THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: July 11, 2006 09:30 AM Tuesday;
Millie meeting at Kaiser treatment plan IBC cancer relapse post-surgery.
2...Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
3...Vitals Show Stable Medical Condition
4...CA 15-3 Cancer Marker 71 Rise from 63 Past 3 Weeks
5...CA 15-3 71 Cancer Marker Rises Significantly Above Target Level 39
6...Esophagitis in PET Test and Nodes Right Paratracheal Found CT Test
7...Xray Pneumonia Resolved Clears Patient to Start Cancer Treatment
8...Penumonia Recovery Verified by Xray Enables Cancer Treatment to Start
........Test History No Evidence Distant Metastasis
9...Left Auxilary No Evidence Lymphadenopathy
10...Lymphedema Left Arm Lump Under Arm Diagnosis Not Cancer
11...Post Operation Localized Edema Left Axillary Swelling Reduced
12...Right Axillary FDG SUV 2.5 Lump Discomfort Not Reported by Patient
13...Radiation Treatment Cancer Relapse Left Supraclavicular and IBC
14...Left Supraclavicular Examination PET Test Report Finding SUV 4.5
15...Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
16...Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
17...Cancer Metastatic Disease 3rd Relapse IBC Left Breast
18...Diagnosis IBC Relapse Left Breast at Mastectomy Incision Wound
19...Examination Left Breast IBC Inflammation Mastectomy Incision Wound
20...IBC Inflammation Left Breast Incision for Mastectomy Surgery on 051021
21...Case Study Scope Mastectomy Reduce Risk Relapse
22...Case Study Local Regional Distant Metastatic Cancer Disease
.......Case Study Cancer Terminology Local Regional Distant Metastasis
23...Case Study Risk Microscopic Cancer Not Treated Mastectomy Chemo
24...Biopsy to Determine Biology of IBC and Guide Choice of Treatment
25...Distant Metastasis PET CT Image Testing No Evidence for 5 Years
26...PET CT Image Testing No Evidence Distant Metastatic Disease 5 Years
27...IBC Image Tests PET CT Sometimes Identify Skin Thickening Case Study
28...Image PET CT Test IBC Difficult to See Skin Thickening Case Study
29...Image Test Case Study IBC Reported Skin Dermal Thickening Nodes Swell
30...Skin Thickening IBC Difficult for Image PET CT Testing Recognize
31...Emotional Trauma Eased by Engagement with Work Family and Exercise
32...Exercise Vigor Strength Engagement Ease Distress Living with Cancer
33...Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
34...MRI Showed No Evidence of Disease in Head Brain
35...Dizziness Occurs Occasionally MRI Finds No Evidence of Disease Head
36...Pool Chemotherapy Drugs Available to Treat IBC
37...Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
38...Treatment Work Up Plan Effective Against IBC and Reduce Side Effects
39...Strategy Issues for Treatment Plan Based on Patient History...
40...High Dose Chemotherapy HDC Strategy Balance Patient Tolerance
41...Side Effects Tolerate High Dose Chemotherapy for Effectiveness
42...HDC Strategy Reverse Growth Cancer When Patient Tolerance High
43...Treatment Effectivenss Balance Patient Tolerance Side Effects
............HDC May Fail Theory Flawed Requires Careful Analysis
44...Treatment Start with Capecitabine (Xeloda) and Taxotere
........Navelbine Treatment of Relapse, Side Effects Uncertain
........Cancer Patients Noble Suffers Pioneers Exemplars Saviors
........Navelbine Capecitabine (Xeloda) Combined
........CA 15-3 300 High Breast Cancer Marker Not Millie's History
........300 CA 15-3 Breast Cancer Marker Well Above Millie's Highest
........Gemzar and Taxotere Treatment for IBC
........Drug Trial - Doctor Checking with Rosalie
........Novel Expthilones BMS-247550 Plus Capecitabine
45...Breast Replacement Surgery Deferred in 2005 Review Options in 2006
46...Radiation Treatment Left Supraclavicular Per Tumor Board
47...Schedule Treatment Meeting Pharmacist, Zan Start Xeloda Taxotere
48...Pharmacist Zan Schedules Treatment with Capecitabine Taxotere
49...Port Catheter Flush Performed at Kaiser to Maintain Chemo Treatment
50...Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
51...Treatment Options Limited Status Not Changed by Retest Biopsy 040419
52...Work Plan Received Communications Doctor/Patient Partnership
53...Communications Doctor Submits Work Plan Doctor/Patient Partnership
54...Doctor/Patient Partnership Communications Doctor Submits Work Plan
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1...The core question is how much time is available to experiment finding
Meeting Doctor Examine Recovery from Mastectomy Surgery Response to
0403 - ..
0404 - Summary/Objective
040501 - Follow up ref SDS B3 0000. ref SDS 98 0000.
040503 - CA 15-3 continues rising, ref SDS 0 GJ5M, and red rash on left breast
040504 - spreads. ref SDS 0 025H Diagnosis is IBC 3rd relapse. ref SDS 0 025H
040505 - Medical costs were reduced by not ordering a biopsy to verify
040506 - condition, and check for staging status change. ref SDS 0 KT7J The
040507 - doctor found status change report based on the biopsy taken 040419;
040508 - shows status has not changed, which continues to limit treatment
040509 - options. ref SDS 0 ZR6J Treatment will start with 2 cycles of
040510 - capecitabine (Xeloda) and Taxotere, which was previously effective.
040511 - ref SDS 0 PF3O Treatment strategy based on comprehensive list of
040512 - available drugs, and review of surgery options is needed. ref SDS 0
040513 - K36G Protocol nurse researching drug trials that fit Millie's patient
040514 - profile. ref SDS 0 WB9K Pharmacist provided orientation and notified
040515 - the Infusion Department to schedule Millie for treatment as soon as
040516 - possible. ref SDS 0 N96O
040518 - [On 060806 Kaiser notified IBC progressing rapidly after 1st cycle
040519 - Taxotere capecitabine treating recurrence. ref SDS C4 7Q95
040521 - ..
040522 - [On 060807 Kaiser schedules urgent meeting for 060808 to change
040523 - treatment plan. ref SDS C5 423C
040525 - ..
040526 - [On 060808 emergency meeting with backup doctor to consider
040527 - switching treatments; patient reports possible improvement with IBC
040528 - inflammation beginning to subside. ref SDS C7 0001
040530 - ..
040531 - [On 080306 4th relapse of IBC, doctor finds progression of disease,
040532 - orders increasing treatment on clinical study by adding Carboplatin
040533 - to cetuximab. ref SDS E7 NW3N
040540 - ..
0408 - Progress
040901 - Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
040903 - Follow up ref SDS B3 SM6M, ref SDS 98 SM6M.
040905 - This is the 6th review meeting with primary care physician following
040906 - mastectomy surgery on 051021, ref SDS 82 0001, and after post op
040907 - examination by the surgeon on 051027 reported status was "no evidence
040908 - of disease (NED)". ref SDS 84 M58G On 060623 examination finding red
040909 - rash indicates IBC cancer relapse, ref SDS B3 025H; focus turns to
040910 - planning treatment.
040912 - ..
040913 - Millie submitted agenda prior to the meeting so the doctor could be
040914 - prepared. Prior to the meeting, Millie listed the agenda on the
040915 - marking board in the examination room to guide discussions...
040917 - 1. CA 15-3 cancer marker report............... ref SDS 0 GJ5M
040918 - 2. Pneumonia recovery xray results............ ref SDS 0 TV5G
040919 - 3. Lymphedema improving with treatment........ ref SDS 0 MW8J
040920 - 4. Breast exam IBC relapse diagnosis.......... ref SDS 0 025H
040921 - 5. Dizziness MRI test results................. ref SDS 0 PT4K
040922 - 6. Treatment plan strategy.................... ref SDS 0 K36G
040923 - 7. Status change treatment options............ ref SDS 0 ZR6J
040925 - [...below, doctor comments on agenda issues. ref SDS 0 FW6K
040927 - ..
040928 - Scheduled next meeting in 6 weeks after the doctor returns from
040929 - vacation. on August 25, 2006
Vitals Show Stable Medical Condition Meeting Primary Care Physician
060401 - ..
060402 - Vitals Show Stable Medical Condition
060404 - Follow up ref SDS B3 KB5L, ref SDS 98 KB5L.
060406 - ..
060407 - Bld Prssr Pulse Temp Weight SaO2
060408 - ..
060409 - 060711................. 172 87 54 97.5 147
060410 - 060623................. 141 87 71 98.0 147 99%
060411 - 060428................. 129 73 80 99.4 149 99%
060412 - 060217................. 153 81 61 98.6 150 99%
060414 - ...per Doctor's report, shown below. ref SDS 0 JQ4J
CA 15-3 71 and 32 Above 39 Signals Relapse IBC Growing Red Rash and
180401 - ..
180402 - CA 15-3 Cancer Marker 71 Rise from 63 Past 3 Weeks
180404 - Follow up ref SDS B3 087J, ref SDS 98 087J.
180406 - The most recent blood test on 060616 shows CA 15-3 now at 63 continues
180407 - rising; since dropping to 28 on 051202 there has been accelerated rise
180408 - until 060522, then slightly reduced rate of increase. The test report
180409 - received today shows...
180411 - ..
180412 - Test Date Date Received
180413 - 060708......... 71 H............. 060711, ref SDS 0 087J
180414 - 060616......... 63 H............. 060623, ref SDS B3 UQ5Q
180415 - 060522......... 59 H............. 060605, ref SDS A8 UQ5Q
180416 - 060501......... 49 H............. 060522, ref SDS A5 MC4F
180417 - 060421......... 44 H............. 060428, ref SDS 99 087J
180418 - 060330......... 40 H............. 060428, ref SDS 99 087J
180419 - 060303......... 36............... 060428, ref SDS 99 087J
180420 - 060210......... 33............... 060217, ref SDS 89 087J
180421 - 060109......... 34............... 060126, ref SDS 88 KV59
180422 - 051223......... 34............... 060106, ref SDS 87 087J
180423 - 051202......... 28............... 060106, ref SDS 87 087J
180424 - 051116......... 31............... 051121, ref SDS 85 087J
180425 - 051109......... 30............... 051121, ref SDS 85 087J
180426 - 051102......... 34............... 051121, ref SDS 85 087J
180427 - 050909......... 45 H............. 051007, ref SDS 78 087J
180428 - 050826......... 45 H............. 050913, ref SDS 72 087J
180429 - 050819......... 45 H............. 050913, ref SDS 72 087J
180430 - 050812......... 39 .............. 050819, ref SDS 65 3K6L
180431 - 050729......... 45 H............. 050819, ref SDS 65 EA5G
180432 - 050708......... 46 H............. 050729, ref SDS 64 087J
180433 - 050701......... 37 .............. 050729, ref SDS 64 087J
180434 - 050617......... 45 H............. 050729, ref SDS 64 087J
180435 - 050527......... 56 H............. 050610, ref SDS 61 087J
180436 - 050512......... 67 H............. 050520, ref SDS 59 087J
180437 - 050506......... 80 H............. 050520, ref SDS 59 087J
180438 - ..
180439 - 050415.........105 H............. 050422, ref SDS 57 087J
180440 - 050325.........100 H............. 050329, ref SDS 55 087J
180441 - 050318.........101 H............. 050325, ref SDS 54 2N5J
180442 - 050304......... 88 H............. 050311, ref SDS 52 087J
180443 - 050225......... 95 H............. 050308, ref SDS 51 0001
180444 - 050211......... 78 H............. 050214, ref SDS 50 02BB
180445 - 050128......... 67 H............. 050204, ref SDS 49 087J
180446 - 041228......... 56 H............. 041230, ref SDS 48 087J
180447 - 041204......... 43 H............. 041210, ref SDS 47 087J
180448 - 041007......... 39............... 041104, ref SDS 43 087J
180449 - 040923......... 49 H............. 041005, ref SDS 42 087J
180450 - 040908......... 44 H............. 040909, ref SDS 41 087J
180451 - 040825......... 47 H............. 040909, ref SDS 41 087J
180452 - 040811......... 42 H............. 040812, ref SDS 40 087J
180453 - 040728......... 43 H............. 040729, ref SDS 38 2N5J
180454 - 040712......... 47 H............. 040713, ref SDS 37 087J
180455 - 040614......... 55 H............. 040615, ref SDS 36 PX6X
180456 - 040517......... 78 H............. 040601, ref SDS 34 2N5J
180457 - 040311......... 70 H............. 040318, ref SDS 28 SM6M
180458 - 040205......... 60 H............. 040211, ref SDS 26 SM6M
180459 - 031201......... 62 H............. 031205, ref SDS 25 SM6M
180460 - 030912......... 66 H............. 030915, ref SDS 24 SM6M
180461 - 030708......... 68 H............. 030710, ref SDS 23 SM6M
180462 - 030503......... 54 H............. 030508, ref SDS 21 SM6M
180463 - 030403......... 45 H............. 030508, ref SDS 21 SM6M
180464 - 030215......... 46 H............. 030220, ref SDS 20 5E6L
180465 - 030106......... 37 H............. 030109, ref SDS 19 SM6M
180466 - 021202......... 41 H?............ 021204, ref SDS 18 SP5G
180467 - 021111......... 36 H?............ 021113, ref SDS 17 Y65I
180468 - 021023......... 33 H?............ 021023, ref SDS 16 SQ5I
180469 - 020930......... 33 H?..29........ 021002, ref SDS 15 SQ5I
180470 - 020917......... 36 H?............ 020924, ref SDS 14 SQ5I
180471 - 020717......... 59 H?............ 020726, ref SDS 13 YN5K
180472 - 020629......... 75 H ............ 020705, ref SDS 11 UX6I
180473 - 020608........ 67 H ............ 020614, ref SDS 9 0001
180474 - 020603........ 108 H ............ 020607, ref SDS 8 X67F
180475 - 020511........ 117 H ............ 020603, ref SDS 7 PJ4J
180476 - 020419......... 81 H ............ 020430, ref SDS 5 7N5H
180477 - 020321......... 85 H ............ 020405, ref SDS 4 6T8K
180483 - ..
1807 - Analysis
180801 - CA 15-3 71 Cancer Marker Rises Significantly Above Target Level 39
180803 - Follow up ref SDS B3 GJ5M, ref SDS 98 GJ5M.
180805 - ..
180806 - The most recent CA 15-3 test on 060708 rose from 63 to 71, well above
180807 - the cancer signal level of 39, and consistent with spreading IBC
180808 - relapse observed by examination today of red rash on left breast at
180809 - mastectomy incision. ref SDS 0 025H
180811 - [On 060810 CA 15-3 jumps to 87, 7 above the 80 level cited for
180812 - considering change of treatment, and a very large jump in
180813 - patient history, ref SDS C8 2N5J, order follow up test to
180814 - assess correlation between observed decline IBC inflammation
180815 - and rising CA 15-3. ref SDS C8 854L
180817 - ..
180818 - [On 060817 CA 15-3 73 dramatic improvement, reversing 6 month rise
180819 - of cancer marker, now falling back below critical 80 level,
180820 - ref SDS C9 TS5O; supports observation impression on 060808 that
180821 - IBC red rash subsiding and breaking up, ref SDS C7 VO6G, further
180822 - reported on 060817, ref SDS C9 NU6L, evidence patient experiencing
180823 - delayed response to treatment under scenario #1, developed on
180824 - 060808. ref SDS C7 J16O
180826 - ..
180827 - CA 15-3 complements PET scan test results on 060428, ref SDS 98 A544,
180828 - and CT test report on 060523, ref SDS A5 014T, which do not find
180829 - rising cancer activity, because IBC does not display in imaging tests,
180830 - except as "skin thickening," if an analyst checks for this condition,
180831 - discussed previously on 060623, ref SDS B3 BB9M, and noted in research
180832 - on 040517. ref SDS 33 LK8L
180834 - ..
180835 - Research today shows CA 15-3 tests can register above 300. ref SDS 0
180836 - 9U3L Since Millie's maximum test report was 117 shown on 020511,
180837 - ref SDS 0 KV59, this suggests cancer may not have reached a level that
180838 - cascades out of control.
180840 - [On 061208 after about 7 cycles with Taxotere and capecitabine
180841 - IBC worsened; Kaiser considered switching to Navelbine,
180842 - however, review of the record today indicating poor prognosis
180843 - with Navelbine led to investigation of clinical drug trial
180844 - options presented during 2nd opinion review at UCSF.
180845 - ref SDS E3 XC8K
Esophagitis PET Scan Test Not Compared with Prior Report Symptoms Mi
220401 - ..
220402 - Esophagitis in PET Test and Nodes Right Paratracheal Found CT Test
220404 - Follow up ref SDS B3 DH4O, ref SDS 98 DH4O.
220406 - Issues and background on diagnosis of esophagitis reported in PET scan
220407 - test performed on 060120, and received on 060126, ref SDS 88 DH4O, and
220408 - contrast CT test study on 060505 reporting on 060523 findings of less
220409 - than 1 cm nodes in the right paratrachael region, ref SDS A5 4O8P,
220410 - were most recently reviewed on 060623. ref SDS B3 DH4O
220412 - ..
220413 - At that time, on 060623 follow up on diagnosis of esophagitis was
220414 - deferred because of difficulty accessing records on Kaiser's
220415 - computers. ref SDS B3 463H
220417 - ..
220418 - About week ago, Millie had a strong episode of reflux, sometimes
220419 - associated with esophagitis.
220421 - ..
220422 - Today, the doctor seemed to have resolved prior access problems and
220423 - reviewed Kaiser's computer files discussed during the meeting on
220424 - 060623, ref SDS B3 J56J, including PET and CT scan imaging tests on
220425 - 060120 and on 060505, which show findings related to esophagitis.
220426 - ref SDS B3 QF6L There was no access to the test files during the
220427 - meeting today, however, the doctor referred to independent review
220428 - subsequent to the meeting on 060623.
220430 - ..
220431 - The doctor advised that attending physicians, who treated Millie for
220432 - pneumonia in the Emergency Room on 060607, and asked about a
220433 - pre-existing diagnosis of esophagitis, ref SDS A9 K66E, made a mistake
220434 - interpreting computer image test files as establishing diagnosis of
220435 - esophagitis. The doctor explained that imaging tests do not
220436 - "diagnose," per se; only the doctor makes this decision based on full
220437 - assessment of patient history.
220439 - ..
220440 - The doctor indicated that the patient's report today of occassional
220441 - digestion problems supports deferring investigation of PET and CT scan
220442 - imaging test findings, until clinical symptoms become more prominent
220443 - for esophagitis.
220445 - [On 061110 patient reports rising indigestion; symptoms
220446 - still too infrequent to treat esophagatis. ref SDS D9 0R8J
220448 - ..
220449 - There is no correction in the doctor's medical chart, shown below,
220450 - ref SDS 0 1248, to cite CT test on 060505 reporting nodes in the right
220451 - paratracheal, which may relate to esophagitis, ref SDS 0 1248, as
220452 - noted on 060623. ref SDS B3 6W4M
Xray Pneumonia Resolved Clears Patient to Start Cancer Treatment Joh
280401 - ..
280402 - Xray Pneumonia Resolved Clears Patient to Start Cancer Treatment
280403 - Penumonia Recovery Verified by Xray Enables Cancer Treatment to Start
280405 - Follow up ref SDS B3 TV5G, ref SDS A9 PT7S.
280407 - Millie was treated in the ER on 060607 for temperature of 104+, and
280408 - diagnosis was pneumonia. ref SDS A9 PT7S She was released on 060609
280409 - and later reported recovery on 060615. ref SDS B1 TC4T
280411 - ..
280412 - On 060623 the doctor ordered an xray to verify pneumonia is clear from
280413 - the lungs, ref SDS B3 6W9G, as a predicate to starting chemotherapy
280414 - for IBC relapse, diagnosed at that time on 060623. ref SDS B3 025H
280416 - ..
280417 - Test History No Evidence Distant Metastasis
280419 - Type Date Received Source
280420 - MRI 060708 reported on 060711........... ref SDS 0 PT4K
280421 - Xray 060623 reported on 060711........... ref SDS 0 WJ6G
280422 - CT 060505 reported on 060523........... ref SDS A5 009L
280423 - PET 060414 reported on 060428........... ref SDS 98 WJ6G
280424 - PET 060120 reported on 060126........... ref SDS 88 WJ6G
280425 - PET 051005 reported on 051007........... ref SDS 78 WJ6G
280426 - CT 050530 reported on 050610........... ref SDS 61 G75L
280427 - CT 050325 reported on 050422........... ref SDS 57 G75L
280428 - CT 041217 reported on 041230........... ref SDS 48 G75L
280429 - CT 041103 reported on 041104........... ref SDS 43 NL4N
280430 - CT 040921 reported on 041005........... ref SDS 42 NL4N
280431 - CT 040710 reported on 040811........... ref SDS 39 DU9I
280432 - CT 040410 reported on 040416........... ref SDS 30 HX4K
280433 - CT 040307 reported on 040318........... ref SDS 28 LK5L
280434 - CT 031031 reported on 031205........... ref SDS 25 IG9K
280435 - CT 030626 reported on 030710........... ref SDS 23 AL6N
280436 - CT 030428 reported on 030508........... ref SDS 21 LK5L
280437 - PET 021218 reported on 030109........... ref SDS 19 LK5L
280438 - PET 020529 reported on 020603........... ref SDS 7 0001
280441 - ..
280442 - CHEST XRAY (Digital)
280447 - ..
280448 - Patient
280456 - ..
280457 - History
280459 - H/O LLL inflitrate
280461 - ..
280462 - Findings
280464 - The lungs are clear and the costophrenic angles are sharp. The
280465 - heart, mediastinum and bony thorax are unremarkable. Right
280466 - central catheter is noted.
280468 - ..
280469 - Impression
280471 - No acute disease in the chest.
280473 - ..
280474 - These findings resolve pneumonia found in the xray test on 060607.
280475 - ref SDS A9 PT7S
280477 - ..
280478 - Xray test report concludes...
280480 - RAD.REP
280481 - MTZRAJ................... 07/11/06 09:11
280483 - ..
280484 - The doctor advised that this test report showing pneumonia resolved
280485 - clears Millie for cancer treatment, previously delayed to verify that
280486 - chemotherapy would have no risk of compounding medical problems due to
280487 - lowered white blood cell (WBC) condition, reported on 060623.
280488 - ref SDS B3 6W9G
280490 - [...see below consideration for prescribing nupigen, similar to
280491 - prior circumstances of lowered immune system. ref SDS 0 O16H
Left Auxillary No Evidence Lymphadenopathy Lymphedema Left Arm Lump
380401 - ..
380402 - Left Auxilary No Evidence Lymphadenopathy
380403 - Lymphedema Left Arm Lump Under Arm Diagnosis Not Cancer
380404 - Post Operation Localized Edema Left Axillary Swelling Reduced
380406 - Follow up ref SDS B3 MW8J, ref SDS 98 MW8J.
380408 - ..
380409 - Patient history of left axillary lymphadenopathy and lymphedema is
380410 - reported on 060106. ref SDS 87 S164
380412 - ..
380413 - On 060710 physical therapist found significant improvement; decided to
380414 - end physical therapy, since patient making good progress with
380415 - self-care. ref SDS B4 Q05H
380417 - ..
380418 - There was no examination today of the left auxillary, and there was no
380419 - complaint of lump or discomfort by the patient, consistent with image
380420 - test reporting during the meeting on 060623 indicating no findings of
380421 - lymphadenopathy at this time, ref SDS B3 MW8J, therefore, suggesting
380422 - cancer relapse seems primarily local.
Right Axillary Clinical Examination Finds No Lump Patient Complains
430401 - ..
430402 - Right Axillary FDG SUV 2.5 Lump Discomfort Not Reported by Patient
430404 - Follow up ref SDS B3 CZ8L, ref SDS 98 CZ8L.
430406 - Patient history of rising FDG SUV activity by PET testing, reported on
430407 - 060428, ref SDS 98 CZ8L, and no adenopathy found in contrast CT test
430408 - reported on 060526, ref SDS A5 4O8P, which further failed to perform
430409 - contrast with the PET test findings, ref SDS A4 WT6M, was reviewed
430410 - during a meeting with the doctor on 060623. ref SDS B3 CZ8L
430412 - ..
430413 - At that time on 060623 attention switched from the right axillary to
430414 - IBC relapse in the left breast, based on examination showing red rash
430415 - on left breast. ref SDS B3 6X3N
430417 - ..
430418 - As a result, there was no examination of the right axillary, and no
430419 - further direction to correct possible error in the CT test on 060526.
430420 - ref SDS A5 006P
Left Supraclavicular Neck CT Test Contrast Study on 060505 Finds No
510401 - ..
510402 - Radiation Treatment Cancer Relapse Left Supraclavicular and IBC
510403 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
510404 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
510405 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
510407 - Follow up ref SDS B3 8R6M, ref SDS 98 8R6M.
510409 - Background of conflict in image testing, ref SDS B3 II4L, and
510410 - consideration for radiation treatment of left supraclivicular is
510411 - reported on 060623. ref SDS B3 8R6M
510413 - ..
510414 - There was no examination of left supraclavicular due to focus on IBC
510415 - relapse in left breast, and planning for treatment.
510417 - [On 060929 Doctor Benz 2nd opinion notes that failure of CT
510418 - test to report findings in left supraclavicular where PET test
510419 - finds nodes progressing in size raises concerns. ref SDS D4
510420 - WI4I
Examination Finds Cancer Recurrence IBC 3rd Relapse Doctor Observes
670401 - ..
670402 - Cancer Metastatic Disease 3rd Relapse IBC Left Breast
670403 - Diagnosis IBC Relapse Left Breast at Mastectomy Incision Wound
670404 - Examination Left Breast IBC Inflammation Mastectomy Incision Wound
670405 - IBC Inflammation Left Breast Incision for Mastectomy Surgery on 051021
670407 - Follow up ref SDS B3 025H, ref SDS 98 025H.
670409 - The doctor examined the left breast and observed increasing red rash
670410 - was not relieved with Lamisil treatment, tried on 060623, further
670411 - indicating patient status change to cancer relapse. ref SDS B3 GV6K
670412 - Observable progression of disease on the left breast aligns with
670413 - rising CA 15-3 the past 5 months, per above, ref SDS 0 GJ5M, and with
670414 - results of PET scan test on 060416, which were reported in the record
670415 - meeting with the doctor on 060428. ref SDS 98 MU5M
670417 - [On 080306 4th relapse of IBC, doctor finds progression of
670418 - disease, orders increasing treatment on clinical study by adding
670419 - Carboplatin to cetuximab. ref SDS E7 NW3N
670421 - ..
670422 - There was no examination by stethoscope of lung and heart function
670423 - today, see also the doctor's report, ref SDS 0 BU7I, since primary
670424 - focus now is scheduling treatment, as further shown below in the
670425 - doctor's report. ref SDS 0 125V
670427 - ..
670428 - IBC recurrence aligns with research on 040517 indicating this form of
670429 - cancer has a higher rate of recurrence. ref SDS 33 L19H
670431 - ..
670432 - This is the 3rd relapse...
670434 - first relapse.................. 040318, ref SDS 28 8R6M
670435 - second relapse................. 041210, ref SDS 47 028N
670436 - third relapse.................. 060711, ref SDS 0 025H
670438 - [On 061201 1530 Millie suffers 4th relapse of cancer and
670439 - 3rd relapse of IBC. ref SDS E0 H54F
670441 - ..
670442 - Today, the doctor seemed to comment that diagnosis takes account of
670443 - "total cancer burden," and in connection with MDR1 and MDR2 resistance
670444 - to treatment. He seemed to support anlaysis in the record on 060607
670445 - that cancer markers measure accumulation of disease which may be so
670446 - diffuse throughout the body that nothing is large enough to be shown
670447 - by image testing. ref SDS A9 7O5R Research on the Internet does not
670448 - yield a narrative that easily relates "total cancer burden" to current
670449 - patient symptoms. Millie's experience shows the cancer marker can
670450 - rise without image test findings of tumor mass, except for "thickened
670451 - skin," per below. ref SDS 0 EY5O Swelled lymph nodes are another
670452 - signal of IBC. So far, during this relapse period, there is no
670453 - evidence of lymphadenopathy nor thickened skin reported in image
670454 - tests.
670456 - [...below research another IBC case where CA 15-3 above 300, and
670457 - no evidence of cancer in image tests. ref SDS 0 R34G
670459 - ..
670460 - This record of minimal cancer signs by test criteria indicates cancer
670461 - relapse may be in formative stages, and so may be more susceptible to
670462 - treatment through local control, than if disease has advanced beyond
670463 - regional sites.
670465 - ..
670466 - "Wide mastectomy" on 051021 was not wide enough to remove all infected
670467 - microscopic IBC tissue, ref SDS 82 8K6N, discussed with the surgeon at
670468 - that time, ref SDS 81 MM6M, further considered by the primary care
670469 - physician during the meeting on 051027. ref SDS 84 F25H
670471 - ..
670472 - What can be learned from this case to increase chances of successful
670473 - surgery on the right breast, if needed, and for other patients? Does
670474 - criteria leap out for widening surgical removal of infected tissue?
670475 - Would a different test procedure, perhaps more thin sliver biopsies,
670476 - e.g., take 6 or 8 instead of only 4.
670478 - ..
670479 - Does the fact that IBC rash relapse seems concentrated just left of
670480 - the sternum at the right end of the mastectomy incision, and then
670481 - appears as very fine lines of sprinkled red dots occurring .5" above
670482 - and below the incision line, suggest a wider diameter of testing could
670483 - be more helpful?
670485 - ..
670486 - Alternatively, the evident meandering line of infection above and
670487 - below the incision, and eminating from the larger concentration of IBC
670488 - near the sternum, may suggest IBC is "leaking" from this area, and
670489 - that if this had been removed, then removing a "wider" area of tissue
670490 - from above and below the breast would not have been necessary.
670492 - ..
670493 - What level of post operation review can advance the art of mastectomy
670494 - surgery for IBC patients? Should the tissue biopsy be checked for
670495 - errors that found no IBC from the surgery on 051021? For example,
670496 - nominally it would be expected the highest rate of IBC infection would
670497 - occur near the center of the original breast that showed the most
670498 - pronounced coloration, approximate location of the biopsy on 040419.
670499 - ref SDS 31 1572 The biopsy reported finding no evidence of disease,
670500 - received during the meeting on 051027. ref SDS 84 616P How then did
670501 - disease spread from beyond an area with no infection?
670503 - ..
670504 - Since test history, ref SDS 0 FE8F, indicates relapse seems to have
670505 - occurred only in the left breast area, this is fairly favorable
670506 - compared to other patients who relapse with multiple problems, see
670507 - illustrative example below. ref SDS 0 K16G
670509 - ..
670510 - Observation of patient condition today shows...
670512 - 1. Approximate 1" diameter area of red skin on the left side near
670513 - the sternum, and at the end of the mastectomy incision closure
670514 - line. Initially, this appeared as tiny red dots, and has
670515 - gradually filled in, becoming a continuous, uniform red rash,
670516 - following examination on 060428 that showed no evidence of
670517 - inflammation. ref SDS 98 HJ5N
670519 - [On 061110 after 6 treatments mass of intense IBC rash near
670520 - sternum seems less severe, possibly responding to treatment;
670521 - a new mass of intensity approxiately .5" diamater has
670522 - appeared above the incision line and 1" left of the sternum.
670523 - ref SDS D9 PT4H
670525 - ..
670526 - The incision for the mastectomy on 051021 appears as a straight
670527 - line extending from approxmiately the sternum on a diagonal
670528 - toward the left axilla, as explained in the doctor's
670529 - post-surgery report on 051021. ref SDS 82 TH50 This reflects a
670530 - procedure that evidently closed an "oval" incision to remove
670531 - breast and skin tissue just beyond the permiter marked by test
670532 - biopsies performed on 051012, as reported by the surgeon,
670533 - reviewed on 051027. ref SDS 84 RA3H
670535 - ..
670536 - 2. There are very few red dots extending irregularly from the 1"
670537 - diameter mass at the sternum and meandering both above and
670538 - below the mastectomy incision line by about .5" - .75", with
670539 - length approximately 2 inches. These two (2) areas of red
670540 - dots, appear as thin lines that become slightly wider and more
670541 - pronounced as a red rash toward the end of the 2" line. Skin
670542 - tissue between the meandering lines above and below the
670543 - incision line, and the incision line itself, appear normal at
670544 - this time.
670548 - ..
670549 - Case Study Scope Mastectomy Reduce Risk Relapse
670551 - Relapse condition relates to original considerations for determining
670552 - scope of surgery, including the amount of breast and chest skin to
670553 - remove and replace with breast reconstruction, after IBC had extended
670554 - toward the neck....
670556 - Surgeon cannot tell scope of
670557 - mastectomy........................... 050324, ref SDS 53 WH5L
670559 - ..
670560 - Boundaries of surgery difficult to
670561 - determine............................ 050324, ref SDS 53 0347
670563 - ..
670564 - Surgeon found ample healthy tissue
670565 - above and below the breast to close
670566 - mastectomy surgery after IBC rash
670567 - subsided............................. 050727, ref SDS 63 JV5F
670569 - ..
670570 - Doctor Grissom 2nd opinion proposes
670571 - series of thin skin biopsies to
670572 - investigate recovery from IBC and
670573 - set boundaries for very wide
670574 - simple mastectomy to try removing
670575 - all infected skin, including
670576 - previously irradiated skin to
670577 - reduce risk of relapse............... 050920, ref SDS 74 XL8U
670579 - ..
670580 - Doctor Grissom proposed preoperative
670581 - thin skin biopsies to identify scope
670582 - of tissue to remove.................. 050920, ref SDS 74 GT3M
670584 - ..
670585 - Doctor Grissom discussed breast
670586 - reconstruction to reduce risk of
670587 - relapse by replacing previously
670588 - infected skin, and to permit
670589 - localized radiation in the event
670590 - of relapse........................... 050920, ref SDS 74 U34J
670592 - ..
670593 - Plastic surgeon at Kaiser discussed
670594 - very wide mastectomy to reduce risk
670595 - of relapse by removing infected skin
670596 - and replacing with contemporaneous
670597 - breast reconstruction................ 050928, ref SDS 77 QS65
670598 - recommended postponing breast
670599 - reconstruction until clear margins
670600 - established for standard
670601 - closure.............................. 050928, ref SDS 77 245N
670605 - ..
670606 - Case Study Local Regional Distant Metastatic Cancer Disease
670608 - Problem to solve is local IBC left breast post surgery, since at this
670609 - time, there is no evidence of distant metastasis in image testing,
670610 - listed above. ref SDS 0 FE8F
670612 - ..
670613 - During the meeting today, the doctor seemed to comment that distant
670614 - metastasis has been diagnosed. Nothing was cited during the meeting
670615 - showing distant metastasis. Doctor's notes today cite metastatic
670616 - disease. ref SDS 0 1248 Research on 050324 lists three (3) forms of
670617 - metastatic disease. ref SDS 53 O84N The following terms have been
670618 - presented throughout patient history in this case...
670620 - ..
670621 - Case Study Cancer Terminology Local Regional Distant Metastasis
670624 - local metastatic disease........
670626 - 020321, ref SDS 3 ON5I
670627 - 041209, ref SDS 46 SN97
670628 - 050727, ref SDS 63 2A8F
670629 - 050907, ref SDS 69 AE7R
670631 - ..
670632 - regional disease reported...
670634 - 020321, ref SDS 3 6Q6N
670635 - 050424, ref SDS 53 M54Q
670636 - 050424, ref SDS 53 TN76
670637 - 050727, ref SDS 63 CT7J
670638 - 050823, ref SDS 67 GK8M
670639 - 050826, ref SDS 68 F49H
670641 - ..
670642 - distant metastatis not diagnosed...
670644 - 020321, ref SDS 3 6R5X
670645 - 050727, ref SDS 63 V58O
670646 - 050907, ref SDS 69 555G
670647 - 050907, ref SDS 69 F49H
670650 - ..
670651 - Case Study Risk Microscopic Cancer Not Treated Mastectomy Chemo
670653 - Recurrence of cancer in the left breast reflects prior analysis of
670654 - microscopic cancer cells not fully eliminated by systemic chemotherapy
670655 - treatments nor by surgery....
670657 - Surgeon......................... 050727, ref SDS 63 R34I
670658 - Primary care physician.......... 051007, ref SDS 78 I482
670659 - Plastic surgeon................. 050923, ref SDS 76 KF6I
670660 - Study on challenges............. 051027, ref SDS 84 XA5N
670661 - Analysis risks.................. 051027, ref SDS 84 WG6N
Biopsy Determine Biology of IBC Guide Choice Configuration Chemother
690401 - ..
690402 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
690404 - Can a biopsy contribute to patient work up for developing a strategy
690405 - and treatment plan, per below? ref SDS 0 K36G
690407 - Today, the doctor decided against biopsy considered previously on
690408 - 060623 to verify diagnosis of IBC relapse, and help guide selection of
690409 - treatment targeted to IBC recurrence. ref SDS B3 6Z4N
690411 - [On 060802 2nd opinion Doctor Grissom proposes biopsy to help guide
690412 - choice of chemotherapy treatment. ref SDS C3 GM5M
690414 - ..
690415 - [On 060806 IBC progressing rapidly after 1st cycle Taxotere
690416 - capecitabine treating recurrence. ref SDS C4 7Q95
690418 - ..
690419 - The doctor seemed to indicate that a biopsy would not be cost
690420 - effective, since patient history shows IBC, and the red rash seems
690421 - similar to prior symptoms, originally diagnosed as cellulitus on
690422 - 030109, ref SDS 19 0T6N, again on 040318, ref SDS 28 IM6J, and then
690423 - "reaction to radiation treatments" on 040402, ref SDS 29 IM6J, The
690424 - doctor feels ensuing experience together with rising CA 15-3, and no
690425 - cooberation in image testing fits the past pattern of IBC without
690426 - going to the expense of performing a biopsy, as related on 040504.
690427 - ref SDS 32 UR6M
Distant Metastasis No Evidence PET CT Image Tests for 5 Years Millie
730401 - ..
730402 - Distant Metastasis PET CT Image Testing No Evidence for 5 Years
730403 - PET CT Image Testing No Evidence Distant Metastatic Disease 5 Years
730406 - ..
730407 - Patient history of recent image testing following surgery on 051021
730408 - have not identified cancer, as reported in the most recent CT test
730409 - reviewed with the doctor on 060623. ref SDS B3 II4L
730411 - ..
730412 - PET scan and CT imaging tests listed on 060523, ref SDS A5 SJ65, have
730413 - never reported distant metastasis, and generally do not expressly
730414 - diagnose IBC, because there is no tumor mass. The tumor is in the
730415 - skin.
730417 - ..
730418 - CA 15-3 rising indicates recurrence of IBC or that cancer is growing
730419 - at distant sites, but not yet of sufficient mass to be recognized by
730420 - PET and CT tests, per above comments by the doctor. ref SDS 0 YO6I
730421 - Another patient had similar experience. ref SDS 0 R34G
IBC Image Tests PET CT Sometimes Identify Skin Thickening Difficult
780401 - ..
780402 - IBC Image Tests PET CT Sometimes Identify Skin Thickening Case Study
780403 - Image PET CT Test IBC Difficult to See Skin Thickening Case Study
780404 - Image Test Case Study IBC Reported Skin Dermal Thickening Nodes Swell
780405 - Skin Thickening IBC Difficult for Image PET CT Testing Recognize
780407 - Sometimes image tests seem conflicting with rising CA 15-3 cancer
780408 - marker, because these tests do not expressly recognize IBC.
780410 - ..
780411 - Research on 040517 indicates symptoms of IBC are skin thickening and
780412 - swelled lymph nodes in the axilla and supraclavicular. ref SDS 33 S65H
780414 - ..
780415 - PET scan and CT testing sometimes report IBC as "skin" and or "dermal"
780416 - thickening. Swelled lymph nodes, lymphadenopathy, in the axilla and
780417 - supraclavicular are also associated with IBC, shown in the following
780418 - image tests...
780420 - ..
780421 - Test date Review date Details
780422 - 021218 (left upper chest wall).... 030109, ref SDS 19 L66M
780423 - 030626 ........................... 030710, ref SDS 23 VM7I
780424 - 031031 ........................... 031205, ref SDS 25 VM7I
780425 - 040307 ........................... 040318, ref SDS 28 VM7I
780426 - 041103 ........................... 041104, ref SDS 43 QP6S
780428 - ..
780429 - Recent tests have not identified "skin" or "dermal" thickening,
780430 - possibly indicating IBC condition is in formative stages, or that this
780431 - condition was not noticed by the analyst.
Emotional Trauma Eased by Engagement with Work Family and Exercise V
850401 - ..
850402 - Emotional Trauma Eased by Engagement with Work Family and Exercise
850403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
850404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
850406 - Follow up ref SDS B3 Y642, ref SDS 98 Y642.
850408 - Realizing Lamisil failed to clear rash eliminates hope of avoiding
850409 - further chemotherapy treatment.
850411 - ..
850412 - Administration of launching treatment again, considering a biopsy to
850413 - verify condition and evaluate status change to expand treatment
850414 - options are all very emotional.
MRI Head Finds Cancer Not Found Distant Metastasis in Light of Risin
920401 - ..
920402 - MRI Showed No Evidence of Disease in Head Brain
920403 - Dizziness Occurs Occasionally MRI Finds No Evidence of Disease Head
920405 - Follow up ref SDS B3 PT4K, ref SDS 98 PT4K.
920407 - ..
920408 - Dizziness mild symptoms persist. On 060623 the doctor ordered MRI of
920409 - head to rule out cancer that may be driving CA 15-3, though physical
920410 - examination on 060623 showing possible IBC red rash seems more likely
920411 - the cause of rising CA 15-3. ref SDS B3 025H
920413 - [On 061012 dizziness symptom pulmonary embolism from heart
920414 - disorder of enlarged right ventricle, ref SDS D5 GH4M,
920415 - diagnosed by CT scan test. ref SDS D5 294Q
920417 - ..
920418 - MRI report shows nothing remarkable in the brain, ref SDS 0 CO80,
920419 - eliminating brain cancer as a source of distant metastasis that might
920420 - be driving CA 15-3 to rise, per above. ref SDS 0 GJ5M
920422 - MRI OF BRAIN (Digital)
920427 - ..
920428 - Patient
920436 - ..
920437 - History
920439 - Metastatic breast cancer.
920441 - ..
920442 - Findings
920444 - The brain MRI was performed with and without Gadolinium.
920445 - There is no prior study for comparison.
920447 - ..
920448 - MRI on the brain was previously performed on 020617 and received from
920449 - the doctor on 020628. ref SDS 10 5S5M
920451 - ..
920452 - This repeats the error in the CT test that compared the wrong prior
920453 - test from a year earlier, rather than the PET scan test from a month
920454 - earlier, as requested, reported on 060523. ref SDS A5 006P
920456 - [On 061012 patient history of testing mistakes that fail to
920457 - make correct comparisons, or omit comparison entirely,
920458 - because analyst cannot find prior reports. ref SDS D5 R29L
920460 - ..
920461 - [On 061024 case study medical practice computer access
920462 - limited even with everything on the computer, people can't
920463 - find details stored in parts of the computer (software
920464 - modules) that are not frequently used. ref SDS D8 JD9L
920466 - ..
920467 - Findings continue...
920469 - The ventricles and sulci are normal and symmetric. There is no
920470 - mass, mass effect or shift of mid line. There is no
920471 - significant white matter disease. There is no abnormal
920472 - enhancement following Gadolinium. There is no diffusion
920473 - restriction. There is no evidence of blood products or
920474 - significant extra axial fluid collection. The paranasal
920475 - sinuses are clear.
920477 - ..
920478 - Impression
920480 - Unremarkable brain MRI.
920482 - ..
920484 - DD 07/13/2006 DT 07/13/2006 BB
920485 - SSPRLP 03/13/2006 1628
Treatment Plan IBC 3rd Relapse Scope Strategy Options Planning Balan
A90401 - ..
A90402 - Pool Chemotherapy Drugs Available to Treat IBC
A90403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
A90404 - Treatment Work Up Plan Effective Against IBC and Reduce Side Effects
A90406 - Follow up ref SDS B3 K36G, ref SDS 98 K36G.
A90408 - ..
A90409 - Pneumonia recovery is sufficient for chemotherapy treatment to begin,
A90410 - shown by xray report above. ref SDS 0 TV5G
A90412 - ..
A90413 - Strategy needed for deciding which treatment to use first, second,
A90414 - third..., and what combinations to try...
A90416 - ..
A90417 - Tumor Board may be a good source for assistance developing treatment
A90418 - strategy based on prior work in 2002 and 2004, as reported on 040517.
A90419 - ref SDS 33 MB7G Millie's letter to the doctor on 060512 asked about
A90420 - Tumor Board review. ref SDS A4 4T3S During the meeting on 060623 the
A90421 - doctor asked about the scope for a hearing. ref SDS B3 K36G
A90424 - ..
A90425 - Strategy Issues for Treatment Plan Based on Patient History...
A90428 - On 041130 the doctor submitted a list of treatment options in
A90429 - this case. ref SDS 45 9V63
A90431 - [On 060720 letter to Kaiser requests work plan strategy for
A90432 - treating 3rd relapse of IBC, ref SDS B6 21A6; asks about
A90433 - Tumor Board review. ref SDS B6 5S8F
A90435 - ..
A90436 - [On 060721 primary care physician responded saying in part
A90437 - "What has or has not been done, what has or has not been
A90438 - effective, what we can or cannot do again in the future,"
A90439 - ref SDS B8 YU46; and continued saying "Currently our
A90440 - options alimited to a decreasing pool of chemotherapeutic
A90441 - agents." ref SDS B8 H45G
A90443 - ..
A90444 - [On 060721 primary care physician responded saying in part
A90445 - "Tumor Board could offer no more." ref SDS B8 IP9L
A90447 - ..
A90448 - Initial plan to start with previous treatment that was
A90449 - successful in 2005, per below. ref SDS 0 PF3O
A90451 - [On 060806 notify Kaiser that disease progressing rapidly,
A90452 - requires change in treatment plan. ref SDS C4 OJ7S
A90454 - [On 060807 Kaiser schedules urgent meeting for 060808 to
A90455 - change treatment plan. ref SDS C5 423C
A90457 - ..
A90458 - [On 060808 emergency meeting to review rise of IBC red
A90459 - rash, Kaiser deferred review of available treatments,
A90460 - because by the time of examination IBC rash seemed to
A90461 - decline. ref SDS C7 YJ9J
A90463 - ..
A90464 - The only drug on the list received on 041130 that has been used
A90465 - so far is Taxotere.
A90467 - ..
A90468 - Other drugs used and proposed in this case, e.g., Xeloda,
A90469 - Gemzar, Navelbine, Novel Expthilones BMS-247550, plus multiple
A90470 - combinations -- none of these were on the original list. This
A90471 - indicates there is an expanding list of drugs for treating
A90472 - cancer.
A90474 - ..
A90475 - What is the source for these other drugs, and what is the basis
A90476 - for giving one drug or some combination of drugs priority in
A90477 - the order of treatment?
A90479 - ..
A90480 - Biopsy of current IBC disease to guide choice of chemotherapy
A90481 - configuration, per above? ref SDS 0 KT7J
A90483 - ..
A90484 - [On 060720 letter to doctor asks what drugs are available
A90485 - for chemotherapy in forming treatment strategy. ref SDS B6
A90486 - 5S9M
A90488 - ..
A90489 - [On 060721 primary care physician responded by restating
A90490 - the issue, ref SDS B8 YU46; and said there is a decreasing
A90491 - pool of drugs, but did not have time to list the drugs with
A90492 - a treatment strategy and work plan. ref SDS B8 H45G
A90494 - ..
A90495 - [On 060721 develop planning for 2nd opinion. ref SDS B7
A90496 - IS6F
A90498 - ..
A90499 - [On 090204 2nd opinion discusses testing tissue to develop
A90500 - best agent for treating cancer. ref SDS E1 9K9W
A90502 - ..
A90503 - Does Kaiser maintain a more comprehesive list of cancer drugs,
A90504 - if so, what is on the list. Are there Kaiser Oncology
A90505 - bulletins announcing trends in patient histories that suggest
A90506 - one drug or another might be better suited to treat IBC?
A90508 - ..
A90509 - Are there sources on the Internet that list chemotherapy drugs
A90510 - for IBC that can be reviewed with links to patient histories?
A90512 - ..
A90513 - What is the typical patient work up for treating IBC relapse
A90514 - after surgery? Is there an industry standard; is there a
A90515 - Kaiser standard, as reported previously on 041130? ref SDS 45
A90516 - UB4H
A90518 - ..
A90519 - Capecitabine and Taxotere were effective during 2005; there was also
A90520 - considerable physical wear on the patient, reported for example on
A90521 - 050520 when the doctor reduced the dose in order to moderate side
A90522 - effects. ref SDS 58 NT3I Since patient continued to improve under
A90523 - the reduced dosage, how does this record impact determinations of
A90524 - dosage at this time?
High Dose Chemotherapy HDC Treatment Strategy Best Chance Stop Sprea
AD0401 - ..
AD0402 - High Dose Chemotherapy HDC Strategy Balance Patient Tolerance
AD0403 - Side Effects Tolerate High Dose Chemotherapy for Effectiveness
AD0404 - HDC Strategy Reverse Growth Cancer When Patient Tolerance High
AD0405 - Treatment Effectivenss Balance Patient Tolerance Side Effects
AD0407 - Might a strategy be tried with reduced dose of capecitabine and
AD0408 - Taxotere to see if effective treatment can be achieved without
AD0409 - burdensome side effects, as shown in patient history listed on 050422?
AD0410 - ref SDS 57 VE68
AD0412 - [On 060724 diary side effects for 2nd phase taking Taxotere
AD0413 - and capecitabine (Xeloda). ref SDS C0 QX8K
AD0415 - ..
AD0416 - Pharmacist, Zan, in a follow up meeting later in the day plans to
AD0417 - address this issue in consultation with primary care physician.
AD0418 - ref SDS 0 S33L
AD0420 - ..
AD0421 - Research shows some authorties (seems like mostly in the 1990s)
AD0422 - recommend aggressive high dose chemotherapy (HDC) treatment for
AD0423 - inflammatory breast cancer (IBC), because IBC is an aggressive
AD0424 - disease; side effects are a concern, shown by examples...
AD0426 - 1. 1998 Journal of National Cancer Institute (JNCI)
AD0428 - ..
AD0429 - http://jncicancerspectrum.oxfordjournals.org/cgi/content/abstract/jnci%3b90/3/210
AD0431 - ..
AD0432 - Department of Psychosocial Research and Epidemiology, The
AD0433 - Netherlands Cancer Institute/Antoni van Leeuwenhoek
AD0434 - Hospital, Amsterdam.
AD0436 - ..
AD0437 - Although high-dose chemotherapy is rapidly gaining
AD0438 - acceptance as a treatment option for a number of cancers,
AD0439 - the long-term toxic effects of such therapy are a concern.
AD0440 - Cognitive deficits (e.g., problems with memory and
AD0441 - concentration) are not uncommon after chemotherapy, but
AD0442 - they have not been documented systematically.
AD0444 - ..
AD0445 - CONCLUSION: High-dose chemotherapy appears to impair
AD0446 - cognitive functioning more than standard-dose
AD0447 - chemotherapy. Central nervous system toxicity may be a
AD0448 - dose-limiting factor in high-dose chemotherapy regimens.
AD0450 - ..
AD0451 - 2. 2003 IBC Support
AD0453 - http://www.ibcsupport.org/treatment.html
AD0455 - ..
AD0456 - You may be advised by your oncologist to do high dose
AD0457 - chemotherapy . This involves higher doses and/or more
AD0458 - frequent infusions, often with some kind of support for
AD0459 - your bone marrow. The support could be a bone marrow or
AD0460 - stem cell transplant or injections of various growth
AD0461 - factors that stimulate production of new blood cells.
AD0463 - ..
AD0464 - High dose chemotherapy is a fairly new approach, and it has
AD0465 - not yet been proven more effective than standard doses,
AD0466 - although it has become pretty standard treatment in the
AD0467 - United States. HDC is best done at a major hospital or one
AD0468 - with lots of experience, since the immunosuppression caused
AD0469 - by the high doses can lead to mortality rates of up to 10%
AD0470 - from the procedure itself.
AD0473 - ..
AD0474 - HDC May Fail Theory Flawed Requires Careful Analysis
AD0476 - The whole principle behind HDC/SCR may be flawed, and it
AD0477 - may be more like antibiotics -- if you pick the wrong one,
AD0478 - higher doses won't make any difference. It's also possible
AD0479 - that since the doses we're talking about can only be used
AD0480 - once or twice, some cells won't be dividing while the
AD0481 - drugs are in your system and will survive, while more
AD0482 - doses at a lower level would have killed more.
AD0484 - ..
AD0485 - CONCLUSION: HDCT in selected patients with HRBC is safe
AD0486 - and warrants further evaluation. Patients with
AD0487 - receptor-negative, high-grade, or inflammatory tumors
AD0488 - require improvement in their therapeutic options. Better
AD0489 - assessment of the role of HDCT awaits completion of
AD0490 - ongoing randomized trials.
AD0492 - ..
AD0493 - Today, discussion with the doctor and the Pharmacist, Zan, focused on
AD0494 - starting with a low dose to assess effectivenss, while reducing side
AD0495 - effects.
AD0497 - ..
AD0498 - Considered strategy to start again using the higher dose for the first
AD0499 - few treatments, as was done beginning on 050415, before the dosage was
AD0500 - reduced for better tolerance, reported 050516. ref SDS 58 AQ6G Even
AD0501 - though this will be hard to tolerate, if it is more effective relative
AD0502 - to the lower dose, then the aim should be for effectivenss to the
AD0503 - point of intollerance, replicating results reported on 050520.
AD0504 - ref SDS 59 025H Since the patient had received 4 cycles of AC prior
AD0505 - to starting Taxotere and capecitabine (Xeloda) on 050415, this may
AD0506 - have contributed to low tolerance for HDC at that time. Since the
AD0507 - patient has been off treatment for 9 months, there may now be greater
AD0508 - tolerance for stronger HDC treatment to "break the back" of disease
AD0509 - progression.
AD0511 - ..
AD0512 - Research today, indicates prior success may not be reproducable, see
AD0513 - example. ref SDS 0 R27H
AD0515 - [On 060806 letter notifies Kaiser that disease progressing
AD0516 - rapidly, requires change in treatment plan. ref SDS C4 OJ7S
AD0518 - [On 060808 patient reports possible delayed response to
AD0519 - reduced treatment dose, ref SDS C7 VO6G, and analysis
AD0520 - reviews factors considered today, which support conclusion
AD0521 - of delayed response, ref SDS C7 J16O, leading to doctor's
AD0522 - recommendation to maintain original prescription.
AD0523 - ref SDS C7 K36G
AD0525 - ..
AD0526 - The current IBC cells may be more resistant to capecitabine and
AD0527 - Taxotere, since they survived the prior treatment. Right now Millie
AD0528 - is stronger and healthier than in 2 months, 4 months time going
AD0529 - forward after treatments start. If lower dose treatments are not
AD0530 - effective, increasing the dose may not be practical with tolerance
AD0531 - weakened by ensuing treatments.
AD0533 - ..
AD0534 - If cancer has mutated from microscopic cells that survived prior
AD0535 - treatment in 2005 with Taxotere and capecitabine (Xeloda), then other
AD0536 - drugs may be needed to treat recurrence, per discussion of biopsy for
AD0537 - tailoring treatment. ref SDS 0 KT7J
AD0539 - [On 060806 letter notifies Kaiser that disease progressing
AD0540 - rapidly, requires change in treatment plan. ref SDS C4 OJ7S
Capecitabine (Xeloda) Taxotere Treatment 3rd Relapse IBC Start with
AI0401 - ..
AI0402 - Treatment Start with Capecitabine (Xeloda) and Taxotere
AI0404 - The doctor wants to begin treatment as soon as possible, starting with
AI0405 - two (2) cycles of capecitabine (Xeloda) and Taxotere using a reduced
AI0406 - dose of 1.5 500 MG tablets taken twice a day, which was successful
AI0407 - last year, reported on 050727. ref SDS 63 YY7F Progress will then be
AI0408 - evaluated for continuing with the same regimin or switching treatments
AI0409 - based on strategy analysis, per above. ref SDS 0 FP9H
AI0411 - [On 060724 diary side effects for 2nd phase taking Taxotere
AI0412 - and capecitabine (Xeloda). ref SDS C0 QX8K
AI0414 - ..
AI0415 - [On 060806 IBC progressing rapidly after 1st cycle Taxotere
AI0416 - capecitabine treating recurrence. ref SDS C4 7Q95
AI0418 - ..
AI0419 - [On 060807 Kaiser schedules urgent meeting for 060808 to change
AI0420 - treatment plan. ref SDS C5 423C
AI0422 - ..
AI0423 - [On 060808 examination shows improvement, IBC red rash
AI0424 - delayed reaction to treatment, inflammation begins to
AI0425 - wain. ref SDS C7 VO6G
AI0427 - ..
AI0428 - [On 060922 slow response to treatment for 3rd IBC relapse reported
AI0429 - in a letter to the doctor, ref SDS D2 LE48; study of patient
AI0430 - history may indicate recovery compares favorably to treatment in
AI0431 - 2005 for 2nd IBC relapse. ref SDS D2 9F35
AI0433 - ..
AI0434 - How does this relate to HDC reviewed above? ref SDS 0 RH9L
AI0436 - ..
AI0437 - The doctor indicated that dosage of treatments can be discussed with
AI0438 - the pharmacist. He left the meeting briefly to arrange discussions
AI0439 - with Zan on scheduling start of treatment, getting blood tests, and
AI0440 - other details for configuring the dose. (see below, ref SDS 0 N96O)
AI0442 - ..
AI0443 - The doctor reported today that "status change" does not support
AI0444 - expanding treatment options, per below. ref SDS 0 ZR6J
AI0446 - ..
AI0447 - If cancer cells have mutated, then previously successful treatment may
AI0448 - not be effective. per analysis above, ref SDS 0 R04K Another strategy
AI0449 - might be to try Gemzar Taxotere immediately, as recommended by Benz in
AI0450 - the 2nd opinion received on 041117. ref SDS 44 OU6S
AI0452 - [On 060806 IBC progressing rapidly after 1st cycle Taxotere
AI0453 - capecitabine treating recurrence. ref SDS C4 7Q95
AI0455 - ..
AI0456 - [On 060808 examination shows improvement, IBC red rash
AI0457 - delayed reaction to treatment, inflammation begins to
AI0458 - wain. ref SDS C7 VO6G
AI0460 - ..
AI0461 - Research today shows that Navelbine and Xeloda (capecitabine) could be
AI0462 - combined in a treatment. ref SDS 0 FE3O
AI0464 - ..
AI0465 - The core question is how much time is available to experiment finding
AI0466 - an effective drug and combinations, before a critical mass of disease
AI0467 - occurs that resists all treatments? What is the basis for trying one
AI0468 - drug or another and in what combinations, per above? ref SDS 0 QO7O
AI0470 - ..
AI0471 - Can a biopsy help tailor treatment of mutated cancer disease, per
AI0472 - above? ref SDS 0 KT7J
Navelbine Chemotherapy Treatment IBC Relapse Side Effects Uncertain
AO0401 - ..
AO0402 - Today, the doctor reviewed the following...
AO0405 - ..
AO0406 - Navelbine Treatment of Relapse, Side Effects Uncertain
AO0408 - On 060428 the doctor proposed considering Navelbine
AO0409 - chemotherapy. ref SDS 98 9H5I Review at that time indicated
AO0410 - this treatment has been used for many years. The doctor said
AO0411 - today that side effects are very severe. This updates research
AO0412 - on 060428 indicating that Navelbine is well tolerated.
AO0413 - ref SDS 98 JF8L
AO0415 - ..
AO0416 - Navelbine is not on the list submitted by the doctor on 041130.
AO0417 - ref SDS 45 9V63
AO0419 - ..
AO0420 - Capecitabine (Xeloda) and Gemzar, both evidently effective
AO0421 - cancer treatments were not on the doctor's list submitted on
AO0422 - 041130. This raises the question of what is the complete list
AO0423 - of drugs, and what basis determines the order to treatment?
AO0425 - ..
AO0426 - There is also a report that Navelbine is used for patients who
AO0427 - have failed standard first-line chemotherapy or who have
AO0428 - relapsed within six months of anthracycline-based adjuvant
AO0429 - therapy. ref SDS 98 JF42
AO0431 - ..
AO0432 - One patient combined Navelbine with capcitabine (Xeloda); this
AO0433 - was not effective because cancer had progressed beyond reach of
AO0434 - treatment. ref SDS 0 FE3O
AO0436 - ..
AO0437 - Nothing in the professional research reports effectiveness of
AO0438 - Navelbine treating IBC.
AO0440 - ..
AO0441 - One patient reported initial improvement, but within 2 months,
AO0442 - cancer progressed. ref SDS 0 R15I
AO0444 - ..
AO0445 - Research on the Internet at...
AO0447 - ..
AO0448 - Susie's story....
AO0450 - Diagnosed 930813, passed 980618, age 55
AO0452 - http://www.ibcsupport.org/suzie.html
AO0454 - ...says in part the following regarding an IBC patient...
AO0456 - The next chemo was navelbine (with one dose of novantrone
AO0457 - thrown in) and I started getting it once a week with 5
AO0458 - days of neupogen shots. (I was rather naive thinking my
AO0459 - insurance would cover this expensive shot, but didn't find
AO0460 - out the truth until after the navelbine was very
AO0461 - successful.)
AO0463 - ..
AO0464 - Right before Christmas there was a terrific improvement in
AO0465 - the redness, ridginess, and general activity of the skin
AO0466 - crud. Later in January we discovered the cancer got wise
AO0467 - to navelbine and started growing again.
Cancer Patients Noble Sufferers Pioneers Exemplars Saviors Illustrat
AU0401 - ..
AU0402 - Cancer Patients Noble Suffers Pioneers Exemplars Saviors
AU0405 - ..
AU0406 - There are a great many stories of cancer patients who elevate and
AU0407 - inspire by not giving up. They breath energy into patients, doctors,
AU0408 - care givers, researchers, and to everyone struggling with daily
AU0409 - affairs, large and small. These case histories of noble sufferers
AU0410 - insisting on living life to the fullest illustrate the meaning of
AU0411 - grit, pride, courage, and charcter. Powerful guidance helps patients
AU0412 - and practitioners shape better strategies from paths of those who
AU0413 - share their experience.
AU0415 - ..
AU0416 - Kim's story...
AU0418 - Diagnosed 030115, passed 040515, age 50.
AU0420 - http://www.ibcmemorial.org/kim.html
AU0422 - ..
AU0423 - For the first seven months of 2003, she suffered silently
AU0424 - through 16 individual high dose intravenous chemotherapy
AU0425 - treatments lasting anywhere from four to six hours each.
AU0426 - In August she endured a disfiguring operation, and from
AU0427 - mid September and all of October, she underwent six weeks
AU0428 - of daily radiation - all this without complaining, and
AU0429 - always with a positive attitude and her head held up high.
AU0431 - ..
AU0432 - Kim never took any sick leave for the first seven months
AU0433 - of 2003 except for the day of her chemotherapy. She even
AU0434 - started a new job in March of 2003 with the Marine Corps
AU0435 - Systems Command while undergoing chemotherapy. That was a
AU0436 - God send, for she was now able to focus on getting the job
AU0437 - done for her Marines as she called them, instead of
AU0438 - thinking about her disease. So to Kim, the Marines and
AU0439 - staff at Systems Command had become her second family
AU0440 - during the difficult fight.
AU0442 - ..
AU0443 - In November of 2003, her tumor markers and CAT scans and
AU0444 - MRIs all indicated she was free from disease. We
AU0445 - celebrated. We took trips to San Antonio and Las Vegas,
AU0446 - went to the Marine Corps Birthday Ball, and Kim went to
AU0447 - Florida to visit her mother. Life suddenly seemed to be
AU0448 - returning to normal. But the war was not over yet.
AU0450 - ..
AU0451 - Just one month later in December 2003, the cancer returned
AU0452 - with a vengeance. This time it was inoperable and
AU0453 - radiation was not an option. The only weapon she had was
AU0454 - more chemotherapy.
AU0456 - ..
AU0457 - But this time, the chemotherapy wasn't working. Kim's
AU0458 - oncologist said he could try a high dose of a chemotherapy
AU0459 - drug that had previously worked to reduce her tumor, but
AU0460 - the side effects were dangerous. Kim was a fighter; so she
AU0461 - said OK, bring it on. She told me that she would rather go
AU0462 - out feeling crummy from chemotherapy than sit around and
AU0463 - wonder if each day would be her last.
AU0465 - ..
AU0466 - But, in the cruelest of ironies, the drug that had reduced
AU0467 - her tumor last time didn't work this time and instead gave
AU0468 - her kidney failure. So, she now had to have dialysis three
AU0469 - times a week with each session lasting four and a half
AU0470 - hours. She was now fighting a two front war - cancer and
AU0471 - kidney failure - and the effects were beginning to show.
AU0472 - But, she continued to display a positive attitude even
AU0473 - with this major setback, but I was becoming distraught,
AU0474 - feeling helpless. She could sense that and she held me in
AU0475 - her arms and told me she was worried about me and not to
AU0476 - worry because everything would be OK. That was Kim, always
AU0477 - thinking of the other person first. She was the one with
AU0478 - cancer, but she was worried about me.
AU0480 - ..
AU0481 - Technical explanation of Kim's struggle...
AU0483 - On December 19, 2003, just one month after completing six
AU0484 - weeks of daily radiation, a follow up MRI showed that Kim
AU0485 - had a recurrence of the IBC. It showed a 7 cm X 8 cm right
AU0486 - chest wall and axillary tumor involving the thoracic
AU0487 - musculature with nodular components extending to ribs.
AU0489 - ..
AU0490 - At this time, Millie's recurrance seems limited to left breast
AU0491 - inflammation, per above. ref SDS 0 8Z8G
AU0494 - ..
AU0495 - Navelbine Capecitabine (Xeloda) Combined
AU0498 - Kim's story continues...
AU0500 - There were a few contiguous masses involving right
AU0501 - axillary tissues and brachial plexus. Kim also began to
AU0502 - experience severe right arm pain. The doctors said the
AU0503 - tumor was inoperable and too big for radiation to be
AU0504 - effective. So, from January 2 to February 9, 2004, Kim had
AU0505 - two cycles of systemic chemotherapy consisting of
AU0506 - Navelbine and Xeloda. A follow up MRI taken on February
AU0507 - 12, 2004, indicated a dramatic interval chest wall growth,
AU0508 - now 12 cm by 17 cm, which extended to the axilla and
AU0509 - brachial plexus. One portion of the tumor insinuated
AU0510 - between the ribs and budged the plural surface of the
AU0511 - lung.
AU0513 - ..
AU0514 - Navelbine/Xeloda treatment was discontinued as ineffective
AU0515 - on February, 2004 and replaced with Gemzar and Cisplatin.
AU0517 - ..
AU0518 - After just one dose of Cisplatin and Gemzar, Kim suffered
AU0519 - severe vomiting, neurotoxicity (tremor, shaking,
AU0520 - disorientation), ototoxicity (hearing impairment ),
AU0521 - nephrotoxicity (severe edema and acute kidney failure),
AU0522 - and extremely low white, red, and platelet counts. She was
AU0523 - hospitalized for kidney failure from March 1 to March 11,
AU0524 - 2004, received several platelet and blood transfusions,
AU0525 - and daily dialysis due to the kidney failure. She also had
AU0526 - a thoracentesis procedure to relieve a large right side
AU0527 - pleural effusion (500 cc of fluid removed).
AU0529 - ..
AU0530 - On April 13, 2004, Kim began chemotherapy again. She
AU0531 - received low dose Epirubicin and Paclicitaxol. The
AU0532 - following week her platelets crashed at 15,000, down from
AU0533 - 106,000 the week before. Even with a platelet transfusion,
AU0534 - Kim's platelets never recovered so further chemotherapy
AU0535 - was put on hold. (Kim's platelets never did return, and
AU0536 - this was the last time she had chemotherapy before she
AU0537 - died.).
AU0540 - ..
AU0541 - CA 15-3 300 High Breast Cancer Marker Not Millie's History
AU0542 - 300 CA 15-3 Breast Cancer Marker Well Above Millie's Highest
AU0544 - Another patient's case history gives perspective on Millie's
AU0545 - propsects at this stage of progression.
AU0547 - ..
AU0548 - Jodi's story....
AU0550 - Diagnosed 000322, passed 030607, age 39
AU0552 - http://www.ibcmemorial.org/jodi.html
AU0554 - In March of this year Jodi's tumor markers shot up over
AU0555 - 300, and her breast oncology team confirmed that she had a
AU0556 - recurrence, though the cancer was so diffuse and small
AU0557 - that it could not be detected on various scans, including
AU0558 - CT and PET. Jodi decided to start navelbine chemo right
AU0559 - away, and had undergone 9 treatments.
AU0561 - ..
AU0562 - Mil's cancer marker has never approached 300, which suggests she has
AU0563 - not reached a severe stage of disease, per above. ref SDS 0 087J and
AU0564 - so may have good chances of arresting the current relapse, to get
AU0565 - another treatment holiday.
AU0567 - [On 061208 after about 7 cycles with Taxotere and capecitabine
AU0568 - IBC worsened; Kaiser considered switching to Navelbine,
AU0569 - however, review of the record today indicating poor prognosis
AU0570 - with Navelbine led to investigation of clinical drug trial
AU0571 - options presented during 2nd opinion review at UCSF.
AU0572 - ref SDS E3 XC8K
AU0574 - ..
AU0575 - Primary care physician discussed today a phrase like "total cancer
AU0576 - burden," ref SDS 0 YO6I, which sounds similar to Jodi's case history,
AU0577 - per above. ref SDS 0 R34G
Gemzar Taxotere Treatment for IBC Relapse Side Effects May Be More T
B00401 - ..
B00402 - Gemzar and Taxotere Treatment for IBC
B00404 - The doctor today indicated consideration of Gemzar, and seemed
B00405 - to suggest this treatment is easier to tolerate than Navelbine.
B00406 - Gemzar is noted in the doctor's record for the meeting today.
B00407 - ref SDS 0 125V
B00409 - ..
B00410 - Gemzar is not on the list submitted by the doctor on 041130.
B00411 - ref SDS 45 9V63
B00413 - ..
B00414 - Second opinion from Doctor Benz received on 041117 recommended
B00415 - consideration of combining Gemzar with Taxotere, ref SDS 44
B00416 - OU6S, similar to using capecitabine with Taxotere.
Drug Trials Protocol Nurse Searching for Fit with Millie's Patient P
B40401 - ..
B40402 - Drug Trial - Doctor Checking with Rosalie
B40404 - The doctor will review with the protocol nurse, Rosalie,
B40405 - opportunities for Millie to participate in trials for new
B40406 - cancer treatment drugs being proposed to treat IBC.
B40408 - ..
B40409 - Millie's status as stage IV IBC relapse, and post mastectomy
B40410 - surgery limits qualifying for drug trials, reported by Rosalie
B40411 - on 041230, ref SDS 48 028N, reporting a mixup in planning on
B40412 - 041210 for Millie to participate in a drug trial. ref SDS 47
B40413 - 028N This was further confirmed during a meeting on 050204.
B40414 - ref SDS 49 028N See as well in the same record. ref SDS 49
B40415 - JF4M
B40417 - ..
B40418 - Some treatments in trials the past few years may have proven
B40419 - effective, and so available without using a formal trial to
B40420 - deliver treatment.
B40422 - ..
B40423 - On 050520, Millie asked primary care physician to investigate
B40424 - prospects of a trial at UCSF using combination of AG 013736
B40425 - with Codetaxel compared to Docetaxel alone. ref SDS 59 L27G
B40427 - ..
B40428 - Previously, Doctor Benz had indicated that UCSF may have drug
B40429 - trials that benefit Millie, and recommended in a 2nd opinion
B40430 - reviewed on 041117 contacting the medical center for details.
B40431 - ref SDS 44 OV3T
B40433 - ..
B40434 - Subsequently, on 050909 Doctor Bailey discussed a drug trial at
B40435 - UCSF that might benefit Millie and fit her patient profile.
B40436 - ref SDS 71 AL3N
B40438 - ..
B40439 - Background is reported in the record for a meeting with the
B40440 - primary care physician on 050913. ref SDS 72 L27G These might
B40441 - be avenues for inquiry by the protocol nurse.
Novel Expthilones BMS-247550 Plus Capecitabine (Xeloda) Previous Che
BA0401 - ..
BA0402 - Novel Expthilones BMS-247550 Plus Capecitabine
BA0404 - This combination was in trial in 2004, and might be available
BA0405 - to treat Millie this year or next, under consideration for
BA0406 - treatment reported on 041230. ref SDS 47 028N
BA0408 - ..
BA0409 - There was no discussion today of chemotherapy targeted to treat IBC,
BA0410 - reported in the record on 040517. ref SDS 33 JK8L and with expanding
BA0411 - prognosis for longevity. ref SDS 33 0141
Breast Replacement Surgery Deferred in 2005 Review Options in 2006 R
BE0401 - ..
BE0402 - Breast Replacement Surgery Deferred in 2005 Review Options in 2006
BE0404 - Surgery originally proposed to re-build the left breast in order to
BE0405 - avoid relapse by replacing diseased tissue with skin grafts that
BE0406 - provide blood vessels for delivery of immune system nutrients, and
BE0407 - also deliver chemotherapy systemic treatment in the event of future
BE0408 - relapse, discussed with plastic surgeon on 050928. ref SDS 77 248I,
BE0409 - Doctor Bailey noted during 2nd opinion consultation on 051011 that
BE0410 - removing all infected tissue was critical for success of mastectomy
BE0411 - surgery, ref SDS 79 G65S, and that removing breast mass would increase
BE0412 - risk of treatment failure unless breast replacement was performed to
BE0413 - restore the loss of blood vessels. ref SDS 79 G69U Replacing
BE0414 - previously radiated tissue to permit additional radiation treatment in
BE0415 - the event of relapse, may still be an option, based on planning with
BE0416 - plastic surgeon on 050928. ref SDS 77 253H At that time, the plastic
BE0417 - surgeon wanted to defer an aggressive solution, until a conservative
BE0418 - approach was tried. ref SDS 77 4S8G The doctor's report received a
BE0419 - week or so later on 051007 confirmed understandings recommending that
BE0420 - breast reconstruction be "postponed" to evaluate recovery from
BE0421 - standard mastectomy. ref SDS 78 635M
BE0423 - ..
BE0424 - Since there is still no evidence of distant metastasis other than the
BE0425 - supraclavicular noted by the doctor on 040318, ref SDS 28 8R6M, and
BE0426 - which is a symptom of IBC evident locally in the left breast, reported
BE0427 - on 040517, ref SDS 33 S65H, what steps can be taken to evaluate the
BE0428 - original plan addressing the local problem?
BE0430 - ..
BE0431 - Does the surgeon's post-op report on 051021 disclose any procedures or
BE0432 - findings that render mute the plastic surgeon's planning to postpone
BE0433 - breast reconstruction? ref SDS 82 369L
BE0435 - [On 060821 Doctor Benz did not have enough time during the
BE0436 - meeting for 2nd opinion consultation at UCSF to consider
BE0437 - surgery options. ref SDS D0 X54L
BE0439 - ..
BE0440 - Reexcision to get clear margins, discussed on 051027, ref SDS 84 JN3L,
BE0441 - might this still be an issue for the surgeon?
Radiation Treatment Left Supraclavicular Per Tumor Board Develop Rad
BH0401 - ..
BH0402 - Radiation Treatment Left Supraclavicular Per Tumor Board
BH0404 - Follow up ref SDS B3 Z26K, ref SDS 98 Z26K.
BH0406 - Background considering radiation treatment is reported in the record
BH0407 - on 060623. ref SDS B3 Z26K
BH0409 - ..
BH0410 - Surgeon's notes reported on 051021 indicated previously radiated skin
BH0411 - may have been removed with a wide area mastectomy. ref SDS 82 TH50
BH0412 - This may permit further radiation treatment of IBC relapse.
BH0414 - ..
BH0415 - There was no discussion of this today as part of a comprehensive
BH0416 - strategy for planning. treatment.
BH0418 - [On 060720 letter to doctor asks about role of radiation and
BH0419 - support from Tumor Board in forming treatment strategy. treatment
BH0420 - strategy ref SDS B6 Z68I
Schedule Treatment Meeting Pharmacist Zan Start Capecitabine (Xeloda
BK0401 - ..
BK0402 - Schedule Treatment Meeting Pharmacist, Zan Start Xeloda Taxotere
BK0403 - Pharmacist Zan Schedules Treatment with Capecitabine Taxotere
BK0405 - Zan discussed implementing the doctor's plan to start with 2 cycles of
BK0406 - capecitabine (Xeloda) and Taxotere, per above. ref SDS 0 PF3O
BK0408 - ..
BK0409 - Zan previously provided guidance on 050415 when treatment was switched
BK0410 - from Adriamycin Cytoxin (AC) to Capecitabine (Xeloda) and Taxotere.
BK0411 - ref SDS 56 PS6X
BK0413 - ..
BK0414 - At that time dosage was adjusted to accomodate concurrent treatments
BK0415 - for pulmonary emboli with Coumadin (Warfarin), ref SDS 56 BU67, and
BK0416 - based on family medical history of related problems with blood clots,
BK0417 - reported to Kaiser on 040812. ref SDS 40 MG5K This adjusted level of
BK0418 - treatment was effective, reported on 050520. ref SDS 59 025H
BK0420 - ..
BK0421 - Side effects at the adjusted level shown in patient history on 050422,
BK0422 - ref SDS 57 VE68, became intolerable, and further adjustment of dosage
BK0423 - was made on 050516. ref SDS 58 AQ6G Reduced dosage continued to yield
BK0424 - favorable response to treatment, reported on 050727. ref SDS 63 YY7F
BK0426 - [On 060724 diary side effects for 2nd phase taking Taxotere
BK0427 - and capecitabine (Xeloda). ref SDS C0 QX8K
BK0429 - ..
BK0430 - Since Millie is no longer on Coumadin, reported on 051121, ref SDS 85
BK0431 - RZ4I, how will this influence calculation of treatment dosage, and in
BK0432 - light of prior experience showing favorable response, but severe side
BK0433 - effects, that resulted in continuing favorable response with a reduced
BK0434 - dose for tolerable side effects?
BK0436 - [On 060929 patient reports heavy chest, difficulty breathing
BK0437 - symptoms pulmonary emboli, pharmacist not aware of correlations
BK0438 - with Taxotere and capecitabine (Xeloda). ref SDS D3 F44F
BK0440 - ..
BK0441 - Zan said he will consult with the doctor and prepare the dosage of
BK0442 - chemotherapy based on Millie's weight, and other factors.
BK0444 - [On 060714 oldest son hospitalized again with pulmonary emboli.
BK0445 - ref SDS B5 8S6I
BK0447 - ..
BK0448 - [On 060722 oldest son reports doctors performed tests and found
BK0449 - genetic cause of blood clots that will require continuing
BK0450 - treatment. ref SDS B9 3D9T
BK0452 - ..
BK0453 - [On 060724 notified Kaiser of new information on family history of
BK0454 - blood clot problems, and report of medical study showing genetic
BK0455 - cause. ref SDS C1 NL5Q
BK0457 - ..
BK0458 - [On 060726 letter from Arlette says Kaiser received this
BK0459 - notice and forwarded to the primary care physician.
BK0460 - ref SDS C2 0001
BK0462 - ..
BK0463 - Kaiser's guidance for patients to use collateral treatments that
BK0464 - reduce side effects are in the record on 050415. ref SDS 56 BV50
BK0466 - ..
BK0467 - Instructions and a timeline diagram for taking capecitabien (Xeloda)
BK0468 - pills and support medications are also, listed on 050415. ref SDS 56
BK0469 - PP8L
BK0471 - ..
BK0472 - Millie did not recall discussion of Nupigen, which the doctor
BK0473 - prescribed on 050415 to start treatments with capecitabine (Xeloda)
BK0474 - and Taxotere. ref SDS 56 KX49
BK0476 - ..
BK0477 - The doctor needs to address the nupigen issue, as was done on 050415.
BK0478 - ref SDS 56 649X
BK0480 - ..
BK0481 - One reason nupigen may have been needed previously was because Millie
BK0482 - was hospitalized twice with immune system issues, prior to starting
BK0483 - Capecitabine (Xeloda) and Taxotere, and she had been treated with AC
BK0484 - chemotherapy for 3 months, all the while IBC disease was progressing.
BK0485 - This combination of events may have lowered white blood cells, which
BK0486 - required nupigen to restore. Now, however, Millie has been off
BK0487 - treatment for about 9 months. Her system is fairly strong. She was
BK0488 - treated for pneumonia on 060607. ref SDS A9 PT7S The doctor
BK0489 - determined today that xrays show sufficient recovery to permit
BK0490 - starting chemotherapy, per above. ref SDS 0 FF4K Does this present a
BK0491 - comparable risk that justifies prescribing nupigen, as was done on
BK0492 - 050415? ref SDS 56 XU7L
BK0494 - [On 060720 patient writes to doctor asking about requirements for
BK0495 - nupigen, based on patient history. ref SDS B6 185S
BK0497 - ..
BK0498 - [On 060721 doctor monitoring situation, and will prescribe nupigen
BK0499 - if needed. ref SDS B8 OK3M
BK0501 - ..
BK0502 - [On 060722 oldest son reports doctors performed tests and found
BK0503 - genetic cause of blood clots that will require continuing
BK0504 - treatment. ref SDS B9 3D9T
BK0506 - ..
BK0507 - [On 060724 notified Kaiser of new information on family history of
BK0508 - blood clot problems, and report of medical study showing genetic
BK0509 - cause. ref SDS C1 NL5Q
BK0511 - ..
BK0512 - Zan will have someone in the Infusion Department call Millie tomorrow
BK0513 - to coordinate on scheduling the start of treatment, including a blood
BK0514 - test.
BK0516 - ..
BK0517 - Millie said she still has some pills for decadron.
BK0519 - ..
BK0520 - Zan said to bring them to the Infusion Department on the first day of
BK0521 - treatment. He will visit Millie while treatment is underway, and then
BK0522 - place an order with the pharmacy for capecitabine (Xeloda), and for
BK0523 - Decadron. Millie can get the medication from the pharmacy after
BK0524 - treatment, as was done previously.
Port Catheter Flush Performed for Blood Draws with Chemotherapy Trea
BM0401 - ..
BM0402 - Port Catheter Flush Performed at Kaiser to Maintain Chemo Treatment
BM0404 - Follow up ref SDS B3 SH5N, ref SDS 98 SH5N.
BM0406 - ..
BM0407 - Millie had the port catheter flushed on 060501.
BM0409 - ..
BM0410 - She was in the hospital on 060607 for treatment of pneumonia, and the
BM0411 - port catheter was used for antibiotics. ref SDS A9 K645
BM0413 - ..
BM0414 - Port catheter flush not needed for 4 - 6 weeks OA 060715.
BM0416 - ..
BM0417 - Treatments will start in a week or so, which will preclude need for
BM0418 - another port flush, because blood draws and treatments flush the port.
Status Change Did Not Occur Retest Biopsy 040419 HER2/NEU Treatment
CD0401 - ..
CD0402 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
CD0403 - Treatment Options Limited Status Not Changed by Retest Biopsy 040419
CD0405 - Follow up ref SDS B3 ZR6J, ref SDS 98 ZR6J.
CD0407 - Background on status change is reported in the record of the meeting
CD0408 - on 060428. ref SDS 98 ZR6J
CD0410 - ..
CD0411 - Since there is now strong evidence of IBC relapse, can a biopsy to
CD0412 - verify IBC also demonstrate whether there is a status change that
CD0413 - increases treatment options, per analysis of Doctor Shim on 050909
CD0414 - that proposed retest of the biopsy on 040419 that identified IBC,
CD0415 - ref SDS 70 P58N, and in order to expand treatment options, based on
CD0416 - the 2nd opinion received on 041117 from Doctor Benz at UCSF.
CD0417 - ref SDS 44 OU6W
CD0419 - ..
CD0420 - The doctor checked the computer and found a report showing status is
CD0421 - unchanged based on the biopsy performed on 040419, which previously
CD0422 - was not included with the biopsy report received from the primary care
CD0423 - physician, as shown in the record on 040517 when the biopsy report was
CD0424 - first submitted to the patient. ref SDS 33 736K
CD0426 - [On 060825 biopsy left breast to establish IBC, evaluate status
CD0427 - change since 040419 biopsy, and determine measureable disease
CD0428 - to qualify for drug trials at UCSF. ref SDS D1 FF9K
CD0430 - ..
CD0431 - [On 070105 Millie's triple negative status qualifies for
CD0432 - treatment on clincial study with cetuximab and
CD0433 - carboplatin. ref SDS E4 PK7L
CD0435 - ..
CD0436 - [On 071007 support group seminar indicates criteria for
CD0437 - HER2 negative may have dropped from 2 to 1.6; ask Doctor
CD0438 - Rugo at UCSF about propsects of expanding treatment to
CD0439 - use Herception available onlyt to HER2 positive patient
CD0440 - status. ref SDS E5 S68T
CD0442 - ..
CD0443 - [On 071009 Doctor Rugo advises that UCSF continue to rely
CD0444 - on HER2 negative standard at 2, i.e., there has been not
CD0445 - change in criteria. ref SDS E6 4Q4K
CD0447 - ..
CD0448 - [On 081016 Millie's IBC disease progresses; Doctor Rugo
CD0449 - proposes treatment with new sunitinib metronomic protocol
CD0450 - designed for multi-targeted treatment of cancer receptors;
CD0451 - Kaiser ordered biopsy of left supraclavicular lump to evaluate
CD0452 - status change again. ref SDS E8 J36R
CD0454 - ..
CD0455 - [On 081119 Kaiser submits summary of final pathology report,
CD0456 - ref SDS F1 5O8G, for the biopsy on 081107, ref SDS F0 496L, and
CD0457 - it shows status is unchanged, still triple negative.
CD0458 - ref SDS F1 UQ5P
CD0460 - ..
CD0461 - Doctor Johnson explained that the pathology report on the biopsy
CD0462 - performed on 040419 and which presents analysis of status change is
CD0463 - located in another part of Kaiser's computer system, which requires
CD0464 - access with particular steps using the keyboard and pointer tools
CD0465 - (mouse), and which were previously overlooked in prior meetings with
CD0466 - the doctor discussing this issue, beginning on 040517. ref SDS 33 6T5G
CD0468 - [On 081106 0913 Head and Neck Department changes schedule 3
CD0469 - times and then reverts to original schedule, because staff
CD0470 - cannot find original records in Kaiser computer system.
CD0471 - ref SDS E9 IP7L
CD0473 - ..
CD0474 - Access today to patient history shows improvement learning Kaiser's
CD0475 - computer system, which has proven problematic; for example on 040318,
CD0476 - ref SDS 28 8T8K, and again a few months later on 040812. ref SDS 40
CD0477 - LQ5L More recently, the record on 060126 lists several occassions
CD0478 - when analysts failed to make relevant comparisons because reports on
CD0479 - prior tests could not be easily found on Kaiser's computer system.
CD0480 - ref SDS 88 LC7N More recently, on 060428 the doctor could not access
CD0481 - the PET scan test to review diagnosis of esophagitis, ref SDS 98 KC5K,
CD0482 - and so took no action for treatment. Two months later on 060607
CD0483 - Millie was treated in Emergency Room and the attending physician asked
CD0484 - how long Millie has been treated for esophagitis shown in Kaiser's
CD0485 - computer. ref SDS A9 K66E Computer access problems occurred again on
CD0486 - 060623. ref SDS B3 463H
CD0488 - [On 061020 Oncology staff explains Kaiser technology engineers
CD0489 - change Kaiser computers to roll out improvements that require
CD0490 - using cut and paste to transfer data between three (3) software
CD0491 - programs with duplication; increases burden to learn functions,
CD0492 - and increases chance of mistakes. ref SDS D6 TR53
CD0494 - ..
CD0495 - [On 061020 Kaiser Oncology pharmacy was not aware from reading
CD0496 - Kaiser's computer that on 061002 a prescription was ordered for
CD0497 - a cancer patient being treated with capecitabine (Xeloda)
CD0498 - cheotherapy drug agent, to treat pulmonary embolism with
CD0499 - Coumadin, which has a conflict with capecitabine. ref SDS D6
CD0500 - T650
CD0502 - ..
CD0503 - [On 061020 primary care physician suprised and frustrated that
CD0504 - automatic notification of patient medications on Kaiser
CD0505 - computers was not effective. ref SDS D7 YQ7L
CD0507 - ..
CD0508 - [On 061024 Coagulation Treatment Clinic uses software that
CD0509 - requires accessing another part of Kaiser's computer system to
CD0510 - coordinate patient treatments; such access requires training,
CD0511 - and time for performance; therefore direct notice from the
CD0512 - doctor and support staff in Oncology Pharmacy, as occurred
CD0513 - today, per below, ref SDS D6 VE57, and also by the patient, as
CD0514 - encouraged by the pharmacist, per above, ref SDS D6 S69H,
CD0515 - assists the Coagulation Treatment Clinic in making an accurate
CD0516 - and effective balance of treatments for pulmonary embolism with
CD0517 - chemotherapy treatments for cancer using capecitabine (Xeloda)
CD0518 - in this case. ref SDS D8 TZ4I
CD0520 - ..
CD0521 - [On 061024 case study medical practice computer access limited
CD0522 - even with everything on the computer, people can't find details
CD0523 - stored in parts of the computer (software modules) that are not
CD0524 - frequently used. ref SDS D8 JD9L
CD0526 - ..
CD0527 - This biopsy report does not indicate any "retest" was performed, but
CD0528 - seems to indicate the status was originally reported, and not noticed
CD0529 - by the primary care physician, nor by Doctor Shim in the Oakland
CD0530 - Office, reported last year on 050907.
CD0532 - [On 060807 Doctor Grissom may be proposing that since IBC is
CD0533 - not responding to treatment that was previously effective, this
CD0534 - could indicate a change in the biology that could yield a
CD0535 - change in status, which increases treatment options.
CD0536 - ref SDS C6 T69N
CD0538 - ..
CD0539 - Another possiblity is that retesting was performed, but not
CD0540 - identified in Kaiser's record.
CD0542 - ..
CD0543 - Received the following report from the primary care physician, and for
CD0544 - the biopsy on 040419 that supplements the report received on 040517...
CD0546 - Patient Provider Category View FR Date To Date
CD0559 - ** SAN FRANCISCO MEDICAL CENTER **
CD0561 - ..
CD0562 - Immunohistochemistry Lab, Northern California. Unless otherwise
CD0563 - specified, it has not been cleared or approved by the USFDA,
CD0564 - although such approval is not required for analyte specific
CD0565 - reagents of this type. Hercepest is FDA approved. Unless
CD0566 - otherwise specified, the inflitrating component is evaluated.
CD0568 - IMMUNOHISTOCHEMESTRY (LEFT BREAST WCRS05-9966)
CD0570 - ..
CD0571 - Estrogen Receptor - negative, positive external control
CD0572 - Progesterone Receptor - negative, positive external control
CD0573 - Herceptest (DAKO) - negative, 10%, 1+/weak (a30)
CD0575 - ..
CD0576 - On 020321 the primary care physcian originally reported
CD0577 - immunohistochemestry. ref SDS 3 6Q6J
CD0579 - ..
CD0580 - Biopsy report on 040419 concludes...
CD0582 - WEN JING, MD
CD0584 - ..
CD0585 - HISTORY
CD0587 - ..
CD0588 - PAT.RES <SHIFT F9> for complete results MTZRAJ 060711 0935
Work Plan Doctor Submits Doctor/Patient Partnership Communications I
CI0401 - ..
CI0402 - Work Plan Received Communications Doctor/Patient Partnership
CI0403 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
CI0404 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
CI0406 - Follow up ref SDS B3 FE4I, ref SDS 98 FE4I.
CI0408 - Doctor patient communication improving. Contemporaneous notes of work
CI0409 - in progress provided to the patient in printed media take hours to
CI0410 - render for precision access and connection. Productivity saving
CI0411 - lives, time, and money was significantly increased today, aided by
CI0412 - Kaiser's technology tools for medical practice. The doctor invested 5
CI0413 - seconds to capture the record from the medical chart prepared during
CI0414 - the meeting. He used the computer operating system (OS) to copy
CI0415 - progress notes and paste the record into an email, which was
CI0416 - transmitted electronically to the patient for efficient work up into
CI0417 - medical intelligence.
CI0419 - [On 060808 backup doctor submits excellent report on the
CI0420 - work rendered in conventional printed media that was
CI0421 - difficult to read and took hours converting into an
CI0422 - electronic record that supports precision access for
CI0423 - working intelligently. ref SDS C7 FE4I
CI0425 - ..
CI0426 - [On 060825 primary care physician returns from vacation,
CI0427 - and submits electronic record from medical chart on meeting
CI0428 - with the patient. ref SDS D1 FE4I
CI0430 - ..
CI0431 - [On 061020 Kaiser continues to facilitate intelligence
CI0432 - suport for performing due diligence. ref SDS D7 FE4I
CI0434 - ..
CI0435 - Progress continues toward good management using the doctor patient
CI0436 - partnership for timely review of patient history in the medical chart,
CI0437 - called out in Kaiser's Healthwise Handbook, reviewed on 990625,
CI0438 - ref SDS 2 TD5S, and recently reported on 060106. ref SDS 87 FE4I
CI0440 - 1. 07/11/2006 09:20 AM
CI0442 - Wcr-ONnc2 > Main Campus
CI0445 - ..
CI0446 - 2. Your primary care clinician is listed as...