
770622 - ..
770623 - The surgeon said that if the surgical biopsies and PET scan
770624 - tests show no evidence of disease, then a standard mastectomy
770625 - could be performed with conventional closure using tissue that
770626 - now appears fully recovered from IBC, rather than perform an
770627 - immedicate reconstruction. Boundary for mastectomy was
770628 - proposed by the doctor on 050727 describing a wider than normal
770629 - mastectomy to reduce the risk of IBC relapse. ref SDS 41 JV5F
770631 - [...see below, surgeon explains risks of standard
770632 - mastectomy for Millie's patient profile. ref SDS 0 KF6I
770634 - ..
770635 - [On 051021 surgeon performed surgery and explained that a
770636 - very wide mastectomy was accomplished with standard closure
770637 - and without complications. ref SDS 72 MM6M
770639 - ..
770640 - About this time, a nurse knocked on the door, and reminded the
770641 - doctor she has another matter to attend, either a surgery or a
770642 - meeting. There was, as a result, no discussion of the doctor's
770643 - proposal for a standard mastectomy if testing shows no disease.
770645 - ..
770646 - This may conflict with Doctor Grissom's recommendations under
770647 - analysis above, ref SDS 0 4G4F, calling for a very wide
770648 - mastectomy to remove previously infected breast skin in order
770649 - to reduce the risks of relapse in the event two (2) criteria
770650 - are met: (1) no distant metastasis is found by tests; and (2)
770651 - local biopsy finds cancer, or finds no evidence of cancer.
770652 - ref SDS 59 XL8U This matter was set out in the record on
770653 - 050918 reviewing Doctor Bailey's first draft, and has not yet
770654 - been addressed. ref SDS 58 E38J Hopefully, we can get
770655 - feedback.
770657 - [On 050927 the surgeon's notes confirm this perspective was
770658 - presented today. ref SDS 62 EU67
770660 - ..
770661 - [On 051012 4 biopsies were taken during minor surgery at
770662 - Kaiser in Walnut Creek. ref SDS 69 DG6J
770664 - ..
770665 - The patient requested a joint meeting with the oncologist, the
770666 - mastectomy surgeon and the plastic surgeon to obtain close
770667 - order collaboration for evaluation of prospects and risks.
770669 - [On 050928 meeting with plastic surgeon at Kaiser scheduled
770670 - for 050928. ref SDS 64 8H5J
770672 - ..
770673 - [On 061027 Millie diagnosed lymphedema and Cellulitis
770674 - caused by removing lymphatics during mastectomy surgery,
770675 - which was not a risk presented by Kaiser. ref SDS 79 HZ7N
770677 - ..
770678 - The surgeon explained that, as seen from difficulty
770679 - collaborating with the primary care physician in oncology,
770680 - reported today, per above, ref SDS 0 N45O, scheduling a joint
770681 - meeting with the plastic surgeon is difficult. She will try to
770682 - make these arrangements. The surgeon further noted that
770683 - doctors at Kaiser can access notes from meetings which make
770684 - joint meetings unnecessary overkill. There was brief
770685 - discussion that typically meeting notes are sparse and lack
770686 - context and accuracy due to lack of connections with prior
770687 - related events and lack of feedback, all due to limited time.
770688 - A joint meeting enables questions to assess silent implied
770689 - assumptions for effective collaboration required by Kaiser's
770690 - Team Care practice.
770692 - [On 050927 surgeon's notes illustrate scope and utility of
770693 - typical work records. ref SDS 62 T14N
770695 - ..
770696 - At the end of the meeting, the surgeon coordinated with the
770697 - nursing staff to schedule minor surgery for thin skin
770698 - biopsies to assess recovery from IBC and to guide layout of
770699 - "very wide mastectomy surgery" in the event the patient
770700 - consents to this procedure after all tests are evaluated.
Experience Performing Very Wide Mastectomy Surgeon Related During Me
810401 - ..
810402 - 6. Experience Performing Very Wide Mastectomy
810404 - Follow up ref SDS 32 QJ3Q.
810406 - Experience performing mastectomy surgery for IBC patients
810407 - criteria listed on 050324. ref SDS 32 YW6O Previously on
810408 - 050727, the surgeon confirmed understandings from the meeting
810409 - on 050324 having limited experience treating patients with IBC,
810410 - ref SDS 32 QJ44, noting this is a rare form of cancer that
810411 - occurs in less than 1% of breast cancer patients, reported
810412 - previously from research on 040517. ref SDS 12 TO7L
810414 - ..
810415 - During the meeting on 050909 Doctor Bailey related that the
810416 - scope of surgery in Millie's case requires a surgeon
810417 - experienced operating on patients with IBC. ref SDS 54 MA5F
810419 - ..
810420 - During the meeting on 050912, Doctor Grissom indicated that
810421 - operating on an IBC patient requires experience that is much
810422 - different from performing mastectomy surgery on a patient who
810423 - does not have IBC. ref SDS 55 X545 Later, during the same
810424 - meeting on 050912 Doctor Grissom seemed to say that a surgeon
810425 - with experience doing mastectomy surgery on patients without
810426 - IBC, could be sufficient to operate on an IBC patient with the
810427 - addition of consultation from a surgeon who has previously
810428 - performed a very wide mastectomy a patient who has contracted
810429 - IBC on relapse. This understanding was set out in the record
810430 - on 2nd opinions presented to the primary care physician during
810431 - a meeting on 050913, ref SDS 56 X545, but is not stated in
810432 - Doctor Grissom's 2nd opinion filed on 050920. ref SDS 59 PR7H
810434 - ..
810435 - The surgeon today described prior experience doing "very wide
810436 - mastectomy" operations, and in collaboration with a plastic
810437 - surgeon to perform contemporaneous reconstructive surgery in a
810438 - complicated 10 hour surgery, as explained in 2nd opinions by
810439 - Doctors Grissom and Bailey. Kaiser's Healthwise Handbook calls
810440 - for review of experience performing specific surgery
810441 - procedures? ref SDS 0 CO5J
Due Diligence Mastectomy Surgery Time Out Risk Management Evaluate I
A30401 - ..
A30402 - Due Diligence Communicate Collaboration Leverage Experience
A30403 - Mastectomy Time Out Evaluate Treatment Options Secondary IBC
A30404 - Time Out Mastectomy Due Diligence IBC No Tumor Pulmonary Emboli
A30406 - Follow up ref SDS 41 O85O, ref SDS 32 O85O.
A30408 - The doctor commended Millie for taking Time Out to follow up
A30409 - recommendations on 050727 to perform due diligence with 2nd
A30410 - opinions on surgery options, ref SDS 41 O85O, as discussed
A30411 - during the meeting today, per above, ref SDS 0 7J67, and called
A30412 - out further by Kaiser's Healthwise Handbook, reviewed on
A30413 - 990625. ref SDS 1 455N Working intelligently with accurate
A30414 - patient history and analysis of context aids medical management
A30415 - for diagnosis and treatment planning through collaboration in
A30416 - the doctor/patient partnership, also, reviewed on 990625.
A30417 - ref SDS 1 3190
A30419 - [On 051012 prepared letter requesting Kaiser implement
A30420 - requirements for "Time Out" to perform due diligence with
A30421 - risk analysis of mastectomy surgery proposal. ref SDS 69
A30422 - 6D4F
A30424 - ..
A30425 - [On 051019 revised draft letter on Kaiser performing Time
A30426 - Out risk management requirements for due diligence.
A30427 - ref SDS 71 JO4N
A30429 - ..
A30430 - Kaiser's website...
A30432 - http://www.permanente.net/handbook/healthwisehandbook/ch_01/ch_01.htm#surgery
A30434 - ...supports risk management in medical practice with a due
A30435 - diligence checklist of requirements in the Healthwise Handbook
A30436 - that are implemented by a "Time Out" notice in the examination
A30437 - room of the primary care physician for the Oncology Department,
A30438 - and which were not performed during the meeting on 050913 due
A30439 - to the flow of communications on that day. ref SDS 56 Q95M
A30440 - Like the "Time Out" notice, Kaiser's Healthwise Handbook says
A30441 - in part...
A30443 - ..
A30444 - Shared Decisions About Surgery
A30446 - Every surgery has risks. Only you can decide if the benefits
A30447 - are worth the risks.
A30449 - ..
A30450 - Learn the facts:
A30452 - What is the name of the surgery?
A30454 - Get a description of the surgery.
A30456 - Why does your physician think you need the surgery?
A30458 - ..
A30459 - Are there other options besides surgery?
A30461 - ..
A30462 - Is this surgery the most common one for this problem? Are
A30463 - there other types of surgery?
A30465 - ..
A30466 - Is the surgery a covered benefit or is there a charge?
A30468 - ..
A30469 - Can it be done on an outpatient basis?
A30472 - ..
A30473 - Consider the risks and benefits:
A30475 - How many similar surgeries has the surgeon performed?
A30477 - ..
A30478 - How many surgeries like this are done at this hospital?
A30480 - ..
A30481 - What is the success rate?
A30483 - What does success mean to your physician?
A30485 - ..
A30486 - What would success mean to you?
A30488 - ..
A30489 - What can go wrong?
A30491 - How often does this happen?
A30493 - [On 061027 Millie diagnosed lymphedema and Cellulitis
A30494 - caused by removing lymphatics during mastectomy
A30495 - surgery. ref SDS 79 HZ7N
A30497 - ..
A30498 - [...below, surgeon asks Millie what she thinks about
A30499 - risks of mastectomy surgery; there is no disclosure of
A30500 - recurring lymphedema and Cellulitis. ref SDS 0 G49M
A30502 - ..
A30503 - How will you feel afterward?
A30505 - ..
A30506 - How long will it be before you're fully recovered?
A30508 - ..
A30509 - How can you best prepare for the surgery and the recovery
A30510 - period?
A30513 - ..
A30514 - Let your physician know:
A30516 - How much the problem really bothers you.
A30518 - Are you willing ot put up with the symptoms to avoid
A30519 - surgery?
A30521 - ..
A30522 - Your concerns about the surgery?
A30524 - ..
A30525 - Whether or not you want to have the surgery at this time.
A30527 - ..
A30528 - If you want a second opinion. Second opinions are helpful
A30529 - if you have any doubt that the proposed surgery is the
A30530 - best option for your problem. If you want a second
A30531 - opinion, ask your primary care physician or your surgeon
A30532 - to recommend another specialist. Ask that your test
A30533 - results be sent to the second physician. Consider getting
A30534 - an opinion from a physician who isn't a surgeon and who
A30535 - treats similar problems.
Criteria Approve Surgery for Extending Quality of Life Where Researc
AA0401 - ..
AA0402 - 7. Criteria to Approve Surgery for Extending Quality of Life
AA0403 - Patient Decision to Have Surgery Consult with the Oncologist
AA0404 - Regional Lymph Nodes Metastatic Cancer Surgery Close Call
AA0405 - Surgery Close Call Regional Lymph Nodes Metastatic Cancer
AA0407 - Follow up ref SDS 41 VL4O, ref SDS 32 VL4O.
AA0409 - Previously, on 050727 the surgeon reviewed risk of metastatic
AA0410 - cancer relapsing. ref SDS 41 R34I Today, the doctor cited the
AA0411 - report on 040309 that biopsy on 040303 diagnosed cancer in the
AA0412 - neck and on the left side. ref SDS 7 0001
AA0414 - ..
AA0415 - Today, the surgeon adamently noted cancer was found above the
AA0416 - supraclavicular commonly associated with IBC, reported on
AA0417 - 040517, ref SDS 12 N23J, and further noted this finding
AA0418 - indicates distant metastatic disease, which makes relapse
AA0419 - likely, regardless of success treating the left breast with
AA0420 - mastectomy for local control, as discussed recently with the
AA0421 - primary care physician, per above. ref SDS 0 7K6K The primary
AA0422 - care physician diagnosed distant metastatic cancer on 040318,
AA0423 - and based on the biopsy taken 040303. ref SDS 8 8R6M At that
AA0424 - time on 040303 the doctor who took biopsies indicated good
AA0425 - practice is to remove suspicious lymph nodes to avoid future
AA0426 - problems. ref SDS 6 Y193 Since only systemic treatment was
AA0427 - used, this area remains at risk.
AA0429 - ..
AA0430 - [On 051007 patient history shows background on surgery
AA0431 - for local control. ref SDS 67 MW5O
AA0433 - ..
AA0434 - [On 051121 primary care physician finds patient has no
AA0435 - evidence of disease (NED) based on estensive testing with
AA0436 - biopsy, PET, CA 1503; prognosis is for future relapse due
AA0437 - to diagnosis of metastatic cancer, and therefore
AA0438 - mastectomy surgery on 051021 was palliation for furture
AA0439 - relapse. ref SDS 76 LH7M
AA0441 - ..
AA0442 - The surgeon today said that even if PET scan tests and skin
AA0443 - biopsies planned in this case, per above, ref SDS 0 OV5H, find
AA0444 - no evidence of cancer, surgery for Millie's patient profile of
AA0445 - secondary IBC, history of relapse, and pulmonary emboli
AA0446 - presents high risk for complications performing mastectomy
AA0447 - surgery. Standard mastectomy cutting into previously infected
AA0448 - breast skin, also, discussed above, ref SDS 0 4G4L, can cause
AA0449 - IBC to relapse due to microscopic cancer cells that remain in
AA0450 - the skin, and which are not detectable by testing. Millie
AA0451 - could have the same problem healing a new surgical wound for
AA0452 - mastectomy that occurred last year when the punch biopsy, which
AA0453 - discovered IBC, did not heal for nearly a year, noted by the
AA0454 - surgeon during the meeting on 050107. ref SDS 26 IS5N There is
AA0455 - also a difficult balance to strike between pausing chemotherapy
AA0456 - long enough to allow the surgical wound to heal, but resuming
AA0457 - treatment before cancer in the skin relapses.
AA0459 - ..
AA0460 - [On 050927 surgeon's notes of the meeting today state
AA0461 - incorrectly patient understanding that mastectomy is for
AA0462 - local control only and will have NO influence on her
AA0463 - distant disease or survival. ref SDS 62 AK4T
AA0465 - ..
AA0466 - [On 050928 Doctor Smith in Plastic Surgery cites high
AA0467 - risk performing mastectomy surgery for Millie's patient
AA0468 - profile. ref SDS 64 9W4I
AA0470 - ..
AA0471 - [On 051007 Doctor Smith's notes from meeting confirm risk
AA0472 - that surgical wound may not heal due to cancer cells
AA0473 - remaining from IBC. ref SDS 67 KO64
AA0475 - ..
AA0476 - [On 051007 primary care physician recommends standard
AA0477 - mastectomy for palliation strategy, ref SDS 67 6A4N,
AA0478 - because microscopic cancer cells may cause relapse in the
AA0479 - future. ref SDS 67 IV4G
AA0481 - ..
AA0482 - [On 051010 Doctor Grissom explains purpose of very wide
AA0483 - mastectomy for patient presenting with secondary IBC and
AA0484 - no evidence of distant metastasis for 4 years is for
AA0485 - local control that could yield a cure. ref SDS 68 GW5K
AA0487 - ..
AA0488 - [On 051021 Millie has surgery for very wide mastectomy to
AA0489 - reduce risks of relapse by removing skin previously
AA0490 - infected with IBC and which main contain microscopic
AA0491 - cancer cells that could otherwise cause relapse.
AA0492 - ref SDS 72 EG5L
AA0494 - ..
AA0495 - Millie's history of relapse while off treatment was reported on
AA0496 - 041230, ref SDS 24 025H, and aligns with research on 040517
AA0497 - citing IBC as the most likely breast cancer to relapse. Rather
AA0498 - than increase local control leading to possible recovery,
AA0499 - mastectomy surgery can make IBC worse...
AA0501 - ...because inflammatory breast cancer involves lymphatic
AA0502 - vessels of the skin, mastectomy can increase the chances
AA0503 - for the cancer to recur (since the skin is stitched
AA0504 - together after mastectomy). ref SDS 12 S74N
AA0506 - ..
AA0507 - Doctor Bailey's consultation on 050909 warned that mastectomy
AA0508 - for Millie's patient profile can spread disease, and was then
AA0509 - discussed with the primary care physician on 050913.
AA0510 - ref SDS 56 X584 Doctor Bailey confirmed this in a 2nd opinion
AA0511 - report received on 050922, ref SDS 60 XD6U, and discussed with
AA0512 - the surgeon today, per above. ref SDS 0 7J6F
AA0514 - ..
AA0515 - [On 050928 Doctor Smith explained risks that a wide
AA0516 - mastectomy with immediate resonstruction to reduce risk
AA0517 - of relapse, could fail testing for clear margins.
AA0518 - ref SDS 64 2491
AA0520 - ..
AA0521 - Doctor Bailey also warns that time off Coumadin for treating
AA0522 - pulmnary emboli risks death, reported on 050922. ref SDS 60
AA0523 - 6Z5Q
AA0525 - ..
AA0526 - [On 051021 Millie has mastectomy surgery; nurse draws
AA0527 - blood to evaluate pulmonary emboli risk related to
AA0528 - treatment with Coumadin. ref SDS 72 QW4I
AA0531 - ..
AA0532 - The surgeon said none of these risks may actually occur, but
AA0533 - they are elevated for secondary IBC patients considering a
AA0534 - standard mastectomy.
AA0536 - ..
AA0537 - The surgeon asked Millie what she thinks about risks of
AA0538 - mastectomy surgery? This implements Kaiser's guidelines for
AA0539 - doctor patient partnership collaborating to make team care
AA0540 - effective by evaluating risks of what can go wrong, per above.
AA0541 - ref SDS 0 CP30
AA0543 - [On 051007 primary care physician recommends mastectomy
AA0544 - surgery without disclosing risks of recurring lymphedema
AA0545 - and Cellulitis. ref SDS 67 P64J
AA0547 - ..
AA0548 - [On 051019 prepare letter for notifying Kaiser to perform
AA0549 - due diligence cites "what do you think...) ref SDS 71 O26Q
AA0551 - ..
AA0552 - [On 061027 Millie diagnosed lymphedema and Cellulitis
AA0553 - caused by removing lymphatics during mastectomy surgery,
AA0554 - which was not a risk presented by Kaiser. ref SDS 79 HZ7N
AA0556 - ..
AA0557 - [On 070607 Cellulitis and lymphedema recurrence again,
AA0558 - Millie treated at UCSF after treatment for cancer,
AA0559 - ref SDS 80 ZH6I, Millie suffers significant emotional
AA0560 - stress. ref SDS 80 R46O
AA0562 - ..
AA0563 - Millie said she would like to follow advice of the primary care
AA0564 - physician and investigate mastectomy surgery to reduce side
AA0565 - effects of continuous chemotherapy treatments for local
AA0566 - control. On 050913 the primary care physician emphasized that
AA0567 - surgery is the best chance of extending quality of life.
AA0568 - ref SDS 56 5T4J This fits comments from Doctor Grissom the day
AA0569 - before on 050912 indicating that surgery is very high risk, but
AA0570 - a very wide mastectomy that removes previously infected skin on
AA0571 - the left breast offers the best chance to reduce chemotherapy
AA0572 - treatments, at least for awhile. ref SDS 55 MW67
AA0574 - ..
AA0575 - Millie noted that the first step in risk assessment requires
AA0576 - completing PET scan and biopsy tests discussed today, per
AA0577 - above. ref SDS 0 OV5H If this is favorable, then we can begin
AA0578 - planning surgery to see if risks can be reduced. For example,
AA0579 - if breast tissue is replaced with DIEP flap or TRAM technique,
AA0580 - ref SDS 0 E863, does this reduce chance of recurrence, perhaps
AA0581 - through radiation treatments? Can a very wide mastectomy be
AA0582 - performed to reduce the risk of relapse by removing skin
AA0583 - previously infected with IBC, and which may still contain
AA0584 - microscopic cancer cells, cited by the surgeon today, per
AA0585 - above, ref SDS 0 KF6I, and can closure be accomplished without
AA0586 - immediate reconstruction? What options are available to make
AA0587 - surgery effective?
AA0589 - ..
AA0590 - If PET scan if favorable, but one or more thin skin biopsies
AA0591 - are positive for cancer, does this eliminate the surgical
AA0592 - option, or should the perimeter of the very wide mastectomy be
AA0593 - extended based on further skin biopsies?
AA0595 - ..
AA0596 - The surgeon will submit written analysis of the meeting today
AA0597 - for follow up with doctors who have submitted 2nd opinions, and
AA0598 - requesting feedback on the idea presented today, that if all
AA0599 - tests are favorable, then a standard mastectomy can be
AA0600 - performed, rather than the "very wide" scheme discussed today,
AA0601 - per above. ref SDS 0 4G4L
AA0603 - [On 050927 received surgeon notes; review shows close
AA0604 - alignment with the record today. ref SDS 62 T14N