CONTACTS 
0201 - Stritter Medical Consulting
020101 - Mr. Gwendolyn Stritter, MD
020103 - Executive Office

SUBJECTS
Seminar Patient Advocacy Beyond 2nd Opinions Cancer Research New Tre

1403 -
1403 -    ..
1404 - Summary/Objective
1405 -
140501 - Follow up ref SDS 21 0000, ref SDS 17 MV9V.
140502 -
140503 - Excellent presentation today on clinical advocacy.
140504 -
140505 -
140506 -
140507 -
140508 -
140509 -
140511 -  ..
1406 -
1407 -
1408 - Progress
1409 -
140901 - Cancer Seminar New Treatments Clinical Advocacy
140902 -
140903 - The Wellness Community (sponsored by Kaiser) presented an event today
140904 - that expands support during a seminar at John Muir hospital on 080715,
140905 - that explained medical case management for cancer. ref SDS 21 AC80
140906 - The seminar today complements the prior event by explaining the role
140907 - of patient advocacy.
140909 -  ..
140910 - Doctor Stritter's presentation impresses with astonishing depth and
140911 - range, including specific citations to published literature that gives
140912 - weight and confidence in recommendations.  Equally, her speaking
140913 - skills are professional, clear, and interesting.  She makes complex,
140914 - difficult issues easy to understand.
140915 -
140916 -        [On 081019 Millie notified primary care physician and the
140917 -        medical team about Doctor Stritter's presentation on new
140918 -        treatments for breast cancer. ref SDS 29 DZ6X
140920 -  ..
140921 - Doctor Stritter's patient advocacy practice explained below,
140922 - ref SDS 0 IS68, complements planning reported on 080118 by Millie,s
140923 - primary care physician at Kaiser, Doctor Johnson, for a "Palliation
140924 - Care Project" to integrate medical resources for oncology beyond the
140925 - team care concept. ref SDS 18 KJ40
140926 -
140927 -            [On 090206 Doctor Stritter's letter notes that Millie's
140928 -            case is inspirational surviving a very aggressive cancer
140929 -            and complex case management for so many years. ref SDS 47
140930 -            7Q7J
140932 -             ..
140933 -            [On 090107 Doctor Stritter attending integrative oncology
140934 -            conference in Florida. ref SDS 46 X35I
140936 -  ..
140937 - Doctor Stritter fills a growing need to facilitate effective doctor
140938 - patient partnership called out in Kaiser's Healthwise Handbook,
140939 - reviewed on 990625, ref SDS 5 4185, including requirements for
140940 - patients to have assistance for case management, also, noted in the
140941 - Healthwise Handbook. ref SDS 5 JY9J
140943 -  ..
140944 - Doctor Gwendolyn Stritter made a presentation today.  The doctor has
140945 - a practice...
140946 -
140947 -              Stritter Medical Consulting
140948 -              Beyond the Second Opinion
140949 -              Clinical Advocacy
140951 -               ..
140952 -              1235 Los Trancos Road
140953 -              Portola Valley, CA  94028 8125
140954 -              650 851 0377
140955 -              drgwen@strittermed.org
140957 -  ..
140958 - The brochure says....
140959 -
140960 -    1.  Stritter Medical Consulting is a medical practice dedicated to
140961 -        clinical advocacy.  What is clinical advocacy?  In a nutshell,
140962 -        it is what doctor's do for themselves and their loved ones when
140963 -        they are faced with a life-threatening illness.  It involves...
140965 -  ..
140966 - This seems a bit of a reach.  Advocacy is beyond reach of people who
140967 - lack experience.  It is a different skill set.  Doctors definitely try
140968 - to self-advocate, but debilitating effects of cancer diminish
140969 - capacity.
140971 -  ..
140972 - Good example is the movie about 10 years ago showing a top surgeon had
140973 - difficulty coping with medical machinery when diagnosed with throat
140974 - cancer.
140975 -
140977 -  ..
140978 - Research Cancer Treatments Identify Promising Clinical Trials
140979 -
140980 -
140981 - Stritter brochure continues...
140982 -
140983 -        a.  Staying up to date on the latest advances in diagnosis and
140984 -            treatment (Doctor Stritter attends 3 or 4 oncology
140985 -            conferences every year and reads the medical literature
140986 -            voraciously).
140988 -  ..
140989 - Being aware of new treatments, and distinguishing which have the best
140990 - chance of helping a particular patient is a lot of work, that
140991 - requires experience.
140993 -  ..
140994 - Additionally, Stritter Medical could track treatments tested
140995 - successfully in clinical trials that been approved and so add to the
140996 - inventory of treatments available without requiring administrative and
140997 - payment issues associated with clinical trials.
140999 -  ..
141000 - On 041130 a lot emotional capital was expended to get a list of
141001 - chemotherapy drugs from a doctor that can be considered for a work
141002 - plan to treat the patient. ref SDS 12 763L  Gwen's practice could help
141003 - both the doctor and the patient.
141004 -
141005 -
141006 -
1411 -

SUBJECTS
Default Null Subject Account for Blank Record

1503 -
150401 -  ..
150402 - Stritter brochure continues...
150403 -
150404 -        b.  Presenting your specific case to national and international
150405 -            experts.
150407 -  ..
150408 - This is the most difficult task, because patients and doctors do not
150409 - have time to capture the record, beyond a few jottings here and there.
150410 - Medical records with errors and conflicting data require time and
150411 - expertise to make sense of incomplete of patient history.
150413 -  ..
150414 - Assembling accurate patient history, organizing the record, and
150415 - following up to guide the 2nd opinion process helps patients, doctors
150416 - who are asked for a 2nd opinion, and doctors who apply 2nd opinions,
150417 - illustrated by the record on 041230. ref SDS 12 5X4J
150419 -  ..
150420 - Stritter brochure continues...
150421 -
150422 -        c.  If desired, referral to local or national oncologists who
150423 -            are more closely aligned to your health and life
150424 -            priorities.
150426 -  ..
150427 - This is a very good area for support.
150429 -  ..
150430 - Stritter brochure continues...
150431 -
150432 -        d.  Arming you with medical references and pertinent questions
150433 -            to maximize the effectiveness of your medical appointments.
150435 -             ..
150436 -        e.  Making sure no stone is left unturned, particularly when
150437 -            your oncologist is running our of treatment ideas, or is
150438 -            not thorough in explaining all of your options.
150440 -  ..
150441 - Comprehensive case management, including h, i, and j, ref SDS 0 YO4W,
150442 - requires accurate patient history that "connects the dots" to
150443 - understand trends in time to take effective action.
150444 -
150445 -               [On 081114 Doctor Stritter submitted ideas for finding
150446 -               support to maintain Millie's care at UCSF through
150447 -               Kaiser. ref SDS 38 FJ5J
150449 -                ..
150450 -               [On 090206 Doctor Stritter's letter notes that Millie's
150451 -               case is inspirational surviving a very aggressive cancer
150452 -               and complex case management for so many years.
150453 -               ref SDS 47 7Q7J
150455 -  ..
150456 - Stritter brochure continues...
150457 -
150458 -        f.  Helping design a maintenance program that minimizes your
150459 -            chance of cancer recurrence/metastisis.
150461 -             ..
150462 -        g.  Informing you of complementary and alternative medicine
150463 -            approaches that have objective evidence of effectivness.
150465 -             ..
150466 -        h.  Acting as a sounding board for new treatment ideas.
150468 -             ..
150469 -        i.  Helping you navigate difficult medical decisions.
150471 -             ..
150472 -        j.  Helping you cut through clinical, hospital or insurance
150473 -            red tape.
150474 -
150475 -               [On 081114 Doctor Stritter submitted ideas for finding
150476 -               support to maintain Millie's care at UCSF through
150477 -               Kaiser. ref SDS 38 FJ5J
150479 -                ..
150480 -               [On 090206 Doctor Stritter's letter notes that Millie's
150481 -               case is inspirational surviving a very aggressive cancer
150482 -               and complex case management for so many years.
150483 -               ref SDS 47 7Q7J
150485 -         ..
150486 -    2.  Doctor Striter's practice is telephone based.  You send your
150487 -        medical records then have a phone appointment -- the first one
150488 -        typically lasts for 2 hours.  Doctor Stritter is particularly
150489 -        interested in breast cancer and chronic pain.
150491 -  ..
150492 - Need to invest time reviewing the record and writing up analysis
150493 - rather than talking on the telephone.  Talking is essential, but this
150494 - comes after the writing.
150495 -
150496 -               [On 081112 Doctor Stritter charges $300 for 2nd opinion
150497 -               consultation, including review of medical history.
150498 -               ref SDS 37 K58J
150500 -  ..
150501 - Sending medical records has proven problematic.  The records were sent
150502 - to Benz at UCSF for the first 2nd opinion, and this was ignored,
150503 - reported on 041018. ref SDS 10 LW5V  The doctor advised that he never
150504 - saw patient history. ref SDS 10 EN5L  The doctor waded through a mass
150505 - of paper and asked the patient questions about events from years ago,
150506 - and did a good job piecing together a story, with few errors.
150507 - ref SDS 10 EN69
150509 -  ..
150510 - The same thing happened the next day at Stanford,
150511 - reported 041019.
150512 -
150513 -
1506 -

SUBJECTS
Default Null Subject Account for Blank Record

1603 -
160401 -  ..
160402 - Stritter brochure continues...
160403 -
160404 -    3.  Credentials Doctor Stritter...
160405 -
160406 -        Doctor Stritter is a Stanford trained physician.  She has two
160407 -        board certifications from the American Board of Anesthesiology
160408 -        -- anestheosiology and pain medication.
160410 -         ..
160411 -        A pioneer in clinical advocacy field, she contributed a chapter
160412 -        to the 2007 textbook "Patient Advocacy" (J Earp, editor)
160413 -        detailing how such a practice helps patients and families
160414 -        facing complex, life-threatening illnesses.  She has also
160415 -        appeared in numerous radio shows.
160416 -
160418 -  ..
160419 - Sunitinib Metronomic Cyclophosphamide and Methotrexate Clinical Study
160420 -
160421 - Follow up ref SDS 27 4E88.
160422 -
160423 - Millie arrived early.  She introduced herself, and related planning at
160424 - UCSF to start treatment with Sunitinib, reported in the letter to the
160425 - medical team on 081016. ref SDS 26 J38U
160426 -
160427 -     [On 090213 1140 followed up, ref SDS 48 GC40
160429 -  ..
160430 - Gwen is familiar with research showing promise for the new treatment
160431 - Doctor Rugo proposed to treat Millie's 5th relapse of IBC.
160433 -  ..
160434 - Gwen seemed to say that the Phase I/II study underway at UCSF is
160435 - something beyond a Phase I study, in that some results have been
160436 - recorded, if not published.  Still not sure about this.
160438 -  ..
160439 - Gwen cited a presentation on Sunitinib by a UCSF researcher at an
160440 - oncology conference which she attended last year in San Antonio.  UCSF
160441 - reported Sunitinib Metronomic Cyclophosphamide and Methotrexate
160442 - preliminary studies show that this combination is more effective than
160443 - cetuximab and Carboplatin for recovering from cancer, and more
160444 - importantly this targeted treatment appears to significantly reduce
160445 - recurrence.
160446 -
160447 -        [...below, an attendee at the seminar today asks for
160448 -        information on sunitinib clinical study. ref SDS 0 ED8O
160450 -         ..
160451 -        [On 081114 Doctor Stritter submitted ideas for finding support
160452 -        to maintain Millie's care at UCSF through Kaiser. ref SDS 38
160453 -        FJ5J
160454 -
160456 -  ..
160457 - Multi-targeted Cancer Treatment Sunitinib Clinical Study UCSF
160458 -
160459 - Gwen seemed to indicate that whereas, cetuximab attacks one particular
160460 - carrier of cancer, sunitinib is a "multi-targeted" treatment that
160461 - attacks many carriers of cancer, which prevents or reduces recurrence.
160462 - This aligns with understandings that Doctor Rugo and UCSF researchers
160463 - believe sunitinib will be effectve, shown in the clinical study
160464 - Consent documents reviewed yesterday on 081017. ref SDS 27 006S
160466 -         ..
160467 -        [On 081019 Millie sent a letter to the primary care physician
160468 -        submitting Doctor Stritter's favorable comments on the
160469 -        sunitinib clinical trial for treatting Millie's 5th relapse of
160470 -        IBC. ref SDS 29 D13Q
160472 -         ..
160473 -        [On 081021 Consent document for Sunitinib clinical study sent
160474 -        to primary care physician to prepare for meeting on 081024.
160475 -        ref SDS 32 W83I
160477 -         ..
160478 -        [On 081024 primary care phsyician prescribes treatment for
160479 -        Millie at UCSF with sunitinib metronomic and multi-agent
160480 -        protocol, ref SDS 35 XZ8W, because Millie's advancing cancer
160481 -        has become resistant to chemotherapy and so requires double
160482 -        agent drugs, and Kaiser only has single agent treatments which
160483 -        will be ineffective to treat Millie's 5th relapse of IBC, and
160484 -        further, becauser Kaiser's experience with sunitinib indicates
160485 -        this can be effective for Millie. ref SDS 35 ER4I
160487 -         ..
160488 -        [On 081125 letter to medical team submitting agenda for meeting
160489 -        the next day reports evident response to treatment after 2
160490 -        weeks with sunitinib clinical study at UCSF. ref SDS 40 XX3W
160492 -         ..
160493 -        [On 081202 letter to medical team reports findings from
160494 -        examination on 081126 of recovery from IBC; and days later
160495 -        there was significant increased recovery. ref SDS 41 AS6U
160497 -  ..
160498 - This may explain why Doctor Rugo ordered test for status change on
160499 - 081016.  If Millie remains triple negative, then sunitinib can still
160500 - be effective, noted in the doctor's letter on 081017. ref SDS 27 006S
160501 - If Millie's status has changed from negative to positive for ER, PR,
160502 - and/or HER2neu this may provide more "targets" for sunitinib treatment
160503 - to provide relief and stop the growth of cancer, noted by Doctor
160504 - Stritter today. ref SDS 0 IT8V
160505 -
160506 -        [On 081021 Consent document for Sunitinib clinical study sent
160507 -        to primary care physician to prepare for meeting on 081024.
160508 -        ref SDS 31 7L5S
160510 -         ..
160511 -        [On 081023 agenda for meeting at Kaiser review questions on
160512 -        sunitinib clinical study. ref SDS 33 L45S
160514 -  ..
160515 - Possibly this broader attack on cancer cells can overcome resistance
160516 - to chemotherathy from mutations after Millie's 5th relapse of IBC,
160517 - noted at Kaiser by the primary care physician on 080829, and explained
160518 - in Millie's letter to the medical team at that time. ref SDS 24 RP9R
160519 -
160520 -        [On 081119 Kaiser submitted a summary of final pathology
160521 -        report, ref SDS 39 5O8G, for the biopsy on 081107, ref SDS 36
160522 -        496L, and it appears status is unchanged, still triple
160523 -        negative. ref SDS 39 UQ5P
160525 -  ..
160526 - Coincidentally, during the main presentation today, Doctor Stritter
160527 - discussed advantages of circulating tumor cells (CTCs) for cancer
160528 - treatment.  This is the focus of the clinical trial proposed for
160529 - Millie using sunitinib. ref SDS 27 006S
160531 -  ..
160532 - Millie was relieved to hear that Gwen's research indicates sunitinib
160533 - metronomic cyclophosphamide and methotrexate drugs are easier to
160534 - tolerate than cetuximab and Carboplatin.  This may mean that Millie
160535 - can continue vigorous exercise that has become an aid for qualify of
160536 - life the past 2 years, shown in case study on 081017. ref SDS 28 3E4K
160538 -  ..
160539 - Gwen asked to be included in distribution of Millie's correspondence
160540 - with the medical team on treatment and response at UCSF, as part of
160541 - Gwen's research on sunitinib, discussed today.
160543 -         ..
160544 -        [On 081019 Millie sent a letter to the primary care physician
160545 -        submitting Doctor Stritter's favorable comments on the
160546 -        sunitinib clinical trial for treatting Millie's 5th relapse of
160547 -        IBC. ref SDS 29 D13Q
160549 -         ..
160550 -        [On 081114 Doctor Stritter confirmed the request today for
160551 -        copies of Millie's correspondence, ref SDS 0 1Y4G, with the
160552 -        medical team on treatment protocol and response to treatment
160553 -        with the sunitinib clinical study. ref SDS 38 FJ5J
160555 -         ..
160556 -        [On 081218 Millie sent a copy to Doctor Stritter of a letter
160557 -        notifying the medical team about the meeting at UCSF that
160558 -        reported finding good response to treatment with sunitinib
160559 -        helping Millie recover from a 5th relapse of IBC. ref SDS 42
160560 -        N55I
160562 -         ..
160563 -        [On 081219 Millie sent another letter to Kaiser only that
160564 -        complements the letter today in order to clarify planning
160565 -        options for adjusting treatments to maintain recovery, with
160566 -        less side effects. ref SDS 43 SU8R
160568 -         ..
160569 -        [On 081220 Millie's letter to Doctor Stritter keeping her
160570 -        informed, ref SDS 44 I69Q, to support 2nd opinion process,
160571 -        cites review at Kaiser of UCSF treatment planning. ref SDS 44
160572 -        9G6Q
160574 -         ..
160575 -        [On 081223 Doctor Stritter responded to Millie's letter on
160576 -        081220 noting Millie's case is quite complicated, and
160577 -        submitting procedures for second opinion support. ref SDS 45
160578 -        8N9M
160579 -
160581 -  ..
160582 - New Treatments and Quality of Life Surviving Cancer
160583 -
160584 - Gwen discussed in some depth 10 promising new treatments based on her
160585 - researching literature and attending professional conferences, and she
160586 - presented 5 main factors that affect quality of life...
160588 -  ..
160589 - Initial impression that relates to Millie's case...
160590 -
160591 -    1.  Exercise contributes significantly to recovery from cancer and
160592 -        reducing the rate of recurrence, sounded like somthing on the
160593 -        order of 60%, and evidently cited in a study presented at a
160594 -        recent oncology event.
160596 -         ..
160597 -        Need clarification of "60%" aspect of this matter.
160599 -         ..
160600 -        Gwen's research reported today, aligns with experience the past
160601 -        few years for Millie, listed on 081014, ref SDS 25 3E4K, and
160602 -        reflects Kaiser's oncology practice emphasizing importance of
160603 -        exercise, reported on 030606. ref SDS 8 JP7G
160605 -         ..
160606 -        During the seminar today, Millie's case was discussed briefly
160607 -        to underscore that diet and exercise complement mainline care.
160608 -        Case study on 081014 reports Millie working out in the gym
160609 -        several hours, and then hiking 6 miles. ref SDS 25 3E4K  On
160610 -        080606 her doctor commented on Millie surviving cancer as a
160611 -        Stage IV patient for 7 years, going on 8 years in a few months.
160612 -        ref SDS 22 0T6I  Research indicates 90% of cancer patients do
160613 -        not survive for 7 years on treatment. ref SDS 22 IO5K
160615 -         ..
160616 -        Millie joked that her "secret" diet is avocados!  Mentioned the
160617 -        article in Doctor Moini's office on 020708 that listed avocados
160618 -        as the only food that resists cancer. ref SDS 7 0001  Since we
160619 -        eat a lot of avocados, that "must" be the answer, along with
160620 -        exercise, and a great medical team.
160621 -
160622 -               [On 090206 Doctor Stritter's letter notes that Millie's
160623 -               case is inspirational surviving a very aggressive cancer
160624 -               and complex case management for so many years.
160625 -               ref SDS 47 7Q7J
160627 -         ..
160628 -        On 050609 article reports exercise repairs cumulative damage
160629 -        chemotherapy causes to the immune system; this prolongs
160630 -        effectiveness of chemotherapy treatment to aid recovery from
160631 -        breast cancer, ref SDS 14 F88M; quality of life from strength
160632 -        and range of motion are obvious benefits of exercise.
160633 -        ref SDS 14 F93X
160635 -         ..
160636 -    2.  Memory loss recovered with better cognitive strength.
160637 -
160638 -        This was presented in connection with discussion of chemobrain
160639 -        suffered in varying degrees by cancer patients treated with
160640 -        chemotherapy drugs.
160642 -         ..
160643 -        Doctor Stritter seemed to explain some type of computer game or
160644 -        similar technology that "exercises" the brain to restore and
160645 -        maintain cognitive fitness, i.e., memory.  She may have said
160646 -        this is an expensive solution.
160648 -         ..
160649 -        Aerobic exercise helps prevent memory loss and maintains
160650 -        cognitive strength by increasing blood supply to the brain,
160651 -        noted in a USA Today article published on 070328...
160652 -
160653 -              http://www.usatoday.com/tech/columnist/aprilholladay/2007-03-26-memory-part-three_N.htm
160655 -         ..
160656 -        The author, April Holladay says in part...
160657 -
160658 -            The best way to improve our memories seems to be to
160659 -            increase the supply of oxygen to the brain, which we can do
160660 -            by aerobic exercising.  Walking for three hours each week
160661 -            suffices. Swimming or bicycle riding also work.
160663 -             ..
160664 -            Such aerobic exercise has helped elderly people more
160665 -            easily switch between mental tasks, concentrate better and
160666 -            improve their short-term memory, says Arthur Kramer of the
160667 -            University of Illinois, Urbana, commenting on a number of
160668 -            studies.
160670 -             ..
160671 -            We now know why. Kramer and his team studied 59 healthy
160672 -            volunteers 60 to 79 years old, and found that aerobic
160673 -            exercise increased the number of neurons in their brains
160674 -            and the number of connections between neurons.
160676 -             ..
160677 -            Exercising the brain itself isn't as helpful as we might
160678 -            hope. Several big-name researchers (Columbia, Harvard,
160679 -            Brown, John Hopkins University, the University of
160680 -            Pennsylvania and the Mount Sinai School of Medicine)
160681 -            formed a consortium in 1992. They spent $11.4 million on
160682 -            studies researching memory loss due to aging. Intervention
160683 -            programs they devised produced only modest temporary
160684 -            improvement. Furthermore, results showed "training in a
160685 -            specific task did not lead to improvement in memory
160686 -            capacity overall."
160688 -         ..
160689 -        The article further presents theory of short and long-term
160690 -        memory that correlates to frequency of exposure...
160692 -         ..
160693 -        Communication Metrics uses 8-steps that strengthen memory to
160694 -        augment intelligence, explained in POIMS. ref OF 6 685K,
160696 -         ..
160697 -        Improving memory with Communication Metrics also improves
160698 -        health care to manage complex medical problems.  Research on
160699 -        900319 indicates that a key part of cognitive reasoning is
160700 -        accurate memory. ref SDS 1 1323  When human cognition is
160701 -        overwhelmed, people cannot remember accurately.  This causes
160702 -        mistakes that cost lives, time, and money.  In psychology,
160703 -        better memory is called "reality monitoring," reviewed on
160704 -        951031. ref SDS 3 3488
160706 -         ..
160707 -        On 951117 Doctor Brusman explains narrative therapy in
160708 -        psychology applies Communication Metrics as a solution for
160709 -        reality monitoring. ref SDS 4 9624
160711 -         ..
160712 -        Communication Metrics improves patient memory and provides
160713 -        strong synergy with objectives for better health care.  This
160714 -        reduces stress and anxiety on care providers, illustreated at
160715 -        UCSF on 080219. ref SDS 19 L18L  Another example was work at
160716 -        Kaiser on 041230. ref SDS 13 XQ84  On 041019 Communication
160717 -        Metrics helped care providers at Stanford Medical Center cope
160718 -        with complex details. ref SDS 11 LT60
160720 -         ..
160721 -    3.  Patient advocacy can significantly assist doctors and patients
160722 -        optimize recovery from cancer, and improve quality of life.
160724 -         ..
160725 -        Doctor Stritter emphasized the importance of patient advocate
160726 -        using a spouse, parent, child, friend to faciliate effective
160727 -        meetings with the doctor.  This aligns with Kaiser's Healthwise
160728 -        Handbook, reviewed on 990625. ref SDS 5 JY9J
160730 -         ..
160731 -    4.  Lymphedema presents a major risk to quality of life following
160732 -        aggressive cancer surgery removing lymph nodes in the axilla
160733 -        (under the arm).
160735 -         ..
160736 -        The doctor noted that this problem can become less pronounced
160737 -        over time because remaining lymph nodes become more robust.
160738 -        This aligns with the surgeon's comments at Kaiser on 080606.
160739 -        ref SDS 22 4P7L  Millie has been treated in the ER on 4 or 5
160740 -        occassions the past 3 years, most recently on 080409.
160741 -        ref SDS 20 0001  Vigorous exercise that exceeds capacity of the
160742 -        left arm causes lymphedema that triggers Cellulitis.  She has
160743 -        not suffered further episodes despite increasing exercise,
160744 -        which seems to support Gwen's comments today.
160746 -         ..
160747 -    5.  Gamma Knife Radiation
160748 -
160749 -        An attendee today reported her breast cancer metastasized in
160750 -        her brain.  She was successfully treated at UCSF or Stanford
160751 -        with a new form of radiation:  Stereotactic radiosurgery,
160752 -        better known as "gamma knife" therapy.
160754 -         ..
160755 -        Doctor Stritter explained this technology avoids brain surgery
160756 -        and greatly reduces collateral damage to non-cancerous cells
160757 -        that occurs with traditional radiation.  Multiple low level
160758 -        radiation beams are aimed at the cancer cell in the brain.
160759 -        Each beam is too low to kill any brain cells, but the degree of
160760 -        concentration at the target adds up to to a sufficient level
160761 -        for killing the cancer.
160763 -         ..
160764 -        Research on the Internet found an article...
160766 -             ..
160767 -            Gamma knife has great success against small brain tumors
160769 -             ..
160770 -            SF Gate
160771 -            San Francisco Chronicle
160772 -            September 20, 2005, Friday
160773 -
160774 -                  http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2005/09/30/DDGKPEVKH51.DTL
160776 -             ..
160777 -            Stereotactic radiosurgery -- better known as "gamma knife"
160778 -            radiation therapy -- has become one of the standard
160779 -            treatment options for cancer patients, particularly in
160780 -            cases of small tumors that have spread to the brain and
160781 -            can't be removed surgically.
160783 -             ..
160784 -            There's no knife, either -- just beams of ionizing
160785 -            radiation, generated by a pellet of cobalt 60 and delivered
160786 -            through a helmetlike device fitted to a patient's head.
160788 -             ..
160789 -            The idea is to deliver many beams of radiation to the
160790 -            target at the same time.  Each low-energy beam passes
160791 -            through the skull and brain tissue without causing damage.
160793 -             ..
160794 -            But at the target, where the beams cross, there's enough
160795 -            cumulative energy to damage DNA in the nuclei of the cancer
160796 -            cells and stop them from dividing.
160798 -             ..
160799 -            It's a localized effect, so most surrounding brain cells
160800 -            are spared any harm.
160802 -             ..
160803 -            It may take a half hour to two hours or more to complete
160804 -            the procedure, usually a one-time shot. But it's also
160805 -            possible to do it again if needed.
160807 -             ..
160808 -            Large tumors usually can't be zapped with the gamma knife,
160809 -            UCSF's David A. Larson, clinical director of radiation
160810 -            oncology, said, because that involves too much risk of
160811 -            collateral damage to healthy brain cells.
160812 -
160813 -            "It only works for small targets, but for those it works
160814 -            pretty well," he said.
160816 -             ..
160817 -            Compared with some of the other everyday horrors of cancer
160818 -            treatment, the gamma knife is about as benign as it gets,
160819 -            while still doing some good.
160820 -
160821 -            "This is really easy," Larson said. "You walk in, you walk
160822 -            out and go to the ballgame."
160824 -         ..
160825 -        The attendee asked for information on the sunitinib clinical
160826 -        study at UCSF to investigate treatment that may reduce risks of
160827 -        further recurrence, cited by Gwen, per above. ref SDS 0 IT78
160828 -
160829 -            [On 081019 Millie sent information on the sunitinib
160830 -            clincial study to the attendee. ref SDS 30 VK4Q
160832 -         ..
160833 -        This could be a solution if Millie's cancer spreads to
160834 -        internal organs.
160835 -
160837 -  ..
160838 - Changes to Improve Workshop
160839 -
160840 - Gwen asks about changes to the workshop?
160842 -  ..
160843 - As noted the presentation was excellent.  Considerations for a
160844 - different workshop on doctor patient partnership could address...
160845 -
160846 -    1.  Second opinions are essential diligence to discover
160847 -        opportunities and avoid mistakes by review for correlations,
160848 -        implications, and nuance hidden in place sight by the pace of
160849 -        daily work.
160851 -         ..
160852 -        Many patients are reluctant to get 2nd opinsions, worrying this
160853 -        will make the doctor feel bad, and be seen as a complaint.
160854 -        Kaiser's Healthwise Handbook recommends 2nd opinions to assist
160855 -        the front-line practitioner, reviewed on 990625. ref SDS 5 455N
160857 -         ..
160858 -        The second opinion process invests time for deliberation to
160859 -        generate intellectual capital by "connecting the dots" from
160860 -        bits and pieces of information that are easily overlooked.
160861 -        Adding time for "intelligence" converts the medical chart into
160862 -        the power of knowledge that controls the future, explained in
160863 -        NWO. ref OF 12 I38N
160865 -         ..
160866 -        Doctor Stritter's patient advocacy practice specified above,
160867 -        adds expertise and time to maek the doctor patient partnership
160868 -        effective, described as "beyond the 2nd opinion, per above.
160869 -        ref SDS 0 F49I
160871 -         ..
160872 -        Examples in case studies listed on 061018. ref SDS 16 0001
160874 -         ..
160875 -    2.  Feedback...
160876 -
160877 -        Doctor Stritter requests "feedback" using a form to submit
160878 -        comments from attendees.
160880 -         ..
160881 -        Feedback is critical for knowledge management that enables
160882 -        intelligence support, explained in POIMS. ref OF 3 0367
160884 -         ..
160885 -        There wasn't time during the presentation today for Gwen to
160886 -        explain that "feedback" in doctor patient communications
160887 -        reduces mistakes.  Fewer mistakes increases quality of care to
160888 -        save lives, time, and money.
160890 -         ..
160891 -        There is a lot of resistance to feedback, despite being
160892 -        essential to good mangement at all levels, explained in NWO,
160893 -        ref OF 14 2670, and noted by Justice Stanley Mosk of the
160894 -        California Supremee Court (deceased, circa 2005), reported in
160895 -        the record on 911130. ref SDS 2 6L8H
160897 -         ..
160898 -        Without continual efforts to refine accuracy with feedback,
160899 -        order in the record for understanding cause and effect errodes
160900 -        under constant pressure from the 2nd law of thermodynamics,
160901 -        reported on 040312. ref SDS 9 566F  Rising disorder increases
160902 -        bumbling due to vast complexities of human biology, and growing
160903 -        population that increases informtaion density which overwhelms
160904 -        span of attention, explained in NWO. ref OF 10 1675  Gwen did
160905 -        touch on the opportunity for patients to support the doctor,
160906 -        but this is hard to grasp, because the mind is designed to
160907 -        filter out complexity.  People are usually reliant on the
160908 -        experts, here a "doctor," and feel that providing feedback
160909 -        interferes with the doctor's work.
160911 -         ..
160912 -    3.  Oncology practice requires project management skills.
160913 -
160914 -        This was touched on during the discussion.  It seems like a
160915 -        major focus of Doctor Stritter's practice, per above.
160916 -        ref SDS 0 IS68
160918 -         ..
160919 -        Cancer causes a great many collateral maladies that compound
160920 -        complexities of balancing treatments to avoid conflicts, and
160921 -        also making referrals, coordination, and communication.
160923 -         ..
160924 -        The "comprehensive care" model at UCSF, and the "palliation
160925 -        care" project planned at Kaiser, cited above, ref SDS 0 IS6U,
160926 -        entail many competing objectives, requirements, and
160927 -        commitments, carried out each day with many meetings, calls,
160928 -        and documents.  Discovering and maintaining alignment of
160929 -        correlations, implications, and nuance to make sense of
160930 -        complexity requires tools and practices to manage chronology,
160931 -        context, and connections.  Review at SRI on 000307 found that
160932 -        Knowledge Management is a lot of hard work. ref SDS 6 767G
160934 -         ..
160935 -        If the "project" fails or has serious problems on the job,
160936 -        well, there's always another project.  This is less acceptable
160937 -        when you are the "project."
160939 -         ..
160940 -    4.  Image testing with CT and PET
160941 -
160942 -        Better command and control of the record can improve care,
160943 -        illustrated by the recent test on 080718, reviewed on 080723.
160944 -        ref SDS 23 RU6R
160946 -         ..
160947 -        The case study on 061012, ref SDS 15 A55J
160948 -
160949 -
160950 -
160951 -
160952 -
160953 -
160954 -
160955 -
1610 -