CONTACTS 

SUBJECTS
10th Cycle Treatment Delayed Taxotere Xeloda Capecitabine Chemothera

0503 -
0503 -    ..
0504 - Summary/Objective
0505 -
050501 - Follow up ref SDS 88 0000. ref SDS 74 0000.
050502 -
050503 - Millie was scheduled to start another cycle of chemotherapy today to
050504 - treat the 3rd relapse of IBC.  After being seated in the clinic for
050505 - treatment, Kaiser disclosed that treatment would be delayed for 8 days
050506 - to next Friday. ref SDS 0 5K4F  Millie objected, and so treatment was
050507 - scheduled for next Monday, 060814. ref SDS 0 I25J  ANC composite blood
050508 - counts was 1408 slightly below standing orders criteria of 1500 for
050509 - treatment. ref SDS 0 NH8T  Even though approving treatment for low
050510 - blood counts occurs often in Millie's patient history, ref SDS 0 HV45,
050511 - the Infusion Clinic could not get signature to approve treatment based
050512 - on patient history, because primary care physician is on vacation.
050513 - ref SDS 0 NW9K  Bad news, CA 15-3 has jumped to 87, well above the
050514 - level that has signaled need to change treatments in patient history.
050515 - ref SDS 0 2N5J
050516 -
050517 -    [On 060814 blood counts rose to nearly 7000 indicating patient
050518 -    rapid recovery that justifies timely treatment, ref SDS 96 P560,
050519 -    based on patient history shown in study today. ref SDS 95 HV45
050521 -     ..
050522 -    [On 060817 CA 15-3 73 dramatic improvement, reversing 6 month rise
050523 -    of cancer marker, now falling back below critical 80 level,
050524 -    ref SDS 97 TS5O; supports observation impression on 060808 that IBC
050525 -    red rash subsiding and breaking up, ref SDS 91 VO6G, further
050526 -    reported on 060817, ref SDS 97 NU6L, evidence patient experiencing
050527 -    delayed response to treatment under scenario #1, developed on
050528 -    060808. ref SDS 91 J16O
050529 -
050530 -
050531 -
050533 -  ..
0506 -
0507 -
0508 - Progress
0509 -
050901 - Patient Condition Increases Urgency for Treatment Today
050902 -
050903 - Today, Millie is scheduled for the 10th cycle of treatment ordered by
050904 - the primary care physician during a meeting on 060711. ref SDS 86 N96O
050905 - Prior treatment on 060721 requires regularly scheduled treatment
050906 - tomorrow on 060811; Kaiser moved treatment ahead one day to accomodate
050907 - prior bookings in the Infusion Department. ref SDS 88 QK6L
050909 -  ..
050910 - Background on recent relapse and treatment planning is reported in the
050911 - record on 060721. ref SDS 88 407N
050913 -  ..
050914 - On 060724 diary side effects for 2nd phase taking Taxotere and
050915 - capecitabine (Xeloda). ref SDS 89 QX8K
050917 -  ..
050918 - Patient notified Kaiser on 060806 Kaiser that IBC progressing rapidly
050919 - after 1st cycle Taxotere capecitabine treating recurrence. ref SDS 90
050920 - 7Q95  On 060808 emergency meeting with backup doctor to consider
050921 - switching treatments, based on patient history showing success from
050922 - changing chemotherapy agents. ref SDS 91 UO6J  Visual examination on
050923 - 060808 seemed to show delayed response to treatment. ref SDS 91 VO6G
050924 - Visual signs of improvement could be misleading, as occurred
050925 - previously in 2003. ref SDS 91 NS5J
050927 -  ..
050928 - Backup doctor indicated on 060808 that since patient reported possible
050929 - improvement reducing the spread of disease, and since CA 15-3 results
050930 - were not yet available to verify disease progression or response to
050931 - treatment, that Kaiser policy requires continuing with prescribed
050932 - treatment with Taxotere and capecitiabine (Xeloda), rather than
050933 - switching to a drug that yields better response to treatment.
050935 -  ..
050936 - While we were waiting in the customer area for admission into the
050937 - Infusion Clinic for Millie's treatment, Arlette walked out into the
050938 - common area.  She was accompanied by another nurse.  Millie waived and
050939 - said hellow.  Arlette stopped briefly and gave Millie a hug to
050940 - emphasize good feelings from correspondence a few days ago on 060808,
050941 - when there was good news that treatments may be working, because
050942 - Millie may be getting better. ref SDS 92 DT4R  She was on her lunch
050943 - break, and so Millie said she would stop by Arlette's office in the
050944 - Oncology Department and to chat just for a moment, after the
050945 - treatment.  By that time, Arlette will have returned from lunch.
050947 -  ..
050948 - Arlette said she was glad that Millie decided to get a 2nd opinion at
050949 - UCSF, also, discussed in the correspondence on 060808. ref SDS 92 PRWU
050950 - She offered to assemble a packet of documents on Millie's medical
050951 - history that doctors will need to review her case for a 2nd opinion.
050952 - This would be a huge saving of time and effort, because the previous
050953 - two (2) times working with the Business Office getting medical records
050954 - for 2nd opinions had problems, reported on 060721, ref SDS 87 JV5M,
050955 - and discussed on 060809 with Margaret at UCSF on providing patient
050956 - history for Doctor  Benz. ref SDS 94 P06O
050957 -
050958 -     [On 060814 picked up documents on Mil's medical history from the
050959 -     attendant at the Oncology Department front desk. ref SDS 96 407N
050961 -      ..
050962 -     [On 060819 organize Kaiser's documents to facilitate 2nd opinion
050963 -     review by UCSF. ref SDS 98 LK4M
050965 -      ..
050966 -     [On 061011 commend Kaiser and Arlette for extra work providing a
050967 -     packet of documents to facilitate 2nd opinion review by UCSF,
050968 -     reducing the cost by 30%. ref SDS A0 QY4I
050970 -  ..
050971 - Later, when it turned out that Millie could not get treatment today,
050972 - and so we left the hospital before Arlette returned from lunch, per
050973 - below. ref SDS 0 NH8T  Once it was settled that treatment would be
050974 - next Monday, on 060814, ref SDS 0 HJ6N, Millie left a note for Arlette
050975 - saying we will be back on Monday, and, asked if we can, at that time,
050976 - pickup the packet of documents for the 2nd opinion?
050978 -  ..
050979 - Arlette called the house later in the day, and said she will have the
050980 - documents ready when we come in on Monday.
050982 -  ..
050983 - Millie had a blood draw yesterday on Wednesday, 060809.
050984 -
050988 -  ..
050989 - Initially, as we were walking into the Infusion Department, Diana said
050990 - that Millie's blood counts are good.  Millie was seated in a treatment
050991 - station, and Diana left to get the Taxotere drip treatment from the
050992 - pharmacy.
050994 -  ..
050995 - About 10 minutes later, Diana returned with the report on the blood
050996 - test yesterday, shown below. ref SDS 0 Q659
050997 -
050998 -
050999 -
051000 -
0511 -

SUBJECTS
Treatment Delay 10th Cycle Taxotere Xeloda Capecitabine Chemotherapy

1403 -
140401 -  ..
140402 - Kaiser Advances Treatment 1 Day Out of Cycle Causes 1 Week Delay
140403 - Blood Counts Slightly Low Delay Treatment 1 Week Risk Losing Control
140404 - Treatment Delay Risks Losing Control IBC Kaiser Error 1 Week Delay
140405 - Mistake Blood Counts Low Treatment Delayed 1 Week Due to 1 Day Advance
140406 -
140407 - Follow up ref SDS 88 QK6L.
140408 -
140409 - Diana said there was a mistake, and so Millie cannot get treatment
140410 - today afterall, because a composite blood count calculation is only
140411 - 1408, and the primary care physician left written instructions before
140412 - leaving on vacation that the caluclation must be at least 1500 in
140413 - order to give Millie treatment today.
140415 -  ..
140416 - Diana's report aligns with the study reported by Reuters on 051027
140417 - that found 34% of patients received the wrong medication, improper
140418 - treatment, incorrect or delayed test results during the last two
140419 - years. ref SDS 79 HQ6I
140421 -  ..
140422 - Diana said treatment must be delayed for a week in order for blood
140423 - counts to rise.  She scheduled Millie for treatment next Friday, on
140424 - 060818.  Millie asked if delaying treatment is the best solution, and
140425 - recalled getting treatment many times when blood counts were low, like
140426 - today, because the doctor made reasonable estimates of trends, based
140427 - on patient history, per below. ref SDS 0 HV45  Diana said there is
140428 - nothing she can do to help the patient, so we left the hospital.
140429 -
140430 -            [On 060814 blood counts rose to nearly 7000 indicating
140431 -            patient rapid recovery that justifies timely treatment,
140432 -            ref SDS 96 P560, based on patient history shown in study
140433 -            today. ref SDS 95 HV45
140435 -             ..
140436 -            [On 070301 example ANC low blood counts; cetuximab clinical
140437 -            study weekly treatments not enough time for bone marrow to
140438 -            replenish blood, wicked problem because cancer spreading
140439 -            requires increasing chemotherapy which reduces blood
140440 -            counts, weakening the immune system, which in turn
140441 -            increases risk of contracting other infectious diseases.
140442 -            ref SDS A2 D24M
140444 -  ..
140445 - Driving home, Millie recalled that last month on 060721, Kaiser policy
140446 - prevented delaying treatment 3 days from Friday to Monday, because
140447 - this reduces concentration of treatment in the patient, and so Kaiser
140448 - moved treatment ahead 1 day to today, to avoid harming the patient at
140449 - a time when local control seemed not at risk. ref SDS 88 KP6J  Millie
140450 - also remembered the doctor talking about maintaining concentration of
140451 - drugs in order to make treatment effective, discussed during a meeting
140452 - on 040614, ref SDS 27 6T7F, and previously on 030606. ref SDS 7 JP7G
140453 -
140454 -               [...below, Millie drive back to Kaiser and negotiated
140455 -               earlier treatment. ref SDS 0 I25J
140457 -  ..
140458 - Previously, on 050128 Nurse Barbara advised that Kaiser calculates a
140459 - composite blood count, ref SDS 49 TZ3N, with the following formula...
140460 -
140461 -            ANC = WBC x 1000 x (Neutrophils + Bands)
140462 -
140463 -                      [On 060814 Diana clarified the formula.
140464 -                      ref SDS 96 P563
140466 -                       ..
140467 -                      [On 070301 research on neutropenia explains
140468 -                      calcualtion of ANC at Kaiser and NEUTS at UCSF.
140469 -                      ref SDS A2 516G
140471 -  ..
140472 - At that time, on 050128 this calculation was 1443, and the primary
140473 - care physician signed authorization for treatment to proceed, despite
140474 - falling below the 1500 level. ref SDS 49 TZ3N
140476 -  ..
140477 - Today, the same calculation would be...
140478 -
140479 -                  WBC               =   3.2
140480 -                  Seg Neutrophils   =    .43
140481 -                  Bands             =    .1
140482 -
140483 -            ANC = 3.2 x 1000 x (.43 + .1) = 1408
140485 -  ..
140486 - This aligns with Diana's report, per above, ref SDS 0 5K4F, and is
140487 - below the 1500 level authorized by the doctor for treatment.  Using
140488 - the same formula indicates the primary care physician approved
140489 - treatment on 050916 when the composite value was only 1271,
140490 - ref SDS 0 5V7M, well below 1408 cited as grounds for delaying
140491 - treatment today. ref SDS 0 5K4F
140493 -  ..
140494 - Patient history presents several issues...
140496 -         ..
140497 -    1.  Patient history for 5 years, from 2002 up to today, shows that
140498 -        Kaiser has routinely given treatment when blood counts were
140499 -        "low" because patients need a steady dose level of chemotherapy
140500 -        in order for treatments to be effective recovering from cancer.
140501 -        ref SDS 0 HV45  Examination at Kaiser on 050724 shows this
140502 -        practice has been successful. ref SDS 67 WI6K  A biopsy
140503 -        reported by Kaiser on 051027 shows that treating the patient
140504 -        with low blood counts yielded findings of no evidence of
140505 -        disease (NED). ref SDS 78 616P
140506 -
140508 -         ..
140509 -        Treatment Critical CA 15-3 Sudden Jump to 87 3rd Relapse IBC
140510 -        CA 15-3 Jumps 14 to 87 Needs Timely Treatment Maintain Control
140511 -        Lessons Learned Cancer Treatment Backup Doctor Decision Support
140512 -
140513 -    2.  Kaiser's record shows a strong bias toward giving treatment
140514 -        under conditions of low blood counts encountered today, for
140515 -        reasons presented by the primary care physician on 030606,
140516 -        ref SDS 7 JP7G, and again the following year on 040614 the
140517 -        doctor explains effect of exercise on replenishing blood
140518 -        counts. ref SDS 27 RS6N  Earlier, on 030710 the primary care
140519 -        physician advised that CA 15-3 rising above 80 signals extra
140520 -        effort is required to treat the patient in time to prevent
140521 -        cancer from cascading out of control. ref SDS 8 WS42
140523 -         ..
140524 -        Since the blood report today shows CA 15-3 has made a
140525 -        significant jump from 73 to 87, ref SDS 0 5K6K, and since the
140526 -        patient reported to Kaiser on 060806 that IBC rash is
140527 -        progressing rapidly, these factors require caution to err on
140528 -        the side of giving treatment rather than delay under conditions
140529 -        where treatment has been given routinely in this case.  Since
140530 -        blood test was performed several days before the day for
140531 -        regurlar treatment, and since Kaiser chose to provide treatment
140532 -        a day ahead of regular schedule for treatment on 3 week cycles,
140533 -        actual blood counts will likely be much closer or exceed 1500
140534 -        by the date of regular schedule for treatment.  Patient history
140535 -        shows the primary care physician has routinely estimated
140536 -        continued rise of blood counts to approve rather than delay
140537 -        treatment, or has taken same-day blood tests to verify the
140538 -        patient meets safe criteria for treatment, rather than delay
140539 -        treatment. ref SDS 0 HV45
140541 -         ..
140542 -        What tools support nurses in providing the level of care
140543 -        established by pattern and practice of the primary care
140544 -        physician, especially when, as here, conditions vary from
140545 -        standing instructions, there is strong evidence of rising
140546 -        disease that requires immediate tratement, and the primary care
140547 -        physician is not available?
140549 -         ..
140550 -        What tools are available to patients to support nurses and
140551 -        Kaiser's management team in making a comprehensive review that
140552 -        optimizes treatment decision making?
140554 -  ..
140555 - Summarizing...
140557 -  ..
140558 - Since Kaiser advanced treatment by one day, there is reasonable
140559 - expectation that by tomorrow blood counts will be higher, near or
140560 - above the target level that qualify for treatment, shown by patient
140561 - history. ref SDS 0 HV45
140562 -
140563 -            [On 060814 blood counts rose to nearly 7000 indicating
140564 -            patient rapid recovery that justifies timely treatment,
140565 -            ref SDS 96 P560, based on patient history shown in study
140566 -            today. ref SDS 0 HV45
140568 -  ..
140569 - Previously, the primary care physician routinely signed authorization
140570 - for same-day treatment in order to give the patient a chance to fight
140571 - off advancing disease with continuity of chemotherapy drug levels. see
140572 - the study, ref SDS 0 HV45
140573 -
140574 -
140575 -
140576 -
1406 -

SUBJECTS
Culture Restrains Nurse Doctor Communication for Patient Treatment 4

2303 -
230401 -  ..
230402 - Culture Restrains Communication for Patient Treatment
230403 - Treatment Delayed 4 Days 1 More than Determined Harmful to Patient
230404 - Cognitive Overhead Disruptive Makes 4 Better than 3 Days Delay
230405 - Kaiser Mitigates Mistake Reduces Treatment Delay from 7 to 4 Days
230406 -
230407 - After leaving the hospital, we drove back and walked up the stairs to
230408 - the Oncology Department on the 2nd floor.  The attendant at the
230409 - customer counter called Diana in the Infusion Department, and handed
230410 - the telephone to Millie.  They discussed advancing treatment to align
230411 - with patient history, per above. ref SDS 0 I245  Evidence of cancer
230412 - progressing requires maintaining concentration of chemotherapy by
230413 - minimizing treatment delays, also, per above. ref SDS 0 J63J
230414 -
230415 -     [On 060825 primary care physician changed the schedule back to
230416 -     Fridays by adding another 4 day delay in treatment, but at a time
230417 -     when evidence indicates patient is responding to treatment.
230418 -     ref SDS 99 3U7J
230420 -  ..
230421 - Diana was glad Millie called, and agreed that treatment should be
230422 - advanced.  She has thought further about the discussion 20 minutes
230423 - ago, ref SDS 0 5K4F, and remembered worrying last time on 060721 that
230424 - delaying treatment 3 days would harm the patient. ref SDS 88 KP6J
230426 -  ..
230427 - Diana said that Kaiser cannot treat Millie today, because Kaiser's
230428 - Quality Control Best Practices policy for patient treatment requires
230429 - that she ask the backup doctor for signed authorization to waive
230430 - standing orders to delay treatment when blood counts are below 1500,
230431 - as today, per above. ref SDS 0 5K4F  Diana doesn't want to take time
230432 - to ask the backup doctor because that would disrupt his work.  The
230433 - primary care physician makes decisions based on personal memory of
230434 - patient history, shown by the record on 050128. ref SDS 49 HZ5F
230435 - However, the backup doctor does not have experience with patient
230436 - history, and so feels uncomfortable making snap judgements.
230437 - Disrupting work to study Kaiser's records for pattern and practice in
230438 - this case would take a long time.  This makes people mad, shown by the
230439 - study on 050218, ref SDS 51 XY4I, also, reported in NWO, ref OF 15
230440 - LH6K, and discussed recently on 051110. ref SDS 80 J659  It would,
230441 - also, take time away from Diana treating other patients in the
230442 - Infusion Deparment to assemble a report showing pattern and practice
230443 - in Millie's case that supports waiving standing orders, as the primary
230444 - care physician has often done, based on personal memory. (see study
230445 - below showing standing order waived 10 times. ref SDS 0 HV45)
230446 -
230447 -        [On 070301 treatment approved because cancer spreading; example
230448 -        ANC low blood counts; 1 week not enough time for bone marrow to
230449 -        replenish blood, wicked problem because increasing chemotherapy
230450 -        to treat expanding cancer but further reduces blood counts
230451 -        increasing exposure to risk of other infectious diseases.
230452 -        ref SDS A2 D24M
230454 -  ..
230455 - Diana feels treatment cannot be given tomorrow because the Infusion
230456 - Department is still booked.  Diana proposed that Kaiser treat Millie
230457 - on Monday, reducing delay to only to 4 days, rather than delay
230458 - treatment for 7 days until the following Friday, as initially
230459 - scheduled, per above. ref SDS 0 NH8T  She feels that delaying
230460 - treatment 1 day more than previously determined is harmful to the
230461 - patient is the best solution that does not disrupt Kaiser operations
230462 - and good working relations by burdening staff with cognitive overhead.
230463 - see NWO, ref OF 15 LH6K)
230465 -  ..
230466 - Millie agreed to move treatment ahead 3 days in order to improve
230467 - effectiveness of chemotheraphy, as called out by the primary care
230468 - physician on 040614, ref SDS 27 RS6N, and per above. ref SDS 0 HI8O
230470 -  ..
230471 - Diana changed the order for blood tests to occur on Sunday, 060813 in
230472 - time to evaluate for treatment on Monday....
230474 -  ..
230475 - Schedule....
230476 -
230477 -       060813 1600.... Chemotherapy Taxotere 10th Cycle
230478 -       060825 1440.... Meeting primary care physician
230479 -
230480 -
230481 -
230482 -
230483 -
2305 -

SUBJECTS
Blood Tests Chemotherapy White Cell Count Low 10th Cycle Taxotere Ca

2603 -
260401 -  ..
260402 - Blood Counts Low Chemotherapy Treatment Delayed
260403 -
260404 - Follow up ref SDS 88 Q659, ref SDS 74 Q659.
260406 -  ..
260407 - Diana submitted the report showing...
260408 -
260409 -    Patient   Provider  Category   View      FR Date   To Date
260415 -     ..
260416 -    Procedure              Results             Reference Range
260417 -
260420 -
260421 -                  ** Marina Way South **
260423 -     ..
260424 -    Test Name              Value Unit     <-------- RANGE-------->
260425 -    @CBC
260426 -    WBC x 10-3     L         3.2 K/uL           3.5   -     12.5
260427 -    RBC x 10-6              4.40 M/uL           3.60  -      5.70
260428 -    Hemoglobin              14.0 g/dL          11.5   -     15.0
260429 -    Hematocrit              40.9 %             34.0   -     46.0
260430 -    MCV                       93 fL            80.0   -    100.0
260431 -    RDW                     12.9 %             11.9   -     14.3
260432 -    Plt x10-3              293   K/uL         140     -    400
260433 -     ..
260434 -    Seg Neutrophils           43 %             50     -     70
260435 -    Lymphocytes               46 %             20     -     50
260436 -    Monocyte                  10 %              0     -     11
260437 -    Eosinophils        No Report %              1     -      5
260438 -    Basophil           No Report %              0     -      2
260439 -    Bands                      1 %              0     -      5
260441 -     ..
260442 -    CA 15-3                   87 U/mL          -<     -     39
260444 -     ..
260445 -    Alkaline Phos             67 U/L           38     -    126
260446 -    Bili, Tot Adult          0.5 mg/dL        0.2     -    1.3
260447 -    Creatinine               0.9 mg/dL        0.6     -    1.2
260448 -    AST (SGOT       H         43 U/L           14     -     36
260449 -    ALT (SGPT                 34 U/L           11     -     66
260451 -     ..
260452 -    RBC Morphology        Normal
260453 -    Poikilocytosis  *          1+
260454 -    Anisocytosis    *          1+
260455 -    Schistocytes    *          1+
260456 -    PLT Estimate       Confirmed
260457 -    PLT Morphology        Normal
260458 -
260459 -
260460 -
260461 -
2605 -

SUBJECTS
Case Study Patient Treated Low Blood Counts with Neupogen Millie Pat

3303 -
330401 -  ..
330402 - Blood Counts Low Patient Routinely Treated with Neutropenia
330403 - Case Study Patient Treated Low Blood Counts Suffering Neutropenia
330404 - Treatment Approved Routinely Patient History Low Blood Counts
330405 - Neutropenia Patient Routinely Treated with Low Blood Counts Case Study
330406 -
330407 - Treatment was denied today because ANC 1408 was blow the level 1500
330408 - which Kaiser policy sets for safe chemotherapy, per above. ref SDS 0
330409 - 5K4F
330411 -  ..
330412 - Steady Dose Chemotherapy Makes Treatments Effective Recovering from Cancer
330413 -
330414 - Patient history shows Millie has nearly always received treatment when
330415 - blood counts are below target levels, because, as noted on 030606,
330416 - ref SDS 0 065K, patients need to maintain a steady dose level of
330417 - chemotherapy in order for treatments to be effective recovering from
330418 - cancer...
330419 -
330420 -        1.  Blood counts low, treatment
330421 -            delayed 1 week.................. 020513, ref SDS 2 0001
330423 -             ..
330424 -        2.  Neupogen 5-day treatment prescribed
330425 -            for low blood counts, treatment
330426 -            was not deferred................ 020520, ref SDS 3 3W8J
330427 -            self-injection procedure
330428 -            demonstrated by
330429 -            nurse........................... 020520, ref SDS 3 RF4M
330431 -             ..
330432 -        3.  Blood counts low, WBC 3.2;
330433 -            treatment was not
330434 -            delayed......................... 020701, ref SDS 5 EN50
330436 -             ..
330437 -        4.  Blood counts low, treatment
330438 -            was not delayed................. 021002, ref SDS 6 LY3G
330440 -             ..
330441 -        5.  Chemotherapy reduces ANC blood
330442 -            counts causing cancer to cascade
330443 -            out of control, and also weakens
330444 -            immune system which increases
330445 -            infirmities of age with declining
330446 -            fitness, causing higher risk of
330447 -            dying from disease and infection
330448 -            than from cancer; requires continual
330449 -            exercise to maintain fitness that
330450 -            enables getting steady dose
330451 -            of chemotherapy required
330452 -            to recover from
330453 -            cancer.......................... 030606, ref SDS 7 JP7G
330455 -             ..
330456 -        6.  Blood counts low, treatment
330457 -            with reduced dose............... 040427, ref SDS 18 Q659
330459 -             ..
330460 -        7.  Blood counts low ANC 1482
330461 -            treatment with reduced
330462 -            dose............................ 040525, ref SDS 23 4N5M
330464 -             ..
330465 -        8.  Blood counts low ANC 1406
330466 -            treatment with reduced
330467 -            dose............................ 040601, ref SDS 24 3589
330469 -             ..
330470 -        9.  Low Blood counts and strategies discussed
330471 -            with doctor to maintain dose levels of
330472 -            chemotherapy required for effective
330473 -            treatments recovering from
330474 -            cancer.......................... 040614, ref SDS 27 6T7F
330476 -             ..
330477 -       10.  Blood counts rise, treatment
330478 -            with full dose.................. 040615, ref SDS 28 4N5M
330480 -             ..
330481 -       11.  Neupogen and Procrit treatment
330482 -            to increase blood counts in order
330483 -            provide full dose of chemotherapy
330484 -            was cancelled, because blood counts
330485 -            increased without Neupogen
330486 -            and Procrit..................... 040615, ref SDS 28 3P5O
330488 -             ..
330489 -       12.  Blood counts low, Kaiser planned
330490 -            retest to see if counts rising
330491 -            so treatment could occur on
330492 -            schedule rather than be delayed
330493 -            and in order to maintain a
330494 -            steady level of
330495 -            treatment....................... 040629, ref SDS 30 J08J
330497 -             ..
330498 -       13.  Blood counts low ANC 1332
330499 -            treatment with reduced
330500 -            dose............................ 041007, ref SDS 41 4N5M
330502 -             ..
330503 -       14.  Blood counts low, caluculation
330504 -            1443, requires doctor signature
330505 -            for treatment below 1500, doctor
330506 -            signed authorization for
330507 -            treatment....................... 050128, ref SDS 49 TZ3N
330509 -             ..
330510 -       15.  Blood counts low, treatment
330511 -            delayed 1 week because primary
330512 -            care physician not available
330513 -            and backup physician not
330514 -            comfortable adjusting
330515 -            criteria to approve
330516 -            treatment....................... 050318, ref SDS 53 0001
330518 -             ..
330519 -       16.  Deferred treatments dilute
330520 -            concentration of chemotherapy
330521 -            agents, caused treatment to
330522 -            fail; switched agents to
330523 -            Taxotere capecitabine........... 050329, ref SDS 55 T57M
330525 -             ..
330526 -       17.  Neupogen 3-day treatment prescribed
330527 -            for low blood counts, treatment
330528 -            was not deferred................ 050415, ref SDS 57 SQ4H
330530 -             ..
330531 -       18.  Blood counts low, ANC calculation
330532 -            1271, well below 1500 target
330533 -            level for treatment; primary
330534 -            care physician approved
330535 -            treatment....................... 050916, ref SDS 74 R43M
330537 -             ..
330538 -       19.  Kaiser implements policy maintain
330539 -            steady dose level of chemotherapy
330540 -            for effective cancer
330541 -            treatment....................... 060721, ref SDS 88 KP6J
330543 -             ..
330544 -       20.  Formula calculate ANC - absolute
330545 -            neutrophils count............... 060810, ref SDS 0 GL4M
330547 -             ..
330548 -       21.  Blood counts slightly low ANC 1408
330549 -            1 day before regular schedule for
330550 -            treatment, but doctor not available
330551 -            to approve treatment based on
330552 -            patient history so treatment
330553 -            withheld initially 7 days and
330554 -            reduced to 4 days for patient
330555 -            with rising CA 15-3 cancer
330556 -            marker at 87 and signs
330557 -            of advancing
330558 -            disease......................... 060810, ref SDS 0 NH8T
330560 -             ..
330561 -       22.  Blood counts rise dramatically
330562 -            from 1408 1 day before regular
330563 -            scheduled treatment to nearly
330564 -            7000 3 days afterward........... 060814, ref SDS 96 P560
330566 -             ..
330567 -       23.  Formula calculate ANC clarify
330568 -            includes bands.................. 060814, ref SDS 96 C56L
330570 -             ..
330571 -       24.  Neupogen 1-day treatment prescribed
330572 -            on leaving hospital continuing
330573 -            Neupogen given previous day of
330574 -            emergency treatment for Cellulitis
330575 -            intended to maintain ANC blood
330576 -            counts for getting treatment
330577 -            the next
330578 -            day............................. 061101, ref SDS A1 OU5J
330580 -             ..
330581 -       25.  Blood counts ACN 1230 significantly
330582 -            below UCSF and Kaiser criteria of
330583 -            1500 for safe chemotherapy
330584 -            treatment approved.............. 070301, ref SDS A3 P560
330586 -             ..
330587 -       26.  Neutropenia research on low blood
330588 -            counts explains how ANC and
330589 -            NEUTS are calculated............ 070301, ref SDS A2 O59H
330590 -            research explains severity neutropenia
330591 -            with low ANC (NEUTS at UCSF) weakens
330592 -            immune system increasing risk of
330593 -            disease and infection; so far,
330594 -            Millie has "mild"
330595 -            neutropenia..................... 070301, ref SDS A2 R13I
330597 -             ..
330598 -       27.  Treatment approved to prevent cancer
330599 -            from cascading out of control;
330600 -            cetuximab clinical study weekly
330601 -            treatments not enough time for bone
330602 -            marrow to replenish blood, wicked
330603 -            problem increasing chemotherapy to
330604 -            stop progression of cancer reduces
330605 -            blood counts; weakening immune
330606 -            system increases exposure to
330607 -            risk of other infectious
330608 -            diseases........................ 070301, ref SDS A2 D24M
330610 -             ..
330611 -       28.  Change procedure and test for low
330612 -            blood counts after examination and
330613 -            starting treatment relying on
330614 -            high blood counts from testing
330615 -            a week earlier.................. 070424, ref SDS A4 1V3F
330617 -             ..
330618 -       29.  Blood counts 1.47 below criteria
330619 -            1.50 for safe treatments reported
330620 -            after treatment completed; medical
330621 -            team contacted to request
330622 -            authorizations.................. 070426, ref SDS A5 P560
330624 -             ..
330625 -       30.  Blood counts NEUTS 1.19 substantial
330626 -            decline 1 week earlier NEUTS 1.67
330627 -            which was big increase from month
330628 -            earlier showing erratic labs may
330629 -            be due to over 60 treatments
330630 -            cetuximab....................... 080207, ref SDS A7 IU3F
330632 -             ..
330633 -       31.  Low blood counts NEUTS 1.32 shows
330634 -            difficulty maintaining immune system
330635 -            essential for weekly treatments with
330636 -            chemotherapy even starting
330637 -            treatments on 2nd arm of
330638 -            clinical study adding
330639 -            Carboplatin..................... 080214, ref SDS A8 UL4N
330641 -             ..
330642 -       32.  Blood counts low NEUS 1.28 below 1.50
330643 -            criteria; medical team deferred
330644 -            chemotherapy treatment.......... 080320, ref SDS A9 SE5R
330646 -             ..
330647 -       33.  Neupogen 1-day treatment UCSF
330648 -            prescribed; approved chemotherapy
330649 -            with blood counts NEUTS 1.34
330650 -            slightly below 1.50 for
330651 -            safe treatment.................. 080403, ref SDS B0 XV4G
330653 -             ..
330654 -       34.  Blood counts low again NEUTS 1.34
330655 -            treatment with Carboplatin chemotherapy
330656 -            withheld; Millie treated only
330657 -            with cetuximab......... ........ 080417, ref SDS B1 L55L
330659 -             ..
330660 -       35.  UCSF plans to discuss treatment
330661 -            plan at next meeting on 080501
330662 -            to add Neupogen and lower dose
330663 -            of Carboplatin chemotherapy
330664 -            to maintain blood counts for
330665 -            steady treatments of
330666 -            Carboplatin..................... 080418, ref SDS B2 P45J
330668 -             ..
330669 -       36.  Patient proposes discussing on
330670 -            080501 lowering dose Carboplatin
330671 -            chemotherapy for 2 treatments, and
330672 -            increasing to full dose on 3rd
330673 -            treatment because the next week
330674 -            blood counts will rise naturally
330675 -            due a bye for chemotherapy in
330676 -            4th week of the treatment
330677 -            cycle........................... 080423, ref SDS B3 OY7S
330679 -             ..
330680 -       37.  UCSF doctor discloses that, unlike
330681 -            experience at Kaiser, if Carboplatin
330682 -            chemotherapy is lowered to reduce
330683 -            impact on blood counts, then the
330684 -            dose cannot be later increased
330685 -            to full dose when
330686 -            blood counts
330687 -            rise............................ 080423, ref SDS B3 I49N
330689 -             ..
330690 -       38.  Patient notifies UCSF to maintain
330691 -            full dose of Carboplatin to optimize
330692 -            treatment for cancer, and increase
330693 -            Neupogen, delay treatments to
330694 -            maintain blood
330695 -            counts.......................... 080423, ref SDS B3 TY6Y
330697 -             ..
330698 -       39.  UCSF discusses strategies for
330699 -            balancng chemotherapy and blood
330700 -            counts; agrees to maintain full
330701 -            dose Carboplatin and increase
330702 -            Neupogen to maintain blood
330703 -            counts.......................... 080501, ref SDS B4 CZ3N
330705 -             ..
330706 -       40.  Neupogen 1 treatment prescribed
330707 -            to increase blood counts for
330708 -            getting Carboplatin chemotherapy
330709 -            treatment....................... 080501, ref SDS B4 4G7G
330711 -             ..
330712 -       41.  Patient letter to UCSF confirms
330713 -            treatment plan instruction to take
330714 -            1 Neupogen treatment and continue
330715 -            full dose Carboplatin
330716 -            chemotherapy.................... 080501, ref SDS B5 MG3P,
330718 -             ..
330719 -       42.  Patient told after meeting that
330720 -            clinical study management changed
330721 -            prescription to 2 Neupogen
330722 -            treatments...................... 080501, ref SDS B4 QF3N
330724 -             ..
330725 -       43.  UCSF letter changes Neupogen back to
330726 -            1 treatment because previously
330727 -            blood counts increased significantly
330728 -            with only 1 Neupogen
330729 -            treatment....................... 080501, ref SDS B4 M658
330731 -             ..
330732 -       44.  Chemotherapy Orders for 080501
330733 -            show 2 Neupogen treatments and
330734 -            reduce dose of Carboplatin
330735 -            contrary to discussion on 080501
330736 -            and communication with patient
330737 -            on 080423 to continue full
330738 -            dose of Carboplatin............. 080529, ref SDS B6 PVVR
330740 -             ..
330741 -       45.  Patient told to take 1 Neupogen
330742 -            treatment per week for new cycle
330743 -            but Chemotherapy Orders received
330744 -            a week later on 080605
330745 -            prescribe 2 Neupogen
330746 -            treatments...................... 080529, ref SDS B6 PWSY,
330747 -            and show dose for Carboplatin
330748 -            reduced but marked as being
330749 -            an error........................ 080529, ref SDS B6 PVUQ
330751 -             ..
330752 -       46.  Blood counts low NEUTS 1.37 (ANC
330753 -            1370); Neupogen not prescribed because
330754 -            Millie was not treated with
330755 -            Carboplatin this
330756 -            week............................ 080814, ref SDS B7 PU6K
330758 -             ..
330759 -       47.  Neupogen 2-day treatment due to
330760 -            low blood counts; chemotherapy
330761 -            Carboplatin deferred to
330762 -            next week....................... 080821, ref SDS B8 RV8O
330764 -             ..
330765 -       48.  Neutropenia case study causing
330766 -            missed chemotherapy due to low
330767 -            blood counts 2nd arm clinical
330768 -            study at UCSF................... 081023, ref SDS C0 QQ8H
330769 -
330770 -
330771 -
330772 -
330773 -
330774 -
330775 -
330776 -
3308 -

SUBJECTS
CA 15-3 87 Big Rise 16 from 71 and 7 Above 80 Cancer Signal for Chan
CA 15-3 73 Big Drop 14 from 87 and 7 Below 80 Cancer Signal Response

3704 -
370501 -  ..
370502 - CA 15-3 87 Major Jump Above Cancer Target Level for Changing Course
370503 -
370504 - Follow up ref SDS 88 2N5J, ref SDS 74 2N5J.
370505 -
370506 - CA 15-3 was ordered with the test on 060809, per above.
370507 - ref SDS 0 075H
370509 -  ..
370510 - Last test was reported on 060711 showing CA 15-3 at 71. ref SDS 86
370511 - 087J
370513 -  ..
370514 - CA 15-3 jumped from 71 to 87, 16 points, shown in the blood test
370515 - report received today, per above. ref SDS 0 5K6K  This is one of the
370516 - biggest jumps in patient history, and belies improvement from
370517 - suppression of IBC inflammation on Millie's chest, reported on 060808.
370518 - ref SDS 91 VO6G  Rising CA 15-3 aligns with report on 060806 of IBC
370519 - worsening. ref SDS 90 7Q95  Mixed signals of observation and testing
370520 - fits scenario #2 reviewed on 060808. ref SDS 91 J458
370522 -  ..
370523 - During the meeting on 060808 the backup doctor planned to consider
370524 - treatment change after getting results of CA 15-3. ref SDS 91 TV7L
370526 -  ..
370527 - Yesterday, the advice nurse commented on tracking changes in CA 15-3.
370528 - ref SDS 93 MW4K
370530 -  ..
370531 - Since there was no treatment today, and since treatment was further
370532 - delayed 3 days until Monday, another CA 15-3 test on Sunday will
370533 - indicate a trending direction whether observed decline of IBC
370534 - inflammation (red rash) on the left breast is merely a waning of
370535 - rising cancer, or that treatment is being effective, and can be
370536 - continued, under criteria discussed on 060808. ref SDS 91 J16O
370537 -
370538 -    [On 060817 CA 15-3 73 dramatic improvement, reversing 6 month rise
370539 -    of cancer marker, now falling back below critical 80 level,
370540 -    ref SDS 97 TS5O; supports observation impression on 060808 that IBC
370541 -    red rash subsiding and breaking up, ref SDS 91 VO6G, further
370542 -    reported on 060817, ref SDS 97 NU6L, evidence patient experiencing
370543 -    delayed response to treatment under scenario #1, developed on
370544 -    060808. ref SDS 91 J16O
370545 -
370546 -
370547 -
370548 -
370549 -
370550 -
370551 -
370552 -
3706 -