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: October 24, 2008 11:50 AM Friday; Rod Welch

Millie meeting primary care physician review start new treatment at UCSF.

1...Summary/Objective
2...Examination Progression IBC All Sites
3...IBC Progression Rash Breastbone Left Chest Wall Spreading Toward Back
4...Supraclavicular Left Side Swelled Node Symptom Progression IBC
5...Sunitinib Protocol Work Plan Approved
6...Work Plan Approved for Transition to Sunitinib Protocol
7...Status Change Core Biopsy Test Left Supraclavicular
8...Case Management Documents Lost Sunitinib Protocol
9...Referral Case Management Lost Documents Sunitinib Protocol
10...Documents Sunitinib Protocol Lost in Referral Case Management
11...Test Requirements Prepare Treatment Sunitinib Treatment for IBC
12...Sunitinib Clinical Study Consent Document Screening Tests
13...CT Test Ordered Kaiser Walnut Creek Power Port Include Neck
14...Echocardiogram Ordered Evaluate Heart Suitability for Sunitinib
15...MRI Test Not Specified UCSF Sunitinib Documentation
16...Medical Chart Reports Examination Diagnosis Prescription Prognosis


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CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 49 0000.
040502 -
040503 -
040505 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - The meeting today was delayed from the scheduled time of 1140, because
040902 - at 1130 Millie had to see Doctor Wong in the Head and Neck Department
040903 - about doing a core biopsy. ref SDS 65 G15K
040905 -  ..
040906 - The primary care physician received Millie's letter submitted
040907 - yesterday to Kaiser on 091023 and listing an agenda for the meeting
040908 - today. ref SDS 61 W35K
040910 -  ..
040911 - The doctor was sorry about Doctor Damen's notice yesterday that
040912 - pathology was positive for breast cancer on the FNA biopsy for the
040913 - node in the left supraclavicular performed the day before on 081022.
040914 - ref SDS 63 4Q9Q  The doctor concurs with Doctor Rugo's determination
040915 - in a letter to the medical team also on 081023 that Millie must end
040916 - treatments with cetuximab and Carboplatin at UCSF, ref SDS 64 D65G,
040917 - which has been effective preventing progression of Millie's cancer for
040918 - nearly 2 years, beginning on 070201. ref SDS 24 0001
040920 -  ..
040921 - Today, the doctor feels Millie has been very fortunate responding to a
040922 - single treatment regimen for such a long time (21 months), because
040923 - stage IV cancer patients often suffer progression within 6 months.
040924 - Millie recalled that on 070315 Brigid advised 10 months was the
040925 - longest anyone had been treated with cetuximab and Carboplatin.
040926 - ref SDS 25 6A9H
040928 -  ..
040929 - Millie asked about problems this past May, when there was a mixup in
040930 - communication about dose levels that may have caused relapse in 6
040931 - months, much sooner than the 1-year period expected at UCSF, reported
040932 - on 080306. ref SDS 30 5V4O
040934 -  ..
040935 - On 080423 Millie sent a letter asking the medical team to experiment
040936 - with a lower dose of Carboplatin in order maintain steady treatment
040937 - that aids recovery. ref SDS 35 418K  Adjusting treatment dose levels
040938 - according to blood counts has worked well in Millie's patient history,
040939 - shown by case study on 060810, ref SDS 20 HV45  Adjusting chemotherapy
040940 - dose to blood counts rather than skipping treatments was reviewed at
040941 - UCSF on 080418, ref SDS 34 598J, citing strategies to balance blood
040942 - counts and chemotherapy to optimize treatment for cancer discussed at
040943 - Kaiser on 040614. ref SDS 13 9S9H
040945 -  ..
040946 - Today, Doctor Johnson recalled that on 080403 Doctor Rugo at UCSF
040947 - prescribed Neupgoen treatments at Kaiser to maintain blood counts so
040948 - that Millie could get steady treatment with Carboplatin. ref SDS 32
040949 - 6Y9K  There was confusion using the computer at Kaiser ordering the
040950 - Neupogen treatment, reported on 080502. ref SDS 37 NM3M; and the
040951 - pharmacy had problems filling the doctor's prescription. ref SDS 37
040952 - NM5K  This was finally corrected on 080609, ref SDS 41 IL6I, but with
040953 - more problems using the computer, reported by the doctor at that time
040954 - on 080609. ref SDS 41 837J
040956 -  ..
040957 - Millie is concerned today, that Doctor Rugo said in a letter on 080423
040958 - the dose level of Carboplatin could not be lowered and increased
040959 - according to blood counts, as had been the practice in Millie's
040960 - patient history (see again case study on 060810, ref SDS 20 HV45).
040961 - Doctor Rugo indicated that once the dose of Carboplatin was reduced so
040962 - Millie could get treatment on a day with low blood counts, the dose
040963 - could not be increased even after blood counts improve, ref SDS 35
040964 - I49N, despite success using this practice in Millie's medical history.
040966 -  ..
040967 - As a result of this change in treatment strategy, likely dictated by
040968 - clinical study protocol, Millie notified the medical team to maintain
040969 - treatment with Carboplatin at the maximum dose in order to optimize
040970 - recovery from IBC. ref SDS 35 TY6Y  A week later on 080501 Millie
040971 - confirmed during a meeting at UCSF guidance for the medical team to
040972 - maintain high dose levels of Carboplatin, and to maintain blood counts
040973 - with Neupogen, ref SDS 36 CZ3N, in order to maintain recovery from IBC
040974 - that already been achieved with the full dose of Carboplatin, found by
040975 - examination at that time on 080501. ref SDS 36 LS3J
040977 -  ..
040978 - On 080605 Millie learned that UCSF reduced the dose of Carboplatin
040979 - contrary to guidance, without notice, ref SDS 39 YD51, and evidently
040980 - by mistake, reported in the record on 080529. ref SDS 38 PVUQ  After
040981 - reducing the dose of Carboplatin, Millie began to relapse with rising
040982 - cancer marker, CA 15-3 142 at Kaiser, and expanding rash, cited in
040983 - Millie's letter on 080716. ref SDS 46 IT77
040985 -  ..
040986 - Today, Doctor Johnson recalled getting Millie's letter on 080716 sent
040987 - through Kaiser's Knowledge Management electronic mail system.  A few
040988 - weeks later on 080829 he palpated progression of disease in the left
040989 - supraclavicular, ref SDS 50 RP8T, and recommended Millie start the
040990 - process at UCSF transitioning to a new treatment. ref SDS 50 RP9R
040992 -  ..
040993 - The doctor indicated that despite possible mistakes and mixups in
040994 - communication and changes in chemotherapy dose levels that may have
040995 - reduced Millie's recovery from IBC, he feels treatment with cetuximab
040996 - and Carboplatin has been a stunning success for 23 months.  Millie's
040997 - extremely favorable response makes the doctor's referral on 070105 for
040998 - treatment at UCSF a very good medical decision. ref SDS 22 PK68
040999 - Doctor Rugo commented similarly, when Carboplatin was added to
041000 - cetuximab on 080306. ref SDS 30 5V4O  On 080605 Doctor Riley-Paull was
041001 - surprised Millie is still alive, ref SDS 40 0T6I; research at that
041002 - time indicates 90% of stage IV cancer patients do not survive for 7
041003 - years. ref SDS 40 SG4M
041004 -
041005 -            [On 090213 Doctor Johnson met with Millie at Kaiser and
041006 -            advised that Kaiser has been successful providing effective
041007 -            care that has extended Millie's survival well beyond
041008 -            expectations. ref SDS 77 NY7L
041010 -  ..
041011 - Millie is concerned today that starting new treatment with sunitinib
041012 - will repeat delays that occurred last year starting cetuximab at UCSF,
041013 - reported in case study on 070130. ref SDS 23 2X6L
041015 -  ..
041016 - Doctor Rugo has ordered a lot of tests and screening procedures listed
041017 - for the work plan on 081016. ref SDS 57 J36R  Kaiser will go into
041018 - insurance policy interpretation mode that was extremely stressful to
041019 - the medical team for the entire year of 2007, shown by Paula McPhail's
041020 - call to Millie on 071005. ref SDS 27 KA5J  Bob Schwartz at UCSF noted
041021 - in a letter to Millie on 071007, ref SDS 28 X65I, that his friend,
041022 - Kitty Cook, at Kaiser called Millie with a claim that HIPAA, which has
041023 - nothing to do with payments, required Millie to pay money to UCSF
041024 - which in fact Kaiser owed. ref SDS 28 JW7M
041026 -  ..
041027 - Everyone was overwhelmed by complexities of case management balancing
041028 - requirements for patient care against cost containment, discussed at
041029 - Kaiser on 070921, ref SDS 26 QY96  Finding people responsible for
041030 - referral delays and roadblocks, and communicating to correct mistakes
041031 - proved so frustrating that Doctor Johnson prescribed Prozac medication
041032 - for Millie to cope with stress, reported on 080305 ref SDS 29 5L5M,
041033 - expanding an earlier prescription on 070921, ref SDS 26 QY9V, to
041034 - increase Atavin drugs that can be safely taken with mental health
041035 - therapy, for coping with panic attacks from emotional trauma from
041036 - trying to understand conflicting and unsupported medical billings,
041037 - ref SDS 26 QY45, noted in the medical chart at that time. ref SDS 26
041038 - WF8P
041040 -  ..
041041 - Today, Millie said that she cannot survive another nightmare like
041042 - 2007.
041044 -  ..
041045 - Doctor Johnson feels treatment will not be delayed again, because he
041046 - has already submitted authorization for Millie to get treatment at
041047 - UCSF to recover from the 5th relapse of IBC, as planned in the medical
041048 - chart on 080829, ref SDS 49 PX5V, and with the sunitinib multi-agent
041049 - protocol prescribed by Doctor Rugo in the UCSF work plan on 081016.
041050 - ref SDS 57 J38U  The doctor feels timely authorization today will make
041051 - referral go more smoothly this time, without all the problems that
041052 - occurred starting out treatment for the 4th relapse of IBC in January
041053 - of 2007 at UCSF, shown by case study on 070130. ref SDS 23 2X6L
041054 -
041055 -        [...below in this record on 081024 1150 Doctor's medical chart
041056 -        says treatment with sunitinib approved. ref SDS 0 OZ5F
041058 -         ..
041059 -        [On 081024 1354 Millie's letter notifies medical team that
041060 -        during meeting at Kaiser with primary care physician the doctor
041061 -        confirmed authorization for Millie's treatment in the sunitinib
041062 -        clinical study that is a double agent "targeted" treatment, and
041063 -        Kaiser does not have equal or better treatments for Millie.
041064 -        ref SDS 66 XZ8W
041066 -  ..
041067 - Doctor Johnson emphasized that, since Millie has suffered relapse of
041068 - IBC 5-times, he wants to prevent administrative problems that delayed
041069 - her treatment last year, and caused cancer to worsen for weeks, per
041070 - above. ref SDS 0 K66I
041072 -  ..
041073 - The doctor was disappointed that Millie's letter on 081016 to the
041074 - medical team did not provide a list of drugs at UCSF for future
041075 - relapses. which was discussed in the meeting at Kaiser on 080829,
041076 - ref SDS 49 PX5V, and noted in Millie's letter to the team the same
041077 - day, reported on 080829 2256. ref SDS 50 RP9R
041079 -  ..
041080 - Millie advised that the meeting on 081016, with Doctor Rugo and Tara
041081 - at UCSF was very hectic and emotional, noted in her letter.  She was
041082 - elated to hear that Doctor Rugo has more treatments lined up to treat
041083 - more relapses, noted in the record on 081016. ref SDS 57 NW6M
041085 -  ..
041086 - Today, Doctor Johnson was understanding that the meeting at UCSF on
041087 - 081016, diagnosing and telling the patient about relapse, and then
041088 - scheduling all of the tasks for the next treatment was hectic and
041089 - emotional for everybody, not just Millie, because the details are
041090 - extremely complex, as shown on 081016. ref SDS 57 J36R  He smiled and
041091 - said that even doctors cannot think of everything at once.
041093 -  ..
041094 - Doctor Johnson feels that, since Millie's care is now a very complex,
041095 - and Doctor Rugo has many more patients, also, with complex situations,
041096 - getting the actual written list of additional treatments UCSF plans
041097 - for Millie is helpful, so that critical details for future work don't
041098 - "slip through the cracks" and delay getting treatment again, when
041099 - there will be less time to avoid losing control.
041101 -  ..
041102 - The doctor explained that cancer cells which survive multiple
041103 - treatments are very robust, and so resist standard chemotherapy drugs
041104 - available at Kaiser.  Millie's patient profile of 5-relapses indicates
041105 - her cancer has mutated into a more aggressive disease that requires
041106 - timely treatment with agents, like cetuximab, targeted to the genetic
041107 - profile of the cancer.  Doctor Johnson noted that, since cancer
041108 - becomes more aggressive with each relapse, there is less time for
041109 - starting treatment in order to maintain control.  The doctor was
041110 - therefore pleased that UCSF has identified a line of drugs that will
041111 - be ready in time to be effective for Millie to recover from future
041112 - relapses, reported on 081016, ref SDS 57 NW6M, but asked to remind
041113 - the team to submit a list so things are not so hectic the next time,
041114 - and the next, etc.
041116 -  ..
041117 - This aligns with Doctor Johnson's explanation on 030710 that cancer
041118 - mutates to survive chemotherapy, and so new treatment must be started
041119 - quickly in time to be effective. ref SDS 8 IV4N  Brigid made a similar
041120 - explanation during the meeting at UCSF on 070315, saying that each
041121 - time cancer relapses and the patient has to change treatment, the time
041122 - to progression of disease shortens due to mutation from surviving
041123 - prior treatments. ref SDS 25 6A9H  This makes starting new treatment
041124 - quickly an increasingly urgent priority for effective care.
041125 -
041126 -        [...below in this record on 081024 1150 Doctor's medical chart
041127 -        says treatment with sunitinib approved. ref SDS 0 OZ5F
041129 -         ..
041130 -        [On 081024 1833 Millie notified the medical team that Doctor
041131 -        Johnson was implementing Doctor Rugo's planning for Millie's
041132 -        care at UCSF. ref SDS 66 IY5J
041134 -         ..
041135 -        [On 081219 1140 doctor explains urgency of timely treatment
041136 -        increases for each relapse, delaying treatment increases risk
041137 -        of losing control for cancer that mutates into more aggressive
041138 -        disease. ref SDS 74 KU6F
041140 -         ..
041141 -        [On 090123 1326 Doctor Johnson calls and concurs Millie has
041142 -        suffered IBC relapse with cancer marker CA 15-3 303 in blood
041143 -        test on 090116 at Kaiser; confirms Millie's cancer has mutated
041144 -        to resist treatments available at Kaiser, authorizes UCSF to
041145 -        prescribe next treatment. ref SDS 75 RK6O
041147 -         ..
041148 -        [On 090204 0219 Millie's letter asks Doctor Rugo to submit
041149 -        proactive planning for follow on treatment after hyperthermia
041150 -        and Doxil for Millie's 6th relapse of IBC. ref SDS 76 278T
041152 -         ..
041153 -        [On 090213 1140 doctor attributes sudden rapid advance of IBC
041154 -        after significant recovery signals mutated cancer into much
041155 -        more aggressive disease that requires getting treeatment in
041156 -        time to be effective. ref SDS 77 GC6N
041158 -         ..
041159 -        [On 090218 1205 Millie's letter notifies medical team that
041160 -        Doctor Johnson has ordered Millie's continued care at UCSF,
041161 -        citing prior instructions on 080829, 081026, 081219, and on
041162 -        090123, all authorizing UCSF to begin planning for Millie's
041163 -        next treatment, so that past delays are avoided, because
041164 -        Millie's cancer has mutated through multiple relapses
041165 -        (total of 7 so far) into a very aggressive disease which
041166 -        requires treatment quickly in order to be effective.
041167 -        ref SDS 78 TH6U
041168 -
041169 -
041171 -  ..
041172 - Examination Progression IBC All Sites
041173 - IBC Progression Rash Breastbone Left Chest Wall Spreading Toward Back
041174 -
041175 - Examination today shows significant progression of disease, notably
041176 - increased nodules and intensity of IBC on the breastbone area.  There
041177 - is also increased IBC inflammation on the upper left arm, and spread
041178 - of rash from the left chest toward the abodmen and wrapping toward the
041179 - back.  This aligns with findings during examination at UCSF on 081016.
041180 - ref SDS 57 J34U
041181 -
041182 -        [...below medical chart reports progression of IBC. ref SDS 0
041183 -        CV44
041185 -  ..
041186 - The doctor concurred with findings at UCSF on 081016 that IBC has
041187 - increased substantially. ref SDS 57 J34U   This aligns with the last
041188 - cancer marker test at Kaiser on 080708 showing CA 15-3 141.
041189 - ref SDS 44 05YW  The doctor recalled that CA 141 is the highest ever
041190 - recorded for Millie at Kaiser, and so signals significant progression
041191 - of cancer.  The cancer marker at UCSF using a different scale from
041192 - Kaiser has increased less since July, reported on 081016. ref SDS 56
041193 - W28I
041195 -         ..
041196 -        [On 081024 1354 Millie's letter to Doctor Rugo reported that
041197 -        Doctor Johnson concurred today with UCSF examination on 081016
041198 -        finding progression of disease, and approved Millie for
041199 -        treatment wih sunitinib clinical study. ref SDS 66 XZ8W
041200 -
041201 -
041203 -  ..
041204 - Supraclavicular Left Side Swelled Node Symptom Progression IBC
041205 -
041206 - The doctor again palpated the lump in the left supraclavicular and
041207 - indicated this is larger than presented during examination on 080829.
041208 - ref SDS 50 RP8T  This further supports similar findings at UCSF on
041209 - 081016, ref SDS 57 J34X, and correlates with the pathology report of
041210 - recurrent cancer received from the Kaiser Head and Neck Department
041211 - yesterday on 081023. ref SDS 63 4Q9Q
041212 -
041213 -        [...below medical chart reports palpation LN in left
041214 -        supraclavicular. ref SDS 0 TN6H
041216 -         ..
041217 -        [...below medical chart lists pathology for biopsy on 081022 of
041218 -        lymph node in left supraclavicular findings positive for breast
041219 -        cancer. ref SDS 0 VV7L
041221 -         ..
041222 -        [On 081024 1354 Millie's letter to Doctor Rugo reported that
041223 -        Doctor Johnson concurred today with UCSF examination on 081016
041224 -        finding progression of disease, and approved Millie for
041225 -        treatment wih sunitinib clinical study. ref SDS 66 XZ8W
041226 -
041227 -
041229 -  ..
041230 - Sunitinib Protocol Work Plan Approved
041231 - Work Plan Approved for Transition to Sunitinib Protocol
041232 -
041233 - The doctor approved the UCSF work plan for transitioning Millie to
041234 - treatment with the sunitinib clinical trial, submitted to the medical
041235 - team on 081016. ref SDS 57 BV9J
041237 -  ..
041238 - He feels communication between Kaiser and UCSF is critical now for
041239 - collaboration on starting Millie's treatment with sunitinib in time to
041240 - be effective.
041242 -         ..
041243 -        [...below medical chart reports examination finding progression
041244 -        of cancer. ref SDS 0 CV44
041246 -         ..
041247 -        [...below assessment finds progression of IBC. ref SDS 0 336O
041249 -         ..
041250 -        [On 081024 Millie's letter notifies medical team that
041251 -        during meeting at Kaiser with primary care physician the
041252 -        doctor confirmed authorization for Millie's treatment in
041253 -        the sunitinib clinical study that is a double agent
041254 -        "targeted" treatment, and Kaiser does not have equatl or
041255 -        better treatments for Millie. ref SDS 66 XZ8W
041256 -
041258 -  ..
041259 - Status Change Core Biopsy Test Left Supraclavicular
041260 -
041261 - The doctor asked about the meeting with Doctor Wong earlier today at
041262 - 1130 on performing the core biopsy to test for status change, which is
041263 - the first action item in Doctor Rugo's work plan. ref SDS 57 BV9J
041265 -  ..
041266 - Millie advised that Doctor Wong decided to delay the work until after
041267 - she returns from vacation on 081107, because of risk that infection
041268 - might occur.  Doctor Wong feels more comfortable handling this risk
041269 - with Millie at home where treatment is available at Kaiser by doctors
041270 - familiar with Millie's complex patient history. ref SDS 65 6N6H
041271 -
041272 -        [...below medical chart Plan lists core biopsy 081107.
041273 -        ref SDS 0 OZ6H
041274 -
041276 -  ..
041277 - Case Management Documents Lost Sunitinib Protocol
041278 - Referral Case Management Lost Documents Sunitinib Protocol
041279 - Documents Sunitinib Protocol Lost in Referral Case Management
041280 -
041281 - During the meeting, the doctor asked about the consent document for
041282 - Millie to get treatment in the sunitinib clinical study at UCSF?
041284 -  ..
041285 - Millie explained this was submitted previously to the medical team on
041286 - 081016, ref SDS 57 J38U, and reviewed by Millie on 081017. ref SDS 58
041287 - HF5H  The doctor apologized for mixups that required a second
041288 - submission to Kaiser on 081021, ref SDS 59 W83I  A few days ago on
041289 - 081022, Millie hand carried a printed copy of the constent document
041290 - and left it at the front desk for Doctor Johnson to prepare for the
041291 - meeting today. ref SDS 60 XK5H
041293 -  ..
041294 - The doctor said that he still has not seen the Consent Document.
041295 - People get busy with a hectic schedule and forget to distribute
041296 - documents left at the front counter for Oncology.
041298 -  ..
041299 - Millie brought another copy to the meeting.
041300 -
041302 -  ..
041303 - Test Requirements Prepare Treatment Sunitinib Treatment for IBC
041304 - Sunitinib Clinical Study Consent Document Screening Tests
041305 -
041306 - Doctor Johnson read through the consent document and discussed issues
041307 - from Millie's review on 081017. ref SDS 58 YX9N  Millie was mainly
041308 - concerned about side effects. ref SDS 58 4G7G  She recalled Doctor
041309 - Rugo indicating during the meeting at UCSF on 081016, that the most
041310 - common side effect was a dry mouth that caused saliva. ref SDS 57 J35X
041312 -  ..
041313 - The doctor related that exerpience at Kaiser treating patients with
041314 - sunitinib, other than for breast cancer, shows side effects include
041315 - fatigue and some neuropathy with tingling in the skin of fingers and
041316 - toes that can be dibilitating for some patients.  He feels Millie's
041317 - strong physical conditioning from vigorous exercise will help minimize
041318 - difficult side effects.  The dose levels may be different in cases at
041319 - Kaiser from the "low dose" protocol Millie will get in Doctor Rugo's
041320 - study at UCSF, shown in the Consent document on 081017. ref SDS 58
041321 - ZT98
041323 -  ..
041324 - Doctor Johnson suggested that Millie ask Doctor Rugo to clarify side
041325 - effects based on experience of other patients in the study, and with
041326 - respect to Millie's energy level for maintaining vigorouse exercise
041327 - that has contributed to qualify of life.
041328 -
041329 -               [On 081024 1354 Millie's letter to UCSF cites experience
041330 -               at Kaiser with Sunitinib, and asks for comments on
041331 -               differences that can be expected based on metronomic
041332 -               dose levels. ref SDS 66 XZ9V
041333 -
041335 -  ..
041336 - CT Test Ordered Kaiser Walnut Creek Power Port Include Neck
041337 -
041338 - The agenda for the meeting today submitted in a letter to Kaiser
041339 - yesterday on 081023 calls for ordering tests to start new treatment
041340 - with sunitinib. ref SDS 61 TH9K, and as specified in the Consent
041341 - documents, reviewed on 081017. ref SDS 58 NK5I
041343 -  ..
041344 - CT test was scheduled for 081107 1330.
041346 -  ..
041347 - This correlates with Millie's meetings in the morning for treatments
041348 - at UCSF, so there is time to drive back to Kaiser in Walnut Creek.
041349 - San Francisco.
041351 -  ..
041352 - During the meeting today in Oncology, Doctor Johnson used Kaiser's
041353 - Knowledge Management system to schedule Millie for the CT test and to
041354 - order Barrium Sulfate solution.  This is the new oral contrast medium
041355 - Kaiser has adopted for CT tests that changes from Gastrogafin,
041356 - reported on 080822. ref SDS 48 VC42  The order was placed for the
041357 - Yosemite Pharmacy at Park Shadelands.
041358 -
041359 -        [...in another record today on 081024 1354 Millie's letter to
041360 -        the medical team coordinated planning by Kaiser for the CT test
041361 -        using the Power Port, ref SDS 66 XZ9P, Millie stopped at
041362 -        Yosemite Pharmacy at Kaser Park Shadelands to purchase barrium
041363 -        sulfate sulfate contrast medium. ref SDS 66 ML7I
041365 -  ..
041366 - Doctor Johnson ordered the test at the Walnut Creek Kaiser CT
041367 - Department, and added to the referral that the test will be performed
041368 - using Millie's Power Port for injecting contrast medium, as requested
041369 - in Millie's letter yesterday on 081023, ref SDS 61 TH9K, and also will
041370 - include the neck to evaluate the node in the left supraclavicular
041371 - cited in examination at UCSF reported in the letter on 081016.
041372 - ref SDS 57 J34X
041374 -  ..
041375 - Ordering this CT test at Kaiser in Walnut Creek implements prior
041376 - planning on...
041377 -
041378 -               080917............................ ref SDS 54 SG4X
041379 -               081015............................ ref SDS 55 K354
041380 -               081016............................ ref SDS 57 J44X
041381 -               081023............................ ref SDS 61 TH9K
041383 -  ..
041384 - Previously, Millie coordinated on 080711 with Paula in the Infusion
041385 - Clinic, ref SDS 45 OC9G, and then with Ike in the CT Department to
041386 - schedule the CT test on 080718 to use the Power Port. ref SDS 45 PP6O
041387 - Difficulties with technology transfer caused problems using the Power
041388 - Port for the CT test on 080718. ref SDS 47 LK3R  The next CT test was
041389 - done at Kaiser in Oakland.  On 080905, the primary care physician
041390 - approved coordination to arrange for Millie's CT test. ref SDS 51 S28G
041392 -  ..
041393 - As a result, the doctor asked Millie to coordinate with the CT
041394 - Department in Walnut Creek about using Millie's Power Port for
041395 - pressure injection of contrast medium, to perform the action item in
041396 - the agenda for the meeting today, submitted to the medical team
041397 - yesterday on 081023. ref SDS 61 I55F
041399 -                ..
041400 -               [On 081024 1354 Millie's letter to the medical team
041401 -               notifies UCSF that Doctor Johnson ordered CT testing
041402 -               required for screening to participate in the sunitinib
041403 -               clinical study. ref SDS 66 XZ9P
041404 -
041405 -
041407 -  ..
041408 - Echocardiogram Ordered Evaluate Heart Suitability for Sunitinib
041409 -
041410 - The doctor used Kaiser's computer to order an Echocardiogram test on
041411 - 081110 0930. required by UCSF Consent Documents for screening to
041412 - participate in the sunitinib protocol, listed on 081017. ref SDS 58
041413 - LH53
041415 -                ..
041416 -               [On 081024 1354 Millie's letter to the medical team
041417 -               notifies UCSF that Doctor Johnson ordered the
041418 -               echoccardiogram test required for screening to
041419 -               participate in the sunitinib clinical study. ref SDS 66
041420 -               XZ9S
041421 -
041423 -  ..
041424 - MRI Test Not Specified UCSF Sunitinib Documentation
041425 -
041426 - Millie asked about an MRI?  She recalled last week Thursday on 081016
041427 - that Glenna came into the Infusion Clinic after the meeting with
041428 - Doctor Rugo in the Breast Care Clinic, and submitted the Consent
041429 - Documents.  Millie remembered that Glenna went over screening tests
041430 - needed at Kaiser, and seemed to say there is a brain MRI required.
041431 - ref SDS 57 J38U
041433 -  ..
041434 - Doctor Johnson looked again through the Consent Documents and could
041435 - not find anything about an MRI.  As a result, this was not ordered.
041436 -
041437 -
041438 -
041439 -
0415 -

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

2303 -
230401 -  ..
230402 - Medical Chart Reports Examination Diagnosis Prescription Prognosis
230403 -
230404 - Follow up ref SDS 49 YT5N, ref SDS 43 YT5N.
230405 -
230406 - Received the doctor's report in the medical chart for the meeting
230407 - today...
230408 -
230409 -    1.  Received:  10/27/08 3:19 PM
230410 -
230411 -        Patient presents with:  recheck - 8 wk
230413 -         ..
230414 -    2.  History of Present Illness:
230415 -
230416 -        The patient is a 72 Y female with a history of [secondary] IBC
230417 -        of left breast who was initially diagnosed 03/04/02 [with
230418 -        biopsy reported in the record on 020306, ref SDS 1 5K9F -
230419 -        pathology findings "left breast infiltrating carcinoma"
230420 -        presented to patient on 020321, ref SDS 3 YE5N; surgery left
230421 -        breast sentinel node procedure with left axillary disection and
230422 -        left breast lumpectomy performed 020312, ref SDS 2 Q78M, and
230423 -        pathology reported on 020321. ref SDS 2 Q78M  Phase I adjuvant
230424 -        treatment started with AC on 020423, ref SDS 4 0001; after 2
230425 -        cycles cancer marker CA 15-3 rising and PET scan test indicated
230426 -        cancer spreading, so on 020610 switched to Taxotere for last 2
230427 -        cycles of Phase I; ref SDS 5 MR5I; radiation was completed on
230428 -        020910 with 2 weeks of additional treatment, reported on
230429 -        020924. ref SDS 6 0J7H  Phase II with 4 cycles of Taxotere
230430 -        completed adjuvant treatment on 021204. ref SDS 7 F5Z5]  She
230431 -        had recurrent disease noted in the cervical LN's 03/03/04. [as
230432 -        shown in patient history, ref SDS 9 Y171, and results reported
230433 -        to patient on 040309, ref SDS 10 0001.  Pathology findings for
230434 -        biopsy on 040419 diagnosed IBC, reported to the patient on
230435 -        040517, ref SDS 12 RH5V].  On E2100 Study with Avastin
230436 -        ([beginning on 040420, ref SDS 11 9Z5J], but she had a PE noted
230437 -        on CT 11/03/2004 [reported 041104, ref SDS 14 RZ4I; treatment
230438 -        was resumed with 4 cycles of AC on 050104, ref SDS 15 407N].
230439 -        Progression of disease required changing treatment to Taxotere
230440 -        and Xeloda started on 4/15/05. ref SDS 16 407N  She had a total
230441 -        of 8 cycles ending 9/16/05. ref SDS 17 407N  [IBC symptoms
230442 -        fully subsided, and cancer marker declined].  She had a
230443 -        palliative left mastectomy performed 10/21/05. ref SDS 18 EG5L
230444 -        Then her left chest lesions began expanding again.  The patient
230445 -        started Taxotere and Xeloda again 07/21/06 for 7 cycles.
230446 -        ref SDS 19 407N  She was started on [weekly treatments in ] a
230447 -        Clinical Trial 02/01/07 at UCSF and was randomized to the
230448 -        Erbitux only (no Carbo) Arm. ref SDS 24 XR3M  She had weekly
230449 -        Carboplatin added 03/13/08 because of progression of disease.
230450 -        ref SDS 31 TZ8I  Her disease has progressed again [for the 5th
230451 -        time] and she is being considered for Phase I/II Study of
230452 -        Sunitinib (SU11248) at UCSF [shown by patient's letter to the
230453 -        medical team on 081016, ref SDS 57 J38U, and listing UCSF work
230454 -        plan. ref SDS 57 J36R]  Lengthy discussion and review of study
230455 -        and drug side effects and potential effectiveness [per above,
230456 -        ref SDS 0 C46G].
230458 -         ..
230459 -    3.  Current medications:
230460 -
230461 -        HYDROCODONE/ACETAMINOPHEN 5 5
230462 -        combined in tablets of...... Vicodin/Lortab 080708, ref SDS 44 BT8C
230463 -        PROCHLORPERAZINE 10MG....... Compazine. 080313, ref SDS 30 FA4H
230464 -        ONDANSETRON 8 MG TABLETS.... Zofran.... 080313, ref SDS 30 FA4H
230465 -        CEPHALEXIN 500 MG CAPSULES.. Keflex.... 080409, ref SDS 33 F142
230466 -        FLUOXETINE 20 MG CAPSULES... Prozac.... 080305, ref SDS 29 5L5M
230467 -        NEUPOGEN 480MCG/1.6ML.................. 080502, ref SDS 37 NL4M  ,
230468 -        WARFARIN 4 MG TABLETS....... Coumadin.. 061002, ref SDS 21 MI5I
230469 -        TIMOLOL MALEATE 0.5% EYE.... Eye drops
230470 -        ACYCLOVIR 800MG............. Zoviraxe.. 070614 (no record prescribed by Doctor Rugo to treat cold sore on lip)
230471 -        LORAZEPAM 1 MG.............. Ativan.... 070921, ref SDS 26 3N8J
230473 -  ..
230474 - The medical chart does not include contrast medium Gastrografin 66/10
230475 - solution treatment for CT tests, ordered by Kaiser for Millie on
230476 - 080617, ref SDS 42 DF64, and reported in Kaiser's list of medications
230477 - received during the meeting on 080502. ref SDS 37 SY4M  Continues
230478 - omission of contrast medium for the CT test on 080911, ref SDS 52
230479 - X56N, from the medical chart on 080829. ref SDS 49 554I
230480 -
230481 -        Barrium Sulfate Suspension............. 080222, ref SDS 48 6T9K
230483 -  ..
230484 - On 081016 Doctor Rugo prescribed sunitinib, cyclophosphamide, and
230485 - Methotrexate. ref SDS 57 J38U  Treatment is pending completion of work
230486 - plan, ref SDS 57 J36R, including scanning criteria, e.g., CT test.
230487 - ref SDS 57 J44X
230488 -
230489 -               [On 081114 Millie begins treatment with sunitinib alone
230490 -               to evaluate tolerance for the full regimen. ref SDS 69
230491 -               505G
230493 -                ..
230494 -               [On 081128 Millie begins taking Prilosec to relieve
230495 -               heartburn side effects taking sunitinib. ref SDS 72 NT5H
230497 -                ..
230498 -               [On 081129 Millie begins treatment adding
230499 -               cyclophosphamide and Methotrexate to sunitinib.
230500 -               ref SDS 73 VR5F
230501 -  ..
230502 - Medical Chart continues...
230503 -
230504 -    4.  Review of systems:
230505 -
230506 -        a.  Constitutional: Appetite and energy level are good.  No
230507 -            recent fevers.
230509 -             ..
230510 -        b.  ENT: No mucositis or nose bleeds.
230512 -             ..
230513 -        c.  Cardiovascular: No SOB, palpitations or chest pain
230515 -             ..
230516 -        d.  Respiratory: No hemoptysis or cough
230518 -             ..
230519 -        e.  GI: No nausea, vomiting, diarrhea or abdominal pain
230521 -             ..
230522 -        f.  Musculoskeletal: Bone pain with Neupogen
230524 -             ..
230525 -        g.  Skin: IBC progressing on LUE
230526 -
230527 -                [On 081219 1140 medical chart on 081219 does not list
230528 -                IBC rash for "skin" systgem. ref SDS 74 6L8S
230530 -             ..
230531 -        h.  Neurological: No confusion, sensory changes or motor
230532 -            weakness
230534 -             ..
230535 -        i.  Psychiatric: Less depression
230537 -             ..
230538 -        j.  Hemat/Lymph: No bleeding or bruising
230540 -         ..
230541 -    5.  Physical Examination
230542 -
230543 -        a.  ECOG Performance Score 0
230545 -  ..
230546 - Previously, the medical chart used an account for "Performance Status"
230547 - which seems to be similar to this new account. ref SDS 49 NP5M
230549 -  ..
230550 - Medical Chart continues...
230551 -
230552 -        b.  BP 157/84  Pulse 52  Temp (Src) 96.9 F (36.1 C) (Oral)
230553 -            Wt 137 lb 9.6 oz (62.415 kg) | SpO2 95%
230555 -             ..
230556 -        c.  Head: normocephalic
230558 -             ..
230559 -        d.  Eyes: normal conjunctiva
230561 -             ..
230562 -        e.  Lymph: left supraclavicular LN, ref SDS 0 PV5I, but no
230563 -            nodes palpable in axillae
230565 -             ..
230566 -        f.  Lungs: clear to percussion and auscultation
230568 -             ..
230569 -        g.  Chest Wall: Progression of IBC involving th skin,
230570 -            ref SDS 0 WK82
230572 -  ..
230573 - Finding progression of IBC aligns with prior examination on 080829,
230574 - ref SDS 49 1Z6O, that reported progression since examination on
230575 - 080627. ref SDS 43 1Z6O  This further aligns with approval of UCSF
230576 - work plan for transition to new treatment with sunitinib. ref SDS 0
230577 - Y85H
230578 -
230579 -               [On 081024 1354 Millie's letter to Doctor Rugo reported
230580 -               that Doctor Johnson concurred today with UCSF
230581 -               examination on 081016 finding progression of disease,
230582 -               and approved Millie for treatment wih sunitinib clinical
230583 -               study. ref SDS 66 XZ8W
230585 -  ..
230586 - Medical Chart continues...
230587 -
230588 -        h.  Heart: regular without murmur or gallop
230590 -             ..
230591 -        i.  Abdomen: soft with normal bowel sounds.  No masses or
230592 -            organomegaly
230594 -             ..
230595 -        j.  Ext: no edema
230597 -             ..
230598 -        k.  Skin: progression of IBC on lateral surface of upper arm
230600 -             ..
230601 -        l.  Bones: no tenderness
230603 -             ..
230604 -        m.  Neuro: awake, alert, and oriented. Moves all extremities
230605 -            well.  Normal gait.
230606 -
230608 -         ..
230609 -    6.  Laboratory
230611 -  ..
230612 - Medical Chart shows no document source identification.  Valuations are
230613 - consistent with laboratory report on blood tests performed at Kaiser
230614 - for Millie's surgery on 080708; but excludes about 50% of the
230615 - report.  The basis for listing some and not all of the test results
230616 - is not indicated in the medical chart...
230617 -
230618 -        Creatinine 0.39 mg/dL
230619 -        CA 15-3 H 141 U/mL
230620 -        BUN 9 mg/dL
230621 -        Chloride H 111 mEq/L
230622 -        CO2 L 20 mEq/L
230623 -        Creatinine 0.39 mg/dL
230624 -        Glucose Random 86 mg/dL
230625 -        Potassium H 5.4 mEq/L
230626 -        Sodium 139 mEq/L
230627 -        Anion Gap 8 mEq/L
230628 -        PT, Patient 11.0 Sec
230629 -        PT INR 1.1 Ratio
230631 -  ..
230632 - Note INR 4.2 on test at UCSF on 081016 shows adjustment following
230633 - surgery on 080708 when INR 1.1 occurred. ref SDS 56 PU7Y  Yesterday on
230634 - 081023 UCSF blood test INR 2.3 shows complete adjustment to within
230635 - target criteria 2.0 - 3.0. ref SDS 62 K66J
230636 -
230637 -               [On 081126 Millie's INR 3.4 blood counts increased,
230638 -               possibly due to new cancer treatment with sunitinib;
230639 -               Millie notified the Kaiser Coagulation Control Clinic,
230640 -               ref SDS 70 J45H; Gloria, Millie's case manager sent a
230641 -               letter confirming changes to the dose of Coumadin
230642 -               required to manage Millie's chronic pulmonary embolism
230643 -               condition. ref SDS 71 VQ8V
230645 -  ..
230646 - Medical Chart continues...
230647 -
230648 -    7.  Pathology Biopsy FNA Left Supraclavicular Lymph Node
230649 -
230650 -        Collected: 10/22/2008
230651 -        Fine Needle Aspiration Cytology Report
230652 -        FINAL PATHOLOGIC DIAGNOSIS
230653 -        A: NECK, FNA - LEFT
230654 -        RED BLOOD CELLS, LYMPHOCYTES.
230655 -        LARGE MALIGNANT CELLS CONSISTENT WITH BREAST PRIMARY; PLEASE
230657 -  ..
230658 - These results establish progression of disease discussed with the
230659 - doctor during the meeting today, per above. ref SDS 0 PV5I
230661 -  ..
230662 - Medical Chart continues...
230663 -
230664 -    8.  Imaging:
230665 -
230666 -        09/11/08 CT THORAX, ABDOMEN, PELVIS W CONTRAST -
230667 -
230668 -        Status post left mastectomy.  There has been little interval
230669 -        change.  Prominent right axillary lymph nodes are again noted,
230670 -        little changed in size, which could be accounted for by
230671 -        sampling variability. Reticular densities and tiny punctate
230672 -        densities in the lungs are not significantly changed, and there
230673 -        are no new identifiable lesions.  No new adenopathy or ascites.
230675 -         ..
230676 -        [Complete history of imaging tests shows no evidence distant
230677 -        metastsis, listed on 080912. ref SDS 53 GM3N
230679 -  ..
230680 - The doctor used cut and paste to incorporate the "Impression" section,
230681 - ref SDS 53 FY5O, into the medical chart language from the CT test at
230682 - Kaiser in Oakland on 080911, which was received in the record on
230683 - 080912. ref SDS 53 DA6Q  Key findings are stable nodes in left
230684 - supraclavicular. ref SDS 53 4K5H
230686 -  ..
230687 - This changes the format listing imaging patient history in the medical
230688 - chart for prior tests, shown in the record on 080829. ref SDS 49 Q89J
230690 -  ..
230691 - Medical Chart continues...
230692 -
230693 -    9.  Assessment:
230694 -
230695 -        1.  Metastatic breast cancer (IBC) lung, lymph node and chest
230696 -            wall; left supraclavicular LN progression
230697 -        2.  Anemia due to chemotherapy
230698 -        3.  Anticoagulation monitoring
230700 -  ..
230701 - "Assessment" changes heading from "Impression" in prior medical chart,
230702 - shown in the record on 080829. ref SDS 49 114B
230704 -  ..
230705 - Finding "progression" aligns with approval of UCSF work plan to change
230706 - treatment discussed today, per above. ref SDS 0 Y85H
230708 -  ..
230709 - Medical Chart continues...
230710 -
230711 -   10.  Plan:
230712 -
230713 -        1.  D/C [discontinue] Clinical Trial on Erbitux with weekly
230714 -            Carbo because of progression
230716 -             ..
230717 -        2.  Reviewed Phase I/II Study of Sunitinib (SU11248) and agree
230718 -            with proceeding. ref SDS 0 Y85H
230720 -  ..
230721 - This implements the doctor's findings from examination that IBC has
230722 - progressed, per above, ref SDS 0 WK82, and discussion that Kaiser will
230723 - expedite referral tasks to prevent cancer from worsening because of
230724 - delays performing administrative tasks for referral and tests at
230725 - Kaiser, ref SDS 0 GF9M; and, that timely treatment is essential for
230726 - Millie to recover from the 5th relapse of IBC, because cancer has
230727 - mutated to become much more aggressive disease. ref SDS 0 BO9F
230729 -                ..
230730 -               [On 081024 1354 Millie's letter notifies medical team
230731 -               that during meeting at Kaiser with primary care
230732 -               physician the doctor confirmed authorization for
230733 -               Millie's treatment in the sunitinib clinical study that
230734 -               is a double agent "targeted" treatment, and Kaiser does
230735 -               not have equatl or better treatments for Millie.
230736 -               ref SDS 66 XZ8W
230738 -                ..
230739 -               [On 081219 1140 Doctor Johnson finds favorable response
230740 -               to treatment with sunitinib, ref SDS 74 3L9L; the doctor
230741 -               cites urgency of timely treatment increases when Millie
230742 -               suffers relapse; delay increases risk of losing control
230743 -               for cancer that mutates into more aggressive disease.
230744 -               ref SDS 74 KU6F  Doctor Johnson asked Millie to notify
230745 -               Doctor Rugo about planning treatment for the 6th relapse
230746 -               to ensure treatment starts in time to be effective,
230747 -               ref SDS 74 V93O, and asked for a letter from UCSF to
230748 -               facilitate the next referral, ref SDS 74 SU8G; because
230749 -               the 6th relapse will be very serious, ref SDS 74 NS8H;
230750 -               further emphasized need for letter from UCSF
230751 -               recommending treatment on referral from Kaiser.
230752 -               ref SDS 74 E84J
230754 -             ..
230755 -        3.  Core needle biopsy pending 11/07/08, ref SDS 0 K69J
230757 -             ..
230758 -        4.  CT Neck, Chest, Abdomen, Pelvis Nov 7, 2008, ref SDS 0
230759 -            454L,
230761 -  ..
230762 - CT test ordered today uses Millie's Power Port ordered by Doctor
230763 - Johnson on 080502, ref SDS 37 WX6I; surgery was performed on 080708.
230764 - ref SDS 44 0001
230766 -  ..
230767 - The doctor asked Millie to coordinate referral with CT Department.
230768 - ref SDS 0 P67O
230769 -
230770 -               [On 081024 1354 Millie's letter to the medical team
230771 -               notifies UCSF that Doctor Johnson ordered CT testing
230772 -               required for screening to participate in the sunitinib
230773 -               clinical study. ref SDS 66 XZ9P
230774 -
230776 -                ..
230777 -               [On 081107 CT test performed at Kaiser in Walnut Creek,
230778 -               few mistakes. ref SDS 68 3G5I
230780 -             ..
230781 -        5.  Echocardiogram Nov 10, 2008
230782 -        6.  RTC 8 weeks
230783 -
230784 -
230785 -
230786 -
230787 -
230788 -
230789 -
230790 -
230791 -
230792 -
230793 -
230794 -
230795 -
230796 -
230797 -
230798 -
230799 -
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