CONTACTS 

SUBJECTS
Enlarged Right Ventricle Cor Pulmonale Heart Disorder Doctor Fails R

2303 -
2303 -    ..
2304 - Summary/Objective
2305 -
230501 - Follow up ref SDS 57 0000. ref SDS 56 0000.
230502 -
230503 - Doctor clarifies prior understandings saying heart disorder Cor
230504 - Pulmonale diagnosed in CT scan on 060930 likely caused by pulmonary
230505 - embolism, and does not discuss patient's request for examination by
230506 - heart specialist in connection with rising symptoms, and clearance to
230507 - resume work outs in the gym to restore physicial fitness. ref SDS 0
230508 - JU7L  Ending treatment for pulmonary embolism on 051007 could be
230509 - related to diagnosis of heart disorder. ref SDS 0 XW8K  Case study
230510 - shows referral to heart doctor for backup analysis presents difficult
230511 - challenge for Kaiser's Team Care practice. ref SDS 0 JU9L  Received a
230512 - good summary of patient history Kaiser submitted to UCSF for
230513 - qualifying Millie to participate in a drug trial.  The doctor
230514 - describes this summary as providing a 5-year review requested by the
230515 - patient for a Tumor Board. ref SDS 0 OU5K  A summary by the primary
230516 - care physician does not accomplish purpose of Tumor Board for detailed
230517 - analysis with "fresh eyes," and diverse experience, expertise.
230518 - ref SDS 0 NP8G
230519 -
230520 -
230521 -
230522 -
230524 -  ..
2306 -
2307 -
2308 - Progress
2309 -
230901 - Symptoms Cor Pulmonale Continue Fatigue Shortness Breath Heavy Chest
230902 - Cor Pulmonale Heart Disorder Request Examination Heart Specialist
230903 - Heart Examination Enlarged Right Ventricle Request Heart Specialist
230904 - Enlarged Right Ventricle Examination Heart Specialist Patient Request
230905 -
230906 - Follow up ref SDS 57 VC4M, ref SDS 54 VC4M.
230907 -
230908 - Background on Millie requesting referral for examination of heart
230909 - disorder by a cardiologist is reported in the record on 061227,
230910 - ref SDS 57 VC4M, including concern that the doctor is not aware of
230911 - rising symptoms for pulmonary embolism, and Cor Pulmanele. ref SDS 57
230912 - 645I
230914 -  ..
230915 - Millie received ref DRT 1 0001 from primary care physician responding
230916 - to her letter, ref DIP 9 0001, submitted yesterday to Kaiser on 061227
230917 - requesting referral to a heart specialist for examination of heart
230918 - disorder, ref SDS 57 KX6N, described as Cor Pulmonale in research on
230919 - 061012. ref SDS 44 L35J
230921 -  ..
230922 - Primary care physician says...
230923 -
230924 -        "Most likely" your enlarged right ventricle is due to your
230925 -        previous pulmonary emboli.  Advanced cor pulmonale will have
230926 -        edema involving the lower extremities.  When those advanced
230927 -        symptoms appear, then treatment with diuretics can be helpful.
230928 -        ref DRT 1 0001
230930 -  ..
230931 - The doctor clarifies understandings from the meeting on 061020 that
230932 - Cor Pulmonale enlarged right ventricle heart disorder is not related
230933 - to pulmonary embolism, ref SDS 45 3Q5H, saying today that most likely
230934 - they are connected, with pulmonary embolism causing Cor Pulmonale.
230935 -
230936 -               [On 080507 Millie reports spike in heart beat (pulse)
230937 -               while laying down in bed; case study shows occassional
230938 -               spike in pulse reported by heart monitor during
230939 -               exercise, evaluated previously as defective equipment.
230940 -               ref SDS 65 CK4K
230942 -  ..
230943 - Research on 061012 indicates that enlarged right ventricle causes
230944 - pulmonary embolism, ref SDS 44 IN3H, rather the other way around
230945 - presented in the doctor's letter today. ref SDS 0 JU7L
230947 -  ..
230948 - Research on 061012 further indicates symptoms of Cor Pulmonale heart
230949 - disorder enlarged right ventricle are fatigue, shortness of breath,
230950 - heavy chest, dizziness, ref SDS 44 IR46, which Millie has suffered for
230951 - many months now, cited on 061012, ref SDS 44 GH4M, and noted in case
230952 - study today. ref SDS 0 JU9L
230954 -  ..
230955 - The doctor seems to associate ending treatment last year for pulmonary
230956 - embolism on 051007, ref SDS 27 RZ4I, with finding of enlarged right
230957 - ventricle in the CT test on 060930, reported on 061012, ref SDS 44
230958 - 7E5L, and further reporting at that time pulmonary embolism
230959 - recurrence. ref SDS 44 294Q
230961 -  ..
230962 - On 050729 the doctor attributed symptoms of pulmonary emobolism
230963 - chronic fatigue, shortness of breath, heavy chest, etc., to loss of
230964 - fitness from lack of exercise due to debilitating effects of
230965 - chemotherapy, and noted that the patient's plans to work out in the
230966 - gym would help resolve the issue. ref SDS 24 XX7G
230967 -
230969 -  ..
230970 - Case Study Request Examination Heart Specialist Resume Exercise Gym
230971 -
230972 - Reason for seeking expert opinion on Cor Pulmonale is difference
230973 - between recovering from pulmonary embolism after notice on 041104.  At
230974 - that time, after a few weeks of treatment, symptoms were relieved and
230975 - Millie resumed working out in the gym.  Recovery has not occurred with
230976 - treatment for recurrence, as reported in Millie's letter to Kaiser on
230977 - 061027. ref SDS 46 MS5P
230979 -  ..
230980 - Millie wants to avoid advanced complications in the lower extremities,
230981 - cited in the doctor's letter today, per above, ref SDS 0 JU7L, and
230982 - regain health for vigorous exercise that has maintained her vitality,
230983 - immune system, and zest for life, reported on...
230984 -
230985 -        1.  Millie asked the doctor how serious
230986 -            pulmonary embolism, how enlarged
230987 -            is the right ventricle, can she
230988 -            resume working out at the
230989 -            gym to restore
230990 -            fitness........................... 061020, ref SDS 45 VJ4J
230992 -             ..
230993 -        2.  Millie letter advises Kaiser that
230994 -            symptoms pulmonary embolism continue
230995 -            fatigue, shortness of breath; asks
230996 -            about prognosis for getting back in
230997 -            the gym to improve fitness, which
230998 -            previously were attributed to
230999 -            symptoms for pulmonary
231000 -            embolism.......................... 061027, ref SDS 46 MS5P
231002 -             ..
231003 -        3.  Millie reported continuing shortness
231004 -            of breath, fatigue; hectic schedule
231005 -            doctor did not have time to discuss
231006 -            treatment plan to restore cardio
231007 -            pulmonary health so Millie can get
231008 -            back in the gym to improve fitness,
231009 -            build immune system and emotional
231010 -            stability; no discussion of team care
231011 -            collaboration with heart specialist
231012 -            to assess enlarged right
231013 -            ventricle......................... 061110, ref SDS 47 GR3J
231015 -             ..
231016 -        4.  Millie again requests examination
231017 -            by heart specialist on severity of
231018 -            heart disorder Cor Pulmonale enlarged
231019 -            right ventricle to get clearance on
231020 -            working out in gym to restore
231021 -            physical fitness and strengthen
231022 -            immune system..................... 061208, ref SDS 51 HZ39
231024 -             ..
231025 -        5.  Millie letter confirms request for
231026 -            examination by heart specialist to
231027 -            advise on resume working out in the
231028 -            gym to restore physical fitness and
231029 -            relieve pulmonary embolism symptoms
231030 -            chronic fatigue, shortness of
231031 -            breath and heavy
231032 -            chest............................. 061218, ref SDS 54 VC61
231034 -             ..
231035 -        6.  Millie letter notifies Kaiser of
231036 -            continuing symptoms pulmonary embolism
231037 -            and heart disorder Cor Pulmonale from
231038 -            enlarged right ventricle; proposes
231039 -            examination by heart
231040 -            specialist........................ 061227, ref SDS 57 645I
231042 -             ..
231043 -        7.  Doctor advises Cor Pulmanele heart
231044 -            disorder most likely caused by
231045 -            pulmonary embolism; proposes waiting
231046 -            to take action until advanced
231047 -            complictions of edema in lower
231048 -            extremities occur; does not comment
231049 -            on relieving current symptoms;
231050 -            does not comment on request for
231051 -            examination by heart
231052 -            specialist........................ 061228, ref SDS 0 JU7L
231054 -             ..
231055 -        8.  Millie may have suffered permanent
231056 -            lung damage that prevents regaining
231057 -            prior levels of exercise in the gym
231058 -            to restore fitness that strengthens
231059 -            immune system to resist
231060 -            cancer............................ 070105, ref SDS 61 WR4J
231062 -             ..
231063 -        9.  Kaiser reviewed findings CT test on
231064 -            071210 showing mildly enlarged heart;
231065 -            doctor feels no referral to cardio
231066 -            pulmonary specialist required to
231067 -            investigate until treatable
231068 -            symptoms become
231069 -            evident........................... 080118, ref SDS 63 HP9T
231071 -             ..
231072 -       10.  Millie letter to Kaiser with copy to
231073 -            UCSF requests comment from medical
231074 -            team, including notice to coagulation
231075 -            control case management on CT test
231076 -            findings possibly related to
231077 -            increasing pulmonary
231078 -            embolism.......................... 080226, ref SDS 64 S14Y
231079 -
231080 -
231081 -
231082 -
231083 -
231084 -
2311 -

SUBJECTS
Drug Trials Kaiser Collaborating Due Diligence Submits Report to UCS

4003 -
400401 -  ..
400402 - Kaiser Review Patient Status Recovery 5 Year Case History
400403 - UCSF 2 Drug Trial Proposals Kaiser Collaborating to Help Millie
400404 - Drug Trials Kaiser Collaborating UCSF Consider Proposals Help Millie
400405 -
400406 - Follow up ref SDS 57 086H, ref SDS 56 086H.
400407 -
400408 - On 061226 Millie received a letter from the doctor dated 061220, and
400409 - notifying about Kaiser's progress contacting UCSF on Millie
400410 - participating in clinical drug trials. ref SDS 56 YE6N  Yesterday, on
400411 - 061227, Millie requested copies of communication between Kaiser and
400412 - UCSF on collaborating about clinical trials in Millie's case.
400413 - ref SDS 57 KO3P
400415 -  ..
400416 - Millie received ref DRT 2 0001 from the primary care physician
400417 - saying...
400418 -
400419 -    1.  This is the e-mail that I have sent to Dr.  Rugo at UCSF.  This
400420 -        should also serve as a "5 year review" with an opinion from a
400421 -        breast expert. ref DRT 2 0001
400423 -  ..
400424 - The doctor explains transmitting language below submitted to UCSF, as
400425 - requested yesterday on 061227. ref SDS 57 KO3P
400426 -
400427 -           [On 070315 Millie submitted to primary care physician at
400428 -           Kaiser progress report on recovering from IBC 3rd relapse
400429 -           with treatment starting on 070201 clinical study cetuximab
400430 -           at UCSF. ref SDS 62 VP5N
400432 -  ..
400433 - The doctor errs submitting this summary for a "5 year review," which
400434 - Millie requested on 061218 asking for Tumor Board support, ref SDS 54
400435 - MN9L, followed up yesterday in another letter, ref SDS 57 6L3F, and
400436 - confirming discussion with the doctor during the meeting at Kaiser on
400437 - 061208. ref SDS 51 P69G
400439 -  ..
400440 - Kaiser's letter today is a good summary of patient history helping an
400441 - executive quickly grasp the gist of the case.  This is different from
400442 - reviewing details of patient history with citations for accuracy to
400443 - find opportunities and constraints on treatment.  Kaiser's letter to
400444 - UCSF presents no "opinion," nor ideas, options, analysis nor criteria
400445 - for making choices, because the purpose is to qualify for a drug
400446 - trial.  Whereas, a 5 year review would include prospects for drug
400447 - trials as part of patient treatment options.
400449 -  ..
400450 - The purpose of Tumor Board review provides fresh eyes, with no history
400451 - of involvement in the case, and diverse experience and expertise for
400452 - quality control to complement and support work by the primary care
400453 - physician, reported on 061218. ref SDS 55 FW9K  A follow up letter to
400454 - the doctor on 061227 noted limitations of Tumor Boards, and suggests
400455 - abandoning the effort, if Kaiser cannot accomplish these goals at this
400456 - time. ref SDS 57 DY5Q
400457 -
400458 -            [On 070105 meeting primary care physician did not present
400459 -            strategy and options. ref SDS 61 XB5H
400461 -  ..
400462 - Letter from primary care physician continues...
400463 -
400464 -    2.  The patient is a 70 year old woman with a history of poorly
400465 -        differentiated infiltrating ductal cancer of left breast (2 cm,
400466 -        4/4 LN's positive with infiltration into the perinodal fat) who
400467 -        was initially diagnosed 03/04/02.  She had lumpectomy, but
400468 -        refused completion ALND, followed by AC X's 2 only because of
400469 -        rising CA 15-3 and clinical progression to inflammatory breast
400470 -        cancer, Taxotere X's 6 and then XRT.  She unfortunately had
400471 -        biopsy proven recurrent disease noted in cervical LN's
400472 -        03/03/04.
400474 -  ..
400475 - "XRT" may be expressing treatments with radiation therapy.  The
400476 - sequence can be clarified to report that after radiation during July -
400477 - September, the patient had 4 more cycles of Taxotere to complete
400478 - initial treatment on 021204. ref SDS 6 0001
400480 -  ..
400481 - Saying treatment with AC was stopped because of clincial progression
400482 - to IBC, ref SDS 0 D79P, conflicts with the record on 020603 showing AC
400483 - was switched to Taxotere due to CA 15-3 rising to 117, and PET scan
400484 - test showing cancer increased in the left axillary. (see summary on
400485 - 050812. ref SDS 25 FP9N)
400486 -
400487 -            [...below, for some reason the doctor does not cite patient
400488 -            history of CA 15-3 demonstrating measurable disease.
400489 -            ref SDS 0 D76P
400491 -  ..
400492 - IBC was diagnosed in a biopsy 2 years later on 040419, and submitted
400493 - to the patient on 040517. (see case study 050812, ref SDS 25 FS6K)
400494 - Research at that time on 040517 indicated IBC is difficult to
400495 - diagnose, because the tumor is in the skin and so does not appear in
400496 - image testing, and symptoms are common to more common ailments like
400497 - reaction to radiation, fungal infections, etc. ref SDS 11 TO7L and
400498 - ref SDS 11 S65K  The primary care physician at Kaiser diagnosed IBC on
400499 - 040614. ref SDS 12 6T5G
400501 -  ..
400502 - Research today found article by MD Anderson Cancer Center confirming
400503 - that IBC is hard to diagnose, ref OF 1 01L6, and that mistakes are
400504 - easy to make, ref OF 1 12WU, which aligns with research on 060722
400505 - reporting pulmonary embolism is also hard to diagnose. ref SDS 37 7P9F
400506 -
400507 -           [On 070101 MD Anderson report cited in case study on patient
400508 -           history showing IBC disease cannot be measured by image
400509 -           tests. ref SDS 59 4Q6K
400511 -  ..
400512 - Letter from primary care physician continues...
400513 -
400514 -    3.  She was placed on the EPP E2100 Trial and was treated with
400515 -        Taxol and Avastin x's 7 cycles.  She developed a PE while on
400516 -        Avastin and she was removed from the Trial 10/21/04.  She has
400517 -        had multiple second opinions, including UCSF (Dr.  Benz).
400519 -  ..
400520 - Attribution reflects professionalism - Benz 2nd opinion for
400521 - consultation at UCSF on 041018, and received on 041117 recommended
400522 - Taxotere and capecitiabine. (see study on 050812. ref SDS 25 DJ4F)
400524 -  ..
400525 - The date of 041021 was the last treatment with Taxol and bevacizumab
400526 - (Avastin). ref SDS 14 0001  However, Millie was "removed from the
400527 - trial" the day after the CT test on 041103.  At that time, on 041104
400528 - Millie was scheduled to receive another cycle of Taxol and Avastin,
400529 - and was told that the CT test the day before prevented this due to
400530 - pulmonary embolism. (see case study on 050812. ref SDS 25 WJ3J)
400532 -  ..
400533 - Letter from primary care physician continues...
400534 -
400535 -    4.  She was then given 4 cycles of AC with no real response ending
400536 -        03/25/05.  The patient then had 8 cycles of Taxotere/Xeloda
400537 -        4/15/05 through 9/16/05.
400539 -  ..
400540 - It might be helpful to report there was strong response with Taxotere
400541 - and capecitiabine (Xeloda), and that surgery attempted wide mastectomy
400542 - to remove all tissue previously infected with IBC guided by trial
400543 - biopsies on 051012 to set boundaries. ref SDS 28 DG6J
400545 -  ..
400546 - Letter from primary care physician continues...
400547 -
400548 -    5.  This was followed by a prophylactic left mastectomy 10/21/05
400549 -        which revealed no residual disease.
400551 -  ..
400552 - Saying "...revealed no residual disease," likely relates to biopsy for
400553 - mastectomy on 051021, and reported on 051027. ref SDS 29 U05M
400555 -  ..
400556 - Letter from primary care physician continues...
400557 -
400558 -    6.  Then her left chest lesions reappeared and began expanding.
400560 -  ..
400561 - It might be helpful to report the date IBC recurrence on 060623.
400562 - ref SDS 32 025H
400564 -  ..
400565 - Letter from primary care physician continues...
400566 -
400567 -    7.  The patient was restarted on Taxotere/Xeloda for 7 cycles
400568 -        07/21/06 through 12/01/06.
400570 -         ..
400571 -    8.  Her only measurable disease are the lesions on her chest wall.
400573 -  ..
400574 - The doctor explains in para 2, above, that rising CA 15-3 signaled
400575 - rising measurable disease that led to switching treatments.
400576 - ref SDS 0 D79P
400578 -  ..
400579 - Doctor Benz 2nd opinion received on 060929 cited requirements for
400580 - measureable disease for Millie to qualify for 2 clinical drug trials.
400581 - ref SDS 42 UI9K
400583 -  ..
400584 - Since IBC does not register well with image testing, per research
400585 - above, ref SDS 0 XP5K, IBC spreading from left to right breast is new
400586 - and significant advance of measurable disease, reported on 061208.
400587 - ref SDS 51 025H
400588 -
400589 -            [...below, letter to Kaiser notes IBC spreading from left
400590 -            to right breast may meet requirements for measurable
400591 -            disease. ref SDS 0 T66Y
400593 -             ..
400594 -            [On 061230 doctor does not cite IBC lesions nor spread from
400595 -            left to right breast answering UCSF question on measureable
400596 -            disease. ref SDS 58 PO3V
400598 -  ..
400599 - During the meeting at UCSF on 060821 Doctor Benz discussed biopsy to
400600 - establish measurable disease. ref SDS 40 6Q6O
400602 -  ..
400603 - Letter from primary care physician continues...
400604 -
400605 -    9.  MRI brain 07/08/06 was negative.  CT 9/30/06 only showed
400606 -        recurrence of PE.  PET scan 12/27/06 showed some equivocal
400607 -        chest wall activity.
400609 -  ..
400610 - Seems like good news that recent PET/CT scan on 061227 shows no
400611 - distant metastasis, and no regional lymphadenopathy.
400613 -  ..
400614 - Letter from primary care physician continues...
400615 -
400616 -   10.  She is now interested in whether she qualifies for any clinical
400617 -        trials; cetuximub alone versus cetuximub plus carboplatinum or
400618 -        Abraxane with lapatinib?
400620 -  ..
400621 - Benz 2nd opinion states Millie qualifies for 2 drug trials at UCSF,
400622 - reviewed on 060929. ref SDS 42 UI9K
400624 -  ..
400625 - Letter from primary care physician continues...
400626 -
400627 -   11.  She otherwise will proceed with Navelbine or Gemzar.
400628 -
400629 -
400630 -
400631 -
400632 -
4007 -

SUBJECTS
PET/CT Test 061227 Report Requested Measurable Disease Spread Left t

4403 -
4404 - 2111
440501 -  ..
440502 - Measurable Disease IBC Spreads from Left to Right Breast
440503 - PET/CT Test Requested Measurable Disease Spread Left to Right Breast
440504 -
440505 - Millie submitted ref DIT 1 0001 thanking the doctor for filing a
440506 - report on qualifying to participate in drug trials.
440507 -
440508 -    1.  Thanks very much for your letter to UCSF submitted today with
440509 -        your letter to me, and as requested in my letter yesterday.
440510 -        ref SDS 57 KO3P
440512 -         ..
440513 -    2.  This is a good summary of a complex case.  Benz did not
440514 -        indicate in his letter what constitutes "measurable" disease.
440515 -        A "curbside" observation suggests spread of IBC from left to
440516 -        the right breast is a major progression of disease, and
440517 -        supported by rising CA 15-3, which might meet UCSF
440518 -        requirements.
440520 -  ..
440521 - Kaiser can supplement initial explanation to UCSF defining measurable
440522 - disease for IBC, which typically does not register in image tests like
440523 - PET and CT scans, noted in the record on 040517, ref SDS 11 S65H, and
440524 - supported today with paper published by MD Anderson, per above,
440525 - ref SDS 0 XP5K; therefore, report of rash progressing from left to
440526 - right breast demonstrates measurable disease, per above. ref SDS 0
440527 - D76P
440529 -             ..
440530 -            [On 061230 doctor does not cite IBC lesions nor spread from
440531 -            left to right breast answering UCSF question on measureable
440532 -            disease. ref SDS 58 PO3V
440534 -  ..
440535 - Letter to primary care physician continues...
440536 -
440537 -    3.  Rugo can dig it out if she has time, but it can be helpful to
440538 -        cite Benz opinion letter on the 060821 consultation where he
440539 -        expressly states I qualify for 2 trials, once measurable
440540 -        disease is established.
440542 -         ..
440543 -    4.  Sounds like the PET/CT results from yesterday are available.
440545 -         ..
440546 -    5.  When time permits, please submit the full report.  Will be
440547 -        interesting to see if they performed comparisons you requested,
440548 -        and if so, results on esophagitis, PE, enlarged right
440549 -        ventricle, and areas being tracked for distant metastasis.
440550 -
440551 -            [On 070102 received report from Kaiser for PET/CT test on
440552 -            061227. ref SDS 60 FV5J
440554 -         ..
440555 -    6.  Thanks again for timely support.
440556 -
440557 -
440558 -
440559 -
440560 -
440561 -
440562 -
440563 -
4406 -