CONTACTS 

SUBJECTS
Meeting Examination Kaiser Backup Doctor Review Strategy Work Plan 3

1303 -
1303 -    ..
1304 - Summary/Objective
1305 -
130501 - Follow up ref SDS B0 0000. ref SDS 92 0000.
130502 -
130503 -
130504 -
130505 -
130506 -
130507 -
130508 -
130510 -  ..
1306 -
1307 -
1308 - Progress
1309 -
130901 - Agenda Integrated Work Plan Kaiser UCSF
130902 -
130903 - Follow up ref SDS B0 QY5I, ref SDS 92 QY5I.
130904 -
130905 -
130906 -     **************************************************************
130907 -
130908 -         Wasn't enough time to create this record; at the end is the
130909 -         doctor's medical chart that is correct. ref SDS 0 YT5N
130911 -          ..
130912 -         Kept this content as a template in case there is time later
130913 -         to write up the record.
130914 -
130915 -     **************************************************************
130916 -
AM0452 -
AM05 -

SUBJECTS
CT Test 080212 Findings Support Diagnosis IBC Progression Disease 4t

B503 -
B50401 -  ..
B50402 - Medical Chart Reports Examination Diagnosis Prescription Prognosis
B50403 -
B50404 - Follow up ref SDS B0 YT5N, ref SDS 92 YT5N.
B50405 -
B50406 - Received the doctor's report in the medical chart for the meeting
B50407 - today...
B50409 -         ..
B50410 -    1.  Received:  8/29/08 1:04 PM
B50412 -         ..
B50413 -    2.  .... [patient] is a 72 Y female with a history of inflammatory
B50414 -        cancer of left breast who was initially diagnosed 03/04/02.
B50415 -        She had recurrent disease noted initially in the cervical LN's
B50416 -        03/03/04.  On E2100 Study with Avastin, but she had a PE noted
B50417 -        on CT 11/03/2004.  Then, because of progression of disease, the
B50418 -        patient was started on Taxotere and Xeloda 4/15/05.  She had a
B50419 -        total of 8 cycles ending 9/16/05.  She had a palliative left
B50420 -        mastectomy performed 10/21/05.  Then her left chest lesions
B50421 -        began expanding again.  The patient started Taxotere and Xeloda
B50422 -        again 07/21/06 for 7 cycles.  She was started on a Clinical
B50423 -        Trial 02/01/07 at UCSF and was randomized to the Erbitux only
B50424 -        (no Carbo) Arm.
B50426 -         ..
B50427 -        She had weekly Carboplatin added 03/13/08 because of
B50428 -        progression of disease.  She has missed a total of 4 treatments
B50429 -        because of neutropenia.  Her CA 15-3 continues to increase
B50430 -        (08/21/08 was 96).
B50432 -  ..
B50433 - Medical chart aligns with case study patient history neutropenia in
B50434 - the record yesterday on 080828. ref SDS C5 8O7I
B50436 -  ..
B50437 - Patient history on 080502, ref SDS 92 SU49, shows Millie responded to
B50438 - full dose Carboplatin 230 mb, prescribed in UCSF Chemotherapy Order on
B50439 - 080313. ref SDS 78 2N4N  On 080423 Millie cited significant recovery
B50440 - from IBC with only 50% of treatments using full dose of Carboplatin.
B50441 - ref SDS 87 OY7S  Another letter to UCSF on 080423 explained dramatic
B50442 - reduction of IBC rash getting full dose of Carboplatin. ref SDS 87
B50443 - TY7X  Examination at UCSF on 080501 found substantial improvement
B50444 - recovering from IBC. ref SDS 91 NW3N  On 080501 UCSF evidently reduced
B50445 - the dose of Carboplatin, which conflicted with patient's letter on
B50446 - 080423, and this was not discovered until 080605, because of delays
B50447 - submitting the Chemotherapy Order, as set out in the record on 080529.
B50448 - ref SDS A0 MM9I  On 080502 examination by primary care physician at
B50449 - Kaiser finds favorable response to treatment, ref SDS 92 NH4N, despite
B50450 - getting only 50% of prescribed Carboplatin chemotherapy, ref SDS 92
B50451 - NH4N, which Millie has tolerated well shown by significantly increased
B50452 - exercise. ref SDS 92 ZD9O
B50454 -  ..
B50455 - On 080528, Millie notified the medical team updating the record; since
B50456 - 080507 I have increased daily training with respect to distance and
B50457 - faster times.  There have been no further episodes of elevated pulse.
B50458 - I am recovering well after climbing hills (e.g. pulse climbs to 140+
B50459 - or -, then quickly drops back to below 120), which seems like a good
B50460 - sign. ref SDS 98 IK5V
B50461 -
B50462 -            [On 081012 Millie experienced significantly elevated pulse
B50463 -            while hiking at Lafayette reservoir and over a prolonged
B50464 -            period of 2 laps - 5.5 miles.  On the 3rd lap pulse settled
B50465 -            back to normal. ref SDS D0 4I8M
B50467 -  ..
B50468 - CA 15-3 and IBC rash began to increase after dose of Carboplatin was
B50469 - reduced on 080501.
B50471 -  ..
B50472 - Medical Chart continues...
B50473 -
B50474 -    3.  Current Medications
B50475 -
B50476 -        PROCHLORPERAZINE 10MG....... Compazine. 080313, ref SDS 74 FA4H
B50477 -        ONDANSETRON 8 MG TABLETS.... Zofran.... 080313, ref SDS 74 FA4H
B50478 -        CEPHALEXIN 500 MG CAPSULES.. Keflex.... 080409, ref SDS 85 F142
B50479 -        FLUOXETINE 20 MG CAPSULES... Prozac.... 080305, ref SDS 73 5L5M
B50480 -        NEUPOGEN 480MCG/1.6ML.................. 080502, ref SDS 92 NL4M  ,
B50481 -        WARFARIN 4 MG TABLETS....... Coumadin.. 061002, ref SDS 14 MI5I
B50482 -        TIMOLOL MALEATE 0.5% EYE.... Eye drops
B50483 -        ACYCLOVIR 800MG............. Zoviraxe.. 070614 (no record prescribed by Doctor Rugo to treat cold sore on lip)
B50484 -        LORAZEPAM 1 MG.............. Ativan.... 070921, ref SDS 35 3N8J
B50485 -        Cetuximab................... Erbitux... 070201, ref SDS 25 4N5M
B50486 -        Carboplatin............................ 080313, ref SDS 78 2N4N
B50488 -  ..
B50489 - The medical chart does not include contrast medium treatment for CT
B50490 - tests reported in Kaiser's list of medications received during the
B50491 - meeting on 080502. ref SDS 92 SY4M  Continues omission from medical
B50492 - chart on 080627. ref SDS B0 4B5K  Kaiser changed the contrast medium
B50493 - to...
B50494 -
B50495 -        Barrium Sulfate Suspension............. 080222, ref SDS C3 6T9K
B50497 -  ..
B50498 - On 080502 the doctor added Cetuximab and Carboplatin prescribed by
B50499 - UCSF in Chemotherapy Orders, as noted for the meeting with the doctor
B50500 - on 080502, ref SDS 92 NA6F, and citing earlier listings of medications
B50501 - on 080307.  UCSF. ref SDS 76 RW3T
B50503 -  ..
B50504 - On 080708 Kaiser surgery processing asks for Millie's current
B50505 - medications, per above, ref SDS B0 7Y6F, and cannot access patient
B50506 - medical chart; asks patient to verbally cite 14 medications.
B50508 -  ..
B50509 - Kaiser should further add to the medical chart additional medications
B50510 - prescribed by UCSF for weekly treatments...
B50511 -
B50512 -        Dexamethasone............... Decadron.. 080313, ref SDS 78 2N43
B50513 -        Diphenhydramine............. Benedryl.. 080313, ref SDS 78 NX4N
B50515 -  ..
B50516 - Medical Chart continues...
B50517 -
B50518 -    4.  Physical Examination
B50519 -
B50520 -        Performance Status: 0
B50521 -        Lymph nodes: small left supraclavicular LN?
B50522 -        Chest wall: erythema increased some on lower left chest wall
B50523 -        Ext: LUE edema absent, erythema upper arm stable
B50525 -  ..
B50526 - On 080502 the doctor explained that "Performance Status "0" means
B50527 - Millie has evident full mobility and demonstrates no loss of normal
B50528 - functioning. ref SDS 92 NP5M
B50529 -
B50530 -            [On 081024 1150 medical chart changes "Performance Status"
B50531 -            account to "ECOG Performance Score". ref SDS D2 OP5L
B50533 -  ..
B50534 - Small left supraclavicular LN aligns with report at UCSF last week on
B50535 - 080821, ref SDS C2 4C6O, and with rising cancer marker presented in
B50536 - the doctor's medical chart today, per above. ref SDS 0 NN8I
B50538 -  ..
B50539 - The doctor said to notify Doctor Rugo immediately to expedite
B50540 - changing treatments, and that he would approve switching to another
B50541 - "targeted" treatment, because Millie's patient profile is now very
B50542 - resistant to chemotherapy.
B50544 -  ..
B50545 - Erythema increased some on lower left chest wall may also align with
B50546 - rising cancer marker, CA 15-3 cited in doctor's notes, per above.
B50547 - ref SDS 0 NN8I
B50549 -  ..
B50550 - These findings may reverse prior favorable response to treatment on
B50551 - 080627. ref SDS B0 1Z6O
B50552 -
B50553 -            [On 080829 2256 Millie's letter to medical team reports
B50554 -            that primary care physician at Kaiser palpates lump left
B50555 -            supraclavicular, ref SDS C6 RP8T, aligns with findings at
B50556 -            UCSF on 080821. ref SDS C2 4C6O
B50558 -             ..
B50559 -            [On 080918 Brigid's examination at UCSF did not find
B50560 -            swelling in left supraclavicular, which may align with the
B50561 -            CT test not reporting findings in this area. ref SDS C9
B50562 -            N65G
B50564 -             ..
B50565 -            [On 081016 Brigid and Doctor Rugo palpate lump left
B50566 -            supraclavicular, ref SDS D1 J34X; Doctor Rugo orders
B50567 -            biopsy. ref SDS D1 J36R
B50569 -  ..
B50570 - Medical Chart continues...
B50571 -
B50572 -        Lab:
B50573 -        CA 15-3 H 141 U/mL
B50574 -
B50575 -        BUN 9 mg/dL
B50576 -        Chloride H 111 mEq/L
B50577 -        CO2 L 20 mEq/L
B50578 -        Creatinine 0.39 mg/dL
B50579 -        Glucose Random 86 mg/dL
B50580 -        Potassium H 5.4 mEq/L
B50581 -        Sodium 139 mEq/L
B50582 -        Anion Gap 8 mEq/L
B50584 -         ..
B50585 -        Anticoag Ther? WARFARIN
B50586 -        PT, Patient 11.0 Sec
B50588 -  ..
B50589 - The doctor lists blood test results from the lab for surgery on
B50590 - 080708. ref SDS B4 075H
B50592 -  ..
B50593 - Millie's most recent labs are reported in the record on 080828 getting
B50594 - treatment at UCSF yesterday. ref SDS C5 075H
B50596 -  ..
B50597 - Medical Chart continues...
B50598 -
B50599 -    5.  Imaging
B50600 -
B50601 -        07/18/08 CT THORAX, ABDOMEN,
B50602 -                 PELVIS W CONTRAST................... ref SDS B7 0001
B50603 -                 review of test on 080723............ ref SDS B8 IX4F
B50605 -         ..
B50606 -        04/25/08 CT THORAX, ABDOMEN, PELVIS W
B50607 -                 CONTRAST - no change................ ref SDS 88 9W9I
B50608 -                 review of test on 080428............ ref SDS 89 DA6Q
B50610 -         ..
B50611 -        04/09/08 CHEST, TWO VIEWS.................... ref SDS 85 0H92
B50613 -         ..
B50614 -        03/05/08 HUMERUS 2+ VIEWS - normal
B50616 -         ..
B50617 -        02/12/08 CT THORAX, ABDOMEN, PELVIS W
B50618 -                 CONTRAST - increased right
B50619 -                 axillary LN; infiltrate
B50620 -                 RML fissure......................... ref SDS 67 FP5H
B50621 -                 review of test on 080215............ ref SDS 68 EO8F
B50623 -         ..
B50624 -        12/27/06 BASE SKULL TO MIDTHIGH
B50625 -                 PET/CT
B50626 -                 review of test on 070102............ ref SDS 19 XT4M
B50628 -         ..
B50629 -        07/08/06 MRI BRAIN WO/W CONTRAST
B50630 -                 (STD)- negative
B50631 -                 review of test on 060711............ ref SDS 12 068M
B50633 -  ..
B50634 - Patient history on all image testing is listed in the record on
B50635 - 080723. ref SDS B8 GM3N
B50637 -  ..
B50638 - Medical Chart continues...
B50639 -
B50640 -    6.  Imp:
B50641 -
B50642 -        1. Metastatic breast cancer (IBC)lung, lymph node and chest
B50643 -           wall
B50644 -        2. Recurrent leukopenia
B50645 -        3. Hx of pulmonary embolism
B50646 -        4. Anticoagulation monitoring
B50648 -  ..
B50649 - "Leukopenia" is a new term; Millie has a history of "neutropenia," per
B50650 - above. ref SDS 0 NN8I
B50652 -  ..
B50653 - Stable nodules in the lungs were cited by the primary care physician
B50654 - at Kaiser in a letter on 070117 to explain the medical chart reporting
B50655 - lung cancer. ref SDS 22 TS8G
B50657 -  ..
B50658 - Medical Chart continues...
B50659 -
B50660 -    7.  Plan
B50661 -
B50662 -        1.  Continue Clinical Trial on Erbitux with weekly Carbo
B50663 -        2.  Repeat CT Sept 11, 2008 in Oakland
B50665 -  ..
B50666 - On 080903 schedule for CT test at Oakland confirmed. ref SDS C7 025B
B50668 -  ..
B50669 - Medical chart continues...
B50670 -
B50671 -        3.  Continue Neupogen support as needed
B50672 -
B50673 -        4.  Consider different UCSF Clinical Trial if patient
B50674 -            progresses vs receiving a single agent here
B50676 -  ..
B50677 - The doctor explained today that ending cetuximab treatment at UCSF due
B50678 - to progression of disease, shown by new LN in left supraclavicular and
B50679 - rising cancer marker, per above, ref SDS 0 1Z6O, requires treatment
B50680 - with "trargeted" drugs, because Millie's cancer cells have now mutated
B50681 - through 5 relapses to resist chemotherapy.  Earlier on 030606, Doctor
B50682 - Johnson advised that side effects of chemotherapy accumulate to become
B50683 - intolerable, forcing patients to end treatment in order to avoid
B50684 - self-torture, pain and suffering caused by chemotherapy. ref SDS 5
B50685 - ED8H
B50687 -                ..
B50688 -               [On 100702 1424 Millie received a letter in the mail
B50689 -               dated 100624, from Doctor Johnson transmitting Kaiser's
B50690 -               lab report for Millie's blood test on 100622.  The
B50691 -               doctor provides no analysis, nor comment of any kind
B50692 -               except "CA 15-3 1116" is circled in ink. ref SDS D0 NC3F
B50694 -  ..
B50695 - Today, Doctor Johnson indicated that Millie has been given all of the
B50696 - chemotherapy drugs available at Kaiser for breast cancer, except
B50697 - Gemzar and Navelbine.  He feels that since Millie's cancer has mutated
B50698 - to resist chemotherapy, and since prior treatment with numerous
B50699 - chemotherapy agents has accumulated to reduce her body's tolerance for
B50700 - more chemotherapy, Gemzar and Navelbine chemotherapy are no longer
B50701 - appropriate for Millie's patient profile.  Millie needs a strategy
B50702 - using newer drugs that "target" cancer cells, and so do not cause pain
B50703 - and suffering from killing healthy cells, like chemotherapy does.
B50705 -  ..
B50706 - Doctor Johnson called this strategy treating cancer as a "chronic
B50707 - disease" that extends survival with quality of life.  Cetuximab was
B50708 - effective for nearly 2 years, 5-times longer than any other treatment
B50709 - Millie has had in 7 years of treatment for cancer.
B50710 -
B50711 -               [On 090213 1140 Millie's treatment history compares
B50712 -               cetuximab with 9 or so other treatments. ref SDS D7 AC6G
B50714 -                ..
B50715 -               [On 090232 1352 case study cancer marker compares
B50716 -               duration for Millie's many treatments. ref SDS D9 J13O
B50718 -  ..
B50719 - Doctor Johnson asked Millie to notify Doctor Rugo that Kaiser will
B50720 - approve payment for Millie's continued treatment at UCSF with new
B50721 - "targeted" cancer technology, per above. ref SDS 0 PX5V  Previously,
B50722 - Doctor Johnson made the original referral to UCSF, because cetuximab
B50723 - targeted cancer cells, and had minimal side effects with no pain and
B50724 - suffering, reported on 070105 1040. ref SDS 20 PK68  Doctor Johnson
B50725 - wants UCSF to submit proposals on providing more "cetuxiab-like"
B50726 - treatments for Millie, so she can switch quickly enough for treatment
B50727 - to be effective, as her cancer continues to mutate.
B50728 -
B50729 -               [...in another record today on 080829 2256 Millie's
B50730 -               letter to the medical team reports Doctor Johnson's
B50731 -               finding of swelled LN in left supraclavicular,
B50732 -               ref SDS C6 RP8T, and Millie's progression of disease
B50733 -               requires targeted treatments, ref SDS C6 RP9R, wants
B50734 -               UCSF to prescribe new treatment in time to be effective.
B50735 -               ref SDS C6 RP9R
B50737 -                ..
B50738 -               [On 081024 1150 Millie met with Doctor Johnson at Kaiser
B50739 -               and explained Doctor Rugo reported on 081016 that UCSF
B50740 -               has more treatments lined up for future relapses; he
B50741 -               wants to get the list so the details do not slip through
B50742 -               the cracks. followed up, ref SDS D2 PU4L
B50744 -                ..
B50745 -               [On 081024 1150 Millie met with Doctor Johnson at
B50746 -               Kaiser, ref SDS D2 C45H; examination concurred with UCSF
B50747 -               assessment on 081016 finding progression of IBC.
B50748 -               ref SDS D2 WK82  The doctor authorized payment for
B50749 -               Millie continuing treatment on clinical study at UCSF,
B50750 -               ref SDS D2 K67J, and as noted in the Kaiser medical
B50751 -               chart, ref SDS D2 OZ5F, explained requirements for
B50752 -               treatment to start in time to be effective because
B50753 -               Millie's cancer has mutated into a more aggressive
B50754 -               disease; the doctor entered into Kaiser's medical chart
B50755 -               approval for treatment at UCSF with the sunitinib study.
B50756 -               ref SDS D2 OZ5F
B50758 -                ..
B50759 -               [On 081024 Millie's letter notifies medical team that
B50760 -               during meeting at Kaiser with primary care physician the
B50761 -               doctor confirmed authorization for Millie's treatment in
B50762 -               the sunitinib clinical study, because Millie needs a
B50763 -               double agent "targeted" treatment, and Kaiser does not
B50764 -               have treatments that can help recover from the 5th
B50765 -               relapse of IBC. ref SDS D3 XZ8W
B50767 -                ..
B50768 -               [On 081219 1140 Doctor Johnson finds favorable response
B50769 -               to treatment with sunitinib, ref SDS D4 3L9L; the doctor
B50770 -               cites urgency of timely treatment increases when Millie
B50771 -               suffers relapse; delay increases risk of losing control
B50772 -               for cancer that mutates into more aggressive disease.
B50773 -               ref SDS D4 KU6F  Doctor Johnson asked Millie to notify
B50774 -               Doctor Rugo about planning treatment for the 6th relapse
B50775 -               to ensure treatment starts in time to be effective,
B50776 -               ref SDS D4 V93O, and asked for a letter from UCSF to
B50777 -               facilitate the next referral, ref SDS D4 SU8G; because
B50778 -               the 6th relapse will be very serious, ref SDS D4 NS8H;
B50779 -               further emphasized need for letter from UCSF
B50780 -               recommending treatment on referral from Kaiser.
B50781 -               ref SDS D4 E84J
B50783 -                ..
B50784 -               [On 090123 1326 Doctor Johnson calls and concurs Millie
B50785 -               has suffered IBC relapse with cancer marker CA 15-3 303
B50786 -               in blood test on 090116 at Kaiser; confirms Millie's
B50787 -               cancer has mutated to resist treatments available at
B50788 -               Kaiser, authorizes UCSF to prescribe next treatment.
B50789 -               ref SDS D5 RK6O
B50791 -                ..
B50792 -               [On 090204 0219 Millie's letter asks Doctor Rugo to
B50793 -               submit proactive planning for follow on treatment after
B50794 -               hyperthermia and Doxil for Millie's 6th relapse of IBC.
B50795 -               ref SDS D6 278T
B50797 -                ..
B50798 -               [On 090218 1205 Millie's letter notifies medical team
B50799 -               that Doctor Johnson has ordered Millie's continued care
B50800 -               at UCSF, citing prior instructions on 080829, 081026,
B50801 -               081219, and on 090123, all authorizing UCSF to begin
B50802 -               planning for Millie's next treatment, so that past
B50803 -               delays are avoided, because Millie's cancer has mutated
B50804 -               through multiple relapses (total of 7 so far) into a
B50805 -               very aggressive disease which requires treatment quickly
B50806 -               in order to be effective. ref SDS D8 TH6U
B50807 -
B50809 -  ..
B50810 - Medical chart continues...
B50811 -
B50812 -        5.  RTC 8 weeks
B50813 -
B50815 -         ..
B50817 -
B50818 -
B50819 -
B50820 -
B50821 -
B50822 -
B50823 -
B50824 -
B50825 -
B50826 -
B509 -