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 øF (36.1 øC) (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 -
2308 -