CONTACTS 

SUBJECTS
Meeting Doctor Examine Recovery from Mastectomy Surgery Response to
Meeting Backup Doctor Emergency Examination Rapidly Expanding Red Ra

0404 -
0404 -    ..
0405 - Summary/Objective
0406 -
040601 - Follow up ref SDS B8 0000. ref SDS B6 0000.
040602 -
040603 - Excellent emergency meeting with backup doctor; examination showed IBC
040604 - red rash spread significantly during 1st cycle of treatment with
040605 - Taxotere and Xeloda; but may have begun to subside since yesterday.
040606 - ref SDS 0 VO6G  The doctor determined this patient history, along with
040607 - rising CA 15-3 for 6 months does not support changing treatment,
040608 - ref SDS 0 K36G, and that results of new cancer marker test tomorrow
040609 - will not be available in time to change treatment, even if evidence
040610 - indicates current protocol is not effective. ref SDS 0 PF3O  Good
040611 - discussion today on risks of radiation exposure from image testing.
040612 - ref SDS 0 3T7L  Deferred decision on biopsy to explore expanding
040613 - treatment options. ref SDS 0 KT7J  Patient exposure to pulmonary
040614 - emboli from recently discovered family genetics was not reviewed in
040615 - connection with chemotherapy treatments and dose levels. ref SDS 0
040616 - 9W4L
040617 -
040618 -    [On 060817 CA 15-3 73 dramatic improvement, reversing 6 month rise
040619 -    of cancer marker, now falling back below critical 80 level,
040620 -    ref SDS D5 TS5O; supports observation impression on 060808 that IBC
040621 -    red rash subsiding and breaking up, ref SDS 0 VO6G, further
040622 -    reported on 060817, ref SDS D5 NU6L, evidence patient experiencing
040623 -    delayed response to treatment under scenario #1, developed on
040624 -    060808. ref SDS 0 J16O
040626 -     ..
040627 -    [On 060817 commendation to backup doctor and Oncology team for
040628 -    dramatic reversal of rising cancer marker, and breakup of IBC
040629 -    disease, indicating patient on the mend. ref SDS D5 L29J
040630 -
040631 -
040632 -
040633 -
040635 -  ..
0407 -
0408 -
0409 - Progress
0410 -
041001 - Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
041002 -
041003 - Follow up ref SDS B8 SM6M, ref SDS B6 SM6M.
041004 -
041005 - This is the 2nd review meeting following start of treatment on 060711
041006 - for 3rd relapse of IBC. ref SDS B8 SM6M  We are meeting with a backup
041007 - physician, because the primary care physician is on vacation.
041009 -  ..
041010 - Millie submitted agenda prior to the meeting so the doctor could be
041011 - prepared.  Prior to the meeting Millie listed the agenda on the
041012 - marking board in the examination room to guide discussions...
041013 -
041014 -    1.  Breast exam IBC relapse diagnosis.......... ref SDS 0 025H
041015 -    2.  Treatment plan strategy.................... ref SDS 0 K36G
041016 -    3.  HDC treatment.............................. ref SDS 0 KY4G
041017 -    4.  Status change treatment options............ ref SDS 0 ZR6J
041018 -    5.  Doctors notes prior exam................... ref SDS 0 NP6L
041019 -
041020 -            [...below backup doctor does not address agenda issues.
041021 -            ref SDS 0 FW6K
041023 -  ..
041024 - Scheduled next meeting in about 2 weeks after the doctor returns from
041025 - vacation. on August 25, 2006
041026 -
041027 -
041028 -
041029 -
041030 -
041031 -
0411 -

SUBJECTS
Vitals Pending from Backup Doctor for Emergency Examination Not Subm

0603 -
060401 -  ..
060402 - Vitals Show Stable Medical Condition
060403 -
060404 - Follow up ref SDS B8 KB5L, ref SDS B6 KB5L.
060406 -                           ..
060407 -                          Bld Prssr   Pulse   Temp   Weight  SaO2
060408 -     ..
060409 - *  060808.................
060410 -    060711................. 172 87     54     97.5    147
060411 -    060623................. 141 87     71     98.0    147     99%
060412 -    060428................. 129 73     80     99.4    149     99%
060413 -    060217................. 153 81     61     98.6    150     99%
060414 -
060415 - ...per Doctor's report, shown below, vitals were not reported for some
060416 - reason. ref SDS 0 JQ4J
060417 -
060418 -
060419 -
060420 -
060421 -
060422 -
0605 -

SUBJECTS
CA 15-3 71 Next Test May Indicate Treatment Failed Despite Red Rash

1603 -
160401 -  ..
160402 - CA 15-3 Cancer Marker 71 No Test Current Period Since 060711
160403 -
160404 - Follow up ref SDS B8 087J, ref SDS B6 087J.
160405 -
160406 - There have been no CA 15-3 tests this period.  The next test is
160407 - tomorrow to prepare for the next cycle of treatment.
160409 -           ..
160410 -          Test Date                         Date Received
160411 -          060708......... 71 H............. 060711, ref SDS B8 087J
160412 -          060616......... 63 H............. 060623, ref SDS B6 UQ5Q
160413 -          060522......... 59 H............. 060605, ref SDS B1 UQ5Q
160414 -          060501......... 49 H............. 060522, ref SDS A8 MC4F
160415 -          060421......... 44 H............. 060428, ref SDS A2 087J
160416 -          060330......... 40 H............. 060428, ref SDS A2 087J
160417 -          060303......... 36............... 060428, ref SDS A2 087J
160418 -          060210......... 33............... 060217, ref SDS 92 087J
160419 -          060109......... 34............... 060126, ref SDS 91 KV59
160420 -          051223......... 34............... 060106, ref SDS 90 087J
160421 -          051202......... 28............... 060106, ref SDS 90 087J
160422 -          051116......... 31............... 051121, ref SDS 88 087J
160423 -          051109......... 30............... 051121, ref SDS 88 087J
160424 -          051102......... 34............... 051121, ref SDS 88 087J
160425 -          050909......... 45 H............. 051007, ref SDS 81 087J
160426 -          050826......... 45 H............. 050913, ref SDS 75 087J
160427 -          050819......... 45 H............. 050913, ref SDS 75 087J
160428 -          050812......... 39 .............. 050819, ref SDS 68 3K6L
160429 -          050729......... 45 H............. 050819, ref SDS 68 EA5G
160430 -          050708......... 46 H............. 050729, ref SDS 67 087J
160431 -          050701......... 37 .............. 050729, ref SDS 67 087J
160432 -          050617......... 45 H............. 050729, ref SDS 67 087J
160433 -          050527......... 56 H............. 050610, ref SDS 64 087J
160434 -          050512......... 67 H............. 050520, ref SDS 62 087J
160435 -          050506......... 80 H............. 050520, ref SDS 62 087J
160436 -  ..
160437 -          050415.........105 H............. 050422, ref SDS 58 087J
160438 -          050325.........100 H............. 050329, ref SDS 56 087J
160439 -          050318.........101 H............. 050325, ref SDS 55 2N5J
160440 -          050304......... 88 H............. 050311, ref SDS 53 087J
160441 -          050225......... 95 H............. 050308, ref SDS 52 0001
160442 -          050211......... 78 H............. 050214, ref SDS 51 02BB
160443 -          050128......... 67 H............. 050204, ref SDS 50 087J
160444 -          041228......... 56 H............. 041230, ref SDS 49 087J
160445 -          041204......... 43 H............. 041210, ref SDS 48 087J
160446 -          041007......... 39............... 041104, ref SDS 44 087J
160447 -          040923......... 49 H............. 041005, ref SDS 43 087J
160448 -          040908......... 44 H............. 040909, ref SDS 42 087J
160449 -          040825......... 47 H............. 040909, ref SDS 42 087J
160450 -          040811......... 42 H............. 040812, ref SDS 41 087J
160451 -          040728......... 43 H............. 040729, ref SDS 39 2N5J
160452 -          040712......... 47 H............. 040713, ref SDS 38 087J
160453 -          040614......... 55 H............. 040615, ref SDS 37 PX6X
160454 -          040517......... 78 H............. 040601, ref SDS 35 2N5J
160455 -          040311......... 70 H............. 040318, ref SDS 29 SM6M
160456 -          040205......... 60 H............. 040211, ref SDS 27 SM6M
160457 -          031201......... 62 H............. 031205, ref SDS 26 SM6M
160458 -          030912......... 66 H............. 030915, ref SDS 25 SM6M
160459 -          030708......... 68 H............. 030710, ref SDS 24 SM6M
160460 -          030503......... 54 H............. 030508, ref SDS 22 SM6M
160461 -          030403......... 45 H............. 030508, ref SDS 22 SM6M
160462 -          030215......... 46 H............. 030220, ref SDS 21 5E6L
160463 -          030106......... 37 H............. 030109, ref SDS 20 SM6M
160464 -          021202......... 41 H?............ 021204, ref SDS 19 SP5G
160465 -          021111......... 36 H?............ 021113, ref SDS 18 Y65I
160466 -          021023......... 33 H?............ 021023, ref SDS 17 SQ5I
160467 -          020930......... 33 H?..39........ 021002, ref SDS 16 SQ5I
160468 -          020917......... 36 H?............ 020924, ref SDS 15 SQ5I
160469 -          020717......... 59 H?............ 020726, ref SDS 14 YN5K
160470 -          020629......... 75 H ............ 020705, ref SDS 12 UX6I
160471 -          020608........  67 H ............ 020614, ref SDS 10 0001
160472 -          020603........ 108 H ............ 020607, ref SDS 9 X67F
160473 -          020511........ 117 H ............ 020603, ref SDS 8 PJ4J
160474 -          020419......... 81 H ............ 020430, ref SDS 6 7N5H
160475 -          020321......... 85 H ............ 020405, ref SDS 5 6T8K
160476 -
160477 -
160478 -
160479 -
160481 -  ..
1605 -
1606 -
1607 - Analysis
1608 -
160801 - CA 15-3 71 Cancer Marker Test Tomorrow Influence Treatment Decision
160802 -
160803 - Follow up ref SDS B8 GJ5M, ref SDS B6 GJ5M.
160805 -  ..
160806 - The most recent CA 15-3 test on 060708 rose from 63 to 71, well above
160807 - the cancer signal level of 39, and consistent with spreading IBC
160808 - relapse observed by examination on 060711 showing expanding red rash
160809 - on left breast at mastectomy incision. ref SDS B8 025H
160811 -  ..
160812 - The backup doctor did not have a more recent CA 15-3 test today for
160813 - trend analysis to compare with examination of IBC red rash, discussed
160814 - below. ref SDS 0 VO6G  CA 15-3 will be included in the blood test
160815 - tomorrow to evaluate treatment status.  The doctor indicated that
160816 - typically results the CA 15-3 cancer marker part of the test will not
160817 - be available from the blood test tomorrow in time to change treatments
160818 - on Thursday, 060810, even if CA 15-3 has increased dramatically, for
160819 - example to 80 or 90, which have previously signaled failed treatment,
160820 - as discussed below under scenario #2. ref SDS 0 J458  Doctor's
160821 - Progress Note does not mention consideration of CA 15-3. ref SDS 0
160822 - ZL7N
160824 -         ..
160825 -        [On 060810 CA 15-3 87 significant jump, which is 7 above the
160826 -        80 level cited for considering change of treatment, and a very
160827 -        large jump in patient history, ref SDS D3 2N5J, order follow up
160828 -        test to assess correlation between observed decline IBC
160829 -        inflammation and rising CA 15-3. ref SDS D3 854L
160831 -         ..
160832 -        [On 060817 CA 15-3 73 dramatic improvement, reversing 6 month
160833 -        rise of cancer marker, now falling back below critical 80
160834 -        level, ref SDS D5 TS5O; supports observation impression on
160835 -        060808 that IBC red rash subsiding and breaking up, ref SDS 0
160836 -        VO6G, further reported on 060817, ref SDS D5 NU6L, evidence
160837 -        patient experiencing delayed response to treatment under
160838 -        scenario #1, developed on 060808. ref SDS 0 J16O
160839 -
160840 -
160841 -
160842 -
1609 -

SUBJECTS
Esophagitis PET Scan Test Not Compared with Prior Report Symptoms Mi

2003 -
200401 -  ..
200402 - Esophagitis in PET Test and Nodes Right Paratracheal Found CT Test
200403 -
200404 - Follow up ref SDS B8 JP6K, ref SDS B6 DH4O.
200405 -
200406 - Issues and background on diagnosis of esophagitis reported in PET scan
200407 - test performed on 060120, and received on 060126, ref SDS 91 DH4O,
200408 - were most recently reviewed on 060623. ref SDS B6 DH4O
200410 -  ..
200411 - At that time, on 060623 follow up on diagnosis of esophagitis was
200412 - paused. ref SDS B6 RB4H
200414 -  ..
200415 - Millie had a strong episode of reflux, sometimes associated with
200416 - esophagitis, and which occurred about a week prior to the last
200417 - examination on 060711. ref SDS B8 KH7N
200419 -  ..
200420 - There was no discussion of esophagitis today, shown by the doctor's
200421 - record. ref SDS 0 1248  This is an interim, emergency examination on
200422 - changing chemotherapy treatment.
200423 -
200424 -
200425 -
200426 -
200427 -
200428 -
2005 -

SUBJECTS
Left Axillary No Evidence Lymphadenopathy Lymphedema Left Arm Lump    2

3003 -
300401 -  ..
300402 - Left Axillary No Evidence Lymphadenopathy
300403 - Lymphedema Left Arm Lump Under Arm Diagnosis Not Cancer
300404 - Post Operation Localized Edema Left Axillary Swelling Reduced
300405 -
300406 - Follow up ref SDS B8 MW8J, ref SDS B6 MW8J.
300408 -  ..
300409 - Patient history of left axillary lymphadenopathy and lymphedema is
300410 - reported on 060106. ref SDS 90 S164
300412 -  ..
300413 - On 060710 physical therapist found significant improvement; decided to
300414 - end physical therapy, since patient making good progress with
300415 - self-care, ref SDS B7 Q05H, further reported during the examination on
300416 - 060711. ref SDS B8 U433
300418 -  ..
300419 - The backup doctor made no examination today of the left axillary, and
300420 - there was no complaint of lump or discomfort by the patient,
300421 - consistent with image test reporting during the meeting on 060623
300422 - indicating no findings of lymphadenopathy at this time, ref SDS B6
300423 - MW8J, therefore, suggesting cancer relapse seems primarily local.
300424 -
300425 -
300426 -
300427 -
3005 -

SUBJECTS
Right Axillary Clinical Examination Finds No Lump Patient Complains

3503 -
350401 -  ..
350402 - Right Axillary FDG SUV 2.5 Lump Discomfort Not Reported by Patient
350403 -
350404 - Follow up ref SDS B8 3D6K, ref SDS B6 CZ8L.
350405 -
350406 - Patient history of rising FDG SUV activity by PET testing, reported on
350407 - 060428, ref SDS A1 CZ8L, and no adenopathy found in contrast CT test
350408 - reported on 060526, ref SDS A8 4O8P, which further found failed make
350409 - the contrast with the PET test findings, ref SDS A7 WT6M, was reviewed
350410 - during a meeting with the doctor on 060623. ref SDS B6 CZ8L
350412 -  ..
350413 - At that time on 060623 attention switched from the right axillary to
350414 - IBC relapse in the left breast, based on examination showing red rash
350415 - on left breast. ref SDS B6 6X3N
350417 -  ..
350418 - Primary attention today during the interim meeting was on treatment.
350420 -  ..
350421 - The backup doctor made no examination of the right axillary, and no
350422 - further direction to correct possible error in the CT test on 060526.
350423 - ref SDS A8 006P
350424 -
350425 -
350426 -
350427 -
350428 -
350429 -
3505 -

SUBJECTS
Left Supraclavicular Neck CT Test Contrast Study on 060505 Finds No

4303 -
430401 -  ..
430402 - Radiation Treatment Cancer Relapse Left Supraclavicular and IBC
430403 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
430404 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
430405 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
430406 -
430407 - Follow up ref SDS B8 8R6M, ref SDS B6 8R6M.
430408 -
430409 - Background of image testing, and consideration for radiation treatment
430410 - of left supraclivicular is reported on 060623. ref SDS B6 8R6M
430412 -  ..
430413 - There was no examination of left supraclavicular due to focus on IBC
430414 - relapse in left breast, and planning for treatment.
430415 -
430416 -
430417 -
430418 -
430419 -
430420 -
4305 -

SUBJECTS
Examination 2 Scenarios Finds IBC Red Rash Increased During 1st Cycl

6203 -
620401 -  ..
620402 - Red Rash Subsides Left Breast Hopeful Response to Treatment
620403 - Examination Left Breast IBC Inflammation Red Rash Seems to Subside
620404 - IBC Inflammation Left Breast Red Rash Subsides Response to Treatment
620405 - Response to Treatment IBC Inflammation Left Breast Red Rash Subsides
620406 -
620407 - Follow up ref SDS B8 025H, ref SDS B6 025H.
620408 -
620409 - Background on prior relapse examinations is listed on 060711.
620410 - ref SDS B8 8Y7O
620412 -  ..
620413 - Millie submitted a letter to Kaiser yesterday on 060807, ref SDS C9
620414 - 423C, presenting the purpose of an exigent meeting today, so that the
620415 - backup doctor could be prepared. ref SDS C9 5P65  The doctor did not
620416 - mention this morning having seen nor reviewed Millie's letter within
620417 - Kaiser's guidance on communications for doctor/patient partnership,
620418 - see below. ref SDS 0 FE4I
620420 -  ..
620421 - The letter describes expansion of IBC red rash on the left breast
620422 - after the first treatment on 060721, which contrasts with rapidly
620423 - declining IBC rash under the same treatment in 2005, and illustrated
620424 - by the record on 050502, ref SDS 59 EO5J, and confirmed in a meeting
620425 - with the primary care physician on 050520. ref SDS 62 025H
620426 -
620427 -     [On 060922 case study analysis indicates that improvement may be
620428 -     more rapid during the current treatment than occurred in 2005.
620429 -     ref SDS D7 0D4T
620431 -  ..
620432 - Before the meeting, self-examination this morning showed possible
620433 - reduction in the severity of IBC rash, compared with findings from
620434 - observation on 060711, ref SDS B8 8Z8G, and discussed further below.
620435 - ref SDS 0 8Z8G  This change in status was reported to the backup
620436 - doctor during the meeting; hopeful indicator of delayed response to
620437 - treatment. ref SDS 0 K36G
620438 -
620439 -     [...below doctor's Progress Note cites patient's report of
620440 -     possible decline in red rash on left breast. ref SDS 0 MO4O
620442 -      ..
620443 -     [On 060810 CA 15-3 jumps to 87, 7 above the 80 level cited for
620444 -     considering change of treatment, and a very large jump in
620445 -     patient history, ref SDS D3 2N5J, order follow up test to
620446 -     assess correlation between observed decline IBC inflammation
620447 -     and rising CA 15-3. ref SDS D3 854L
620449 -      ..
620450 -     [On 060817 CA 15-3 73 dramatic improvement, reversing 6 month rise
620451 -     of cancer marker, now falling back below critical 80 level,
620452 -     ref SDS D5 TS5O; supports observation impression on 060808 that
620453 -     IBC red rash subsiding and breaking up, ref SDS 0 VO6G, further
620454 -     reported on 060817, ref SDS D5 NU6L, evidence patient experiencing
620455 -     delayed response to treatment under scenario #1, developed on
620456 -     060808. ref SDS 0 J16O
620458 -      ..
620459 -     [On 060922 Millie asks about slow recovery from IBC,
620460 -     ref SDS D7 MG6F, analysis indicates recovery may be ahead
620461 -     of rate IBC rash receded during 2005, ref SDS D7 9F35, and
620462 -     cites resistance to treatment from mastectomy surgery that
620463 -     removed blood vessels which prevents delivering treatment
620464 -     to infected tissue. ref SDS D7 ML3I
620466 -      ..
620467 -     [On 061027 asks Kaiser about slow recovery correlation to
620468 -     mastectomy surgery, ref SDS E0 618J, based on analysis on
620469 -     060922. ref SDS D7 ML3I
620470 -
620472 -  ..
620473 - Experience IBC Backup Doctor Treated 1 Patient
620474 -
620475 - Millie asked the doctor about experience treating patients with IBC,
620476 - and commented on a video recently passed around at her office that
620477 - said IBC is very serious, but few doctors have treated IBC patients,
620478 - because this form of cancer is very rare, reported on 060807.
620479 - ref SDS C9 JR9Y
620481 -  ..
620482 - The doctor described treating at least one IBC patient, and that
620483 - patient is currently off treatment following mastectomy surgery,
620484 - similar to Millie's experience.
620485 -
620486 -        [On 060808 Arlette commends backup doctor's experience.
620487 -        ref SDS D1 8I5K
620489 -  ..
620490 - The backup doctor looked briefly (2 seconds) at the red rash on the
620491 - left breast.  Without prior experience in this case, he could not
620492 - comment on seeing advancing disease.  The doctor indicated he has
620493 - access to the medical chart prepared by the primary care physician for
620494 - the meeting on 060711. ref SDS B8 0001  The doctor said there are no
620495 - diagrams, pictures nor other photographic records showing the area of
620496 - IBC infection at the time of prior meetings.  The doctor advised that
620497 - Progress Notes on examinations in the Medical Chart do not describe
620498 - conditions at prior times with sufficient detail for making comparison
620499 - today. ref SDS B8 BU7I
620500 -
620501 -            [On 070101 photograph records of IBC reviewed for
620502 -            measurable disease to qualify for treatment on clinical
620503 -            study drug trial. ref SDS E3 4Q6K
620505 -  ..
620506 - The doctor therefore relied on the patient's report of possible
620507 - improvement, as follows...
620509 -  ..
620510 - Observation of patient condition today shows...
620511 -
620512 -    1.  Previously, primary focus was an approximate 1" diameter area
620513 -        of red skin on the left side near the sternum, and at the end
620514 -        of the mastectomy incision closure line (see description on
620515 -        060711 citing surgeon's report on 051021, ref SDS B8 9T8I).
620516 -        Initially, on 060623 this appeared as tiny discursive red dots,
620517 -        and then gradually filled in, becoming a continuous, uniform
620518 -        red rash observed during examination on 060711, ref SDS B8
620519 -        8Z8G, sharply contrasted with conditions found during
620520 -        examination on 060428 that showed no evidence of inflammation.
620521 -        ref SDS A1 HJ5N  Also observed on 060711 were two (2) faintly
620522 -        and "meandering" but recognizable thin lines of red dots
620523 -        extending from the sternum area above and below the incision
620524 -        line for about 2" and further becoming wider and more evident
620525 -        near the end of each line.
620527 -         ..
620528 -        Today, the approximate 1" diameter rash appears expanded, but
620529 -        less intense, perhaps indicating IBC is breaking up.  There is
620530 -        now no obvious continuous area, as before.  There are separate,
620531 -        loosely connected small areas of lightly colored skin rash in
620532 -        the same approximate 1" diameter area and compared to the
620533 -        patient's surrounding skin.
620535 -         ..
620536 -        This condition today seems improved compared to observations
620537 -        over the past several weeks, as the 1" area got gradually more
620538 -        intense and larger than reported on 060711, per above,
620539 -        ref SDS 0 8Z8G, leading to a request for the meeting today, as
620540 -        submitted to Kaiser on 060806, ref SDS C8 7Q95, and reported to
620541 -        Kaiser for the backup doctor to prepare for the meeting,
620542 -        submitted yesterday on 060807. ref SDS C9 423C
620544 -         ..
620545 -    2.  Previously, there were red dots extending irregularly from the
620546 -        1" diameter mass at the sternum and meandering both above and
620547 -        below the mastectomy incision line by about .5" - .75", with
620548 -        length approximately 2 inches.  This two (2) lines of red dots,
620549 -        becomes slightly wider and more pronounced as a red rash toward
620550 -        the end of the 2" line.  Skin tissue between the meandering
620551 -        lines above and below the incision line, and the incision line
620552 -        itself, appeared normal at that time on 060711. ref SDS B8 9T9M
620554 -             ..
620555 -            [On 061110 after 6 treatments mass of intense IBC rash near
620556 -            sternum seems less severe, possibly responding to
620557 -            treatment; a new mass of intensity approxiately .5"
620558 -            diamater has appeared above the incision line and 1" left
620559 -            of the sternum. ref SDS E2 PT4H
620561 -         ..
620562 -        Today, these two (2) meandering lines may be slightly more
620563 -        dense and wider in area than on 060711, but appear reduced and
620564 -        less intense than a few days ago on 060806. ref SDS C8 OJ8V
620565 -        Following the meeting on 060711, these lines consolidated into
620566 -        continuous regions of IBC.  Today, they appear somewhat broken
620567 -        up.
620569 -  ..
620570 - Millie was relieved that the doctor was not alarmed by observations
620571 - today, per above. ref SDS 0 FQ6G  He seemed comfortable working within
620572 - previously established diagnosis, based on the patient's report today
620573 - of possible near term improvement. ref SDS 0 VO6G
620575 -  ..
620576 - Two (2) scenarios were discussed...
620578 -  ..
620579 - Scenario #1 Response Treatment Delayed Lower Dose
620580 -
620581 -
620582 -    1.  Delayed Response to Treatment IBC Subsiding
620583 -
620584 -        Patient has actual and delayed response to treatment of IBC
620585 -        recurrence, per evidence of patient's report, ref SDS 0 VO6G,
620586 -        and direct examination, ref SDS 0 FQ6G, which has been achieved
620587 -        by continuing previously successful treatment using Taxotere
620588 -        and capecitabine (Xeloda), as planned on 060428. ref SDS A1
620589 -        9Y8L  Changes in severity of red rash may reflect compound
620590 -        problem of cellulitis.  Previously, the patient was started on
620591 -        050415 with cycles of high dose chemotherapy (HDC) (2 pills
620592 -        Xeloda 500 MG twice a day for 2 weeks, with a week off).  This
620593 -        followed in the normal sequence after 4 cycles of treatments
620594 -        with AC that seemed unsuccessful, reported on 050329.
620595 -        ref SDS 56 E87M
620597 -         ..
620598 -        Even though AC seemed unsuccessful in 2005, its affect could
620599 -        have been accumulating, i.e., was delayed then, as now.  Thus,
620600 -        when Taxotere and capecitabine were started, it may have
620601 -        continued a recovery already gathering, but not yet manifest in
620602 -        reduction of IBC rash, CA 15-3 marker.  Additionally, since
620603 -        treatment began on 050415 with HDC, the patient's increased
620604 -        treatment level may also have contributed to an immediate
620605 -        response, as reported in patient history. ref SDS 68 9H6F
620607 -            ..
620608 -           [On 060922 response to treatment compare 2005 with current
620609 -           treatment in 2006, ref SDS D7 0D4T; rate of response
620610 -           identifies critical factors, ref SDS D7 GA8H, indicating
620611 -           delayed response favorable in 2006. ref SDS D7 9F35
620613 -            ..
620614 -           [On 061027 Millie hospitalized with cellulitis, examination
620615 -           showed fine red lines running from IBC rash area on left
620616 -           chest to the top of the left shoulder where inflammation
620617 -           engulphed the entire left arm, ref SDS E1 V79M, and so
620618 -           suggesting a compound problem of rash involving the left
620619 -           chest with IBC.
620621 -            ..
620622 -           [On 070130 examination at UCSF finds rash extending toward
620623 -           stomach and wrapping toward back, similiar in appearance to
620624 -           starting red rash of cellulitis on 061027. ref SDS E4 M68J
620626 -         ..
620627 -        In this case, since the patient has been off treatment for 9
620628 -        months, with the last treatment on 050916, ref SDS 76 407N, and
620629 -        therefore has no buildup of chemotherapy, and further since the
620630 -        current treatment prescribes a reduced dose that fits patient
620631 -        tolerance profile, the doctor today feels that response to
620632 -        treatment should be expected to take longer than when used
620633 -        under different prior circumstances in 2005, as set out in the
620634 -        record on 060711 considering HDC. ref SDS B8 RH9L
620636 -  ..
620637 - The above scenario was generally adopted by the doctor today for
620638 - purposes of treatment strategy, per below. ref SDS 0 K36G
620639 -
620640 -           [On 060817 CA 15-3 73 dramatic improvement, reversing 6
620641 -           month rise of cancer marker, now falling back below critical
620642 -           80 level, ref SDS D5 TS5O; supports observation impression
620643 -           on 060808 that IBC red rash subsiding and breaking up,
620644 -           ref SDS 0 VO6G, further reported on 060817, ref SDS D5 NU6L,
620645 -           evidence patient experiencing responding to treatment under
620646 -           scenario #1, developed on 060808. ref SDS 0 J16O
620648 -            ..
620649 -           [On 060922 response to treatment compare 2005 with current
620650 -           treatment in 2006, ref SDS D7 0D4T; rate of response
620651 -           identifies critical factors, ref SDS D7 GA8H, indicating
620652 -           delayed response favorable in 2006. ref SDS D7 9F35
620653 -
620655 -  ..
620656 - Scenario #2 Cancer Rising Treatment Not Effective Not Delivered
620657 -
620658 - This second scenario did not seem to be considered, and could only be
620659 - discussed in fragments, due to limited time focused on the 1st
620660 - scenario...
620662 -         ..
620663 -    2.  Disease Rising Visible Signs Rash Wax and Wane Fool Observer?
620664 -        Treatment Fails Red Rash Wanes Rising CA 15-3 Shows IBC Rising?
620665 -
620666 -        Doctor Benz reported in a second opinion from UCSF Medical
620667 -        Center received on 041117, and reviewed with Kaiser during a
620668 -        meeting on 041130, ref SDS 46 5X4J, that IBC rash in this case
620669 -        shows a history of varying intensity that waxed and waned.
620670 -        ref SDS 45 OS6W  Taking just one of many examples from patient
620671 -        history, in late May 2003, the patient requested an emergency
620672 -        meeting to review sudden appearance of a severe red rash on the
620673 -        left breast, and at a time before IBC was diagnosed and made
620674 -        known to the patient.  Like the examination today, that
620675 -        indicates reduced intensity of IBC rash, ref SDS 0 VO6G, when
620676 -        the patient was examined on 030606, the doctor was not alarmed,
620677 -        because, as Doctor Benz describes, by that time the rash had
620678 -        "waned," and so the primary care physician was comfortable
620679 -        making no change in diagnosis nor prescribing treatment,
620680 -        ref SDS 23 7C6W, which fits the profile that IBC is hard to
620681 -        diagnose, reported on 040517, ref SDS 34 S65K, and cited
620682 -        recently on 060807 when Millie saw a video saying IBC is hard
620683 -        to diagnose and treat. ref SDS C9 JR9Y  IBC relapse presents
620684 -        challenges to recognize when cancer does not respond to
620685 -        treatment that was previously effective, and change to another
620686 -        protocol in time to be effective before cancer cascades out of
620687 -        control, discussed by the primary care physician on 030606.
620688 -        ref SDS 23 N27L  The problem of ineffective treatment can be
620689 -        compounded by "pockets of resistance" cited by the primary care
620690 -        physician on 050311. ref SDS 53 PA4N  In this case mastectomy
620691 -        surgery on 051021 removed blood vessels which normally deliver
620692 -        treatment and nutrients from the immune system, noted in 2nd
620693 -        opinion consultation on 051011, ref SDS 82 G65S, and so isolate
620694 -        pockets of resistance that prevent recovery.
620696 -             ..
620697 -            [On 060808 Millie's letter to nurse later this evening
620698 -            reports good news of disease possibly subsiding; and worry
620699 -            that visual evidence of less rash merely shows visible
620700 -            signs merely show waxing and waning of symptoms, while the
620701 -            actual disease gets worse. ref SDS D1 TI9N
620703 -             ..
620704 -            [On 060922 response to treatment compare 2005 with current
620705 -            treatment in 2006, ref SDS D7 0D4T; rate of response
620706 -            identifies critical factors, ref SDS D7 GA8H, indicating
620707 -            delayed response favorable in 2006, ref SDS D7 9F35, and
620708 -            citing pockets of resistance from removing blood vessels
620709 -            with mastectomy surgery. ref SDS D7 ML3I
620711 -             ..
620712 -            [On 060929 2nd opinion recieved from Doctor Benz discusses
620713 -            requirements for changing treatments when disease
620714 -            progresses under scenario #2. ref SDS D8 1M4O
620716 -             ..
620717 -            [On 061020 cancer marker CA 15-3 rise with stable to worse
620718 -            IBC rash may indicate pockets of resistance to chemotherapy
620719 -            due to removing blood vessels with mastectomy surgery; or
620720 -            effectivenss of current treatment with Taxotere and
620721 -            capecitabine (Xeloda) may have begun to decline.
620722 -            ref SDS D9 725L
620724 -  ..
620725 - On 030710 the primary care physician advised that CA 15-3 rising above
620726 - 80 signals consideration for changing treatment. ref SDS 24 WS42
620727 -
620728 -            [On 060809 nurse recommends getting 2nd opinion from UCSF
620729 -            and offers assistant assembling medical records needed for
620730 -            the 2nd opinion. ref SDS D2 GG5O
620732 -             ..
620733 -            [On 060809 Millie's letter to Arlette expresses worry about
620734 -            doctors having limited experience treating IBC, and cites
620735 -            discussion with backup doctor today. ref SDS D2 C89J
620737 -  ..
620738 - Today, the doctor feels that CA 15-3 at 71 some 4 weeks ago on 060708,
620739 - per above, ref SDS 0 087J, suggested that getting a CA 15-3 cancer
620740 - marker test tomorrow will help clarify whether IBC improvement
620741 - reported today is mere waning of the rash, as occurred previously in
620742 - 2003, ref SDS 0 J458, or is an actual response to prescribed treatment
620743 - under scenario #1. ref SDS 0 J16O
620745 -  ..
620746 - Based on conditions observed today, the doctor decided to wait for
620747 - results of CA 15-3 test tomorrow before considering changing treatment
620748 - protocol, particularly in light of patient's feeling that progression
620749 - of disease have reversed in the past few days.
620750 -
620751 -        [On 060810 CA 15-3 jumps to 87, 7 above the 80 level cited for
620752 -        considering change of treatment, and a very large jump in
620753 -        patient history, ref SDS D3 2N5J, order follow up test to
620754 -        assess correlation between observed decline IBC inflammation
620755 -        and rising CA 15-3. ref SDS D3 854L
620757 -         ..
620758 -        [On 060817 CA 15-3 73 dramatic improvement, reversing 6 month
620759 -        rise of cancer marker, now falling back below critical 80
620760 -        level, ref SDS D5 TS5O; supports observation impression on
620761 -        060808 that IBC red rash subsiding and breaking up, ref SDS 0
620762 -        VO6G, further reported on 060817, ref SDS D5 NU6L, evidence
620763 -        patient experiencing responding to treatment under scenario #1,
620764 -        developed on 060808. ref SDS 0 J16O
620765 -
620766 -
620767 -
620768 -
6208 -

SUBJECTS
Status Change Biopsy Tissue IBC Recurrence Update Biopsy 040419 for

6703 -
670401 -  ..
670402 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
670403 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
670404 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
670405 - Treatment Options Limited Status Not Changed by Retest Biopsy 040419
670406 -
670407 - Follow up ref SDS B8 KT7J.
670408 -
670409 - Can a biopsy contribute to patient work up for developing a strategy
670410 - and treatment plan, discussed on 060711? ref SDS B8 K36G
670412 -  ..
670413 - On 060711 the primary care physician decided against biopsy considered
670414 - previously on 060623 to verify diagnosis of IBC relapse, and help
670415 - guide selection of treatment targeted to IBC recurrence. ref SDS B6
670416 - 6Z4N
670418 -  ..
670419 - Subsequently, on 060802 a 2nd opinion from Doctor Grissom proposes
670420 - biopsy to help guide choice of chemotherapy treatment. ref SDS C7 GM5M
670422 -  ..
670423 - The letter to Kaiser on 060806 reporting progression of disease
670424 - following treatment with Taxotere and capecitabine, ref SDS C8 7Q95,
670425 - gives rise to consideration for switching treatments, as was done on
670426 - 050329, ref SDS 56 E87M, earlier on 041104, ref SDS 44 N438
670427 - Similarly, treatment was switched on 020603 when AC initially proved
670428 - ineffective. ref SDS 8 WO4O  Switching treatments gives rise to
670429 - searching for ways to expand an otherwise declining pool of
670430 - Chemotherapy agents, noted in the letter from the primary care
670431 - physician on 060721. ref SDS C2 H45G  A letter from Doctor Grissom
670432 - yesterday on 060807 clarified the objective to perform a biopsy to
670433 - test for status change, which would increase the pool of drugs for
670434 - treating Millie. ref SDS D0 WM6V
670436 -  ..
670437 - Perhaps the current cancer has mutated since it is not responding to
670438 - treatment that was previously effective.  This change in biology of
670439 - the cancer, may yield a status change??
670441 -  ..
670442 - Today, the backup doctor made two points...
670443 -
670444 -    1.  Patient's report of possible response to treatment may indicate
670445 -        disease has not in fact mutated, and so there would be no
670446 -        grounds to test for status change.
670447 -
670448 -            [On 060817 CA 15-3 73 dramatic improvement, reversing 6
670449 -            month rise of cancer marker, now falling back below
670450 -            critical 80 level, ref SDS D5 TS5O; supports observation
670451 -            impression on 060808 that IBC red rash subsiding and
670452 -            breaking up, ref SDS 0 VO6G, further reported on 060817,
670453 -            ref SDS D5 NU6L, evidence patient experiencing responding
670454 -            to treatment under scenario #1, developed on 060808.
670455 -            ref SDS 0 J16O
670457 -         ..
670458 -    2.  Time between tests for status change has not been sufficient
670459 -        for mutation that could yield status change.
670461 -  ..
670462 - The doctor asked when status was last reported?
670464 -  ..
670465 - We reviewed the report on 060711 showing the primary care physician
670466 - submitted a report that showed status was not changed. ref SDS B8 SW7O
670468 -  ..
670469 - The doctor commented today that just a few weeks from 060711 to today
670470 - does not justify taking a biopsy to test for status change.  He said
670471 - these events typically occur over many months of disease mutation, if
670472 - at all.
670474 -  ..
670475 - There was further discussion that the report received on 060711 was a
670476 - clarification or update of status change evaluated from a biopsy taken
670477 - on 040419, over 2 years ago.
670479 -  ..
670480 - The doctor decided to defer this matter to the primary care physician
670481 - after vacation at the end of the month.
670482 -
670483 -        [...below, backup doctor's Progress Note reports commenting
670484 -        that status change not expected within 1 year of prior test.
670485 -        ref SDS 0 SE86
670486 -
670487 -
670488 -
670489 -
670490 -
6705 -

SUBJECTS
IBC Image Tests PET CT Scheduled for Quarterly Diagnostics for Dista

7403 -
740401 -     ..
740402 -    PET CT Image Testing Distant Metastasis Risks Secondary Cancer
740403 -    IBC Test Distant Metastasis Discouraged Avoid Risk Secondary Cancer
740404 -    Radiation Image Tests PET CT Limit to Reduce Risk Secondary Cancer
740405 -    Risk Secondary Cancer Exposure Radiation Image Testing CT PET Scan
740406 -
740407 -    Follow up ref SDS B8 EY5O.
740409 -  ..
740410 - Patient history of image tests following surgery on 051021 have not
740411 - identified cancer, as reported in the CT test reviewed with the doctor
740412 - on 060623. ref SDS B6 II4L  In fact, PET scan and CT imaging tests
740413 - listed on 060711, ref SDS B8 FE8F, have never reported distant
740414 - metastasis.
740416 -  ..
740417 - Rising CA 15-3 aligns with recurrence of IBC diagnosed on 060711,
740418 - ref SDS B8 025H, and observed today by the backup doctor. ref SDS 0
740419 - FQ6G
740421 -  ..
740422 - Following mastectomy surgery on 051021, the primary care physician
740423 - planned to assess patient NED status with CA 15-3 blood tests every 2
740424 - weeks complemented by image testing every 3 months, reported on
740425 - 051121. ref SDS 88 NL4N  Recently, on 060802 a 2nd opinion by Doctor
740426 - Grissom, who helped guide Millie's surgery on 051021, proposed another
740427 - PET scan test for distant metastasis in light of rising IBC symptoms,
740428 - including CA 15-3 rising for the past 6 months. ref SDS C7 IT8U  The
740429 - last PET scan test was on 060414.  Quarterly testing calls for a test
740430 - in July.  Since a contrast CT test was done on 060505 (received on
740431 - 060523, ref SDS A8 E355), adjusting for this date would make August an
740432 - appropriate time for another image test within the diagnostic plan
740433 - schedule.
740435 -  ..
740436 - The backup doctor indicated today a practice of prescribing limited
740437 - image testing to limit exposure to medical radiation, and seemed to
740438 - strongly discourage diagnostics with quarterly tests planned in the
740439 - meeting on 051121. ref SDS 88 NL4N  The backup doctor offered
740440 - extensive analysis comparing PET scan and CT testing to risking cancer
740441 - from excessive dental xrays.
740443 -  ..
740444 - Millie commented that public news and the Internet report danger from
740445 - medical radiation causing cancer.  This popular theory suggests that
740446 - radiation treatment prescribed for Millie on 020628, ref SDS 11 QB5Q,
740447 - and performed beginning on 020708, ref SDS 13 0001, may have caused
740448 - IBC in the left breast diagnosed by Kaiser on 040614, ref SDS 36 6T5G,
740449 - with symptoms first reported in PET scan test findings on 021218, and
740450 - received from Kaiser on 030109. ref SDS 20 L66M  If true, a cruel
740451 - irony arises from using a PET scan test that discovered early symptoms
740452 - of devastating, aggressive cancer in time for treatment, but was all
740453 - along the cause of IBC.  Research does not seem to support this
740454 - theory, but rather indicates Kaiser's prescriptions for radiation
740455 - treatment and testing in this case have complied with best practices
740456 - and prudence. ref SDS 0 MV37
740458 -  ..
740459 - The backup doctor did not comment on how radiation treatment for
740460 - breast cancer might somehow cause secondary inflammatory breast cancer
740461 - (IBC).  He emphasized prudence to limit image tests balancing benefits
740462 - of medical radiation against risks of causing cancer.  There was no
740463 - explanation nor numerical analysis of risks to aid striking a prudent
740464 - balance.  Avoiding tests already prescribed by the primary care
740465 - physician seems unsatisfying.
740467 -  ..
740468 - The backup doctor did not order image testing with CT or PET scan to
740469 - evaluate rising concern about progression of disease.  Implementing
740470 - plans for image test diagnostics in this case will be addressed when
740471 - the primary care physician returns from vacation, during the meeting
740472 - on 060825. ref SDS B8 4Y9N
740474 -  ..
740475 - Published support was requested from the doctor on avoiding diagnostic
740476 - testing and other medical radiation as a strategy to reduce risks of
740477 - cancer.  (Later research seems to show such risk is far outweighed by
740478 - benefits when the work is performed by professionals to approved
740479 - standards. ref SDS 0 MV37)
740481 -  ..
740482 - This issue is not presented in the backup doctor's Progress Note for
740483 - for the meeting today, ref SDS 0 FE4I, however, the doctor submitted
740484 - with his notes an article....
740485 -
740486 -                Full-Body CT Scans:  Too Much Radiation?
740487 -
740488 -              http://www.cancer.org/docroot/NWS/content/NWS_2_1x_Full-Body_CT_Scans_Too_Much_Radiation.asp
740489 -
740490 - ...(see again doctor's Progress Note, ref SDS 0 J59O) published on
740491 - 040903. ref OF 1 0001
740493 -  ..
740494 - The article says in part...
740495 -
740496 -        Those full-body CT scans advertised at some health care centers
740497 -        may be delivering as much radiation as a low-dose atomic bomb,
740498 -        according to a new study.  And that means people who get them
740499 -        could be raising their cancer risk, researchers from Columbia
740500 -        University report in the journal Radiology (Vol. 232, No.
740501 -        3:735-738). ref OF 1 ZI5H
740503 -  ..
740504 - This immediately distinguishes radiation treatment Millie received in
740505 - 2002, which is closely targeted to the left breast area, rather than
740506 - to the "whole body."  Similarly, PET scan and CT diagnostic testing
740507 - for distant metastasis in Millie's case have not targeted the
740508 - "full-body."
740510 -  ..
740511 - Article continues...
740512 -
740513 -        "The radiation dose from a full-body CT scan is comparable to
740514 -        the doses received by some of the atomic bomb survivors from
740515 -        Hiroshima and Nagasaki, where there is clear evidence of
740516 -        increased cancer risk," said David J.  Brenner, PhD, D.Sc, lead
740517 -        author of the study and professor of radiation oncology and
740518 -        public health at Columbia University in New York. ref OF 1 5G5K
740520 -  ..
740521 - Doctor Brenner's comment seems unhelpful to patients and doctors
740522 - considering radiation for treatment and diagnostics.  Survivors of
740523 - atomic bomb attacks in Hiroshima and Nagasaki received radiation along
740524 - a continuum from very high dose to zero depending on distance from the
740525 - epicenter, and protection by infrastructure, e.g., were they 500 yards
740526 - from the blast, 5 miles, away, 50 miles away.  Were they in open
740527 - ground, or in a building?  Were they in a basement?  Where they
740528 - downwind, or up wind?  Did they evacuate quickly, for example by car
740529 - or perhaps were leaving the city on a moving train or bus when the
740530 - bomb exploded.
740532 -  ..
740533 - Article continues...
740534 -
740535 -        However, that doesn't mean people should avoid CT scans when
740536 -        they're needed to diagnose a disease. ref OF 1 00GM
740538 -         ..
740539 -        "The risk-benefit equation changes dramatically for adults who
740540 -        are referred for CT scans for medical diagnosis," Brenner said.
740541 -        "Diagnostic benefits far outweigh the risks." ref OF 1 SM4I
740543 -  ..
740544 - Comparative risks noted in this part of the article submitted by the
740545 - backup doctor were not presented during the discussion today.
740546 - ref SDS 0 3T7L  Another article further describes safety and
740547 - therapeutic benefits of medical radiation...
740548 -
740549 -                Health Effects of Medical Radiation
740550 -
740551 - ...published by Health Physics Society on 041118. ref OF 2 0001
740553 -  ..
740554 - This article says in part...
740555 -
740556 -        There is at present no firm evidence of adverse effects from
740557 -        any such exposure using modern technology.  Early studies-from
740558 -        exposures generally in the 1920s to 1940s-did find some harm,
740559 -        but equipment then was much cruder and doses were much greater
740560 -        than today.  Dose limits established for radiation workers and
740561 -        the public are somewhat arbitrary.  The limit of 50
740562 -        millisievert in any year for occupational exposure does not
740563 -        mean that 49 is safe and 51 harmful.  This limit is set based
740564 -        on current knowledge to keep risks of harmful effects no
740565 -        greater than occupational risks for many other worker groups.
740566 -        There is no recommended dose limit for patients.  It would not
740567 -        be appropriate to refuse a medically necessary x-ray exam just
740568 -        because some arbitrary dose limit had been reached.  Patients
740569 -        receive clear benefit from medical exposure, which outweighs
740570 -        any potential for harm.  You should not worry about your
740571 -        medical radiation exposure.  Instead, you should be grateful
740572 -        that this exposure could improve your health. ref OF 2 IL6J
740574 -  ..
740575 - Radiation exposure has risks.  Too much sun causes sunburn, and can
740576 - lead to cancer.  Chemotherapy attacks the immune system, which can
740577 - allow cancer to grow that is not treated by the drug.  Just as these
740578 - risks do not require avoiding getting outside in the sun, nor getting
740579 - treatment for cancer, controlled radiation for diagnostic and therapy
740580 - purposes is designed by professionals weighing all factors in patient
740581 - history to deliver far greater benefits than are risked by exposure.
740583 -  ..
740584 - For example, an article by NIH says in part...
740585 -
740586 -              http://www.nih.gov/health/chip/od/radiation/
740587 -
740588 -        Should patients with cancer be concerned about the radiotherapy
740589 -        they undergo?
740591 -         ..
740592 -        Radiation, surgery, and chemotherapy are the major ways in
740593 -        which cancer is treated; they are used singly or in
740594 -        combinations depending on the cancer.  The effectiveness of
740595 -        radiation in killing cancer cells--and, at the same time, the
740596 -        potential for harm to normal tissues--depends on several
740597 -        things, including the type of radiation used, the extent of the
740598 -        body that is treated, and the patient's age or other medical
740599 -        problems.
740601 -         ..
740602 -        Radiation Large Parts of Body Secondary Cancer NIH
740603 -        Cancer Side Effect Radiation Large Parts of Body NIH
740604 -        NIH Side Effects Radiation Over Exposure Causes Cancer
740605 -
740606 -        Doctors try to avoid exposure of large parts of the body to
740607 -        radiation because this can cause serious side effects like a
740608 -        secondary cancer--one that develops after treatment for the
740609 -        initial cancer.
740611 -  ..
740612 - This is the precise issue Millie discussed today, where her radiation
740613 - treatment was narrowly targeted to the left breast, axilla, and
740614 - supraclavicular, and sometime later she developed symptoms of IBC, per
740615 - above. ref SDS 0 0Z5N
740617 -  ..
740618 - NIH article continues...
740619 -
740620 -        However, only about 5% of all secondary cancers have been
740621 -        linked to radiotherapy.  The risk of leukemia after large doses
740622 -        of radiation to localized areas of the body often is
740623 -        surprisingly low, because the local effect is to kill cells
740624 -        that might, at smaller doses, undergo transformation--the
740625 -        changes that a normal cell undergoes as it becomes
740626 -        malignant--eventually leading to leukemia.  Other side effects
740627 -        of radiotherapy range from mild to serious; many are temporary.
740629 -         ..
740630 -        With the development of better therapy machines and the use of
740631 -        computers to plan the treatment, the safety and efficacy of
740632 -        radiotherapy have steadily improved.  Radiologists make every
740633 -        attempt to minimize harmful effects to normal tissues.  Thus, a
740634 -        patient's risks from exposure to radiation are far offset by
740635 -        the benefits from the treatment.
740637 -  ..
740638 - It would be an interesting study, and should not be hard to determine
740639 - the number of secondary IBC cases diagnosed following adjuvant
740640 - radiation treatment, as occurred in Millie's case.  A study could
740641 - further look for factors that directly associate radiation with onset
740642 - of IBC to guide patients and providers in developing treatment plans.
740644 -  ..
740645 - The frequency and degree of radiation are prescribed and recorded.
740646 - For example, on 020405 the original treatment plan called for
740647 - radiation...
740648 -
740649 -               5 days a week for 4 weeks. ref SDS 11 BV62
740651 -  ..
740652 - This plan was changed on 020708, and radiation was increased...
740653 -
740654 -               5 days a week for 6 weeks. ref SDS 13 AN6I
740655 -
740656 - ...because CA 15-3 was rising, and findings of cancer in a PET scan
740657 - test on 020529, again discussed with radiologist on 020708.
740658 - ref SDS 13 6Q35
740660 -     ..
740661 -    Questions to study medical radiation causing secondary cancer...
740662 -
740663 -
740664 -    1.  Do secondary cancers vary based on the amount and frequency of
740665 -        radiation treatments?
740667 -         ..
740668 -    2.  Do secondary cancers vary based on radiation treatments
740669 -        together with PET scan and CT tests that apply radiation for
740670 -        image testing?
740672 -         ..
740673 -    3.  Do secondary IBC cases rise following radiation treatments and
740674 -        exposure to image testing?  What are the numbers?
740675 -
740676 -
740677 -
740678 -
740679 -
740680 -
7407 -

SUBJECTS
Emotional Trauma Rises Abrupt Changes IBC Worsening Spreading Red Ra

7903 -
790401 -  ..
790402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
790403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
790404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
790405 -
790406 - Follow up ref SDS B8 Y642, ref SDS B6 Y642.
790407 -
790408 - Rise and fall of IBC red rash, with concern about changing treatments
790409 - based on criteria presented by primary care physician, reported today,
790410 - ref SDS 0 VO6G, and sudden improvement, with decision to continue
790411 - current treatment cause sieches to emotional health.
790412 -
790413 -     [On 060817 dramatic rise of CA 15-3 indicating treatment failing,
790414 -     followed by dramatic fall in CA 15-3 supporting visible evidence
790415 -     of IBC breaking up and subsiding presents emotional "roller
790416 -     coaster." ref SDS D5 OE6V
790418 -  ..
790419 - Discussion of dilemma on testing to evaluate requirements for
790420 - treatment, which may in turn cause disease that requires treatment,
790421 - ref SDS 0 3T7L, presents additional, mild emotional trauma.
790422 -
790423 -
790424 -
790425 -
7905 -

SUBJECTS
Dizziness Mild Symptoms End No Evidence of Treatable Disease Patient

8603 -
860401 -  ..
860402 - Dizziness Mild Symptoms End No Evidence of Disease Head
860403 -
860404 - Follow up ref SDS B8 PT4K, ref SDS B6 PT4K.
860406 -  ..
860407 - Dizziness mild symptoms seem to have ended.
860409 -  ..
860410 - There was no examination and no discussion on this issue today, since
860411 - focus was on consideration to change treatment for IBC.
860412 -
860413 -
860414 -
860415 -
860416 -
860417 -
860418 -
8605 -

SUBJECTS
Strategy Treatment Plan IBC 3rd Relapse Scope Strategy Options Plann

A803 -
A80401 -  ..
A80402 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
A80403 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
A80404 -
A80405 - Follow up ref SDS B8 K36G, ref SDS B6 K36G.
A80406 -
A80407 - Backup doctor determined today there has likely been a delayed
A80408 - response to treatment under scenario #1, per above. ref SDS 0 J16O
A80410 -             ..
A80411 -            [On 060817 CA 15-3 73 dramatic improvement, reversing 6
A80412 -            month rise of cancer marker, now falling back below
A80413 -            critical 80 level, ref SDS D5 TS5O; supports observation
A80414 -            impression on 060808 that IBC red rash subsiding and
A80415 -            breaking up, ref SDS 0 VO6G, further reported on 060817,
A80416 -            ref SDS D5 NU6L, evidence patient experiencing delayed
A80417 -            response to treatment under scenario #1, developed on
A80418 -            060808. ref SDS 0 J16O
A80420 -  ..
A80421 - The doctor seemed sensitive to scenario #2 that visible evidence of
A80422 - IBC was previously misleading during 2003, because rising CA 15-3
A80423 - suggests disease is increasing, while visible rash waxed and waned.
A80424 - ref SDS 0 J458  Without additional evidence of rising CA 15-3 the
A80425 - doctor determined today that workup on patient profile for changing
A80426 - treatments was not required.
A80428 -  ..
A80429 - As a result, the 3rd question in the letter yesterday on 060807 was
A80430 - not addressed. ref SDS C9 SL4P
A80432 -  ..
A80433 - Tumor Board reviewing strategy for the order of using drugs and
A80434 - treatment options, including radiation and surgery, and, also, listing
A80435 - the "pool" of chemotherapy drugs available for IBC treatment in this
A80436 - case, which was described as "declining," in a letter from Kaiser on
A80437 - 060721, ref SDS C2 H45G, in relation to the list reported in the
A80438 - record on 041130, ref SDS 46 9V63, and cited in the record on 060711,
A80439 - ref SDS B8 FP9H, and in the letter to Kaiser on 060807, ref SDS C9
A80440 - SL4P, was all deferred until the next meeting with primary care
A80441 - physician on 060825.
A80443 -  ..
A80444 - Without review of treatment options, and associated scenarios,
A80445 - continuing existing treatment under rising CA 15-3 was mandated, per
A80446 - below. ref SDS 0 PF3O
A80448 -  ..
A80449 - Today, research on the Internet listed a few more drugs, which were
A80450 - consolidated into the list on 041130. ref SDS 46 9V63
A80451 -
A80452 -
A80453 -
A805 -

SUBJECTS
High Dose Chemotherapy HDC Treatment Strategy Best Chance Stop Sprea

AC03 -
AC0401 -  ..
AC0402 - High Dose Chemotherapy HDC Strategy Balance Patient Tolerance
AC0403 - Side Effects Tolerate High Dose Chemotherapy for Effectiveness
AC0404 - HDC Strategy Reverse Growth Cancer When Patient Tolerance High
AC0405 - Treatment Effectiveness Balance Patient Tolerance Side Effects
AC0406 -
AC0407 - Follow up ref SDS B8 KY4G.
AC0408 -
AC0409 - Backup doctor recommended against returning to high dose chemotherapy
AC0410 - (HDC) considered on 060711, ref SDS B8 IB9H, and which seemed more
AC0411 - effective following start of treatment on 050415, as reported in
AC0412 - patient history on 050812 citing the report on 050502. ref SDS 68 9H6F
AC0414 -  ..
AC0415 - Doctor's Progress Note does not present analysis of HDC option.
AC0416 - ref SDS 0 ZL7N
AC0418 -  ..
AC0419 - Generally, the backup doctor seemed to indicate that once tolerance
AC0420 - problems occur, as reported on 050514, and Kaiser reduces the dose to
AC0421 - reduce side effects, as occurred on 050520, ref SDS 62 V43H, then
AC0422 - after the patient improves, as a result of treatments, and then been
AC0423 - off treatment for 9 months or so, as in this case, Kaiser practice
AC0424 - prevents trying previously successful HDC over a year later.
AC0426 -  ..
AC0427 - There was no authority presented on this point.
AC0428 -
AC0429 -            [On 060817 CA 15-3 73 dramatic improvement, reversing 6
AC0430 -            month rise of cancer marker, now falling back below
AC0431 -            critical 80 level, ref SDS D5 TS5O; supports observation
AC0432 -            impression on 060808 that IBC red rash subsiding and
AC0433 -            breaking up, ref SDS 0 VO6G, further reported on 060817,
AC0434 -            ref SDS D5 NU6L, evidence patient experiencing delayed
AC0435 -            response to treatment under scenario #1, developed on
AC0436 -            060808, ref SDS 0 J16O, all reduces interest in considering
AC0437 -            HDC.
AC0438 -
AC0439 -
AC0440 -
AC05 -

SUBJECTS
Pulmonary Emboli Family History Blood Clots Possible Genetic Cause R

AG03 -
AG0401 -  ..
AG0402 - Small Inconsequential Error Medical Chart Shows Coumadin Treatment
AG0403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
AG0404 - Pulmonary Emboli Genetic Cause Hypercoabullary Work Up Family History
AG0405 -
AG0406 - Follow up ref SDS C6 0001, ref SDS C5 NL5Q.
AG0407 -
AG0408 - On 060711 chemotherapy treatment was reviewed in connection with
AG0409 - patient history of blood clots, ref SDS B8 S33L, first reported in a
AG0410 - CT test received on 041104, while being treated with Avastin
AG0411 - chemotherapy drugs. ref SDS 44 RZ4I  Millie was treated with Coumadin
AG0412 - until 051121; at that time, she was removed from Coumadin treatment,
AG0413 - ref SDS 88 RZ4I, because she was no longer being treated with Avastin,
AG0414 - as presented earlier on 051007. ref SDS 81 XN7K
AG0416 -  ..
AG0417 - Also, on 051121, the doctor explained hypercoagulable state work up
AG0418 - recommended in Doctor Bailey's 2nd opinion is not required because
AG0419 - pulmonary emboli was thought to be caused in this patient solely by
AG0420 - prior participation in the Avastin trial. ref SDS 88 GW7G
AG0422 -  ..
AG0423 - On 060724 Kaiser was notified about new information on blood clot
AG0424 - problems that came to light on 060722, ref SDS C3 3D9T, citing
AG0425 - findings of genetic cause for family history of pulmonary emboli.
AG0426 - ref SDS C5 NL5Q
AG0428 -  ..
AG0429 - Prescribing Coumadin (Warfarin) to treat family history of genetic
AG0430 - disposition for pulmonary emboli was not discussed today by the backup
AG0431 - doctor.  The doctor mentioned having access to Progress Notes prepared
AG0432 - by primary care physician. ref SDS 0 FQ6G  These notes have
AG0433 - consistently reported patient is being treated with Warfarin, which is
AG0434 - incorrect, since treatment was terminated on 051121, reported in the
AG0435 - record on 060711. ref SDS B8 1265  Erroneous record of prescribed
AG0436 - treatment may explain why notice of pulmonary emboli was not discussed
AG0437 - during the meeting.
AG0438 -
AG0444 -
AG0445 -
AG0446 -
AG0447 -
AG05 -

SUBJECTS
Treatment IBC 2nd Cycle for 3rd Relapse Continue Chemotherapy Agents

AL03 -
AL0401 -  ..
AL0402 - Treatment Continue 2nd Cycle Taxotere and Capecitabine (Xeloda)
AL0403 - 2nd Cycle Taxotere and Capecitabine (Xeloda) Treatment Continue
AL0404 - Taxotere and Capecitabine (Xeloda) 2nd-Cycle Treatment Continue
AL0405 -
AL0406 - Follow up ref SDS B8 PF3O.
AL0407 -
AL0408 - Since the doctor found evidence of delayed response to treatment,
AL0409 - ref SDS 0 J16O, and since there was no review of strategy, ref SDS 0
AL0410 - YJ9J, the backup doctor recommended continuing current treatment plan
AL0411 - for 2 cycles of Taxotere and capecitabine (Xeloda), developed during
AL0412 - the meeting on 060711. ref SDS B8 PF3O (see doctor's Progress Note,
AL0413 - ref SDS 0 ZL7N)
AL0415 -  ..
AL0416 - This answers the first question in the letter to Kaiser on 060807.
AL0417 - ref SDS C9 XC3F
AL0419 -  ..
AL0420 - Consideration was deferred today on changing treatment scheduled for
AL0421 - Thursday, 060810, even if CA 15-3 from the blood test tomorrow makes
AL0422 - another major increase.  The doctor said that CA 15-3 results will
AL0423 - most likely not be available in time to change the treatment even if
AL0424 - the cancer marker indicates the currently prescribed treatment is not
AL0425 - effective, contrary to impression today.
AL0426 -
AL0427 -            [On 060810 CA 15-3 jumps to 87, 7 above the 80 level cited
AL0428 -            for considering change of treatment, and a very large jump
AL0429 -            in patient history, ref SDS D3 2N5J, order follow up test
AL0430 -            to assess correlation between observed decline IBC
AL0431 -            inflammation and rising CA 15-3. ref SDS D3 854L
AL0433 -             ..
AL0434 -            [On 060817 CA 15-3 73 dramatic improvement, reversing 6
AL0435 -            month rise of cancer marker, now falling back below
AL0436 -            critical 80 level, ref SDS D5 TS5O; supports observation
AL0437 -            impression on 060808 that IBC red rash subsiding and
AL0438 -            breaking up, ref SDS 0 VO6G, further reported on 060817,
AL0439 -            ref SDS D5 NU6L, evidence patient experiencing delayed
AL0440 -            response to treatment under scenario #1, developed on
AL0441 -            060808. ref SDS 0 J16O
AL0443 -             ..
AL0444 -            [On 060817 commendation to backup doctor and Oncology team
AL0445 -            for dramatic reversal of rising cancer marker, and breakup
AL0446 -            of IBC disease, indicating patient on the mend. ref SDS D5
AL0447 -            L29J
AL0448 -
AL0449 -
AL0450 -
AL0451 -
AL05 -

SUBJECTS
Navelbine Chemotherapy Treatment IBC Relapse Side Effects Uncertain

AQ03 -
AQ0401 -  ..
AQ0402 - Today, the doctor did not review the following...
AQ0403 -
AQ0405 -         ..
AQ0406 -        Navelbine Treatment of Relapse, Side Effects Uncertain
AQ0407 -
AQ0408 -        Follow up ref SDS B8 PF4M.
AQ0409 -
AQ0410 -
AQ0412 -         ..
AQ0413 -        Navelbine Capecitabine (Xeloda) Combined
AQ0414 -
AQ0415 -        Follow up ref SDS B8 FE3O.
AQ0416 -
AQ0417 -
AQ0418 -
AQ05 -

SUBJECTS
Gemzar Taxotere Treatment for IBC Relapse Side Effects May Be More T

AW03 -
AW0401 -         ..
AW0402 -        Gemzar and Taxotere Treatment for IBC
AW0403 -
AW0404 -        Follow up ref SDS B8 576N.
AW0405 -
AW0406 -
AW0407 -
AW05 -

SUBJECTS
Drug Trials Protocol Nurse Searching for Fit with Millie's Patient P

B003 -
B00401 -         ..
B00402 -        Drug Trial - Doctor Checking with Rosalie
B00403 -
B00404 -        Follow up ref SDS B8 WB9K.
B00405 -
B00406 -        Limitations qualifying for drug trials is cited on 060711.
B00407 -        ref SDS B8 834H
B00409 -         ..
B00410 -        Background on drug trials mentioned by Doctor Benz, and by
B00411 -        Doctor Bailey in connection with work at UCSF is listed in the
B00412 -        record on 060711. ref SDS B8 ED50
B00413 -
B00414 -
B00415 -
B00416 -
B00417 -
B00418 -
B005 -

SUBJECTS
Novel Expthilones BMS-247550 Plus Capecitabine (Xeloda) Previous Che

B603 -
B60401 -         ..
B60402 -        Novel Expthilones BMS-247550 Plus Capecitabine
B60403 -
B60404 -        Follow up ref SDS B8 FW5J.
B60405 -
B60406 -
B60407 -
B60408 -
B60409 -
B605 -

SUBJECTS
Breast Replacement Surgery Deferred in 2005 Review Options in 2006 R

BA03 -
BA0401 -  ..
BA0402 - Breast Replacement Surgery Deferred in 2005 Review Options in 2006
BA0403 -
BA0404 - Follow up ref SDS B8 X54L.
BA0405 -
BA0406 - The backup doctor did not have time to review patient history and the
BA0407 - Medical Chart in Kaiser's online Knowledge Management system to be
BA0408 - prepared for discussing surgery options, previously postponed on
BA0409 - 051007, as reported in the prior record planning strategy to treat
BA0410 - relapse on 060711. ref SDS B8 X54L  As a result, there was no
BA0411 - consideration of options for reconstructive surgery.
BA0412 -
BA0413 -
BA0414 -
BA05 -

SUBJECTS
Radiation Treatment Left Supraclavicular Per Tumor Board Develop Rad

BD03 -
BD0401 -  ..
BD0402 - Radiation Treatment Left Supraclavicular Per Tumor Board
BD0403 -
BD0404 - Follow up ref SDS B8 Z26K, ref SDS B6 Z26K.
BD0405 -
BD0406 - Millie discussed radiation in relation to image testing and possible
BD0407 - link to secondary cancer, per above. ref SDS 0 3T7L
BD0408 -
BD0409 -
BD0410 -
BD0411 -
BD0412 -
BD0413 -
BD05 -

SUBJECTS
Schedule Treatment Meeting Pharmacist Zan Start Capecitabine (Xeloda
Treatment Schedule 060810 Continue Original Date Thursday for 2nd Cy

BF04 -
BF0501 -  ..
BF0502 - Schedule Treatment Continue Prescription Taxotere Capecitabine Xeloda
BF0503 -
BF0504 - Follow up ref SDS B8 N96O.
BF0505 -
BF0506 - Backup doctor further decided to continue current schedule for
BF0507 - treatment on Thursday, 060810, per planning above. ref SDS 0 PF3O
BF0508 - This answers the question in the letter to the Kaiser on 060807.
BF0509 - ref SDS C9 XC3F
BF0511 -  ..
BF0512 - This answers the second question in the letter to Kaiser on 060807.
BF0513 - ref SDS C9 SL9U
BF0514 -
BF0515 -        [On 060810 treatment delayed 1 week for blood counts slightly
BF0516 -        below standing orders, previously waived consistently to
BF0517 -        maintain effective levels of treatment, ref SDS D3 5K4F, delay
BF0518 -        reduced from 7 days to 4 days. ref SDS D3 I25J
BF0520 -         ..
BF0521 -        [On 060814 patient treated starting 10th cycle, and 2nd cycle
BF0522 -        of current prescription, ref SDS D4 407N, as directed today.
BF0523 -
BF0524 -
BF0525 -
BF0526 -
BF06 -

SUBJECTS
Port Catheter Flush Performed for Blood Draws with Chemotherapy Trea

BH03 -
BH0401 -  ..
BH0402 - Port Catheter Flush Performed at Kaiser to Maintain Chemo Treatment
BH0403 -
BH0404 - Follow up ref SDS B8 SH5N, ref SDS B6 SH5N.
BH0405 -
BH0406 - This is no longer an action item, since it occurs with getting
BH0407 - regular treatments every 3 weeks.
BH0408 -
BH0409 -
BH0410 -
BH05 -

SUBJECTS
Work Plan Doctor Submits Doctor/Patient Partnership Communications I

BM03 -
BM0401 -  ..
BM0402 - Work Plan Received Communications Doctor/Patient Partnership
BM0403 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
BM0404 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
BM0405 -
BM0406 - Follow up ref SDS B8 FE4I, ref SDS B6 FE4I.
BM0407 -
BM0408 - Doctor's Progress Note on the meeting today was received on 060814
BM0409 - (six days after the meeting today), and via US mail, which transmitted
BM0410 - printed paper in a font that requires a magnifying glass to read.
BM0411 - This conflicts with new tools and skills applied by the primary care
BM0412 - physician on 060711 to provide electronic media for better
BM0413 - productivity. ref SDS B8 FE4I  Failure to use email further required
BM0414 - the patient to invest an hour or so capturing the record for
BM0415 - Communication Metrics, Knowledge Management, and Intelligence support
BM0416 - under Kaiser's practice of patient care based on effective
BM0417 - communication.  The backup doctor's Progress Note presented an
BM0418 - excellent record for case management.
BM0420 -  ..
BM0421 - For some reason, the doctor did not submit data details on vitals,
BM0422 - labs, treatment history, etc, which is a critical part of the medical
BM0423 - chart that supplements Progress Note.
BM0425 -  ..
BM0426 - The doctor did not mention during the meeting nor in the Progress Note
BM0427 - the patient's letter submitted on 060807 giving notice of change in
BM0428 - patient status to guide being prepared for the meeting, per above.
BM0429 - ref SDS 0 IL6G
BM0431 -  ..
BM0432 - Progress continues toward good management using the doctor patient
BM0433 - partnership for timely review of patient history, called out in
BM0434 - Kaiser's Healthwise Handbook, reviewed on 990625, ref SDS 3 TD5S, and
BM0435 - recently reported on 060106. ref SDS 90 FE4I
BM0436 -
BM0437 -    1.  08/08/2006     09:40 AM
BM0438 -
BM0439 -            Wcr-ONnc2 > Main Campus
BM0442 -         ..
BM0443 -    2.  Your primary care clinician is listed as...
BM0444 -
BM0446 -
BM0733 -
BM0734 -
BM0735 -
BM0736 -
BM0737 -
BM0738 -
BM0739 -
BM08 -