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0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 33 0000. ref SDS 32 0000.
040502 -
040503 -
040504 -
040506 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - Millie sent a letter today notifying the medical team about results of
040902 - a blood test last week on Friday.  The following patient history
040903 - provides context...
040905 -  ..
040906 - Dilemma Balance Pausing Treatment to Build Blood Counts with...
040907 - Daily Sunitinib and Cyclophosphamide Chemotherapy That Reduces Blood Counts
040908 - Case Study Low Blood Counts Neupogen for Sunitinib Cancer Treatments
040909 -
040910 - Many dilemmas occur in health care, example of "wicked problems" on
040911 - 060722 concerning mistaking symptom of serious medical problem for
040912 - symptom of minor problem that requires no care. ref SDS 1 346F
040913 -
040914 -    1.  Case study patient history getting
040915 -        Neupogen treatment when blood counts
040916 -        are too low for chemotherapy
040917 -        treatments............................ 060810, ref SDS 2 HV45
040919 -         ..
040920 -    2.  Neutropenia research reviewed for
040921 -        work at UCSF.......................... 070301, ref SDS 3 O59H
040922 -        Doctor Rugo concerned about holding
040923 -        blood counts with weekly
040924 -        Carboplatin treatments................ 070301, ref SDS 3 VF6O
040926 -         ..
040927 -    3.  Case study Neutropenia Millie had 26
040928 -        treatments with Neupogen due to low
040929 -        blood counts and so missed only 4 of
040930 -        19 chemotherapy treatments prescribed
040931 -        on cetuximab and Carboplatin
040932 -        protocol.............................. 080828, ref SDS 7 8O7I
040933 -        Carboplatin dose was reduced on 080501,
040934 -        ref SDS 4 PVUQ, to help maintian blood
040935 -        counts that enable steady chemotherapy
040936 -        treatments for cancer, and reported
040937 -        as an error on 080529, ref SDS 5 PVUQ;
040938 -        getting less chemotherapy treatment,
040939 -        cancer progressed with cancer marker
040940 -        rising to highest level in patient
040941 -        history reported on 080716,
040942 -        ref SDS 6 IT77 and Millie
040943 -        was taken off this
040944 -        treatment............................. 081023, ref SDS 8 D65G
040946 -         ..
040947 -    4.  Treatment started Sunitinib protocol
040948 -        to recover from 5th relapse
040949 -        IBC................................... 081114, ref SDS 10 505G
040951 -         ..
040952 -    5.  Blood counts NEUTS 1.50 (ANC 1500) at
040953 -        lowest level for safe chemotherapy
040954 -        treatment reported for blood
040955 -        test.................................. 081126, ref SDS 11 2S3G
040957 -         ..
040958 -    6.  Energy declined considerably after 081126
040959 -        when Millie began treatments adding
040960 -        cyclophosphamide and Metotresate
040961 -        to sunitinib
040962 -        reported.............................. 081201, ref SDS 12 LF8M
040964 -         ..
040965 -    7.  IBC 5th relapse Millie continues
040966 -        recovery observed at UCSF
040967 -        on 081126............................. 081202, ref SDS 13 AS6X
040968 -        rate of improvement seems to have
040969 -        slowed, cited in Millie's letter
040970 -        to the medical
040971 -        team.................................. 081202, ref SDS 13 AT4Q
040973 -         ..
040974 -    8.  Millie starts chemotherapy treatments on
040975 -        081126 with cyclophosphamide and Methotrexate;
040976 -        UCSF orders Neupogen treatments deferred
040977 -        to increase blood counts so that Millie
040978 -        can continue daily chemotherapy that
040979 -        complements "targeted" cancer drug
040980 -        sunitinib, reported in Millie's
040981 -        letter to the medical
040982 -        team.................................. 081202, ref SDS 13 AT8U
040984 -         ..
040985 -    9.  Sudden mild poor health and rising
040986 -        fatigue creates worry about low blood
040987 -        counts taking chemo everyday beginning
040988 -        on 081126 reported Millie's letter
040989 -        to medical team....................... 081202, ref SDS 13 AT8U
040991 -         ..
040992 -   10.  Lab test expanded evaluate blood counts
040993 -        for safe cancer treatment ordered by
040994 -        primary care physician at
040995 -        Kaiser................................ 081203, ref SDS 14 7N82
040997 -         ..
040998 -   11.  NEUTS 0.624 (ANC 624) results of blood
040999 -        test on 081203 reported by
041000 -        Kaiser................................ 081205, ref SDS 15 QY6H
041002 -         ..
041003 -   12.  Millie's letter to UCSF reported low blood
041004 -        counts for the lab at Kaiser on 081203,
041005 -        and advised of planning to get
041006 -        Neupogen treatment at Kaiser
041007 -        in order to increase
041008 -        blood counts.......................... 081205, ref SDS 16 YF5I
041010 -         ..
041011 -   13.  Neupogen treatment at Kaiser to increase
041012 -        low blood counts that strengthens immune
041013 -        system so that Millie can continue
041014 -        daily chemotherapy treatments
041015 -        for cancer............................ 081205, ref SDS 17 CH6X
041017 -         ..
041018 -   14.  Nurse recommends Millie ask medical team
041019 -        about getting a third Neupogen treatment
041020 -        rather than just 2 for the week in order
041021 -        increase blood counts to a safe
041022 -        level for chemotherapy
041023 -        treatments............................ 081205, ref SDS 17 X35F
041025 -         ..
041026 -   15.  UCSF objects to Millie self-medicating
041027 -        with Neupogen treatment and advises
041028 -        Neupogen only required for low
041029 -        neutrophils........................... 081205, ref SDS 18 JE5I
041030 -        which is undefined in the record, until
041031 -        Kaiser sets criteria of ANC 1000,
041032 -        per below. ref SDS 0 1R6G
041034 -         ..
041035 -   16.  Case study shows ANC 624 (NEUTS 0.64)
041036 -        blood counts lowest level in patient
041037 -        history causes highest risk of weak
041038 -        immune system indicates requirements
041039 -        for Neupogen treatment to increase
041040 -        blood counts so that Millie can
041041 -        continue getting chemotherapy
041042 -        every day to recover
041043 -        from cancer........................... 081205, ref SDS 15 EC5N
041045 -         ..
041046 -   17.  Neupogen treatment second in two days
041047 -        at Kaiser according to UCSF protocol
041048 -        to increase low blood counts that
041049 -        strengthens immune system so that
041050 -        Millie can continue daily
041051 -        chemotherapy treatments
041052 -        for cancer............................ 081205, ref SDS 17 CH6X
041054 -         ..
041055 -   18.  Kaiser orders interim blood test to evaluate
041056 -        effects of Neupogen treatments on increasing
041057 -        blood counts from lowest level in patient
041058 -        history so that Millie can safely continue
041059 -        getting cancer treatments prescribed
041060 -        by UCSF............................... 081210, ref SDS 19 616R
041061 -
041063 -         ..
041064 -   19.  NEUTS 1.054 (ANC 1054) results of blood
041065 -        test on 081210 reported by
041066 -        Kaiser................................ 081210, ref SDS 20 QY6H
041068 -         ..
041069 -   20.  Platelets 67 and most other CBC
041070 -        lab diagnostics all
041071 -        low................................... 081210, ref SDS 20 OT8J
041073 -         ..
041074 -   21.  ANC 1000 (NEUTS 1.000) Kaiser standards
041075 -        and practice defines "low neutrophils"
041076 -        for ordering Neupogent treatments presented
041077 -        during call with primary care
041078 -        physician............................. 081210, ref SDS 21 J43V,
041080 -         ..
041081 -   22.  Blood counts ANC (NEUTS) falling at rate
041082 -        of 120 points per day on sunitinib with
041083 -        cyclophosphamide and Methotrexate
041084 -        daily treatments for
041085 -        cancer................................ 081210, ref SDS 21 H45O
041087 -         ..
041088 -   23.  Millie letter to medical team asks about
041089 -        effects on health care with platelets
041090 -        falling below 60% of the target
041091 -        range................................. 081211, ref SDS 22 S28P
041092 -        and other blood tests all outside
041093 -        target range.......................... 081211, ref SDS 22 S29S
041095 -         ..
041096 -   24.  Interim blood test results ANC 1054
041097 -        still above 1000...................... 081212, ref SDS 23 PQTQ
041098 -        so Neupogen treatments deferred at
041099 -        Kaiser until next scheduled blood
041100 -        test and examination at UCSF
041101 -        scheduled for
041102 -        081218................................ 081212, ref SDS 24 UZ7K
041104 -         ..
041105 -   25.  NEUTS 0.74 (ANC 740) and Platelets 67
041106 -        Millie's blood counts again very low
041107 -        at UCSF............................... 081218, ref SDS 25 YN8O
041109 -         ..
041110 -   26.  Cancer marker CA 15-3 95 at UCSF declining
041111 -        substantially from CA 15-3 197 at Kaiser
041112 -        on 081210 aligns with examination showing
041113 -        Millie responding well to treatment
041114 -        creates strong incentive for objective
041115 -        of finding a way to continue
041116 -        sunitinib............................. 081218, ref SDS 26 VD4F
041118 -         ..
041119 -   27.  Initial plan to increase blood counts
041120 -        was to continue sunitinib, which is the
041121 -        "targeted" treatment, and showed good
041122 -        initial results, was to eliminate
041123 -        cyclophosphamide and
041124 -        Methotrexate.......................... 081218, ref SDS 26 R65H
041126 -         ..
041127 -   28.  Alternate work plan proposed to increase
041128 -        blood counts in order to maintain
041129 -        treatment with sunitinib, was to eliminate
041130 -        Methotrexate, continue cyclophosphamide
041131 -        and reduce amount of sunitinib from
041132 -        37.5 to 25 mg......................... 081218, ref SDS 26 QW48
041134 -         ..
041135 -   29.  Consideration was then given to maintain
041136 -        rather than reduce sunitinib, since Millie
041137 -        made dramatic recovery with sunitinib
041138 -        alone before adding supplemental
041139 -        drugs, and since Millie was treated with
041140 -        cyclophosphamide in 2002 and 2005, which
041141 -        likely is now resisted by her cancer
041142 -        cells shown by suffering progression
041143 -        of disease, and further since side
041144 -        effects of low blood counts are mostly
041145 -        associated with chemotherapy, like
041146 -        cyclophosphamide rather than
041147 -        with "targeted drugs like
041148 -        sunitinib............................. 081218, ref SDS 26 1G6J
041150 -         ..
041151 -   30.  Lab test was prescribed on 081226 to
041152 -        evaluate Millie's blood counts for
041153 -        maintaining or reducing treatment
041154 -        with sunitinib........................ 081218, ref SDS 26 BQ8F
041156 -         ..
041157 -   31.  Sunitinib treatment paused for a week
041158 -        so that NEUTS (ANC) can recover and for
041159 -        all blood counts to recover, for Millie
041160 -        to recover loss of energy and
041161 -        vitality.............................. 081219, ref SDS 28 716I
041163 -         ..
041164 -   32.  Primary care physician at Kaiser orders
041165 -        labs on 081226 to implement UCSF
041166 -        prescription.......................... 081219, ref SDS 30 3L6L
041168 -         ..
041169 -   33.  Neupogen treatment at Kaiser prescribed
041170 -        by UCSF to increase blood counts so
041171 -        that Millie can get treatment
041172 -        for cancer............................ 081219, ref SDS 29 P73J
041174 -         ..
041175 -   34.  Neupogen treatment at Kaiser prescribed
041176 -        by UCSF to increase blood counts so
041177 -        that Millie can get treatment
041178 -        for cancer............................ 081220, ref SDS 31 P73J
041180 -         ..
041181 -   35.  Millie regaining strength with treatment
041182 -        paused, willing to reduce or end treatment
041183 -        with chemotherapy cyclophosphamide in
041184 -        order to maintain blood counts so that
041185 -        sunitinib can continue at full strenth
041186 -        to optimize recovery; letter to
041187 -        medical team.......................... 081223, ref SDS 32 BW3V
041189 -         ..
041190 -   36.  NEUTS 1.710 (ANC 1710) and Platelets 187
041191 -        lab at Kaiser shows blood counts recover
041192 -        following pause treatment for cancer and
041193 -        getting Neupogen at Kaiser aligns
041194 -        rising energy......................... 081226, ref SDS 37 B35J
041196 -         ..
041197 -   37.  Cancer marker CA 15-3 202 at Kaiser
041198 -        shows another slight increase from
041199 -        CA 15-3 197 at Kaiser on 081210 aligns
041200 -        with pausing treatment for 1 week to
041201 -        allow blood counts to rise, demonstrates
041202 -        significant dilemma balancing treatment
041203 -        for cancer that does not lower blood
041204 -        counts that makes immune system too
041205 -        weak for continuing sunitinib
041206 -        cancer treatments..................... 081226, ref SDS 26 VD4F
041207 -
041208 -
041209 -
041211 -  ..
041212 - Labs Favorable Blood Counts 081226 Treatment Resumed Prescribed Levels
041213 -
041214 - Millie submitted letter notifying medical team favorable results of
041215 - blood test on 081226 based on case study of patient history,
041216 - ref SDS 0 I87N, to explain why amount of sunitinib treatment was
041217 - maintianed rather than reduced.  Millie's letter responds to Glenna's
041218 - letter at UCSF on 081224. ref SDS 35 0E6G
041219 -
041220 -    1.  Subject: Blood Tests Favorable Sunitinib Treatment Resumed
041221 -        Date: Tue, 30 Dec 2008 01:14:58 -0800
041229 -         ..
041230 -    3.  On 081224 there seemed to be significant increase in IBC
041231 -        intensity, ref SDS 34 1Y4I, observed again on 081225.
041232 -        ref SDS 36 1Y4I  The next day on 081226 the rash again
041233 -        subsided, which was a big relief, along with resuming
041234 -        treatment.
041236 -         ..
041237 -    4.  Blood tests ordered at UCSF on 081218, ref SDS 26 BQ8F, were
041238 -        performed at Kaiser on 081226. ref SDS 37 S65I
041240 -         ..
041241 -    5.  NEUTS 1.750 (ANC 1750 at Kaiser), ref SDS 37 B35J, and
041242 -        platelets 187, ref SDS 37 DM6J, were both above targets
041243 -        presented at UCSF on 081218. ref SDS 26 BQ8F [confirmed in
041244 -        Millie's letter to the medical team on 081218. ref SDS 27 GF5X]
041245 -        Therefore, Neupogen was canceled on 081226 and 081227.
041246 -
041247 -            [On 090106 Millie's letter to medical team submitting
041248 -            agenda for meeting at UCSF on 090108, transmits via link
041249 -            the updated report for the blood test on 081226 that
041250 -            includes results for CA 15-3 202, and Lipid panel that
041251 -            shows cholesterol is good. ref SDS 39 YO5U
041253 -         ..
041254 -    6.  I resumed treatment on 081226 with Sunitinib 37.5 mg and
041255 -        cyclophosphamide 50 mg per day.  As well, I did not continue
041256 -        with Methotrexate.
041257 -
041258 -            [On 090109 Millie letter to medical team reports blood
041259 -            counts very low again, NEUTS 0.87, confirms UCSF treatment
041260 -            plan on 090108 continues sunitinib at full strenth, and
041261 -            pauses cyclophosphamice until blood counts rise to NEUTS
041262 -            1.00. ref SDS 40 UF3Q
041264 -         ..
041265 -    7.  As previously, reported energy has increased during the week
041266 -        pause of treatment.  Was able to go to the gym 3 times.
041267 -        Weather prevented hiking until yesterday.  Was pleased to do 1
041268 -        lap, about 3 miles in about 56 minutes.
041269 -
041270 -            [On 090106 Millie submitted agenda to medical team for
041271 -            meeting at UCSF on 090108 and reported energy is not good
041272 -            after 2 weeks resuming treatment, following a 1 week pause;
041273 -            Millie was barely able to hike with assistance another lap
041274 -            at Lafayette. ref SDS 39 YO4S
041276 -         ..
041277 -    8.  On the way home from Lafayette Reservoir, I stopped at
041278 -        Interventional Services to verify arrangements for the CT test
041279 -        today. ref SDS 38 T55G
041281 -         ..
041282 -    9.  Brenda was very helpful.  She walked over to the CT Department
041283 -        and conferred with Cassandra for about 30 minutes. ref SDS 38
041284 -        5F3J  Cassandra, who did the prior test on 081107, ref SDS 9
041285 -        MX6K, advised that the CT Department was not aware of my test
041286 -        using the Power Port, ref SDS 38 5F5M, nor that the Infusion
041287 -        Clinic in Oncology would access the port for injecting contrast
041288 -        medium. ref SDS 38 SS4L  Cassandra planned to call Al, the
041289 -        manager, about ordering support for the test from IS.  Brenda
041290 -        and Cassandra seemed to feel the test will go smoothly today.
041291 -        ref SDS 38 5F4O
041292 -
041298 -
041299 -
041300 -
041301 -
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041303 -
041304 -
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041306 -
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0414 -