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440 Davis Court #1602
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415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: December 18, 2006 08:11 AM Monday; Rod Welch

Case study Kaiser Tumor Board strategy planning treatment IBC 3rd relapse.

1...Summary/Objective
2...Tumor Board Collaboration Conversation Model Knowledge Management
3...Research on Tumor Boards Purpose and Practice Shows...
....1...Massachusetts Medical Society
....2...Radiation Oncology Program
....3...Patient's right to choose enabled by doctor's duty to disclose.
....4...Ospital ng Maynila Medical Center
4...Kaiser Tumor Board Case Study Knowledge Management Application


..............
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CONTACTS 

SUBJECTS
Tumor Board Theory Purpose Practice Communication Collaboration Conv

4103 -
4103 -    ..
4104 - Summary/Objective
4105 -
410501 - Follow up ref SDS 33 5S84, ref SDS 31 K36G.
410502 -
410503 - Research today indicates Tumor Board systems accomplish aims of
410504 - Knowledge Mangement.  Like legal practice, Tumor Boards leverage time
410505 - and energy invested to solve complex cases by applying knowledge from
410506 - lessons learned to help other patients with similar problems, where
410507 - "management" applies technology for command and control of the record
410508 - to organize and find solutions quickly when needed. ref SDS 0 FW9K
410509 - Case study on Millie's patient history working with Kaiser's Tumor
410510 - Board, ref SDS 0 6W3X, aligns with research indicating uneven
410511 - application of procedures yields poor results. ref SDS 0 6G6H
410512 -
410513 -
410514 -
410515 -
410517 -  ..
4106 -
4107 -
4108 - Progress
4109 -
410901 - Tumor Board Collaboration Conversation Model Knowledge Management
410902 -
410903 - Follow up ref SDS 13 VA7I.
410904 -
410905 - Kaiser has a Tumor Board system for quality control that continually
410906 - improves care of cancer patients through continual learning.  Doctors
410907 - assemble every Friday to discuss complex cases, reported on 060809.
410908 - ref SDS 24 NT9S  Tumor Board presentations leverage implicit (also
410909 - "tacit") knowledge from diverse experience, e.g., oncology, surgery,
410910 - radiation, pharmacy, etc.  Collaboration shares information and
410911 - expertise to brainstorm solutions.  Multi-discipline panels focus
410912 - limited time to avoid mistakes under the common rule "many hands make
410913 - light work."  Better accuracy from increased scrutiny of patient
410914 - history and current literature eases the burden on doctors who do not
410915 - have time for review.  Solutions for patients presented to the Tumor
410916 - Board increase knowledge for treating all patients within Kaiser's
410917 - Team Care practice, reviewed on 990625. ref SDS 2 2784  Disseminating
410918 - results to save lives, time, and money is a powerful educational
410919 - derivitive of Tumor Board system, cited in research today. ref SDS 0
410920 - G16H
410922 -         ..
410923 -        [On 061228 doctor submits summary of patient history submitted
410924 -        to UCSF for consideration of participation in clincial drug
410925 -        trial as providing 5 year review of complex patient history in
410926 -        place of Tumor Board review. ref SDS 36 NP8G
410928 -  ..
410929 - Tumor Boards apply well established methods from legal practice for
410930 - solving complex problems, reviewed on 950204. ref SDS 1 WT5J  Pooling
410931 - knowledge and ideas through conversation provides a cross-check for
410932 - accuracy understanding cause and effect in the binary structure of
410933 - personal and organizational memory, explained in POIMS, ref OF 5 1101,
410934 - and sometimes associated with knowledge management, reviewed on
410935 - 011102. ref SDS 3 6E6F  Cross-fertilization is another dimension of
410936 - binary structure for learning through disciplined and directed
410937 - communication afforded by the Tumor Board process, also, cited on
410938 - 011102 as grounded in knowledge management. ref SDS 4 01FT  Literature
410939 - describes the role of structure, procedure, and leadership for
410940 - effective Tumor Board processes. ref SDS 0 2P8V  Legal practice
410941 - manages knowledge with chronology, context, and connections applied
410942 - through procedures, structure, and leadership to reach accurate
410943 - judgements.  Tumor Boards similarly disseminate solutions to
410944 - individual cases, which can help doctors care for other patients, in
410945 - the same way that case law provides an expanding body of knowledge
410946 - that guides everyone in daily life.
410948 -  ..
410949 - Case study today, shown below, ref SDS 0 6W3X, supports comment on
410950 - 060809 that Tumor Board operations can seem superficial with little
410951 - benefits for patient care. ref SDS 24 H66G
410953 -  ..
410954 - Productivity of the Tumor Board yielding benefits that aid patient
410955 - care and increase Team Care productivity through continual learning
410956 - require members to be prepared by reviewing patient history.
410957 - Structure, procedures, and leadership of the hearing focus experience
410958 - and expertise of medical professionals on precise patient requirements
410959 - and constraints.  Adding energy for understanding and leadership to
410960 - "connect the dots" of cause and effect yield the power of knowledge to
410961 - improve diagnosis and treatment for the patient under the locality
410962 - principle, reviewed on 040312. ref SDS 6 YH4G
410964 -  ..
410965 - Conversely, when Board members do not have time to be prepared, and/or
410966 - when insecurity on personal standing withholds information from the
410967 - Tumor Board to avoid embarrassment or reprisal for mistakes, when
410968 - there is no record of patient history that permits people to prepare
410969 - for the hearing, or further when patient history is long and complex,
410970 - and so requires case study to accurately understand connections of
410971 - cause and effect, then the Tumor Board dissipates the power of
410972 - knowedge toward entropy.  Without good management, as defined in
410973 - POIMS, ref OF 3 1X6G, collaboration to leverage human knowledge merely
410974 - wastes time and money that endangers patient lives by failing to
410975 - discover critical connections in time to be effective.  Without order
410976 - and structure for careful, comprehensive review patterns of cause and
410977 - effect are overlooked, rendering Tumor Board hearings mere guess and
410978 - gossip, hunch and hope "water cooler" discussions, as related on
410979 - 041222. ref SDS 13 VA7I
410981 -  ..
410982 - Research today indicates that the purpose and practice of Tumor Boards
410983 - varies, and creates controversey among practitioners and hospital
410984 - management.
410986 -  ..
410987 - Research on Tumor Boards Purpose and Practice Shows...
410988 -
410989 -    1.  Massachusetts Medical Society
410990 -
410991 -              http://www.massmed.org/Content/NavigationMenu/ContinuingEducation/Accreditation/CommitteeonAccreditationReview/Tumor_Board_Guidelin.htm
410992 -
410993 -        Tumor Board Guidelines
410994 -        April 28, 2006
410996 -         ..
410997 -        The purpose of educational activities such as case based,
410998 -        multidisciplinary cancer conferences or tumor boards is to
410999 -        improve the care of cancer patients within an institution.
411000 -        These programs also provide valuable medical education for the
411001 -        medical staff.  All pertinent disciplines are to be encouraged
411002 -        to attend and participate in these conferences.
411004 -         ..
411005 -        Pre-planned Activity
411007 -         ..
411008 -        The Tumor Committee (registry or board) is often responsible
411009 -        for conducting tumor conferences.  Cases of various types of
411010 -        diseases may be selected for presentation based on complexity,
411011 -        unusual manifestation of the disease, or special interest.
411012 -        Case presentation can include the patient's medical history,
411013 -        clinical findings, diagnostic studies, therapy modalities, and
411014 -        research data.  Decide the method of presentation in advance
411015 -        and publicize that information to the audience
411016 -
411018 -         ..
411019 -    2.  Radiation Oncology Program
411020 -
411021 -        Locations: Froedtert Memorial Lutheran Hospital (FMLH), VA
411022 -        Medical Center (VAMC), Childrens Hospital of Wisconsin (CHW),
411023 -        Community Memorial Hospital (CMH), Menomonee Falls
411025 -         ..
411026 -        Chairman: J. Frank Wilson, MD, FACR
411027 -        Program Director: Colleen A. Lawton, MD, FACR
411028 -        Medical Education Assistant: Cheri McElhatton
411029 -        E-mail: cherim@mcw.edu
411030 -        Telephone: (414) 805-4472
411032 -         ..
411033 -        Tumor Board:
411035 -         ..
411036 -        Residents participate in multiple multi-disciplinary tumor
411037 -        boards.  The conferences are working tumor boards whose
411038 -        purpose is to discuss the management of patients currently
411039 -        receiving treatment.  Conferences are attended by attending
411040 -        staff from Radiation Oncology, Medical Oncology, Surgery,
411041 -        Radiology, and Pathology.  Tumor Boards include:
411042 -
411043 -            ENT Tumor Board (VA):  1st and 3rd Wednesday of month.
411044 -            Multi-disciplinary Tumor Board: Weekly, Friday morning
411045 -            Pediatric Tumor Board:  Weekly, Thursday Morning
411046 -            Gynecologic Tumor Board: Weekly, Thursday Morning
411047 -            Breast Tumor Board: Weekly, Monday, Noon.
411048 -            Thoracic Tumor Board (VA):  Alternating Thursdays
411050 -         ..
411051 -        Didactic Lectures:
411053 -         ..
411054 -        Clinical didactic lectures are given by attending staff at
411055 -        Grand Rounds.  These hour-long lectures take place Wednesday
411056 -        evenings at 5:00 pm, September through June.  Topics include
411057 -        reviews of the current status of treatment of various
411058 -        malignancies as well as discussions of novel research concepts
411059 -        and data.
411061 -         ..
411062 -        Didactic lectures in Physics are given twice per week Sept -
411063 -        June.  Lectures will be held at noon on Tuesdays and Fridays.
411064 -        Lectures cover topics required for board exams including
411065 -        production of X-Rays, measurement, dosimetry, radiation safety,
411066 -        etc.
411068 -         ..
411069 -        Lectures in Radiation Biology are held Wednesdays at noon
411070 -        November - June.  Topics covered include cell survival,
411071 -        response of normal tissues, radiation mutagenesis and
411072 -        carcinogenesis, dose and fractionation response data, molecular
411073 -        biology, hyperthermia, etc.
411074 -
411076 -         ..
411077 -    3.  Patient's right to choose enabled by doctor's duty to disclose.
411078 -
411079 -        American Association for Health Freedom
411080 -
411081 -        Amicus Briefs
411082 -
411083 -              http://www.healthfreedom.net/aahf/showarticlenew.asp?articleid=59
411085 -         ..
411086 -        IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA
411087 -        FIRST APPELLATE DISTRICT, DIVISION FOUR
411088 -        RIC SCHIFF AND PAULA SCHIFF,
411089 -        Plaintiffs and Appellants
411090 -        v.
411092 -         ..
411093 -        MICHAEL J. PRADOS,
411094 -        Defendant and Respondent.
411096 -         ..
411097 -        AMICUS CURIAE BRIEF OF THE
411098 -        American Association for Health Freedom
411099 -        IN SUPPORT OF APPELLANTS
411101 -         ..
411102 -        Appeal From The San Francisco County Superior Court
411103 -        Honorable David A. Garcia, Judge
411104 -        SFSC Case No. 982109
411106 -         ..
411107 -        Jonathan W. Emord David Harris
411108 -        Emord & Associates P.C Sinnot, Dito, Moura & Puebla
411109 -        Burke Professional Center 660 South Figueroa Street
411110 -        5282 Lyngate Court Suite 2300
411111 -        Burke, Virginia 22015 Los Angeles, California 90017
411112 -        (202) 466-6937 (213) 996-4200
411114 -         ..
411115 -        Attorneys for Amicus Curiae
411116 -        American Association for Health Freedom
411118 -         ..
411119 -        II Introduction
411121 -         ..
411122 -        The trial court erred in granting summary judgment in this
411123 -        case. Disclosure of potentially efficacious experimental
411124 -        treatments is the minimum legal duty oncologists must bear in
411125 -        the treatment of terminally ill patients for whom conventional
411126 -        treatments have proven ineffective. That is also the minimum
411127 -        duty society must place upon those the state licenses to treat
411128 -        the terminally ill in such circumstances.
411130 -         ..
411131 -        At a minimum, the law of informed consent must ensure that
411132 -        each patient is given the information necessary to exercise
411133 -        informed choice in the selection of treatment. In no case is
411134 -        the law of informed consent more indispensable than in the
411135 -        treatment of the terminally ill for whom conventional
411136 -        treatments have failed. The case of cancer patient Crystin
411137 -        Schiff tragically proves the consequences that befall an
411138 -        innocent child when physicians presume not only the ultimate
411139 -        knowledge of treatment but also the ultimate power to exercise
411140 -        treatment choice.
411142 -         ..
411143 -        It is, in the end, the patient''s right to decide which
411144 -        treatment to accept and the physician''s duty to inform the
411145 -        patient of potentially efficacious treatments.  The medical
411146 -        community is not a dictatorship that reserves unto itself all
411147 -        power over what to introduce into the human body in the fight
411148 -        for wellness.  The body remains the private property of the
411149 -        patient and the doctor remains the patient's servant.
411151 -         ..
411152 -        The physician's duty is to the patient, not the other way
411153 -        around.  It is a relationship of trust and guidance, not
411154 -        unilateral control.  Informed consent means little if it does
411155 -        not empower patient choice.  The Schiffs were denied the right
411156 -        to choose by physicians who presumed it their exclusive
411157 -        province to make treatment choices.  Amicus AAHF hopes this
411158 -        court will recognize the error of that thinking and correct it
411159 -        by reversing and remanding this case for a jury trial.
411161 -         ..
411162 -        The facts of this case make the legal choice a stark one with
411163 -        profound consequences for society. Aware that chemotherapy and
411164 -        radiation therapy had never cured a childhood rhabdoid brain
411165 -        cancer and aware that antineoplastons were a potentially
411166 -        efficacious alternative treatment for that cancer (JA 657:4-9,
411167 -        677), Dr. Prados and the UCSF tumor board nevertheless
411168 -        withheld information about antineoplastons from the Schiffs
411169 -        and led them to believe that their only choice was to pursue
411170 -        treatment regimes that had never succeeded in curing a single
411171 -        childhood rhabdoid brain cancer. The physicians'' failure to
411172 -        disclose deprived Mr. and Mrs. Schiff of the information they
411173 -        needed to exercise a meaningful choice in the treatment of
411174 -        their terminally ill daughter. That failure denied the Schiffs
411175 -        knowledge of the potential risks and potential benefits of
411176 -        antineoplastons and deprived them of an opportunity to compare
411177 -        that experimental treatment with the failed conventional
411178 -        treatments. That failure denied the Schiffs a full and fair
411179 -        opportunity to fight Crystin''s cancer on terms they found
411180 -        acceptable.
411182 -         ..
411183 -        III When a Patient Is Terminally Ill and Conventional
411184 -        Treatments Have Proven Ineffective, Meaningful Informed Consent
411185 -        Requires Physician Disclosure of Experimental Treatments That
411186 -        May Prove Efficacious
411188 -         ..
411189 -        In order to understand why meaningful informed consent
411190 -        necessarily includes disclosure of experimental treatments that
411191 -        may prove efficacious when conventional treatments have failed
411192 -        one must first look to the history of informed consent and its
411193 -        legal development.  When it first arose in the 1950s, informed
411194 -        consent doctrine took one of two approaches - a physician''s
411195 -        point of view or a patient''s point of view.  About half of the
411196 -        states follow the physician''s point of view which requires
411197 -        physicians to disclose to patients information which a
411198 -        "reasonable medical practitioner" would provide.  See Peter H.
411199 -        Schuck, Rethinking Informed Consent, 103 Yale L.J. 899, 916
411200 -        (1994); Barry R.  Furrow et al., Liability and Quality Issues
411201 -        in Health Care 337 (1991).  The other half of the states follow
411202 -        the patient''s point of view which requires physicians to
411203 -        disclose to patients all facts, risks and alternatives that a
411204 -        reasonable person in the patient''s situation would consider
411205 -        important in deciding whether or not to have a recommended
411206 -        treatment.  See generally Canterburry v.  Spence, 464 F.2d 772,
411207 -        787 (D.C.  Cir. 1972).  The patient''s point of view places its
411208 -        emphasis on patient autonomy over physician judgment.
411209 -
411210 -        A. Development of Informed Consent Doctrine in California
411212 -         ..
411213 -        California has adopted the patient''s point of view on informed
411214 -        consent.  See Cobbs v.  Grant, (1972) 8 Cal.3d 229.  In Cobbs,
411215 -        the California Supreme Court held a duty of "reasonable
411216 -        disclosure of the available choices with respect to proposed
411217 -        therapy, and of the dangers inherently involved in each" an
411218 -        integral part of the physician's overall obligation to the
411219 -        patient.  Id. at 243.  The Cobbs' Court further stated: "The
411220 -        patient's right of self-decision is the measure of the
411221 -        physician''s duty to reveal.  That right can be effectively
411222 -        exercised only if the patient possesses adequate information to
411223 -        enable an intelligent choice.  The scope of the physician's
411224 -        communications to the patient, then, must be measured by the
411225 -        patient's need, and that is whatever information is material to
411226 -        the decision." Id. at 245.  Therefore, a physician has a legal
411227 -        duty to disclose to the patient all material information.  In
411228 -        the Schiff case, Dr.  Prados and the UCSF tumor board violated
411229 -        the patient's right of self decision by depriving the patient
411230 -        and her parents of basic information about a potentially
411231 -        efficacious experimental alternative to the failed approach of
411232 -        chemotherapy and radiation.
411234 -         ..
411235 -        B. Context of the Circumstances, Not a Bright Line Exclusionary
411236 -        Rule, Should Determine What Information Must Be Disclosed in
411237 -        Order for There to Be Meaningful Informed Consent
411239 -         ..
411240 -        Three years after Cobb, the California Supreme Court stated
411241 -        that "material information is that which the physician knows or
411242 -        should know would be regarded as significant by a reasonable
411243 -        person in the patient''s position when deciding to accept or
411244 -        reject the recommended medical procedure." Truman v.  Thomas,
411245 -        (1980) 27 Cal.3d 285, 291; see also Sard v.  Hardy, (1977) 281
411246 -        Md. 432, 444; [379 A.2d 1014]; Wilkinson v.  Vesey, (1972) 110
411247 -        R.I. 606, 627 [295 A.2d 676].  To be material, a fact must also
411248 -        be one which is not commonly appreciated.  See Truman, 27
411249 -        Cal.3d at 291; see also Spence, 464 F.2d at 788.  Furthermore,
411250 -        if a physician knows or should know of a patient's unique
411251 -        concern or lack of familiarity with medical procedures, those
411252 -        factors expand the scope of required disclosure.  See Truman,
411253 -        27 Cal.3d at 291.  Moreover, when a given procedure inherently
411254 -        involves a known risk of death or serious bodily harm, at a
411255 -        minimum a doctor has a duty to disclose the potential risks of
411256 -        harm and to explain in lay terms the complications that might
411257 -        occur.  See Cobbs, 8 Cal.3d at 244.  The physician is also
411258 -        required to disclose any additional information a skilled
411259 -        practitioner in good standing would provide under similar
411260 -        circumstances.  See id. at 244-245.  This Court has repeatedly
411261 -        stated that juries are the proper arbiter of whether the
411262 -        information disclosed to a patient is adequate or commonly
411263 -        known and whether there are unique circumstances that require
411264 -        further physician-patient disclosure.  See Arato v.  Avedon,
411265 -        (1993) 5 Cal.4th 1172, 1186-1187; Truman, 27 Cal.3d at 293-294;
411266 -        Cobbs, 8 Cal.3d at 244-245.  The Court has rejected the notion
411267 -        of using bright line rules to determine materiality.  See
411268 -        Arato, 5 Cal.4th at 1186.
411270 -         ..
411271 -        VI. Holding the Tumor Board Liable Is Consistent With Public
411272 -        Policy
411274 -         ..
411275 -        California courts have specified eight factors in determining
411276 -        whether public policy supports recognizing a duty to disclose:
411277 -        (1) "the foreseeability of harm to the plaintiff; (2) the
411278 -        degree of certainty that plaintiff suffered injury; (3) the
411279 -        closeness of the connection between the defendant''s conduct
411280 -        and the injury suffered; (4) the moral blame attached to the
411281 -        defendant''s conduct; (5) the policy of preventing future harm;
411282 -        (6) the extent of the burden to the defendant; (7) the
411283 -        consequences to the community for imposing a duty; and (8) the
411284 -        availability, cost and prevalence of insurance for the risk
411285 -        involved." Christensen v.  Superior Court, (1991) 54 Cal.3d
411286 -        868, 885-886; Rowland v. Chrsitian, (1968) 69 Cal.2d 108, 113.
411288 -         ..
411289 -        In this case, UCSF doctors collectively treated Crystin and
411290 -        named Dr.  Byron Smith her primary doctor.  JA 782:3-4.  Dr.
411291 -        Smith was inexperienced in treating rhabdoid brain tumors.  He
411292 -        therefore sought and relied upon the advice of UCSF''s tumor
411293 -        board for "identifying treatment alternatives." JA 789:2-11.
411294 -        The tumor board, in fact, recommended that Crystin be treated
411295 -        with chemotherapy and high dose radiation, the conventional
411296 -        treatments.  Those treatments, however, have not been
411297 -        demonstrated effective against even a single childhood rhabdoid
411298 -        tumor.  See Exhibits A & B; JA 657:4-9.  Indeed, the
411299 -        conventional wisdom is that neither chemotherapy nor high dose
411300 -        radiation will alter the likelihood of patient death in such
411301 -        circumstances.
411303 -         ..
411304 -        The conventional treatments for a rhabdoid brain tumor are
411305 -        chemotherapy and high dose radiation.  If this were the only
411306 -        known treatment then Dr Byron, or for that matter any
411307 -        physician, would not need the services of a tumor board.
411308 -        Clearly, the tumor board''s purpose was to look at particular
411309 -        cases and make recommendations for other possible therapies.
411310 -        It has already been stated that Dr Byron was inexperienced in
411311 -        treating rhabdoid brain tumors and that he relied upon the
411312 -        tumor board for "identifying alternative treatments." JA
411313 -        789:2-11.  Thus, in responding to Dr Byron''s request, the
411314 -        tumor board had an obligation to disclose to Dr Byron
411315 -        potentially efficacious experimental alternative treatments and
411316 -        to advise him of their potential risks and benefits.  A finding
411317 -        of no duty would obfuscate the need for and purpose of the
411318 -        tumor board in such circumstances.  Therefore, this court
411319 -        should find that the board had a legal duty to provide
411320 -        information on alternative treatments for Crystin''s rhabdoid
411321 -        brain cancer - a duty which it breached.
411322 -
411324 -         ..
411325 -    4.  Ospital ng Maynila Medical Center
411326 -        Department of Surgery
411327 -        Manila, Philippines
411328 -
411329 -              http://omtumorboard.tripod.com/ommc_hosptumorboard03.htm
411331 -         ..
411332 -        Structuring a Hospital Tumor Board - OMMC Experience
411334 -         ..
411335 -        Janix M. De Guzman, M.D.
411336 -        Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
411337 -        ommcsurgery@ yahoo.com
411339 -         ..
411340 -        In the United States, tumor boards have been an integral part
411341 -        of oncology management since the early 1940's.  Scholnik, et
411342 -        al., defines tumor boards as "multidisciplinary conferences
411343 -        convened for the discussion of cancer patients." (1) A Hospital
411344 -        Tumor Board (HTB) includes access to multidisciplinary
411345 -        consultation; wherein a group of physicians meet on a regular
411346 -        basis, to improve the quality of cancer care, provide
411347 -        educational opportunities for participants, and become an asset
411348 -        to the hospital and to the community. (2) Tumor boards now
411349 -        provide a forum for the discussion of treatment strategies,
411350 -        through continual updates of standard approaches from the point
411351 -        of view of all modalities.  Medical experts regard tumor boards
411352 -        as an essential component of quality control in both community
411353 -        hospitals and medical centers.
411355 -  ..
411356 - Additionally....
411357 -
411358 -        The goal of [Tumor Board] is to promote quality service to
411359 -        patients with cancers with the following objectives: to
411360 -        formulate integrated, coordinated, and comprehensive
411361 -        hospital-wide policies on the management of patients with
411362 -        cancer in the hospital; to monitor and continually improve the
411363 -        quality of care to patients with cancers; to conduct
411364 -        educational and training programs for concerned staff so as to
411365 -        facilitate implementation of hospital policies on management of
411366 -        cancer patients; and to promote research on oncology that will
411367 -        continually improve the quality of care for cancer patients.
411369 -  ..
411370 - Policy support sounds in the realm of reviewing case studies.
411372 -  ..
411373 - Problems that render Tumor Boards ineffective....
411374 -
411375 -        This arises primarily because most of hospital tumor boards
411376 -        are not structured.  Other common problems include the
411377 -        following: hospital administrators, appointed chairs, and
411378 -        oncologists do not have a clear idea on the goal and
411379 -        objectives of a Hospital Tumor Board; appointed chairs do not
411380 -        have sufficient leadership and managerial skills; turfing and
411381 -        insecurity among oncologists; and inadequate logistic support.
411382 -
411383 -
411384 -
411385 -
4114 -

SUBJECTS
Kaiser Tumor Board Case Study Knowledge Management Application Milli

6103 -
610401 -  ..
610402 - Kaiser Tumor Board Case Study Knowledge Management Application
610403 -
610404 - Millie's experience working with Kaiser's Tumor Board illustrates
610405 - review of Tumor Board processes, per above, ref SDS 0 FW9K, including
610406 - research, ref SDS 0 6G6H, that finds variability in effectiveness...
610407 -
610408 -    1.  Tumor Board review requested by doctor
610409 -        without notification to patient after
610410 -        a month because phase 1 treatment
610411 -        failed to lower CA 15-3 cancer marker;
610412 -        Kaiser lost hearing record; presentation
610413 -        of patient history, findings and
610414 -        recommendations never
610415 -        submitted............................. 020726, ref SDS 5 WF42
610417 -         ..
610418 -    2.  Tumor Board hearing again evaluates
610419 -        strategy after patient suffers
610420 -        relapse 15 months following primary
610421 -        treatment; suggested strategy of
610422 -        radiation to supraclavicular region
610423 -        after mastectomy
610424 -        surgery............................... 040517, ref SDS 7 4R59
610426 -         ..
610427 -    3.  Tumor Board re-hearing requested by
610428 -        patient to review major change in
610429 -        diagnosis, because biopsy discovers
610430 -        secondary inflammatory breast cancer
610431 -        (IBC) on 040419, 3 days after Tumor
610432 -        Board met on 040416; request re-hearing
610433 -        to review treatment planning
610434 -        rejected as unnecessary
610435 -        overkill.............................. 040517, ref SDS 7 K48O
610437 -         ..
610438 -    4.  Doctor proposed deferring Tumor Board
610439 -        hearing to revise findings and
610440 -        recommendations for treating new
610441 -        diagnosis of IBC until after a few
610442 -        months to assess response to treatment
610443 -        on Taxol and bevacizumab (Avastin)
610444 -        chemothrapy trial
610445 -        protocol.............................. 040614, ref SDS 8 4R59
610447 -         ..
610448 -    5.  Doctor recommended against requesting
610449 -        Tumor Board hearing to help resolve
610450 -        treatment dilemmas presented to the
610451 -        patient, including rising symptoms
610452 -        that have not been diagnosed: chronic
610453 -        cough, shortness of breath, heavy
610454 -        chest, fatigue........................ 040812, ref SDS 9 FV6O
610456 -         ..
610457 -    6.  Pulmonary embolism diagnosed causing
610458 -        cough, heavy chest, shortness of
610459 -        breath; major change patient profile
610460 -        removed from treatment for IBC
610461 -        with Taxol Avastin
610462 -        trial................................. 041104, ref SDS 10 RZ4I
610464 -         ..
610465 -    7.  Tumor Board hearing deferred to obtain
610466 -        guidance on dilemma patient requires
610467 -        immediate treatment for IBC, doctor will
610468 -        not prescribe Taxol nor Taxotere which
610469 -        have been effective without Avastin;
610470 -        doctor does not prescribe Taxotere
610471 -        and capecitabine recommended in
610472 -        2nd opinon by UCSF Cancer
610473 -        Center................................ 041104, ref SDS 10 Q59K
610475 -         ..
610476 -    8.  Patient requests Tumor Board review to
610477 -        develop new treatment plan; doctor
610478 -        rcommended against Tumor Board review
610479 -        to avoid embarrassment submitting a
610480 -        simple case for analysis of Stage IV
610481 -        breast cancer patient, with delayed
610482 -        diagnosis of secondary IBC, who has
610483 -        been removed from treatment due to
610484 -        side effects, and is currently
610485 -        not receiving any
610486 -        treatment............................. 041130, ref SDS 12 YR8F
610488 -         ..
610489 -    9.  IBC inexperience mastectomy surgery
610490 -        patient requests Kaiser assemble
610491 -        Tumor Board with IBC expertise to
610492 -        review risks and opportunities, and
610493 -        methods for defining scope and criteria
610494 -        to perform left breast mastectomy
610495 -        secondary IBC......................... 050324, ref SDS 14 QQ4N
610497 -         ..
610498 -   10.  Time out for due diligence planned
610499 -        to evaluate doctor's proposal for
610500 -        mastectomy surgery.................... 050727, ref SDS 15 O85O
610502 -         ..
610503 -   11.  Patient discusses need for due diligence
610504 -        review of proposal for masectomy
610505 -        surgery............................... 050729, ref SDS 16 XQ41
610507 -         ..
610508 -   12.  Time out for Tumor Board review not
610509 -        provided by Kaiser for patient to consider
610510 -        ramifications of risks and complications
610511 -        from mastectomy surgery, because Tumor
610512 -        Board hearing would delay
610513 -        surgery............................... 050913, ref SDS 17 6W4L
610515 -         ..
610516 -   13.  Tumor Board requested patient letter
610517 -        to Kaiser on strategy for treating
610518 -        3rd relapse IBC....................... 060512, ref SDS 18 4T3S
610520 -         ..
610521 -   14.  Tumor Board requested to assess
610522 -        treatment strategy for IBC
610523 -        3rd relapse........................... 060623, ref SDS 19 K36G
610525 -         ..
610526 -   15.  Tumor Board requested to assess
610527 -        treatment strategy for IBC
610528 -        3rd relapse........................... 060711, ref SDS 20 K36G
610530 -         ..
610531 -   16.  Tumor Board requested again in a
610532 -        letter to Kaiser...................... 060720, ref SDS 21 5S8F
610534 -         ..
610535 -   17.  Doctor feels Tumor Board can do no
610536 -        more than currently being
610537 -        considered............................ 060721, ref SDS 22 IP9L
610539 -         ..
610540 -   18.  Tumor Board review added urgency when
610541 -        IBC symptoms rise; sudden improvement
610542 -        in symptoms support deferring Tumor
610543 -        Board review until doctor returns
610544 -        from vacation......................... 060808, ref SDS 23 YJ9J
610546 -         ..
610547 -   19.  Tumor Board meets at Kaiser every
610548 -        Friday supported by pharmacists,
610549 -        oncologists, and other experts from
610550 -        all over.............................. 060809, ref SDS 24 NT9S
610552 -         ..
610553 -   20.  Patient obtained 2nd opinion support
610554 -        from UCSF, since Kaiser Tumor Board
610555 -        was too difficult to assemble
610556 -        in this case.......................... 060825, ref SDS 26 5R6K
610558 -         ..
610559 -   21.  Tumor board requested for strategy
610560 -        review major change in patient
610561 -        profile; request diverse panel with
610562 -        expertise and experience treating
610563 -        secondary IBC......................... 061208, ref SDS 31 ZN3F,
610564 -
610566 -         ..
610567 -   22.  5 year review Tumor Board assess major
610568 -        change patient profile treatment failed
610569 -        due to pockets of resistance to systemic
610570 -        chemotherapy, cancer may have mutated
610571 -        so switching to another protocol,
610572 -        patient suffers pulmonary embolism
610573 -        recurrence, complications lymphedema,
610574 -        multiple recurrence cellulitis, propose
610575 -        strategy of chemotherapy, drug trials,
610576 -        list of drugs and criteria for order
610577 -        of use, surgery,
610578 -        radiation............................. 061218, ref SDS 34 MN9L
610580 -         ..
610581 -   23.  Tumor Board requested again for help
610582 -        on diagnosis and treatment strategy,
610583 -        with diverse panel doctors with IBC
610584 -        experience............................ 061227, ref SDS 35 6L33
610586 -         ..
610587 -   24.  Doctor submits copy of letter submitted
610588 -        to UCSF summarizing patient history for
610589 -        considering Millie to participate in a
610590 -        clinical drug trial; proposes this
610591 -        provides "5 year review by breast
610592 -        expert................................ 061228, ref SDS 36 OU5K
610593 -
610594 -
610595 -
610596 -
610597 -
610598 -
610599 -
610600 -
610601 -
610602 -
6107 -