THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: March 6, 2008 08:30 AM Thursday; Rod Welch

Millie meeting UCSF evaluate start 15th cycle clinical trial treat IBC.

1...Summary/Objective
2...Referral Coordination Plan UCSF Relies Kaiser Backup Examinations
3...Communication Security Email Complications Compromise Patient Health
4...Coordination Clinical Trial Research and Infusion Clinic
5...Blood Draw Delayed Communication Problems Submitting Prescription
6...Photographs Establish Baseline Evaluate Response to Treatment
7...Labs Blood Counts NEUTS 2.75 (ANC 2750) Rises Unexpectedly
8...Disability Documentation Employer and Insurance Requirements
9...IBC 4th Relapse Patient Scheduled Treatment Cetuximab and Carboplatin
10...Clinical Study 2nd Arm Add Carboplatin Approved to Treat IBC Relapse
11...Progression Disease IBC Doctor Approves Start 2nd Arm Clinical Study
12...2nd Arm Clinical Study Add Carboplatin Approved Treat IBC Progression
13...Progression of Cancer 5th Relapse and 4th Relapse of IBC


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

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 69 0000. ref SDS 60 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040509 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Millie met today with the medical team following up meeting with the
040902 - primary care physician yesterday at Kaiser. ref SDS 71 QY5I
040903 -
040904 -
040905 -
0410 -

SUBJECTS
Backup Teamwork Accuracy Verify Authenticate Quality Care Referral C

3103 -
310401 -  ..
310402 - Referral Coordination Plan UCSF Relies Kaiser Backup Examinations
310403 -
310404 - Brigid commented today that Doctor Rugo feels support has been very
310405 - effective by Doctor Johnson, Millie's primary care physician at
310406 - Kaiser.  Timely 2nd opinion backup helps avoid mistakes for Millie's
310407 - comprehensive care at UCSF Medical Center.  Two months ago on 080118,
310408 - Doctor Johnson reported good communication with Doctor Rugo on
310409 - Millie's care. ref SDS 56 FT5H  Collaboration through 2nd opinions
310410 - have significantly aided Millie's care the past 7 years.
310411 -
310412 -     [On 080307 notified primary care physician at Kaiser that UCSF
310413 -     draws 2nd opinion backup support from Kaiser examinations and
310414 -     reviews of Millie's care on referral at UCSF. ref SDS 74 HT3U
310416 -      ..
310417 -     [On 080312 primary care physician at Kaiser concurrs Kaiser
310418 -     and UCSF functioning as a team for Millie's treatment on
310419 -     referral deserves support. ref SDS 75 HT3U
310421 -      ..
310422 -     [On 080418 Millie coordinates referral tasks on Neupogen
310423 -     prescriptions at UCSF and Pharmacy orders at Kaiser. ref SDS 87
310424 -     GR7U
310426 -      ..
310427 -     [On 090213 1140 case study 2nd opinions implemented by Kaiser have
310428 -     expanded experience and expertise for Millie's health care to
310429 -     significantly extend quality of life. ref SDS 93 J58K
310431 -      ..
310432 -     [On 090213 1140 Doctor Johnson explains Millie's good results
310433 -     surviving stage IV cancer 3 times longer than other patients show
310434 -     benefits of synergy between Kaiser's knowledge of patient history,
310435 -     and UCSF research have been optimized through communication that
310436 -     integrates Kaiser's team care model of case management with the
310437 -     UCSF practice of comprehensive care. ref SDS 93 685I
310439 -  ..
310440 - Collaboration between UCSF and Kaiser is a powerful part of referral
310441 - coordination planning discussed at UCSF on 070222. ref SDS 26 KL5G
310442 - This can be more than mere "lip service" that occurs in Tumor Board
310443 - conversations, illustrated by the record on 040517, ref SDS 10 MB7F,
310444 - and prior proposals for Doctor Moini at Mount Diablo Hospital
310445 - performing Radiation treatment on referral to "backup" the primary
310446 - care physician on analysis of patient status, including response to
310447 - treatment, reported on 020726, ref SDS 6 YO6K, which resulted in no
310448 - discernable work product in the record.
310449 -
310450 -     [On 080307 UCSF blood test report distributed to primary care
310451 -     physician at Kaiser implements referral coordination plan that
310452 -     enables accurate, comprehensive assessment by Kaiser for backup to
310453 -     support comprehensive cancer care for Millie at UCSF. ref SDS 74
310454 -     UF9F
310456 -  ..
310457 - Yesterday, the primary care physician commented that new
310458 - correspondence procedures at UCSF for secure email prevent timely,
310459 - efficient distribution of the record.  He could not figure out what
310460 - buttons to press in order to accomplish anything.  Very frustrating,
310461 - which discourages busy people from communicating. ref SDS 71 US6I
310463 -  ..
310464 - Similarly, the record on 080304, notifying the medical team that
310465 - Millie suffered recurrence, reports that Brigid's response letter
310466 - prepared using UCSF's new policy to protect patient privacy, could not
310467 - be accessed for communication to treat the patient due to conflicts in
310468 - password policies. ref SDS 70 0T8F
310469 -
310470 -
310471 -
3105 -

SUBJECTS
Default Null Subject Account for Blank Record

4903 -
490401 -  ..
490402 - Communication Security Email Complications Compromise Patient Health
490403 -
490404 - Follow up ref SDS 71 US6I, ref SDS 70 0T8F.
490405 -
490406 - Millie asked during the meeting today about recent correspondence
490407 - received from UCSF which was difficult to use, and which Millie's
490408 - primary care physician at Kaiser was unable to access yesterday,
490409 - causing delays and extra expense providing Millie's health care,
490410 - reported on 080305 1200. ref SDS 71 US6I
490412 -  ..
490413 - Brigid explained this morning that UCSF management performed an audit
490414 - of work practices in the breast care clinic.  This resulted in
490415 - ordering the medical team to use a UCSF proprietary email system with
490416 - increased security for protecting patient privacy, compared to the
490417 - current system that relies on public domain email.  There was no audit
490418 - to balance privacy with accuracy and speed required for efficient
490419 - coordination and collaboration that saves lives, time, and money.
490421 -  ..
490422 - This change in procedure adding more steps to communicate with
490423 - intended objectives of better security has unintended consequences of
490424 - compromising accuracy and efficiency essential for patient health,
490425 - reported by primary care physician at Kaiser yesterday, ref SDS 71
490426 - US6I, and cited above, ref SDS 0 RZ4O,
490427 -
490428 -        [On 080403 UCSF asks patient to perform referral coordination
490429 -        because coordinating takes too much for the doctor. ref SDS 83
490430 -        6Y9K
490432 -         ..
490433 -        [On 081103 Millie received "secure email" correspondence from
490434 -        Kaiser, ref SDS 91 XO8J, alleged to be sent by the primary care
490435 -        physician, but which could not be accessed, and which the
490436 -        doctor indicated not having actually sent the letters.
490437 -        ref SDS 91 E59N
490439 -         ..
490440 -        [On 090205 Kaiser asked the patient to use Kaiser's
490441 -        proprietary, closed email system to increase efficiency of the
490442 -        doctor compared to using public domain email that is faster and
490443 -        easier for collaboration among Millie's medical team that
490444 -        includes doctors from Kaise and UCSF. ref SDS 92 278T
490445 -
490446 -
490447 -
490448 -
490449 -
4905 -

SUBJECTS
Default Null Subject Account for Blank Record

5003 -
500401 -  ..
500402 - Coordination Clinical Trial Research and Infusion Clinic
500403 - Blood Draw Delayed Communication Problems Submitting Prescription
500404 -
500405 - Millie had a blood draw in the Infusion Clinic this morning at 0800.
500406 - ref SDS 73 439L  She explained Stephanie's dilemma of seeing
500407 - instructions in the medical chart blood tests on a 6-week cycle, and
500408 - so did only a minimal scope until instructions can be clarified by the
500409 - medical team.
500411 -  ..
500412 - Jackie feels instructions in the medical chart prepared by the
500413 - Infusion Clinic for blood tests on a 6-week schedule reported by
500414 - Stephanie this morning, ref SDS 73 NK5Q, since all instructions for
500415 - the past year have specified a 4-week schedule that aligns with the
500416 - protocol for the cetuximab clinical study protocol, noted in the
500417 - record on 070201. ref SDS 25 5594
500419 -  ..
500420 - Jackie reported that she received the letter on 080304 reminding UCSF
500421 - to order blood tests for Millie's treatment today. ref SDS 70 TN8W
500422 - She prepared the prescription, including blood vials, but was out of
500423 - the office yesterday.  Jackie asked staff to take the order and the
500424 - vials for Millie's blood draw to the Infusion Clinic on the 5th floor.
500425 - Jackie feels this morning that mixup on the 5th floor today occurred
500426 - because the order was delivered to the Lab on the 1st floor.  Perhaps
500427 - her instructions were misunderstood, or by the time the work was
500428 - actually done a day or so later, the precise instruction was
500429 - forgotten, and so people relied on standard procedure and familiar
500430 - practice delivering prescriptions for blood draws to the Lab on the
500431 - 1st floor.  The person who got Jackie's instructions may not have done
500432 - the work, but asked someone else to deliver the order for Millie's
500433 - blood draw, and either forgot and explained incorrectly, or was
500434 - imprecise, and the person who got the instructions misunderstood.
500435 - There are a great many ways for communication mistakes to occur, noted
500436 - by Drucker, reviewed on 931130, saying people have given up because
500437 - communication is very complex process. ref SDS 2 3851  Andy Grove at
500438 - Intel notes the human mind is awfully forgiving of ambiguity, reported
500439 - on 980307. ref SDS 3 3668  Jeremy Campbell notes in his book "The
500440 - Improbable Machine" that people pay a price for relying on assumption
500441 - from personal memory of experience to fill in the gaps of ambiguity in
500442 - routine conversation, reviewed 900303. ref SDS 1 F999
500443 -
500444 -        [On 080402 coordination starting next cycle of treatment in the
500445 -        clinical trial reminds medical team to send the order for blood
500446 -        tests to the Infusion Clinic on the 5th floor, rather than the
500447 -        Lab on the 1st floor. ref SDS 82 Q24T
500449 -  ..
500450 - Jackie left the meeting, to look for the order on Millie's labs.  She
500451 - returned about 15 mintuest later.  Turned out the order was taken to
500452 - the Lab on the 1st floor.  The price today was very small for mistakes
500453 - in communication, and so will be quickly forgotten, as people deal
500454 - with continuing crises.
500455 -
500456 -        [On 080404 people forget how fast and easy mistakes occur using
500457 -        verbal communication that is a lot faster and easier than
500458 -        writing a prescription. ref SDS 84 O76G
500460 -  ..
500461 - Jackie prepared a new order to supplement work Stephanie did earlier
500462 - this morning.
500464 -  ..
500465 - The Breast Care Clinic was very busy today.  Brigid was about 20
500466 - minutes late for the meeting.  Jackie used that time to retrieve the
500467 - blood draw order per above, and correct the problem of incomplete
500468 - initial testing due to erroneous instructions in the medical chart.
500470 -  ..
500471 - During the meeting 080207 Doctor Rugo observed spreading IBC disease,
500472 - ref SDS 60 GH5H, including photograhic evidence. ref SDS 60 GH57  As a
500473 - result, at that time on 080207 the doctor ordered CT testing to be
500474 - expedited to assess evident progression of disease found in the right
500475 - axilla, but not reported in prior tests, ref SDS 60 GH5M  On 080213
500476 - UCSF reported CA 15-3 63, ref SDS 65 VR8N, for labs performed on
500477 - 080207. ref SDS 61 A16M  CT test at Kaiser on 080212, ref SDS 64 FP5H,
500478 - indicates progression of disease based on finding increased adenopathy
500479 - in the right axilla, reviewed on 080215. ref SDS 67 EO8F
500481 -  ..
500482 - Millie's letter to UCSF this morning sets the agenda. ref SDS 68 1K9T
500484 -  ..
500485 - Brigid, RN NP, did the initial examination.
500486 -
500487 -
500488 -
5005 -

SUBJECTS
Default Null Subject Account for Blank Record

5103 -
510401 -  ..
510402 - Brigid and Jackie were pleased to see brusing has substantially
510403 - subsided on the upper right arm, caused by the fall on 080125.
510404 - ref SDS 57 N65K
510405 -
510406 -
510407 -
5105 -

SUBJECTS
Default Null Subject Account for Blank Record

5203 -
520401 -  ..
520402 - Cellulitis rash and swelling from lymphedema on the left are now
520403 - barely visible, much improved from the report on 080304, ref SDS 70
520404 - V45J, and continuing improvement reported at Kaiser yesterday on
520405 - 080305. ref SDS 71 RM6J
520406 -
520407 -     [On 080313 Millie completed 10-day treatment with Keflex for
520408 -     Cellulitis; no visible inflammation or swelling that signal
520409 -     Cellulitis and lymphedema. ref SDS 77 MQ4I
520411 -      ..
520412 -     [On 080314 possible Cellulitis relapse; difficult to
520413 -     distinguish from normal inflammation caused by cetuximab
520414 -     treatments for cancer; Millie begins another 10 day treatment.
520415 -     ref SDS 79 XS82
520416 -
520417 -
5205 -

SUBJECTS
Default Null Subject Account for Blank Record

5303 -
530401 -  ..
530402 - IBC rash seems significantly less intense, with no appreciable spread,
530403 - although there was no discussion of measurements recorded today
530404 - compared to last month on 080207.
530405 -
530406 -
5305 -

SUBJECTS
Default Null Subject Account for Blank Record

5403 -
540401 -  ..
540402 - Photographs Establish Baseline Evaluate Response to Treatment
540403 -
540404 - Jackie took photographs to evaluate response to treatment.   This will
540405 - be the new baseline to assess adding Carboplatin, based on
540406 - determination today that IBC has relapsed into progression of disease.
540407 -
540408 -     [On 080403 examination seems to indicate response to treatment;
540409 -     for some reason clinical trial practice to take photographs for
540410 -     evaluating response to treatment based on measurable disease was
540411 -     not performed. ref SDS 83 SA5J
540412 -
540413 -
5405 -

SUBJECTS
Default Null Subject Account for Blank Record

5503 -
550401 -  ..
550402 - Millie reported examination at Kaiser yesterday.  The primary care
550403 - physician...
550404 -
550405 -    1.  Xray ordered to asses continuing pain in the right arm.
550406 -        ref SDS 71 5M39  Xray was performed after the meeting with the
550407 -        doctor at Kaiser; results will be submitted to UCSF.
550408 -        ref SDS 71 P14M
550409 -
550410 -            [On 080307 xray results negative reported by letter from
550411 -            primary care physician. ref SDS 74 IT8N
550412 -
550413 -
550414 -
5505 -

SUBJECTS
Default Null Subject Account for Blank Record

5603 -
560401 -         ..
560402 -    2.  Prozac prescribed to treat depression from emotional stress,
560403 -        ref SDS 71 5L5M, which evidently replaces Ativan prescribed for
560404 -        panic attacks, reported on 070921. ref SDS 33 N98J
560406 -         ..
560407 -        (side effects - see research. ref SDS 71 GG7M)
560409 -  ..
560410 - Brigid commented that UCSF prescribes Prozac for depression.  Millie
560411 - asked about comment from Kaiser Pharmacy yesterday that Prozac takes 6
560412 - weeks of daily treatments before the patient experiences effects,
560413 - i.e., benefits. ref SDS 71 GG5I
560415 -  ..
560416 - Brigid seemed to indicate UCSF experience that most patients begin
560417 - feeling better with less depression after 2 weeks, and that 6 weeks is
560418 - the longest period some patients take to feel better.
560419 -
560420 -            [On 080312 Millie reported starting Prozac treatments,
560421 -            ref SDS 75 RT8Y; she felt strange after taking the first 2
560422 -            pills (treatments), ref SDS 75 RT4S; improved prospects
560423 -            from rising blood counts, along with increased exercise,
560424 -            ref SDS 75 RT5X, have relieved a lot of emotional stress
560425 -            and depression, so she stopped taking Prozac after the 2
560426 -            treatments, and does not plan to resume at this time.
560427 -            ref SDS 75 RT4W
560429 -  ..
560430 - UCSF gave no explanation today of side effects caused by Prozac, which
560431 - aligns with practice at Kaiser reflecting limited time for customer
560432 - support. ref SDS 71 NE4O
560434 -  ..
560435 - Research reported on 080305 seems to indicate significant risks of
560436 - increasing depression, rather than effective treatment. ref SDS 71
560437 - CY8I
560438 -
560439 -            [On 080312 Millie reported to the medical team feeling
560440 -            badly after taking 2 pills of Prozac; this reaction
560441 -            together with research showing bad side effects led to
560442 -            ending Prozac treatment, ref SDS 75 RT9U; subsequently
560443 -            professional care by the primary care physician and Doctor
560444 -            Rugo at UCSF, and increased exersice have helped relieve
560445 -            former depression. ref SDS 75 RT9U
560447 -             ..
560448 -            [On 080313 Millie reported to Kaiser further research with
560449 -            Wellness Community cancer support group revealed favorable
560450 -            results taking Prozac with minimal side effects.
560451 -            ref SDS 77 TA4U
560453 -             ..
560454 -            [On 080313 primary care physician requests confirmation on
560455 -            whether Millie is taking Prozac. ref SDS 77 UE5N
560457 -             ..
560458 -            [On 080403 meeting at UCSF Millie confirms she is not
560459 -            taking Prozac; emotional trauma subsides with improving
560460 -            health, better medical management and coordination,
560461 -            increased exercise. ref SDS 83 336H
560463 -             ..
560464 -            [On 080502 meeting at Kaiser Millie notified the doctor
560465 -            that she is not taking Prozac because issues causing former
560466 -            emotional stress have subsided, and exercise helps relieve
560467 -            routine stress. ref SDS 88 HH4I
560468 -
560469 -
560470 -
560471 -
5605 -

SUBJECTS
Default Null Subject Account for Blank Record

5703 -
570401 -  ..
570402 - Millie's report on meeting yesterday at Kaiser continues...
570403 -
570404 -    3.  Prescribed Keflex so the patient has inventory to treat future
570405 -        recurrence of Cellulitis. ref SDS 71 RM6J
570407 -         ..
570408 -    4.  IBC concurs with UCSF planning to add Carboplatin. ref SDS 71
570409 -        N15G
570410 -
570411 -
570412 -
5705 -

SUBJECTS
Default Null Subject Account for Blank Record

5803 -
5804 - 0910
580501 -  ..
580502 - Labs Blood Counts NEUTS 2.75 (ANC 2750) Rises Unexpectedly
580503 -
580504 - Brigid was able to get a preliminary report on the blood test this
580505 - morning, per above. ref SDS 0 EX4I
580507 -  ..
580508 - Very favorable, in fact the best, finding for NEUTS 2.75 in the blood
580509 - test report, ref SDS 73 QY6H, which Millie has ever recorded during
580510 - treatments at UCSF spanning more than 13 months.
580511 -
580512 -            [On 080307 letter to primary care physician reports
580513 -            corrections to current medications in medical chart at
580514 -            Kaiser so that primary care physician can provide effective
580515 -            medical opinion to backup care at UCSF. ref SDS 74 JY5K
580517 -             ..
580518 -            [On 080307 worry blood counts too low for safe weekly
580519 -            chemotherapy treatment adding Carboplatin to cetuximab,
580520 -            reported in letter to Kaiser. ref SDS 74 HS6R
580522 -  ..
580523 - There was slight panic by some in the meeting when the screen suddenly
580524 - showed something like 1.3; Brigid explained 2.75 is correct, she had
580525 - simply changed the screen to compare with last month.
580527 -  ..
580528 - NEUTS rising this week well above level of safety for aggressive
580529 - chemotherapy treatment suggests strengthening immune system, which
580530 - makes starting Carboplatin treatment possible today.  Seems to resolve
580531 - issue discussed yesterday on 080305 at Kaiser about emotional stress
580532 - and depression, ref SDS 71 PC6M, and that starting Carboplatin may be
580533 - delayed from further recovery from Cellulitis. ref SDS 71 N15N
580535 -  ..
580536 - There may have been discussion today that sudden, anomolous rise of
580537 - blood counts may relate to the body warding off Cellulitis, rather
580538 - than underlying improvement that will sustain chemotherapy treatment
580539 - with Carboplatin going forward.
580540 -
580541 -
580542 -
580543 -
5806 -

SUBJECTS
Disability Status Benefits Entitlement Documentation Requested Patie

6503 -
650401 -  ..
650402 - Disability Documentation Employer and Insurance Requirements
650403 -
650404 - Millie reported receiving a letter dated 080225 from her employer,
650405 - N&P, and also a request dated 080305 from First Unum Insurance
650406 - Company, both requesting documentation from the doctor showing medical
650407 - status that relates to employment disability and benefits entitlement.
650409 -  ..
650410 - Jackie explained that UCSF has a department that processes disability
650411 - documentation, and prepares a report for the doctor to approve.  She
650412 - asked Millie to submit all of the documents to the attendant at the
650413 - front desk.  Jackie will follow up to expedite processing.
650414 -
650416 -  ..
6505 -
6506 -
6507 - 0943
6508 -
650801 - After the meeting, Millie stopped at the front desk and gave the
650802 - disability documentation to the attendant.  The clerk put the
650803 - documents in a folder, and prepared a sticker with Millie's patient
650804 - identification to manage processing.  She said it usually takes a few
650805 - weeks because of a backlog, but sometimes reports are issued sooner.
650806 -
650807 -        [On 080403 meeting at UCSF Millie reports inquiry from employer
650808 -        and insurance company asking about UCSF progress processing
650809 -        documentation on medical disability entitlement. ref SDS 83
650810 -        I33H
650812 -         ..
650813 -        [On 080409 Millie submitted letter to UCSF asking about
650814 -        progress preparing documentation requested by N&P and Unum
650815 -        Insurance company on Millie's entitlement to medical disability
650816 -        benefits. ref SDS 85 OX3S
650817 -
650818 -
650819 -
650820 -
6509 -

SUBJECTS
Default Null Subject Account for Blank Record

6603 -
6604 - 0922
660501 -  ..
660502 - IBC 4th Relapse Patient Scheduled Treatment Cetuximab and Carboplatin
660503 - Clinical Study 2nd Arm Add Carboplatin Approved to Treat IBC Relapse
660504 - Progression Disease IBC Doctor Approves Start 2nd Arm Clinical Study
660505 - 2nd Arm Clinical Study Add Carboplatin Approved Treat IBC Progression
660506 -
660507 - Doctor Rugo arrived in the examination room.  A brief examination
660508 - concurred with Brigid's earlier review, per above. ref SDS 0 NV4M  The
660509 - doctor indicated confidence in recent findings of CT testing reviewed
660510 - on 080215 shows no evidence of distant metastasis, but does indicate
660511 - progression of IBC disease, ref SDS 67 RX6J, that requires expanding
660512 - chemotherapy treatment for cancer by adding Carboplatin to supplement
660513 - cetuximab treatments the past year, as reported during interim
660514 - examination on 080219, ref SDS 69 3J4I, even without results of CA
660515 - 15-3 from blood tests today.  The cancer marker test increased from 51
660516 - on 080110 by adding 12 points for CA 15-3 63 on 080207 ref SDS 61 A16M
660517 - On 080219 this was described as not significant. ref SDS 69 L18L
660519 -  ..
660520 - Primary care physician at Kaiser noted yesterday on 080305 that Millie
660521 - is ready for adding Carboplatin to cetuximab for treating progression
660522 - of disease on clinical trial, ref SDS 71 N15G, and per report above.
660523 - ref SDS 0 NV56
660524 -
660525 -        [On 080312 letter to UCSF with copy to Kaiser reports IBC rash
660526 -        seems to subside before starting new treatment with Carboplatin
660527 -        added to existing treatment with cetuximab. ref SDS 75 RU4U
660529 -  ..
660530 - Doctor Rugo said that Millie can start getting Carbolatin today, or
660531 - this could wait until next week on 080313.  Approval for starting the
660532 - next phase of IBC treatment by adding Carboplatin chemotherapy to
660533 - cetuximab aligns with strong recovery of blood counts showing NEUTS
660534 - unexpectedly rising today well above the level of safety for
660535 - chemotherapy treatments, per above. ref SDS 0 033B  The primary care
660536 - physician at Kaiser discussed yesterday possibly waiting another week
660537 - for further recovery from Cellulitis. ref SDS 71 N163
660539 -  ..
660540 - Millie wants to start next week on 080313.
660542 -  ..
660543 - Doctor Rugo approved starting Carboplatin next week on 080313.
660545 -  ..
660546 - Progression of Cancer 5th Relapse and 4th Relapse of IBC
660547 -
660548 - Follow up ref SDS 20 H54F, ref SDS 16 8Y8I.
660549 -
660550 - This is the 4th relapse of IBC Millie has suffered, and the 5th
660551 - relapse of her cancer overall.  Original diagnosis of IBC occurred on
660552 - 040517. ref SDS 10 YN3L  However, the doctor diagnosed a general
660553 - initial relapse of breast cancer on 040318, as seen in the following
660554 - case study of patient history...
660555 -
660556 -        1.  Lymph node biopsy positive start
660557 -            bevacizumab Taxotere.............. 040318, ref SDS 9 8R6M
660558 -        2.  Cancer marker IBC increase end
660559 -            bevacizumab Taxotere due to
660560 -            pulmonary embolism................ 041210, ref SDS 11 025H
660561 -        3.  Cancer marker IBC recurs 9 months
660562 -            months after mastectomy........... 060711, ref SDS 16 025H
660563 -        4.  Cancer marker IBC worsens end
660564 -            capeticabine Taxotere............. 061201, ref SDS 20 RU6J
660565 -        5.  IBC progression with increased
660566 -            lymph nodes in axilla add
660567 -            Carboplatin to cetuximab.......... 080306, ref SDS 0 NW3N
660569 -               ..
660570 -              [On 081016 2342 Millie suffers 5th relapse of IBC; ends
660571 -              treatment on cetuximab and Carboplatin clinical study.
660572 -              ref SDS 89 8V5O
660574 -  ..
660575 - The doctor congratulated Millie on being treated for 13 months with
660576 - cetuximab alone, since beginning on 070201. ref SDS 25 G68I  This is 3
660577 - times longer than any previous patient getting cetuximab alone, and
660578 - exceeds the longest period any patient has been treated with both
660579 - cetuximab and Carboplatin.  On 070315 Brigid reported the longest
660580 - period of treatment with both cetuximab and Carboplatin was 10 months.
660581 - ref SDS 28 6A40  The doctor feels that since most patients do better
660582 - with both cetuximab and Carboplatin, there is a good chance Millie can
660583 - continue for another 8 - 12 months, hopefully longer, without
660584 - suffering progression of cancer.  That would more than double the
660585 - longest period of treatment for patients in the study.
660586 -
660587 -        [On 081024 1150 Doctor Johnnson concurred that Kaiser
660588 -        prescribing cetuximab and Carboplatin treatment at UCSF for
660589 -        Millie on 070105 was a stunning success. ref SDS 90 K65M
660591 -  ..
660592 - Millie said her fingers are crossed hoping blood counts hold up for
660593 - weekly chemotherapy treatments with Carboplatin added to cetuximab.
660594 - Problems maintaining blood counts for monthly chemotherapy treatments,
660595 - reported in the study on 060810, ref SDS 18 HV45, cause worry and
660596 - doubt about ability to withstand weekly treatments.  Doctor Rugo
660597 - recalled discussing low blood counts a few weeks ago at UCSF on
660598 - 080219, ref SDS 69 I35G, citing the meeting 2 weeks earlier on 080207.
660599 - ref SDS 60 E14H  Millie's letter to the medical team in the morning on
660600 - 080219 requested ideas to maintain blood counts in order to get the
660601 - full dose of Carboplatin. ref SDS 68 1K4P
660603 -  ..
660604 - Millie asked again today if blood counts can be maintained without
660605 - reducing dose levels of Carboplatin, as Jackie discussed on 080207?,
660606 - ref SDS 60 GI65  Doctor Johnson at Kaiser has talked about synergy
660607 - between exercise that strengthens the natural immune system to augment
660608 - cancer treatments, e.g., discussed on 030606. ref SDS 7 CN3N  The
660609 - past year Millie has been able to get both full strength cetuximab
660610 - while keeping up vigrous daily exercise.  Can these results be
660611 - maintained adding Carboplatin?
660613 -  ..
660614 - Doctor Rugo feels Neupogen treatments can be added to help maintain
660615 - blood counts in order to give Carboplatin an optimal chance on the 2nd
660616 - arm of the study.
660618 -  ..
660619 - Brigid prepared the order to change treatment for IBC by adding
660620 - Carboplatin beginning next week on 080313.  This will complement
660621 - treatment with cetuximab alone that began on 070201, and implements
660622 - the clinical study protocol to evaluate cetuximab with Carboplatin,
660623 - shown in the record on 070116. ref SDS 22 0Q7I
660625 -  ..
660626 - There was brief discussion of side effects from Carboplatin
660627 - chemotherapy drugs.  Experience the past 6 years with AC, Taxol,
660628 - Taxotere, bevacizumab, and capecitabine have demonstrated debilitating
660629 - side effects, illustrated by case study on 050422. ref SDS 12 NT3I
660630 - Worry about side effects was cited in Millie's letter to UCSF on
660631 - 080219, ref SDS 68 1K9W, based on experiencing debilitating loss of
660632 - energy and vitality from side effects of chemotherapy reported in a
660633 - case study on 050422. ref SDS 12 NT3I
660635 -  ..
660636 - Jackie said that most patients seem to tolerate Carboplatin well.
660637 -
660638 -        [On 080313 first chemotherapy treatment with Carboplatin added
660639 -        to cetuximab. ref SDS 76 TZ8I
660640 -
660641 -        [On 080314 Millie reports energetic day after 1st treatment
660642 -        with Carboplatin chemotherapy. ref SDS 78 4W3H
660644 -         ..
660645 -        [On 080320 Millie reports definite loss of energy from
660646 -        treatment adding chemotherapy Carboplatin to cetuximab in the
660647 -        clinical trial. ref SDS 80 1S9L
660649 -         ..
660650 -        [On 030320 blood counts were too low for treatment with
660651 -        Carboplatin, and so Millie received treatment only with
660652 -        cetuximab. ref SDS 81 SE5R
660654 -         ..
660655 -        [On 080402 Millie reported a burst of energy increasing
660656 -        exercise more than any time in the past 4 years.
660657 -        ref SDS 82 Q25V
660659 -         ..
660660 -        [On 080409 Millie reports to Kaiser being thrilled by
660661 -        improvement recovering from IBC disease, and that energy and
660662 -        exercise have increased despite adding Carboplatin chemotherapy
660663 -        to cetuximab for the clinical trial regimen; causing reduced
660664 -        emotional trauma from stress, anxeity, doubt, and worry about
660665 -        the future. ref SDS 86 W14P
660666 -
660667 -
660668 -
660669 -
660670 -
6607 -

SUBJECTS
Default Null Subject Account for Blank Record

6703 -
670401 -  ..
670402 - Jackie discussed continuing for now the current regimen to visit with
670403 - the medical team once a month instituted on 070802. ref SDS 29 0001
670404 - rather than go back to the original schedule of 2 meetings each month.
670405 -
670406 -
670407 -
6705 -

SUBJECTS
Default Null Subject Account for Blank Record

6803 -
680401 -  ..
680402 - Brigid wrote a prescription for drugs to treat nausea that can be a
680403 - side effect of Carboplatin chemotherapy...
680404 -
680405 -        1.  Compazine 10 mg tablets
680406 -
680407 -            T PO -- Q 6 hrs per nausea
680408 -
680409 -                    # 30  refill = 3
680411 -             ..
680412 -        2.  Zofran  5 mb tablets
680413 -
680414 -            T PO -- Q 8 hrs per nausea
680415 -
680416 -                    # 12  refill = 3
680418 -  ..
680419 - Legiblity of handwriting is problematic.  This is a common cause of
680420 - medical mistakes, reported on 990912. ref SDS 4 0900
680422 -  ..
680423 - Brigid asked Millie to coordinate with the primary care physician to
680424 - place the order for these new medications at the Kaiser pharmacy.
680425 -
680426 -            [On 080307 Millie notifies primary care physician at Kaiser
680427 -            to order new medications prescribed the UCSF for Millie's
680428 -            treatment beginning next week. ref SDS 74 RW5V
680430 -             ..
680431 -            [On 080307 Millie commends referral coordination by primary
680432 -            care physician placing timely order for medications at
680433 -            Kaiser prescribed for Millie by UCSF ref SDS 74 GZ4H
680435 -  ..
680436 - There was discussion about cost that was not clear.  Something to the
680437 - effect that one of the drugs is expensive, and the pharmacy and or
680438 - insurance allows only small orders to evaluate effectiveness before
680439 - allowing production level orders.
680440 -
680441 -
680442 -
6805 -

SUBJECTS
Default Null Subject Account for Blank Record

6903 -
690401 -  ..
690402 - These new medications, including Carboplatin need to be added to the
690403 - list at Kaiser reported during the meeting yesterday, ref SDS 71 7Y6F
690404 - for evaluating conflicts, including with Coumadin.
690405 -
690406 -            [On 080307 letter to Kaiser coagulation control clinic in
690407 -            Martinez CA advises of medication changes to correlate
690408 -            Coumadin treatment for pulmonary embolism. ref SDS 74 RW3T
690410 -             ..
690411 -            [On 080307 letter to primary care physician reports
690412 -            corrections to current medications in medical chart at
690413 -            Kaiser so that primary care physician can provide effective
690414 -            medical opinion to backup care at UCSF. ref SDS 74 RW3T
690415 -
690416 -
690417 -
690418 -
690419 -
690420 -
690421 -
690422 -
690423 -
690424 -
6905 -