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


S U M M A R Y


DIARY: October 10, 2005 04:13 PM Monday; Rod Welch

Collaborate with consultants on mastectomy for secondary IBC.

1...Summary/Objective
2...Disease-free Status NED Presents Opportunity for Cure
3...Cure Opportunity Presented by Disease-free Status NED
4...Very Wide Mastectomy Immediate Resonstruction Opportunity for Cure
5...Palliation for Disease-free Patient Cure Purpose Very Wide Mastectomy


..............
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CONTACTS 
0201 - Medical Offices Nima Grissom                                                                                                                                       O-00000849 0601
020101 - Ms. Mary NLN; Secretary                                                                                                                                          O-00000849 0601
020103 - Administration Department                                                                                                                                        O-00000849 0601

SUBJECTS
Letter to Doctor Grissom on Scope of Mastectomy Surgery Kaiser Prima
Letter to Doctor Bailey on Scope of Mastectomy Surgery Kaiser Primar

1804 -
1804 -    ..
1805 - Summary/Objective
1806 -
180601 - Follow up ref SDS 36 0000. ref SDS 34 0000.
180602 -
180603 -
180604 -
180606 -  ..
1807 -
1808 -
1809 - Progress
1810 -
181001 - Submitted letter to Doctor Bailey, following up the doctor's letter on
181002 - 050923, ref SDS 39 4N5J, with copy to Doctor Grissom explaining
181003 - results of meeting with primary care physisian on 051007, and current
181004 - planning to consider standard mastectomy...
181005 -
181006 -    1.  We met with the oncologist, Doctor Johnson, last Friday,
181007 -        051007. ref SDS 44 0000  Very good news.  A PET scan test
181008 -        confirmed prior testing for the past 4 years showing no
181009 -        distant, regional nor local residual nor recurrent disease.
181010 -        ref SDS 44 L66M
181012 -         ..
181013 -    2.  Tomorrow, Mil will have the surgical biopsies on the left
181014 -        breast performed, recommended by Doctor Grissom's 2nd opinion,
181015 -        received on 050920, ref SDS 36 XL7P, and implemented by the
181016 -        surgeon at Kaiser on 050923. ref SDS 40 NT9G
181017 -
181018 -             [On 051021 mastectomy surgery performed, ref SDS 46 0001,
181019 -             and biopsy report received, and indicates complete
181020 -             response to treatment with no evidence of IBC. ref SDS 46
181021 -             LH6O
181023 -         ..
181024 -    3.  During the meeting on Friday, 051007, the oncologist insisted
181025 -        that Millie have a standard mastectomy. ref SDS 44 P64J  He
181026 -        asked Millie to schedule the procedure, and if, as is likely,
181027 -        the work cannot be performed within the next week or so, then
181028 -        Millie will call the doctor, and he will schedule another cycle
181029 -        of Taxotere and capecitabine chemotherapy treatment.
181030 -        ref SDS 44 MW6O
181032 -         ..
181033 -    4.  The primary care physician was asked on Friday about the
181034 -        purpose of a standard mastectomy, ref SDS 44 IV4G, given that
181035 -        there is no evidence of disease in the breast to remove via
181036 -        surgery, based on the recent PET scan test, and that Millie had
181037 -        a lumpectomy to remove tumor, and clear margins were reported
181038 -        in 2002? ref SDS 2 0001
181040 -         ..
181041 -    5.  Research indicates that the purpose of mastectomy in treating
181042 -        IBC is to remove the tumor within the breast that causes IBC in
181043 -        the skin. ref SDS 44 KE9N  The primary care physician said that
181044 -        is not his objective in this case.  He said the purpose of a
181045 -        mastectomy for Millie is palliation. ref SDS 44 6A4N  He
181046 -        expects there remain microscopic remnants of disease, despite
181047 -        favorable tests, that will eventually cause relapse, since the
181048 -        breast has relapsed twice previously. and so he wants surgery
181049 -        at this time to reduce discomfort to the patient if relapse
181050 -        occurs again. ref SDS 44 IV4G  The doctor objected to a request
181051 -        for a written explanation citing appropriate guidance on the
181052 -        rationale for mastectomy. ref SDS 44 438K
181054 -         ..
181055 -    6.  As things stand, it is not clear what palliative or other
181056 -        objective would be served in this case by a standard
181057 -        mastectomy.  Since tumor was previously removed, and tests show
181058 -        no evident target for removal, how does a surgeon decide what
181059 -        to remove and how much in order to achieve a palliative
181060 -        solution?
181062 -         ..
181063 -    7.  To review, on 050727, we met with the surgeon and asked about
181064 -        the scope of surgery. ref SDS 14 JV5F
181066 -         ..
181067 -    8.  The doctor placed her finger on Millie's left breast above the
181068 -        nipple, and said... "Normally I would make an incision here,
181069 -        but in this case (she spread her fingers apart about 1.5
181070 -        inches) I will take out this much more...," or words to that
181071 -        effect.  The rationale for the proposed scope was not
181072 -        presented, and at that time the primary care physician's goal
181073 -        for a palliation solution had not yet been presented.
181075 -         ..
181076 -    9.  If you have time, I would greatly appreciate your comments on
181077 -        palliative benefits are reasonable to achieve with Millie's
181078 -        patient profile, and what risks she faces in consenting to a
181079 -        standard mastectomy?
181080 -
181081 -            [...see below, Doctor Grissom proposes surgery for cure
181082 -            rather than palliation based on disease-free status shown
181083 -            by PET scan tests. ref SDS 0 GW4I
181085 -             ..
181086 -            [On 051011 Doctor Bailey comments. ref SDS 45 X93F
181088 -         ..
181089 -   10.  Previously, you cited interruption of Coumadin treatments for
181090 -        surgery could cause death, reported on 050922, ref SDS 38 6Z5Q,
181091 -        so that is an obvious risk.  You also raised cutting into IBC
181092 -        infected skin that won't heal. ref SDS 38 XD8P  Kaiser expects
181093 -        to address this with a standard mastectomy, which minimizes the
181094 -        healing problem caused by a wide area mastectomy, as presented
181095 -        by the plastic surgeon at Kaiser on 050928. ref SDS 42 245N  At
181096 -        one time, we thought the purpose of mastectomy was to remove
181097 -        previously infected skin, but apparently this is not a standard
181098 -        purpose of mastectomy for IBC.  Nothing has been found on the
181099 -        Internet that describes performing a mastectomy to remove
181100 -        previously infected skin; rather the purpose given is to remove
181101 -        a tumore within the breast, as reported on 040517. ref SDS 3
181102 -        YM3M
181104 -         ..
181105 -   11.  Additionally, on 051007 the doctor ended Millie's treatment
181106 -        with Coumadin.  He indicated that Kaiser normally treats
181107 -        patients for a year on Coumadin, but that cancer patients are
181108 -        treated for life. ref SDS 44 XN7K  It is not clear why an
181109 -        exception was made in this case; perhaps the original evidence
181110 -        of pulmonary emboli was not very strong, i.e., a single CT
181111 -        test, nothing before nor nothing since.
181112 -
181113 -
181114 -
181115 -
181116 -
181117 -
1812 -

SUBJECTS
Cure Patient Opportunity Disease-free Status NED Very Wide Mastectom

3903 -
3904 - 1637
390501 -  ..
390502 - Disease-free Status NED Presents Opportunity for Cure
390503 - Cure Opportunity Presented by Disease-free Status NED
390504 - Very Wide Mastectomy Immediate Resonstruction Opportunity for Cure
390505 - Palliation for Disease-free Patient Cure Purpose Very Wide Mastectomy
390506 -
390507 - Doctor Grissom called back.
390508 -
390509 - The doctor has read the letter reporting on meeting with the primary
390510 - care physician on 051007, per above, ref SDS 0 X93F, and commented
390511 - that Kaiser's proposal for surgery to enable "palliation" of a future
390512 - relapse, ref SDS 0 1U7Y, seems conflicting with patient history listed
390513 - on 050812 that shows symptoms of IBC have already been relieved by
390514 - systemic treatment, ref SDS 20 RM6F, citing examination by the surgeon
390515 - on 050727. ref SDS 14 YY7F
390517 -  ..
390518 - Doctor Grissom said that Millie's test history showing no evidence of
390519 - distant metastasis, ref SDS 44 AG6G, and the recent PET test reported
390520 - on 051007 showing no evidence of locoregional disease, ref SDS 44
390521 - GJ4S, presents Millie with an opportunity for cure with a very wide
390522 - mastectomy that removes and replaces with immediate reconstruction
390523 - skin previously infected with IBC, proposed in the doctor's 2nd
390524 - opinion received on 050920, ref SDS 36 XL8U, and also proposed by
390525 - Doctor Shim at Kaiser in a 2nd opinion received on 050907. ref SDS 28
390526 - F49H
390528 -  ..
390529 - The doctor asked for further news on Millie's decision, and results
390530 - going forward, following up her 2nd opinion on 050920 citing citing
390531 - difficulty of Millie's condition. ref SDS 36 XL4V
390532 -
390533 -        [On 051021 Kaiser performs mastectomy surgery for purpose of
390534 -        palliation. ref SDS 46 8L9K
390536 -         ..
390537 -        [On 051021 surgeon performed surgery and explained that a very
390538 -        wide mastectomy was accomplished with standard closure and
390539 -        without complications. ref SDS 46 MM6M
390541 -         ..
390542 -        [On 051027 examination and biopsy indicate disease-free status,
390543 -        revovering from mastectomy surgery. ref SDS 47 0001
390545 -         ..
390546 -        [On 051007 case study purpose of mastectomy surgery cure, local
390547 -        control, palliation. ref SDS 47 F25H
390549 -         ..
390550 -        [On 051109 notified Doctor Grissom of Millie's decision and
390551 -        initial success of surgery on 051021. ref SDS 48 KS5N
390552 -
390553 -
390554 -
390555 -
390556 -
390557 -
390558 -
390559 -
3906 -
Distribution. . . . See "CONTACTS"