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1...Doctor Benz did not have time today to comment on alternate theories
2...Doctor Benz did not present strategy and criteria for the order of
3...Treatment response expectations in this case for Taxotere and
4...Doctor Benz did not have time today to comment on Novel Epothilones
5...Doctor Benz did not have time today to comment on breast replacement
6...Doctor Benz did not have time today to comment on radiation treatment
UCSF Meeting Doctor Benz 2nd Opinion #3 Develop List Chemotherapy Sy
0703 - ..
0704 - Summary/Objective
070501 - Follow up ref SDS E7 0000, ref SDS E3 0000.
070503 - Productive 2nd opinion consultation at UCSF. Doctor Benz quickly
070504 - grasped complex patient history. He used dates of CA 15-3 cancer
070505 - marker tests to construct a chronology. ref SDS 0 TQ4X Careful,
070506 - thorough examination showed patient's condition may be improving after
070507 - after 2 cycles of chemotherapy treatment for IBC relapse beginning on
070508 - 060721. ref SDS 0 025H Patient history of imaging tests (PET, CT)
070509 - support clinical examination finding no evidence of distant
070510 - metastasis. ref SDS 0 EY5O The doctor indicated that a biopsy would
070511 - establish IBC has relapsed in the left breast. ref SDS 0 KT7J Biopsy
070512 - and image tests identify measureable disease to qualify for UCSF drug
070513 - trials. ref SDS 0 WB9K Work on building another chronology today left
070514 - no time to review scope and criteria for follow on treatments, and for
070515 - consideration of pulmonary emboli listed in the agenda. ref SDS 0 TQ83
070516 - Kaiser's switch to typing doctor's progress notes was helpful to UCSF
070517 - today. ref SDS 0 FE4I Reliance on erroneous records may have
070518 - prevented consideration of pulmonary embolism. ref SDS 0 PM4N
070520 - [On 060929 Doctor Benz 2nd opinion received from Kaiser.
070521 - ref SDS F1 624L
070523 - ..
070524 - [On 060929 Doctor Benz 2nd opinion reviewed. ref SDS F3 0001
070526 - ..
070527 - [On 061002 Kaiser CT test diagnoses pulmonary emboli recurrence.
070528 - ref SDS F4 0001
070535 - ..
0708 - Progress
070901 - Documents from Kaiser Submitted Facilitate 2nd Opinion Review
070903 - Follow up ref SDS E1 SM6M, ref SDS C5 SM6M.
070905 - Background...
070907 - ..
070908 - In a letter to UCSF on 060725, ref DIP 5 0001, Millie requested a 2nd
070909 - opinion for treating IBC. ref SDS D5 ST9O UCSF did not respond.
070910 - Disease progressed on 060806. ref SDS D8 OJ7V On 060808, the Advice
070911 - Nurse at Kaiser recommended a 2nd opinion. ref SDS E2 QO6X On 060809
070912 - Margaret scheduled the meeting today at UCSF. ref SDS E3 YK6N She got
070913 - assistance for UCSF to use the record of patient history submitted
070914 - with the letter on 060725, ref SDS E3 I73H
070916 - ..
070917 - Arrived this morning at about 0910. Millie checked in at the customer
070918 - counter and registered following the procedure from the last visit on
070919 - 041018. ref SDS 47 LW5V
070921 - ..
070922 - Margaret had received the letter, ref DIP 6 0001, submitted to UCSF on
070923 - 060819 with additional issues for the doctor to review today in
070924 - preparing a 2nd opinion. ref SDS E7 IX5S
070926 - [...below Doctor Benz did not have time to discuss the pulmonary
070927 - emboli issue today. ref SDS 0 PM4N
070929 - ..
070930 - Margaret said that Doctor Benz likes printed documents. The doctor
070931 - does not feel comfortable with speed and accuracy using the computer
070932 - for patient history, as planned on 060809 to save time and avoid
070933 - mistakes performing the work. ref SDS E3 6U4G She therefore printed
070934 - the following documents and handed them to the doctor to prepare for
070935 - the meeting today...
070937 - 1. Letter to UCSF on 060725 setting agenda for 2nd opinion.
070938 - ref SDS D5 ST9O
070940 - ..
070941 - 2. Patient history linked in the letter, ref SDS D5 QS4X
070943 - ..
070944 - 3. Letter on 060819 reporting changes in patient status, and
070945 - requesting review of additional issues. ref SDS E7 IX3O
070947 - ..
070948 - Margaret was relieved that Millie brought documents today from Kaiser,
070949 - planned in the letter on 060819. ref SDS E7 IY4S She gave them to the
070950 - doctor supplementing other documents for preparing to meet with
070951 - Millie today.
070956 - ..
0712 - 0948
071301 - Complex Case Many Years Many Issues Many Documents
071303 - Millie was called to meet with the doctor.
071305 - ..
071306 - Doctor Benz came into the examination room with several thick file
071307 - folders overflowing with documents, and commented that this is a very
071308 - complex case, which aligns with the report in the letter from Doctor
071309 - Grissom on 060802. ref SDS D7 IT8P Doctor Benz noted complexity of
071310 - Millie's case previously during the meeting for a 2nd opinion on
071311 - 041018. ref SDS 47 EN69 The doctor set out this complexity in a
071312 - second opinion received on 041117. ref SDS 50 OS7P Doctor Bailey also
071313 - described complexity of Millie's patient history, reported on 050922.
071314 - ref SDS 85 9R8N
071316 - [On 061020 primary care physician feels patient profile has too
071317 - many issues for a 5-year medical history of lumpectomy surgery,
071318 - secondary inflammatory breast cancer (IBC), cellulitus,
071319 - lymphedema, pulmonary embolism, broken finger, citing study on
071320 - case complexity. ref SDS F5 MO4K
071325 - ..
071326 - Agenda Develop Work Plan Stage IV Breast Cancer 9 Mos after Mastectomy
071328 - Doctor Benz asked Millie what she wants UCSF to address in a 2nd
071329 - opinion?
071331 - ..
071332 - Millie's letter to UCSF on 060725 lists an agenda for a 2nd opinion.
071333 - ref SDS D5 QR6Y This was supplemented in the letter a few weeks later
071334 - on 060819, ref SDS E7 IX6T, on 060819, which Margaret gave to the
071335 - doctor about 15 minutes ago, per above. ref SDS 0 UE6H These letters
071336 - list the following agenda for UCSF to address...
071338 - 1. Patient history chronology................. ref SDS 0 TQ4I
071339 - 2. Esophagitis...(added)...................... ref SDS 0 JP6K
071340 - 3. Chemotherapy agents to treat IBC........... ref SDS 0 K36G
071341 - 4. Strategy criteria for order of treatment... ref SDS 0 K36G
071342 - 5. Rate recovery IBC with mastectomy.......... ref SDS 0 NN3H
071343 - 6. Surgery options............................ ref SDS 0 X54L
071344 - 7. Radiation options.......................... ref SDS 0 Z26K
071345 - 8. Biopsy..................................... ref SDS 0 KT7J
071346 - 9. Pulmonary emboli hypercoagulable work up... ref SDS 0 CV5L
Patient History Chronology Reliance of Gist of Story from Patient's
290401 - ..
290402 - Patient History Reliance Verbal Story from Personal Memory
290404 - Previously, during the meeting on 041018, the doctor had read from
290405 - Millie's letter to verify the work for UCSF to perform. ref SDS 47
290406 - LX3U
290408 - ..
290409 - Today, rather than follow prior practice and use the patient's letter
290410 - for an agenda, the doctor asked the patient to verbally restate what
290411 - is in the letters submitted to UCSF, per above. ref SDS 0 TQ83
290413 - ..
290414 - Doctor Benz further asked the patient to explain chronology on patient
290415 - history since his last examination on 041018. ref SDS 47 EN5L
290417 - ..
290418 - The doctor recalled seeing documents from Kaiser prepared by the
290419 - primary care physician for Progress Notes in Millie's medical chart.
290420 - Previously, on 041018, Doctor Benz indicated that Progress Notes
290421 - prepared by frontline doctors are not effective for 2nd opinion review
290422 - because limited time from seeing many patients makes the Medical Chart
290423 - illigible, cursory, and disconnected from chronology and context.
290424 - ref SDS 47 EN63 Erroneous, illegible notes in the medical chart were
290425 - cited in a study on the high cost of medical mistakes, reviewed on
290426 - 990912. ref SDS 3 0001 and ref SDS 3 4T4H Today, since notes from
290427 - Kaiser's computer Medical Chart are legible, beginning on 060428,
290428 - ref SDS A9 FE4I, Doctor Benz saw in flipping through Kaiser's
290429 - documents a partial listing of CA 15-3 cancer marker test results
290430 - entered by primary care physician for the meeting on 060711.
290431 - ref SDS C5 128S
290433 - [...below, reliance on erroenous medical chart showing patient
290434 - being treated for pulmonary embolism, may have prevented doctor
290435 - from complying with patient request for 2nd opinion on symptoms
290436 - of pulmoanry embolism. ref SDS 0 PM4N
290438 - ..
290439 - Doctor Benz was disappointed that the CA 15-3 listing he saw in
290440 - Kaiser's Medical Chart for Millie did not have dates. He asked
290441 - questions about dates and circumstances for the partial listing of CA
290442 - 15-3 tests. He manually wrote down dates and added comments to build
290443 - a chronology of patient history. After spending 5 - 10 minutes on
290444 - this effort, the doctor recalled seeing another Kaiser document
290445 - listing CA 15-3 tests that was longer and had dates. Doctor Benz
290446 - requested assistance finding this longer list among Kaiser's large
290447 - stack of documents, as a guide to construct a chronology of patient
290448 - history.
290450 - ..
290451 - There was brief discussion that the patient's letter to UCSF on 060725
290452 - requesting a 2nd opinion, ref SDS D5 ST9O, provides a comprehensive,
290453 - accurate chronology on patient history, ref SDS D5 QS4X, along with an
290454 - agenda for preparing a 2nd opinion. ref SDS D5 QR6Y On 060809 the
290455 - doctor's assistant at UCSF reviewed patient history, and indicated at
290456 - that time that this was exactly what the doctor needed, and further
290457 - appreciated that the doctor would save a lot time by avoding the usual
290458 - practice of constructing a chronology from interviewing the patient
290459 - and culling documents. ref SDS E3 TM6H
290461 - ..
290462 - Doctor Benz said that Millie has a very complex patient history, and
290463 - that accuracy is less important than getting the gist of the story
290464 - through conversation. Previously, on 040416 the protocol nurse at
290465 - Kaiser had explained the importance of accuracy in medical practice
290466 - supported by audits to authenticate conversation with written records
290467 - for effective patient care. ref SDS 32 6E4K As well, Doctor Benz
290468 - noted on 041018 that conversation in meetings discloses the gist of
290469 - the story, and that publishing a 2nd opinion required documentation to
290470 - verify accuracy. ref SDS 47 L16Q Today, Doctor Benz indicated that CA
290471 - 15-3 test dates and asking questions would be faster and easier than
290472 - relying on patient history for building an accurate chronology. He
290473 - therefore asked again for help finding the list of CA 15-3 tests to
290474 - construct a de novo chronology of Millie's medical history.
290476 - ..
290477 - [On 061020 primary care physician feels patient profile has too
290478 - many issues for a 5-year medical history of lumpectomy surgery,
290479 - secondary inflammatory breast cancer (IBC), cellulitus,
290480 - lymphedema, pulmonary embolism, broken finger, citing study on
290481 - case complexity. ref SDS F5 MO4K
290483 - ..
290484 - [On 071006 Paula in Kaiser's MCRC business unit discovered that
290485 - Knowledge Management practices using SDS records online
290486 - expedites handling documents and facilitates understanding
290487 - complex issues. ref SDS G2 EX8K
290489 - ..
290490 - UCSF reliance on conversation today for the gist of patient history
290491 - from personal memory to prepare a written 2nd opinion, aligns with
290492 - practice at Kaiser asking patients to verbally present from memory
290493 - details of written 2nd opinions on high risk surgery, reported on
290494 - 050913. ref SDS 82 KP9F As well, on 041130 Kaiser objected to written
290495 - records. ref SDS 51 8P8F Knowledge Management practices seem to have
290496 - evolved from using technology to understand complexity, toward
290497 - reliance on conversation to get the gist of the story, reported on
290498 - 011102. ref SDS 5 H461 This supports industry trends using
290499 - conversation for Knowledge Management, reported on 010114, ref SDS 4
290500 - EK3I, and more recently on 040622.
290502 - ..
290503 - Biological drives to avoid stress from cognitive overhead is further
290504 - presented on 011102, citing Larry Prusak at IBM, ref SDS 5 HD8M, and
290505 - is explained in NWO. ref OF 19 LH6K An example from medical practice
290506 - illustrates work today at UCSF. ref OF 19 PXWX On 050414 UCSF was
290507 - credited for remarkable advance applying Knowledge Management.
290508 - ref SDS 63 LX7F
290510 - ..
290511 - Doctor Benz was assisted to find the document he wanted with CA 15-3
290512 - test dates. It was located a few pages into the large stack of
290513 - papers, and is shown below. ref SDS 0 087J
290515 - ..
290516 - Most of the meeting today was consumed by the doctor asking the
290517 - patient to recall from memory without consulting the record details of
290518 - medical history surrounding dates of CA 15-3 testing. The doctor made
290519 - handwritten notations with arrows and cross-outs on the paper with the
290520 - list of CA 15-3 tests, similar to his work 2 years ago on 041018 for a
290521 - prior 2nd opinion consultation. ref SDS 47 EN69
290523 - ..
290524 - Spending all of the time building another chronology left only enough
290525 - time for a physicial examination. There wasn't enough time to review
290526 - issues presented by the patient for UCSF to address in a second
290527 - opinion. ref SDS 0 TQ83
290529 - ..
290530 - Reliance on printed documents from Kaiser without context of patient
290531 - history misled the doctor to avoid reviewing the pulmonary emboli
290532 - problem, noted below. ref SDS 0 H46F
Vitals Examination 2nd Opinion Recover IBC Recurrence Treatment Opti
310401 - ..
310402 - Vitals Show Stable Medical Condition
310404 - Follow up ref SDS E1 KB5L, ref SDS C5 KB5L.
310406 - Before meeting with the doctor a nurse took patient vitals...
310408 - ..
310409 - Date Bld Prssr Pulse Temp Weight SaO2
310411 - ..
310412 - 060821................. 144 88 67 98.3 146
310413 - * 060808................. [not submitted by Kaiser]
310414 - 060711................. 172 87 54 97.5 147
310415 - 060623................. 141 87 71 98.0 147 99%
310416 - 060428................. 129 73 80 99.4 149 99%
310417 - 060217................. 153 81 61 98.6 150 99%
310419 - ...per Doctor's report on 060808 vitals were not reported for some
310420 - reason. ref SDS E1 JQ4J
CA 15-3 Chronology Constructed Conversation Personal Memory for 2nd-
330401 - ..
330402 - CA 15-3 Cancer Marker 73 Drops Dramatically Recent Test on 060815
330404 - Follow up ref SDS E1 087J, ref SDS C5 087J.
330406 - The most recent blood test on 060815 shows CA 15-3 now at 73 is a big
330407 - sudden drop after 2 cycles Taxotere and capecitabine compared to the
330408 - steady rise over the past 8 months....
330410 - ..
330411 - Test Date Date Received
330412 - 060815......... 73 H............. 060817, ref SDS E6 PQWQ
330413 - 060809......... 87 H............. 060810, ref SDS E4 2N5J
330414 - 060809......... 71 H............. 060711, ref SDS C5 UQ5Q
330415 - 060616......... 63 H............. 060623, ref SDS C3 UQ5Q
330416 - 060522......... 59 H............. 060605, ref SDS B8 UQ5Q
330417 - 060501......... 49 H............. 060522, ref SDS B5 MC4F
330418 - 060421......... 44 H............. 060428, ref SDS A9 087J
330419 - 060330......... 40 H............. 060428, ref SDS A9 087J
330420 - 060303......... 36............... 060428, ref SDS A9 087J
330421 - 060210......... 33............... 060217, ref SDS A0 087J
330422 - 060109......... 34............... 060126, ref SDS 99 KV59
330423 - 051223......... 34............... 060106, ref SDS 98 087J
330424 - 051202......... 28............... 060106, ref SDS 98 087J
330425 - 051116......... 31............... 051121, ref SDS 96 087J
330426 - 051109......... 30............... 051121, ref SDS 96 087J
330427 - 051102......... 34............... 051121, ref SDS 96 087J
330428 - 050909......... 45 H............. 051007, ref SDS 89 087J
330429 - 050826......... 45 H............. 050913, ref SDS 82 087J
330430 - 050819......... 45 H............. 050913, ref SDS 82 087J
330431 - 050812......... 39 .............. 050819, ref SDS 75 3K6L
330432 - 050729......... 45 H............. 050819, ref SDS 75 EA5G
330433 - 050708......... 46 H............. 050729, ref SDS 74 087J
330434 - 050701......... 37 .............. 050729, ref SDS 74 087J
330435 - 050617......... 45 H............. 050729, ref SDS 74 087J
330436 - 050527......... 56 H............. 050610, ref SDS 71 087J
330437 - 050512......... 67 H............. 050520, ref SDS 69 087J
330438 - 050506......... 80 H............. 050520, ref SDS 69 087J
330439 - ..
330440 - 050415.........105 H............. 050422, ref SDS 65 087J
330441 - 050325.........100 H............. 050329, ref SDS 62 087J
330442 - 050318.........101 H............. 050325, ref SDS 61 2N5J
330443 - 050304......... 88 H............. 050311, ref SDS 59 087J
330444 - 050225......... 95 H............. 050308, ref SDS 58 0001
330445 - 050211......... 78 H............. 050214, ref SDS 57 02BB
330446 - 050128......... 67 H............. 050204, ref SDS 56 087J
330447 - 041228......... 56 H............. 041230, ref SDS 55 087J
330448 - 041204......... 43 H............. 041210, ref SDS 54 087J
330449 - 041007......... 39............... 041104, ref SDS 49 087J
330450 - 040923......... 49 H............. 041005, ref SDS 46 087J
330451 - 040908......... 44 H............. 040909, ref SDS 45 087J
330452 - 040825......... 47 H............. 040909, ref SDS 45 087J
330453 - 040811......... 42 H............. 040812, ref SDS 44 087J
330454 - 040728......... 43 H............. 040729, ref SDS 42 2N5J
330455 - 040712......... 47 H............. 040713, ref SDS 41 087J
330456 - 040614......... 55 H............. 040615, ref SDS 40 PX6X
330457 - 040517......... 78 H............. 040601, ref SDS 38 2N5J
330458 - 040311......... 70 H............. 040318, ref SDS 31 SM6M
330459 - 040205......... 60 H............. 040211, ref SDS 29 SM6M
330460 - 031201......... 62 H............. 031205, ref SDS 28 SM6M
330461 - 030912......... 66 H............. 030915, ref SDS 27 SM6M
330462 - 030708......... 68 H............. 030710, ref SDS 26 SM6M
330463 - 030503......... 54 H............. 030508, ref SDS 24 SM6M
330464 - 030403......... 45 H............. 030508, ref SDS 24 SM6M
330465 - 030215......... 46 H............. 030220, ref SDS 23 5E6L
330466 - 030106......... 37 H............. 030109, ref SDS 22 SM6M
330467 - 021202......... 41 H?............ 021204, ref SDS 21 SP5G
330468 - 021111......... 36 H?............ 021113, ref SDS 20 Y65I
330469 - 021023......... 33 H?............ 021023, ref SDS 19 SQ5I
330470 - 020930......... 33 H?..39........ 021002, ref SDS 18 SQ5I
330471 - 020917......... 36 H?............ 020924, ref SDS 17 SQ5I
330472 - 020717......... 59 H?............ 020726, ref SDS 16 YN5K
330473 - 020629......... 75 H ............ 020705, ref SDS 14 UX6I
330474 - 020608........ 67 H ............ 020614, ref SDS 12 0001
330475 - 020603........ 108 H ............ 020607, ref SDS 11 X67F
330476 - 020511........ 117 H ............ 020603, ref SDS 10 PJ4J
330477 - 020419......... 81 H ............ 020430, ref SDS 8 7N5H
330478 - 020321......... 85 H ............ 020405, ref SDS 7 6T8K
330484 - ..
3307 - Discussion
330801 - CA 15-3 Doctor Benz Builds Chronology for 2nd-Opinion
330803 - Follow up ref SDS E1 GJ5M, ref SDS C5 GJ5M.
330805 - Doctor Benz noted 8 month trend of rising cancer marker, was reversed
330806 - with the recent test showing a significant decline that may indicate
330807 - treatment started on 060721 may now be starting to yield favorable
330808 - response. ref SDS 0 087J Previously, on 041018 the doctor commented
330809 - that UCSF does not rely on CA 15-3. ref SDS 47 EN6S
330811 - ..
330812 - Today, Doctor Benz requested assistance finding the full history of CA
330813 - 15-3 in the stack of documents received from Kaiser. ref SDS 0 0I4N
330814 - Doctor Benz then used this list of CA 15-3 test dates to construct a
330815 - chronology of patient history, per above. ref SDS 0 FP8N
Distant Metastasis No Evidence PET CT Image Tests for 5 Years Millie
370401 - ..
370402 - Distant Metastasis No Evidence Image Testing PET CT MRI Bone Scans
370403 - Image Tests PET CT MRI Bone No Evidence Distant Metastasis for 5 Years
370405 - Follow up ref SDS E1 EY5O, ref SDS C5 EY5O.
370407 - Millie noted that patient history of image tests following surgery on
370408 - 051021 have not identified cancer, as reported in the CT test reviewed
370409 - with the primary care physician on 060623. ref SDS C3 II4L PET scan
370410 - and CT imaging tests over the entire patient history beginning on
370411 - 020208, and listed on 060711, ref SDS C5 FE8F, have never reported
370412 - distant metastasis in this case.
370414 - ..
370415 - Image test history was cited in the letter on 060725 to UCSF
370416 - requesting a second opinion, ref SDS D5 QS6V, and aligns with clinical
370417 - examination today finding no clear evidence of distant metastasis.
370419 - [On 060929 Benz 2nd opinion notes finding no evidence of
370420 - lymphadenopathy in left axilla, stating on the left there is
370421 - sensation of a 1.5 to 2 cm node present high in the axilla;
370422 - however, I cannot be completely certain about this; for some
370423 - reason, UCSF does not cite history of image testing to
370424 - correlate impressions, nor the record of lymphedema.
370425 - ref SDS F3 WQ4Q
370427 - ..
370428 - Conflicts in image tests most recently concerning left supraclavicular
370429 - on 060523, ref SDS B5 IM9M (see also review below, ref SDS 0 8R6M),
370430 - and listed in the study on 040416, ref SDS 34 GN7J, were not discussed
370431 - with Doctor Benz because all of the time was taken up creating another
370432 - chronology using the history of CA 15-3 tests, per above. ref SDS 0
370433 - FP8N
370435 - ..
370436 - [On 060929 Doctor Benz 2nd opinion notes that failure of CT
370437 - test to report findings in left supraclavicular where PET test
370438 - finds nodes progressing in size raises concerns. ref SDS F3
370439 - WI4I
Esophagitis PET Scan Test on 060101 reported 060126 Not Resolved PET
410401 - ..
410402 - Esophagitis in PET Test and Nodes Right Paratracheal Found CT Test
410404 - Follow up ref SDS E1 JP6K, ref SDS C5 JP6K.
410406 - Issues and background on diagnosis of esophagitis reported in PET scan
410407 - test performed on 060120, and received on 060126, ref SDS 99 DH4O,
410408 - were most recently reviewed on 060623. ref SDS C3 DH4O A contrast CT
410409 - study was performed on 060505. Review on 060523 showed findings of
410410 - nodes within the right paratracheal that might relate to the earlier
410411 - PET test findings on 060120 of likely esophagitis. ref SDS B5 4O8P
410413 - ..
410414 - At that time, on 060623 follow up on diagnosis of esophagitis was
410415 - paused. ref SDS C3 RB4H
410417 - ..
410418 - There was no time today for discussion of this issue, because the
410419 - doctor took most of the time building another patient chronology.
410420 - ref SDS 0 FP8N
410422 - [On 060929 Doctor Benz 2nd opinion notes that failure of CT test to
410423 - report findings in left supraclavicular where PET test finds nodes
410424 - progressing in size raises concerns; however, Doctor Benz does not
410425 - note similar defect in image testing of the chest that diagnosed
410426 - esophagitis. ref SDS F3 WI4I
Left Auxillary No Evidence Lymphadenopathy Lymphedema Left Arm Lump
510401 - ..
510402 - Left Axillary No Evidence Lymphadenopathy
510403 - Lymphedema Left Arm Lump Under Arm Diagnosis Not Cancer
510404 - Post Operation Localized Edema Left Axillary Swelling Reduced
510406 - Follow up ref SDS E1 MW8J, ref SDS C5 MW8J.
510408 - ..
510409 - Patient history of left axillary lymphadenopathy and lymphedema is
510410 - reported on 060106. ref SDS 98 S164 At this time there is no evidence
510411 - of cancer at this location, shown by patient history listed on 060722.
510412 - ref SDS D2 Y34M
510414 - ..
510415 - Doctor Benz examined the left axillary, and noted mild swelling. The
510416 - patient did not complain of discomfort, which previously had signaled
510417 - cancer, as shown in the case study on this issue listed on 040517.
510418 - ref SDS 37 OW3I Examination today aligns with findings at Kaiser on
510419 - 060623 citing recent image test reports that show no evidence of
510420 - cancer at this location. ref SDS C3 MW8J Swelling of the left
510421 - axillary occurs in part from lymphedema diagnosed on 060106, see
510422 - patient history listed on 060722. ref SDS D2 6V3M
510424 - [On 060929 Benz 2nd opinion notes finding no evidence of
510425 - lymphadenopathy in left axilla, stating on the left there is
510426 - sensation of a 1.5 to 2 cm node present high in the axilla;
510427 - however, I cannot be completely certain about this; for some
510428 - reason, UCSF does not cite history of image testing to
510429 - correlate impressions, nor the record of lymphedema.
510430 - ref SDS F3 WQ4Q
Right Axillary Clinical Examination Finds No Lump Patient Complains
560401 - ..
560402 - Right Axillary FDG SUV 2.5 Lump No Discomfort Reported by Patient
560404 - Follow up ref SDS E1 3D6K, ref SDS C5 3D6K.
560406 - Patient history of rising FDG SUV activity by PET testing, reported on
560407 - 060428, ref SDS A9 CZ8L, and no adenopathy found in contrast CT test
560408 - reported on 060526, ref SDS B5 4O8P, which further failed to make the
560409 - contrast study with the PET test findings, ref SDS B4 WT6M, was
560410 - reviewed during a meeting with the doctor on 060623. ref SDS C3 CZ8L
560412 - ..
560413 - Doctor Benz examined the right axillary and noted no swelling. The
560414 - patient did not complain of discomfort, consistent with image testing
560415 - showing slightly elevated FDG SUV that is not sufficient to identify
560416 - cancer, noted in the examination at Kaiser on 060623, ref SDS C3 J79H,
560417 - and citing image testing listed in patient history on 060722.
560418 - ref SDS D2 619F
560420 - [On 060929 Benz 2nd opinion notes finding no evidence of
560421 - lymphadenopathy in right axilla. ref SDS F3 WQ9W
Left Supraclavicular Neck CT Test Contrast Study on 060505 Finds No
640401 - ..
640402 - Left Supraclavicular Examination PET Test SUV 4.5 CT No Findings
640403 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
640405 - Follow up ref SDS E1 8R6M, ref SDS C5 8R6M.
640407 - Patient history of left supraclavicular cancer activity is reported in
640408 - the record on 060217. ref SDS A0 8R6M
640410 - ..
640411 - PET test report finding left supraclavicular rising to FDG SUV 4.5,
640412 - reported on 060428. ref SDS A9 OX68 CT test ordered to contrast with
640413 - PET scan test was performed on 060505, and report received on 060523
640414 - shows analyst failed to make the correct comparison. ref SDS B5 006P
640416 - ..
640417 - Conflict between PET scan and CT scan tests are, also, reviewed above.
640418 - ref SDS 0 GH5G
640420 - ..
640421 - Doctor Benz examined the left and right supraclavicular and noted no
640422 - evidence of swelling, and no discernable differences between the two
640423 - locations. The patient did not complain of discomfort from swelling
640424 - at this location. This aligns with CT test report on 060505 which
640425 - does not find swelling in this area of sufficient size to report,
640426 - reported on 060523. ref SDS B5 4R82 Swelling of SUV FDG in left
640427 - supraclavicular reported in the PET scan test on 060414 is too mild,
640428 - reported on 060426, ref SDS A9 MU5M, to recognize by clinical
640429 - examination.
640431 - [On 060929 Benz 2nd opinion notes finding supraclavicular
640432 - fossae show vague sensation of fullness on the left side, which
640433 - was present during previous examination on 041018, and thus,
640434 - represents no clinical change. ref SDS F3 WQ8Q
640436 - ..
640437 - [On 060929 Doctor Benz 2nd opinion notes that failure of CT
640438 - test to report findings in left supraclavicular where PET test
640439 - finds nodes progressing in size raises concerns. ref SDS F3
640440 - WI4I
Examination Left Breast IBC Red Rash Same Improved Condition Examine
780401 - ..
780402 - Red Rash Subsides Left Breast Hopeful Response to Treatment
780403 - Examination Left Breast IBC Inflammation Red Rash Seems to Subside
780404 - IBC Inflammation Left Breast Red Rash Subsides Response to Treatment
780405 - Response to Treatment IBC Inflammation Left Breast Red Rash Subsides
780407 - Follow up ref SDS E1 025H, ref SDS C5 025H.
780409 - Background on prior relapse examinations is listed on 060711.
780410 - ref SDS C5 8Y7O
780412 - ..
780413 - Doctor Benz examined the left breast IBC red rash previously on
780414 - 041018. ref SDS 47 M66H The second opinion received from UCSF on
780415 - 041117 described a thorough analysis of examination at that time.
780416 - ref SDS 50 EM6O
780418 - ..
780419 - Recent patient history listed in the record on 060722, ref SDS D2
780420 - JD5K, was submitted to UCSF on 060725, ref SDS D5 QS5T, and reviewed
780421 - with UCSF staff on 060819. ref SDS E3 6U4O An extract shows the
780422 - following related to left breast examination...
780424 - 1. Clear of rash reported by Kaiser
780425 - surgeon examination.................. 050727, ref SDS 73 YY7F
780427 - ..
780428 - 2. IBC rash about a year later began
780429 - to show disparate red dots found
780430 - from examination by Kaiser Oncology
780431 - primary care physician............... 060623, ref SDS C3 025H
780433 - ..
780434 - 3. IBC rash intensifies described
780435 - carefully from examination
780436 - to schedule treatment................ 060711, ref SDS C5 8Z8G
780438 - ..
780439 - CA 15-3 71 risis substantially
780440 - from 63.............................. 060711, ref SDS C5 087J
780442 - ..
780443 - Treatment was ordered on 060711;
780444 - began two weeks later................ 060721, ref SDS D0 407N
780446 - ..
780447 - 4. IBC rash spreads and intensifies
780448 - after first treatment on 060721
780449 - with Taxotere capecitabine
780450 - reported in letter to Kaiser
780451 - oncology............................. 060806, ref SDS D8 OJ7S
780453 - ..
780454 - 5. IBC rash suddenly subsides showing
780455 - slight improvement examination
780456 - Kaiser Oncology...................... 060808, ref SDS E1 8Z8G
780458 - ..
780459 - CA 15-3 87 rises substantially
780460 - from 71 creating concern
780461 - patient not responding to
780462 - treatment............................ 060810, ref SDS E4 2N5J
780464 - ..
780465 - CA 15-3 73 falls substantially from
780466 - 87, reversing 6 month continuous
780467 - rise, giving hope patient
780468 - has delayed response to
780469 - treatment............................ 060817, ref SDS E6 TS5O
780471 - ..
780472 - IBC red rash condition examined today by Doctor Benz is unchanged from
780473 - examination on 060808. ref SDS E1 FQ9N
780475 - [On 060929 received Doctor Benz written opinion, provides
780476 - excellent details on examination of left breast that
780477 - enables follow on work to assess change toward recovery, or
780478 - progression of disease. ref SDS F3 WQ8V
780480 - ..
780481 - [On 051110 doctor reports IBC rash on left breast area is
780482 - "stable," ref SDS F6 ZL5W, indicating recovery is very
780483 - slow, because on 051021 blood vessels were removed from the
780484 - treatment area by mastectomy surgery, per analysis of
780485 - expectations on 050929. ref SDS F1 EH3F
780487 - ..
780488 - Patient needs support to analyse two (2) scenarios considered on
780489 - 060808, ref SDS E1 J16O, that impact treatment decisions...
780491 - ..
780492 - 1. Delayed Response to Treatment IBC Subsiding
780494 - Patient has actual and delayed response to treatment of IBC
780495 - recurrence, per evidence of patient's report, ref SDS E1 VO6G,
780496 - and direct examination on 060808, ref SDS E1 FQ6G, which has
780497 - been achieved by continuing previously successful treatment
780498 - using Taxotere and capecitabine (Xeloda), as planned on 060428.
780499 - ref SDS A9 9Y8L Previously, the patient was started on 050415
780500 - with cycles of high dose chemotherapy (HDC) (2 pills Xeloda 500
780501 - MG twice a day for 2 weeks, with a week off). This followed in
780502 - the normal sequence after 4 cycles of treatments with AC that
780503 - seemed unsuccessful, reported on 050329. ref SDS 62 E87M
780505 - ..
780506 - Even though AC seemed unsuccessful in 2005, its affect could
780507 - have been accumulating, i.e., was delayed then, as now. Thus,
780508 - when Taxotere and capecitabine were started, it may have
780509 - continued a recovery already gathering, but not yet manifest in
780510 - reduction of IBC rash, CA 15-3 marker. Additionally, since
780511 - treatment began on 050415 with HDC, the patient's increased
780512 - treatment level may also have contributed to an immediate
780513 - response, as reported in patient history. ref SDS 75 9H6F
780515 - ..
780516 - In this case, since the patient has been off treatment for 9
780517 - months, with the last treatment on 050916, ref SDS 83 407N, and
780518 - therefore has no buildup of chemotherapy, and further since the
780519 - current treatment prescribes a reduced dose that fits patient
780520 - tolerance profile, the doctor today feels that response to
780521 - treatment should be expected to take longer than when used
780522 - under different prior circumstances in 2005, as set out in the
780523 - record on 060711 considering HDC. ref SDS C5 RH9L
780525 - [On 060922 response to treatment compare 2005 with current
780526 - treatment in 2006, ref SDS F0 0D4T; rate of response
780527 - identifies critical factors, ref SDS F0 GA8H, indicating
780528 - delayed response favorable in 2006. ref SDS F0 9F35
780530 - ..
780531 - [On 060929 Benz 2nd opinion finds red rash is not
780532 - established as IBC; requires explanation of rising CA 15-3
780533 - cancer marker; doctor indicates there may be wide spread
780534 - distant metastasis too small for recognition by image
780535 - testing and currently being treated systemcially with
780536 - chemotherapy. ref SDS F3 WQ8V
780539 - ..
780540 - Alternatively, on 060808, ref SDS E1 J458, another scenario requires
780541 - consideration...
780543 - ..
780544 - 2. Treatment Fails Red Rash Wanes Rising CA 15-3 Shows IBC Rising
780546 - Doctor Benz reported in a second opinion from UCSF Medical
780547 - Center received on 041117, and reviewed with Kaiser during a
780548 - meeting on 041130, ref SDS 51 5X4J, that IBC rash in this case
780549 - shows a history of varying intensity that waxed and waned.
780550 - ref SDS 50 OS6W Taking just one of many examples from patient
780551 - history, in late May 2003, the patient requested an emergency
780552 - meeting to review sudden appearance of a severe red rash on the
780553 - left breast, and at a time before IBC was diagnosed or made
780554 - known to the patient. Like the examination on 060808 that
780555 - indicated reduced intensity of IBC rash, ref SDS E1 VO6G, when
780556 - the patient was examined by the doctor on 030606, the doctor
780557 - was not alarmed, because, as Doctor Benz describes, by that
780558 - time the rash had "waned," and so the primary care physician
780559 - was comfortable making no change in diagnosis nor prescribing
780560 - treatment, ref SDS 25 7C6W, which fits the profile that IBC is
780561 - hard to diagnose, reported on 040517, ref SDS 37 S65K, and
780562 - cited recently on 060807 when Millie saw a video saying IBC is
780563 - hard to diagnose and treat. ref SDS D9 JR9Y IBC relapse
780564 - presents challenges for physicians to recognize when cancer
780565 - does not respond to treatment that was previously effective,
780566 - and switch to a different protocol in time to be effective
780567 - before cancer cascades out of control, discussed by the primary
780568 - care physician on 030606. ref SDS 25 N27L The problem of
780569 - ineffective treatment can be compounded by "pockets of
780570 - resistance" cited by the primary care physician on 050311.
780571 - ref SDS 59 PA4N In this case mastectomy surgery on 051021
780572 - removed blood vessels which normally deliver treatment and
780573 - nutrients from the immune system, noted in 2nd opinion
780574 - consultation on 051011, ref SDS 90 G65S, and so isolate pockets
780575 - of resistance that prevent recovery.
780577 - ..
780578 - [On 060922 response to treatment compare 2005 with current
780579 - treatment in 2006, ref SDS F0 0D4T; rate of response
780580 - identifies critical factors, ref SDS F0 GA8H, indicating
780581 - delayed response favorable in 2006. ref SDS F0 9F35
780583 - ..
780584 - Doctor Benz did not have time today to comment on alternate theories
780585 - of patient status because of time required to build another chronology
780586 - of patient history that was already prepared for UCSF, per above.
780587 - ref SDS 0 FP8N
780589 - [On 060929 Benz 2nd opinion finds red rash is not
780590 - established as cancer, not IBC; requires explanation of
780591 - rising CA 15-3 cancer marker; doctor indicates there may be
780592 - wide spread distant metastasis too small for recognition by
780593 - image testing and currently being treated systemcially with
780594 - chemotherapy. ref SDS F3 WQ8V
Biopsy IBC Recurrence Verify Diagnosis Discussed on 060623 and for S
840401 - ..
840402 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
840403 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
840404 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
840405 - Treatment Options Limited Status Not Changed by Retest Biopsy 040419
840407 - Follow up ref SDS E1 KT7J, ref SDS C5 KT7J.
840409 - Doctor Benz asked if the red rash has been tested for IBC with a
840410 - biopsy, as was done for the original diagnosis on 040419? ref SDS 35
840411 - 1572
840413 - ..
840414 - Millie reviewed background on 060623 requesting that Kaiser perform a
840415 - biopsy to verify IBC diagnosis, ref SDS C3 6Z4N, and support patient
840416 - work up for strategy to treat IBC relapse post-surgery, discussed
840417 - later on 060711? ref SDS C5 K36G At that time, on 060711 Kaiser
840418 - decided against performing a biopsy. ref SDS C5 KT7J
840420 - ..
840421 - On 060802 a 2nd opinion from Doctor Grissom proposes biopsy to guide
840422 - treatment planning. ref SDS D7 GM5M
840424 - ..
840425 - Today, Doctor Benz recommended a biopsy to evaluate the red rash for
840426 - IBC on the left breast. The doctor seemed to indicate that biopsy can
840427 - establish measurable disease to qualify Millie for participating in
840428 - UCSF drug trials, discussed below. ref SDS 0 6Q6O
840430 - [...below, biopsy measures disease progression for switching to
840431 - another treatment. ref SDS 0 634O
840433 - ..
840434 - [On 060825 discussed UCSF support for biopsy with primary care
840435 - physician at Kaiser. ref SDS E9 FF4S
840437 - ..
840438 - Millie asked the doctor to mention the recommendation for a biopsy in
840439 - the 2nd opinion letter.
840441 - [On 060929 Doctor Benz mentions in the 2nd opinion that the rash
840442 - has not been evaluated by biopsy. ref SDS F3 WY79 Benz further
840443 - notes that examination without biopsy does not establish lesions
840444 - on left breast are IBC tumor, ref SDS F3 WQ8V; and says that UCSF
840445 - requires evidence of measurable disease to support patient
840446 - treatment with participation in a drug trial; but does not restate
840447 - that biopsy is the method for establishing measureable disease,
840448 - nor does the doctor present any other method for meeting this
840449 - criteria. ref SDS F3 CE4J
840451 - ..
840452 - [On 061020 examination shows disease left breast stable, no
840453 - improvement with 3 additional treatments; patient letter asks
840454 - Kaiser about measurements to qualify for drug trials; Kaiser
840455 - decides against taking measurements. ref SDS F5 JQ3J
840457 - ..
840458 - The patient feels reluctant to approve biopsy for two reasons...
840460 - 1. Biopsy on 040119 took about a year to heal on 050727.
840461 - ref SDS 73 WI6K
840463 - ..
840464 - Slow healing signaled slow response to treatment, until Kaiser
840465 - switched to Taxotere and capecitabine on 050415. ref SDS 64
840466 - 407N
840468 - ..
840469 - 2. Without breast tissue, a punch biopsy could be even more
840470 - painful than the original biopsy on 040419.
840472 - ..
840473 - This might be addressed by taking a scraping of infected
840474 - tissue, rather than perform a punch biopsy without breast
840475 - tissue.
Strategy Treatment Plan IBC 3rd Relapse Scope Chemotherapy Drug Agen
890401 - ..
890402 - Pool Chemotherapy Drugs Available to Treat IBC
890403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
890404 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
890406 - Follow up ref SDS E1 K36G, ref SDS C5 K36G.
890408 - ..
890409 - During a meeting at Kaiser on 060711, the patient requested a work up
890410 - on the 3rd relapse of IBC to include strategy for the order applying
890411 - treatment options, consideration of radiation and surgery, and, also,
890412 - a complete list of chemotherapy drugs available for IBC treatment in
890413 - this case. ref SDS C5 FP9H The patient requested an update and formal
890414 - presentation on an informal, rough listing of chemotherapy agents
890415 - listed by the primary care physician on 041130. ref SDS 51 9V63
890417 - ..
890418 - Kaiser responded in a letter on 060721 saying in part...
890420 - Currently our options [are limited] to a decreasing pool of
890421 - chemotherapeutic agents. ref SDS C9 5S9M
890423 - ..
890424 - Kaiser's response does not list the "pool" of drugs for treating IBC
890425 - that is declining. Subsequently, research on 060808 found a few more
890426 - drugs listed on the Internet, ref SDS 51 9V63, which were consolidated
890427 - into the list on 041130. ref SDS 51 9V63
890429 - ..
890430 - The letter to UCSF on 060725 therefore requests a 2nd opinion on the
890431 - list from the meeting on 041130 at Kaiser for drugs available to treat
890432 - IBC, ref SDS D5 QR6Y, and is the second issue on the agenda for the
890433 - meeting today, as shown above. ref SDS 0 TQ83
890435 - ..
890436 - Today, the time required to review patient history and construct
890437 - another chronology, ref SDS 0 FP8N, left no time for the doctor to
890438 - review the list of drugs on 041130 and comment on scope and order for
890439 - prescribing treatmetns.
890441 - ..
890442 - Doctor Benz referred the patient to the UCSF 2nd opinion from the
890443 - meeting on 041018 and received on 041117 for chemotherapy drugs to
890444 - treat Millie, which says in part...
890446 - 1. ...capecitabine, another form of liposomal anthracycline
890447 - known as Doxil, or combinations in couplets involving such
890448 - agents as Gemzar. ref SDS 50 OU5V
890451 - ..
890452 - Capecitabine By Itself Effective Without Taxotere
890455 - 2. Her success with taxanes would indicate that capecitabene-
890456 - Taxotere or Gemzar-Taxotere combinations might be
890457 - considered upon disease progression. ref SDS 50 OU6S
890459 - ..
890460 - Today, during the meeting at UCSF, Doctor Benz seemed to comment that
890461 - he feels capecitabine by itself is effective without the combination
890462 - of Taxotere.
890464 - ..
890465 - UCSF letter received on 041117 review continued...
890467 - 3. Small molecule kinase inhibitors as part of a protocol
890468 - would certainly be warranted if she were eligible for such
890469 - studies. ref SDS 50 OU6W
890471 - ..
890472 - Drug trials are discussed further below. ref SDS 0 WB9K
890474 - ..
890475 - This record suggests that nothing has emerged nor been learned during
890476 - the past two (2) years on treating IBC for Millie's patient profile.
890478 - [On 060929 Benz 2nd opinion #2 adds Navelbine to list of drugs
890479 - for treating Millie's cancer. ref SDS F3 WR3Y
890481 - ..
890482 - Doctor Benz did not present the steps and scope for "work up" on a 3rd
890483 - IBC relapse post surgery
890485 - ..
890486 - Doctor Benz explained criteria for switching treatments is
890487 - "measurable" advance of disease, discussed earlier concerning a
890488 - biopsy. ref SDS 0 2X6G
890490 - ..
890491 - Doctor Benz did not present strategy and criteria for the order of
890492 - treatment with available chemetherapy agents in Millie's case.
890494 - ..
890495 - Millie asked for a list of drugs that treat IBC, as set out in her
890496 - letter on 060725, and discussed further below.
890498 - ..
890499 - The doctor said there is no more time for the meeting, and cited again
890500 - his letter on 041018, per above. ref SDS 0 FM6K
Mastectomy Removes Blood Vessels Slows Rate Recovery IBC Relapse Exp
960401 - ..
960402 - Blood Vessels Mastectomy Removed Expectations IBC Slow Recovery
960403 - Expectations Slow Recovery IBC Surgery Removed Blood Vessels
960404 - IBC Slow Recovery Expectations Low Mastectomy Removes Blood Vessels
960405 - Mastectomy Removes Blood Vessels Slows Rate Recovery IBC Relapse
960408 - ..
960409 - Treatment response expectations in this case for Taxotere and
960410 - capecitabine are informed by rapid improvement during 2005,
960411 - illustrated by the record on 050502 after 1 cycle, ref SDS 66 EO5J,
960412 - and further reported in a meeting at Kaiser on 050520 after 2 cycles
960413 - of cheotherapy. ref SDS 69 025H So far, the rate of recovery with the
960414 - same treatment seems much slower, shown by examination today after 2
960415 - cycles treating IBC relapse, per above. ref SDS 0 325J The patient's
960416 - letter to Kaiser on 060807 and cited in the meeting at Kaiser the next
960417 - day on 060808 further shows concern about slow response to treatment.
960418 - ref SDS E1 025H
960420 - [On 060922 case study indicates slower response to same treatment
960421 - may be incorrect, and recovery may be the same or faster.
960422 - ref SDS F0 0D4T
960424 - ..
960425 - Should expectations of timely treatment response be tempered by breast
960426 - mastectomy that removed blood vessels and capillaries which normally
960427 - deliver chemotherapy treatment and nutrients from the immune system to
960428 - infected tissue, as noted by Doctor Bailey in consulation 2nd opinion
960429 - reported on 051011? ref SDS 90 G65S
960431 - [...below, Doctor Benz did not have time to comment on
960432 - considerations for breast replacement surgery to repair defective
960433 - blood vessel system and increase effectiveness of chemotherapy for
960434 - relapse. ref SDS 0 X54L
960436 - ..
960437 - [On 061110 doctor reports IBC rash on left breast area is
960438 - "stable," ref SDS F7 ZL5W, indicating recovery is very slow,
960439 - because on 051021 blood vessels were removed from the treatment
960440 - area by mastectomy surgery, per analysis of expectations on
960441 - 050929. ref SDS F2 EH3F
High Dose Chemotherapy HDC Treatment Strategy Implemented Binary Mul
A10401 - ..
A10402 - High Dose Chemotherapy HDC Strategy Balance Patient Tolerance
A10403 - Side Effects Tolerate High Dose Chemotherapy for Effectiveness
A10404 - HDC Strategy Reverse Growth Cancer When Patient Tolerance High
A10405 - Treatment Effectiveness Balance Patient Tolerance Side Effects
A10407 - Follow up ref SDS E1 KY4G, ref SDS C5 KY4G.
A10409 - HDC was initially reviewed on 060711 indicating authorities have mixed
A10410 - views on effectiveness. ref SDS C5 KY4G
A10412 - ..
A10413 - Millie had difficulty tolerating HDC with captecitabine and Taxotere,
A10414 - reported on 050514, ref SDS 67 QC4E, discussed again on 050516,
A10415 - ref SDS 68 AQ6G, and leading to reducing the dose of treatment on
A10416 - 050520. ref SDS 69 NT3I This is discussed below in connection with
A10417 - tolearting Navelbine. ref SDS 0 PF4M
A10419 - ..
A10420 - Conceivably protocols involving multiple, binary, and couplet drug
A10421 - combinations could be considered a dimension HDC treatment, which
A10422 - Millie currently getting with Taxotere and capecitabine (Xeloda).
A10424 - ..
A10425 - Doctor Benz did not have time today to comment on HDC issues because
A10426 - of time spent building another chronology of patient history that was
A10427 - already prepared for UCSF, per above. ref SDS 0 FP8N
Treatment IBC 3rd Relapse Continue Chemotherapy Agents Taxotere Cape
A80401 - ..
A80402 - Treatment Continue 2nd Cycle Taxotere and Capecitabine (Xeloda)
A80403 - 2nd Cycle Taxotere and Capecitabine (Xeloda) Treatment Continue
A80404 - Taxotere and Capecitabine (Xeloda) 2nd-Cycle Treatment Continue
A80406 - Follow up ref SDS E1 PF3O, ref SDS C5 PF3O.
A80408 - ..
A80409 - The doctor seemed to support Kaiser's treatment plan presented in the
A80410 - meeting on 060711. ref SDS C5 PF3O Doctor Benz noted evident
A80411 - improvement with red rash on left breast subsiding somewhat reported
A80412 - on 060808, cited in the study above, ref SDS 0 KS4U, and significant
A80413 - drop in CA 15-3 from 87 to 73 after an 8 month rise, per above.
A80414 - ref SDS 0 087J Doctor Benz proposed...
A80416 - 1. Taxotere and capecitabine (Xeloda) continue until measurable
A80417 - progression of disease.
A80419 - [On 060929 Benz 2nd opinion #2 recommends continuing with
A80420 - current treatment plan until there is measurable
A80421 - progression of disease. ref SDS F3 WQ6Y
A80423 - ..
A80424 - 2. Measureable progression of disease (also discussed below
A80425 - concerning drug trials, ref SDS 0 6Q6O) criteria ..
A80427 - a. Rash spreading
A80428 - b. Image test findings of adenopathy
A80429 - c. CA 15-3 cancer marker rises substantially
A80430 - d. Biopsy emphasized during discussion on diagnosis, per
A80431 - above. ref SDS 0 KT7J, including, ref SDS 0 2X6G
Navelbine Chemotherapy Treatment IBC Relapse Side Effects Uncertain
AG0401 - ..
AG0402 - Navelbine Treatment of Relapse, Side Effects Uncertain
AG0404 - Follow up ref SDS E1 PF4M, ref SDS C5 PF4M.
AG0406 - On 060428 the doctor proposed considering Navelbine chemotherapy.
AG0407 - ref SDS A9 9H5I Review at that time indicated this treatment has been
AG0408 - used for many years. On 060711 the doctor advised that side effects
AG0409 - are very severe for some patients treated with Navelbine chemotherapy
AG0410 - drugs. This modified initial research on 060428 indicating that
AG0411 - Navelbine is well tolerated. ref SDS A9 JF8L
AG0413 - ..
AG0414 - Conceivably Navelbine with HDC treatment could be hard to tolerate,
AG0415 - along the lines of capeticabine (Xeloda) and Taxotere, reported on
AG0416 - 050514, ref SDS 67 QC4E, discussed again on 050516, ref SDS 68 AQ6G,
AG0417 - and leading to reducing the dose of treatment on 050520. ref SDS 69
AG0418 - NT3I
AG0420 - ..
AG0421 - One patient reported initial improvement, but within 2 months,
AG0422 - cancer progressed. ref SDS C5 R15I
AG0426 - ..
AG0427 - Navelbine Capecitabine (Xeloda) Combined
AG0429 - Follow up ref SDS E1 FE3O, ref SDS C5 FE3O.
AG0431 - ..
AG0432 - Doctor Benz did not have time today to comment on prospects for a
AG0433 - treatment option with Navelbine and capecitabine (Xeloda) because of
AG0434 - time spent building another chronology of patient history that was
AG0435 - already prepared for UCSF, per above. ref SDS 0 FP8N
AG0437 - ..
AG0438 - [On 060929 2nd opinion received from Doctor Benz proposes
AG0439 - treatment with Navelbine and capecitabine. ref SDS F3 WR3Y
Novel Epothilone BMS-247550 Capecitabine Kaiser Implement Recommenda
AO0401 - ..
AO0402 - Novel Epothilones BMS-247550 Plus Capecitabine
AO0404 - Follow up ref SDS 54 028N, ref SDS 52 4P9L.
AO0406 - On 041201 Kaiser tried to enroll Millie in a drug trial with Novel
AO0407 - Epothilones BMS-247550 plus capecitabine, ref SDS 52 RO3L The primary
AO0408 - care physician confirmed this treatment plan during a meeting on
AO0409 - 041210. ref SDS 54 028N
AO0411 - ..
AO0412 - On 041203 Millie wrote a letter to Doctor Benz at UCSF advising that
AO0413 - Kaiser was attempting to implement UCSF's first 2nd opinon from the
AO0414 - examination on 041018, and received on 041117, in which Doctor Benz
AO0415 - recommended capecitabine,
AO0417 - ..
AO0418 - On 041230, Kaiser changed the plan and decided to start Millie with
AO0419 - 2-cycles of AC in order to qualify for the drug trial protocol.
AO0420 - ref SDS 55 YR8F Later, on 050204 after 2 more treatments with AC,
AO0421 - Kaiser was unable treat Millie in the capecitabine drug trial
AO0422 - ref SDS 56 JF4M At that time, Kaiser added two (2) more cycles of AC
AO0423 - treatment, making a total of six (6), and when cancer worsened, on
AO0424 - 050329 treatment was switched to Taxotere and capecitabine,
AO0425 - recommended by Doctor Benz on 041117.
AO0427 - ..
AO0428 - This history raises a question of treatment with Novel Epothilones
AO0429 - BMS-247550 Plus Capecitabine?
AO0431 - ..
AO0432 - How did the trial work out?
AO0434 - ..
AO0435 - Is this or a similar treatment available for Millie without protocol
AO0436 - restrictions?
AO0438 - ..
AO0439 - Doctor Benz did not have time today to comment on Novel Epothilones
AO0440 - BMS-247550 and capecitabine treatment options because of time spent
AO0441 - building another chronology of patient history that was already
AO0442 - prepared for UCSF, per above. ref SDS 0 FP8N
Gemzar Taxotere Chemotherapy Treatment for IBC Relapse Side Effects
AW0401 - ..
AW0402 - Gemzar and Taxotere Treatment for IBC
AW0404 - Follow up ref SDS E1 576N, ref SDS C5 576N.
AW0406 - Doctor Benz recommended trying Gemzar and Taxotere, combination in
AW0407 - UCSF 2nd opinion #1 received on 041117. ref SDS 50 OU6S
AW0409 - ..
AW0410 - Today, the doctor did not have time to review this proposal, except by
AW0411 - general reference to his opinion received on 041117, per above.
AW0412 - ref SDS 0 8F75
AW0414 - [On 060929 2nd opinion received from Doctor Benz proposes
AW0415 - treatment with Gemzar and capecitabine, ref SDS F3 WR3Y,
AW0416 - rather than Gemzar and Taxotere, which suggests a change in
AW0417 - UCSF recommendations for Millie.
Drug Trials Kaiser Protocol Nurse Searching for Fit with Millie's Pa
B30401 - ..
B30402 - Drug Trials Millie Qualified for Protocols Under Study by UCSF
B30404 - Follow up ref SDS E1 WB9K, ref SDS C5 WB9K.
B30406 - Background...
B30408 - On 060711 Kaiser searching for drug trials that fit Millie's
B30409 - status, but has not had time to follow up. ref SDS C5 WB9K
B30411 - ..
B30412 - Doctor Benz indicated in a 2nd opinion from examination on 041018
B30413 - and received on 041117 that UCSF may have drug trials that benefit
B30414 - Millie. ref SDS 50 OV3T
B30416 - ..
B30417 - On 050520, Millie asked primary care physician at Kaiser to
B30418 - investigate a trial at UCSF using combination of AG 013736 with
B30419 - Codetaxel compared to Docetaxel alone. ref SDS 69 L27G Kaiser did
B30420 - not have time to follow up. On 050823 Millie wrote to UCSF asking
B30421 - about this trial. ref SDS 77 7I5Y UCSF did not have time to follow
B30422 - up.
B30424 - ..
B30425 - Subsequently, on 050909 Doctor Bailey discussed a drug trial being
B30426 - conducted by Doctor Parks at UCSF that might benefit Millie and fit
B30427 - her patient profile. ref SDS 81 AL3N Kaiser has not had time to
B30428 - follow up.
B30430 - ..
B30431 - Today, Doctor Benz said that Millie would qualify for two (2)
B30432 - chemotherapy drug trials UCSF has underway, except at this time she
B30433 - does not show "measureable disease," per examination above.
B30434 - ref SDS 0 025H
B30436 - [On 060929 2nd opinion letter from Doctor Benz says Millie
B30437 - qualifies for 2 trials at UCSF. ref SDS F3 Z55K
B30439 - ..
B30440 - [On 061020 examination shows disease left breast stable, no
B30441 - improvement with 3 additional treatments; patient letter
B30442 - asks Kaiser about measurements to qualify for drug trials;
B30443 - Kaiser decides against taking measurements. ref SDS F5 JQ3J
B30445 - ..
B30446 - [On 061208 primary care physician observes rash has spread
B30447 - from the left breast to slightly onto the right breast for
B30448 - the first time in 3 years, and so may establish measurable
B30449 - disease to qualify for UCSF drug studies. ref SDS F8 AX6G
B30451 - ..
B30452 - [On 061228 Kaiser's report to UCSF presents lesions on left
B30453 - chest for measurable disease, but does not cite spread of
B30454 - IBC from left to right breast indicating "measurable
B30455 - disease" that qualifies Millie for drug trials. ref SDS F9
B30456 - IQ6J
B30458 - ..
B30459 - [On 061228 letter to Kaiser reminds doctor observed
B30460 - measurable disease with spread from left to right breast.
B30461 - ref SDS F9 T66Y
B30463 - ..
B30464 - [On 061230 correspondence between Kaiser and UCSF discusses
B30465 - cetuximab trial. ref SDS G0 4L9O
B30467 - ..
B30468 - [On 061230 Kaiser's follow up letter responding to
B30469 - questions from UCSF on measurable disease does not cite IBC
B30470 - lesions nor spread from left to right breast. ref SDS G0
B30471 - PO3V
B30473 - ..
B30474 - [On 070130 Doctor Rugo advised that UCSF has other drug
B30475 - trials on clinical study which Millie qualifies to treat
B30476 - her IBC, if disease progresses with cetuximab drug trial.
B30477 - ref SDS F1 TG5G
B30480 - ..
B30481 - Biopsy Verify IBC Recurrence Qualify for Treatment with Clinical Study Drug Trial
B30483 - The doctor discussed criteria to establish measurable disease to
B30484 - qualify for UCSF drug trials, also, cited above on considerations for
B30485 - switching treatments. ref SDS 0 634O
B30487 - 1. Biopsy finding IBC in patient tissue...
B30489 - An example is the report received from Kaiser on 040517 for a
B30490 - biopsy taken on 040419 that showed findings of IBC. ref SDS 37
B30491 - RH59
B30493 - ..
B30494 - The doctor seemed to emphasize the importance of biopsy by
B30495 - asking initially for pathology on new rash on the left breast
B30496 - as IBC, per above. ref SDS 0 KT7J
B30498 - [On discussed UCSF support for biopsy with primary care
B30499 - physician at Kaiser. ref SDS E9 FF4S
B30501 - ..
B30502 - [On 060929 Doctor Benz mentions in the 2nd opinion that the
B30503 - rash has not been evaluated by biopsy, ref SDS F3 WY79, and
B30504 - says that UCSF requires evidence of measurable disease to
B30505 - support patient treatment with participation in a drug
B30506 - trial; but does not restate that biopsy is the method for
B30507 - establishing measureable disease, nor does the doctor
B30508 - present any other method for meeting this criteria.
B30509 - ref SDS F3 CE4J
B30511 - ..
B30512 - 2. Spread of red rash on left breast.
B30514 - There was no criteria presented for measuring spread of IBC;
B30515 - possibly this is an impression on the gist of disease seeming
B30516 - to get bigger without taking measurements.
B30518 - [On 061020 examination shows disease left breast stable, no
B30519 - improvement with 3 additional treatments; patient letter
B30520 - asks Kaiser about measurements to qualify for drug trials;
B30521 - Kaiser decides against taking measurements. ref SDS F5 JQ3J
B30523 - ..
B30524 - [On 061208 rash on left breast spreads to the right breast,
B30525 - ref SDS F8 025H, may present measureable disease to meet
B30526 - UCSF requirements to qualify for drug trials. ref SDS F8
B30527 - P256
B30529 - ..
B30530 - 3. Image tests (PET, CT, MRI, Bone scans, etc.) showing
B30531 - lymphadenopathy based on size criteria.
B30533 - ..
B30534 - The history of image testing listed in the record on 060711 was
B30535 - provided to UCSF in the letter on 060725 requesting a 2nd
B30536 - opinion. ref SDS D5 QS6V
B30538 - ..
B30539 - There are many examples in patient history of image tests
B30540 - reporting measurable lymphadenopathy by size criteria,
B30541 - illustrated by the record on 030710. ref SDS 26 VM7I
B30543 - ..
B30544 - Millie asked about performing drug trials through Kaiser's Infusion
B30545 - Clinic in Walnut Creek. Doctor Johnson has done an outstanding job
B30546 - the past few years improving procedures in the clinic. The trial with
B30547 - bevicizumab (Avastin) and Taxol was accomplished without major
B30548 - incident. As a result, there is a high degree of confidence working
B30549 - with Kaiser, and the location is much more convenient than traveling
B30550 - out to UCSF.
B30552 - ..
B30553 - Doctor Benz said that this might be possible. It can be reviewed if
B30554 - disease progresses, and change in treatment is required.
Breast Replacement Surgery Deferred in 2005 Review Options in 2006 R
B80401 - ..
B80402 - Breast Replacement Surgery Deferred in 2005 Review Options in 2006
B80404 - Follow up ref SDS E1 X54L, ref SDS C5 X54L.
B80406 - Millie's letter on 060725 requesting a 2nd opinion asks UCSF to
B80407 - comment on considerations for performing previously postponed breast
B80408 - replacement surgery, considered in the record for the meeting at
B80409 - Kaiser on 060711, ref SDS C5 X54L, to avoid relapse by replacing
B80410 - infected tissue with reconstructed breast that has intact blood
B80411 - vessels capabile of delivering treatment and nutrients to the region.
B80412 - ref SDS D5 QS7R
B80414 - ..
B80415 - Doctor Benz did not have time today to comment on breast replacement
B80416 - surgery issues and considerations because of time spent building
B80417 - another chronology of patient history that was already prepared for
B80418 - UCSF, per above. ref SDS 0 FP8N
Radiation Treatment Left Supraclavicular Per Tumor Board Hearing 040
BB0401 - ..
BB0402 - Radiation Treatment Left Supraclavicular Per Tumor Board
BB0404 - Follow up ref SDS E1 Z26K, ref SDS C5 Z26K.
BB0406 - On 060808 Millie discussed radiation in relation to image testing and
BB0407 - possible link to secondary cancer. ref SDS E1 3T7L What experience
BB0408 - does UCSF have with this issue?
BB0410 - ..
BB0411 - Background considering radiation treatment is reported in the record
BB0412 - on 060623. ref SDS C3 Z26K
BB0414 - ..
BB0415 - Radiation - as noted, on 040517 Kaiser's Tumor Board considered
BB0416 - further radiation of left supraclavicular in a hearing on 040416.
BB0417 - ref SDS A9 HT6H Since left supraclavicular may present recurrance of
BB0418 - metastatic disease, indicated by PET test report today, ref SDS A9
BB0419 - OX68, should radiologist be consulted on radiating this area?
BB0421 - ..
BB0422 - Doctor Benz did not have time today to comment on radiation treatment
BB0423 - issues and considerations because of time spent building another
BB0424 - chronology of patient history that was already prepared for UCSF, per
BB0425 - above. ref SDS 0 FP8N
Pulmonary Emboli Blood Clots Lungs 2nd Opinion Coumadin Warfarin Tre
C40401 - ..
C40402 - Misleading Computer Data Coumadin Treatments Ended 12 Months ago
C40403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
C40404 - Pulmonary Emboli Genetic Cause Hypercoabullary Work Up Family History
C40406 - Follow up ref SDS E1 CV5L, ref SDS D6 0001.
C40408 - Millie's letter to UCSF on 060819 requested a 2nd opinion on treatment
C40409 - for pulmonary emboli. ref SDS E7 IY3Q
C40411 - ..
C40412 - During the first meeting with Doctor Benz on 041018, Millie explained
C40413 - problems of chronic cough, shortness of breath, and fatigure for 6
C40414 - months while getting treatment on the Avastin drug trial, which had
C40415 - documented side effects of pulmonary emboli. ref SDS 47 LX96 After
C40416 - this meeting, Kaiser scheduled Millie for a CT test, and the next day
C40417 - on 041104 the test report found pulmonary emboli. ref SDS 49 RZ4I
C40418 - Millie was removed from the Avastin trial and started treatment with
C40419 - Coumadin for pulmonary emboli for the rest of her life, based on
C40420 - Kaiser's policy for treating cancer patients. ref SDS 49 4Y9G
C40422 - ..
C40423 - Review on 041104 indicates Doctor Benz contributed to Kaiser testing,
C40424 - discovering, and treating pulmonary embolism, ref SDS 49 NL4N, to
C40425 - relieve rising symptoms first reported on 040517. ref SDS 37 RZ4I
C40426 - Subsequent research on 060722 indicates that pulmonary embolism is a
C40427 - life threatening disease. ref SDS D1 BI5J Therefore, if analysis on
C40428 - 041117 of Benz #1 opinion is correct, then Doctor Benz and UCSF
C40429 - deserve great credit for proactive medical practice that saved the
C40430 - life of the patient. ref SDS 50 OT5Q
C40432 - ..
C40433 - On 051121, the primary care physician explained hypercoagulable state
C40434 - work up recommended in Doctor Bailey's 2nd opinion received on 050922
C40435 - is not required because pulmonary emboli was thought to been caused in
C40436 - this patient solely by prior participation in the Avastin trial.
C40437 - ref SDS 96 GW7G
C40439 - ..
C40440 - Research on 060722 indicates diagnosis of pulmonary emboli presents a
C40441 - "wicked problem" that often causes busy doctors to overlook symptoms.
C40442 - ref SDS D1 346F Patient therefore seeks 2nd opinion on advisability
C40443 - for hypercoagulable state work up. Scope for this work was reviewed
C40444 - in research on 060722. ref SDS D1 7V5L
C40446 - ..
C40447 - On 060724 Kaiser was notified about new information on blood clot
C40448 - problems that came to light on 060722, ref SDS D1 3D9T, citing
C40449 - findings of genetic cause for family history of pulmonary emboli.
C40450 - ref SDS D4 NL5Q The patient's letter on 060819 requests 2nd opinion
C40451 - on advisability of examination for pulmonary emboli. ref SDS E7 IY3Q
C40453 - [On 060929 during meeting at Kaiser patient requests CT
C40454 - test for pulmonary emboli based on rising symptoms.
C40455 - ref SDS F1 DY5M
C40457 - ..
C40458 - [On 061002 CT test reports diagnosis pulmonary emboli
C40459 - recurrence. ref SDS F4 0001
C40461 - ..
C40462 - Today, Doctor Benz reviewed documentation prepared by the primary care
C40463 - physician for the meeting at Kaiser on 060711. ref SDS C5 1A5G
C40464 - Kaiser's records show Coumadin (Warfarin) is prescribed to treat
C40465 - pulmonary emboli, as follows...
C40467 - ..
C40468 - Current medications include:
C40470 - LACTINEX PACKETS
C40471 - LOPERAMIDE 2MG CAPSULES
C40472 - TIMOLOL MALEATE 0.5% EYE DR
C40473 - WARFARIN 4MG TABLETS ............... [Coumadin]
C40474 - HYDROCODONE/ACETAMINOPHEN 5
C40476 - ..
C40477 - Doctor Benz did not have enough time to review patient history
C40478 - submitted to UCSF for preparing a 2nd opinion. He commented that
C40479 - Millie's case is very complex, and that understanding the gist of the
C40480 - story supports the UCSF 2nd opinion process, per above. ref SDS 0
C40481 - YK6N Since Kaiser's record shows the patient is being treated for
C40482 - pulmonary emboli, further review may seem like unnecessary overkill
C40483 - that exceeds the "gist of the story."
C40485 - ..
C40486 - Kaiser's computer record on Coumadin treatments prescribed for Millie,
C40487 - however, is incorrect for the period following 051007 until 060711.
C40488 - ref SDS C5 1A5G
C40490 - ..
C40491 - Treatment with Coumadin (Warfarin) for pulmonary embolism was stopped
C40492 - by the doctor on 051007, ref SDS 89 RZ4I, The doctor ended this
C40493 - treatment in advance of mastectomy surgery, ref SDS 89 RZ4I, performed
C40494 - on 051021, and which Kaiser initially proposed for "local control,"
C40495 - and then later changed to a "palliation" theory, explained on 051007.
C40496 - ref SDS 89 MW5O The order ending treatment with Coumadin was issued
C40497 - again on 051121, because Kaiser's Coagulation Treatment Clinic had
C40498 - resumed treatments after mastectomy surgery, applying guidance to
C40499 - treat cancer patients diagnosed with pulmonary emboli for life,
C40500 - ref SDS 96 RZ4I, which was originally prescribed by Kaiser on 041104.
C40501 - ref SDS 49 4Y9G
C40503 - ..
C40504 - Doctor Benz did not discuss pulmonary emboli issue presented in the
C40505 - patient's request for a 2nd opinion, as amended on 060819, ref DIP 6
C40506 - T353, and received by UCSF, reported by Margaret, per above.
C40507 - ref SDS 0 B76N Lack of attention may refelct reliance on false,
C40508 - misleading list of "current medications" in Kaiser's medical chart for
C40509 - 060711, per above, ref SDS 0 TQ5I, which incorrectly say the patient
C40510 - is being treated for pulmonary emboli with warfarin (Coumadin).
C40511 - ref SDS 0 H46F Research on 060722 indicates that Coumadin is the only
C40512 - way pulmonary embolism can be treated, ref SDS D1 HQ4N, so further
C40513 - review is unnecessry overkill, per above. ref SDS 0 H53K
C40515 - ..
C40516 - Previously, on 041018 the doctor recommended immediate action to
C40517 - investigate similar symptoms leading to discovery and treatment for
C40518 - pulmonary embolism a few weeks later.
C40520 - [On 060929 pulmonary emboli issue is not presented in written
C40521 - opinion received from UCSF. ref SDS F3 0001
C40523 - ..
C40524 - [On 060929 during meeting at Kaiser patient requests CT test
C40525 - for pulmonary emboli based on rising symptoms. ref SDS F1 DY5M
C40527 - ..
C40528 - [On 061002 CT test reports diagnosis pulmonary emboli
C40529 - recurrence. ref SDS F4 0001
C40531 - ..
C40532 - [On 061208 Kaiser "locks down" medical chart preventing
C40533 - doctor from correcting mistakes in progress notes on patient
C40534 - history, eliminating benefits of feedback loops from doctor
C40535 - patient partnerhsip to reduce medical mistakes. ref SDS F8
C40536 - 025H
Legible Contemporaneous Work Record Medical Chart Doctor Progress No
CB0401 - ..
CB0402 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
CB0403 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
CB0405 - Follow up ref SDS E1 FE4I, ref SDS C5 FE4I.
CB0407 - Doctor Benz found Kaiser's medical chart helpful for review of patient
CB0408 - history to prepare a second opinion, because the record is now
CB0409 - legible, per above. ref SDS 0 TQ5I
CB0411 - ..
CB0412 - This represents a sea change in resources available for evaluating
CB0413 - patient history, illustrated by the doctor's reliance on the medical
CB0414 - chart during the meeting.
CB0416 - ..
CB0417 - There is also increased risk relying on momentary, first impressions
CB0418 - of busy practitioners. Kaiser medical management of patient history
CB0419 - calls for feedback loops using a "ping pong" communication system to
CB0420 - authenticate and verify the doctor's records based on a team care and
CB0421 - doctor patient partnership model, see review on 990625. ref SDS 2 3960
CB0423 - ..
CB0424 - In practice, doctors do not handle feedback well due to limited time
CB0425 - and cultural inertia.
CB0427 - ..
CB0428 - As a result errors in the medical chart are easy to make and hard to
CB0429 - remove, even when the doctor is notified. An example is the erroneous
CB0430 - entry saying the patient is being treated with warfarin (Coumadin) for
CB0431 - pulmonary embolism, per above. ref SDS 0 H46F