CONTACTS 

SUBJECTS
Schedule Hyperthermia Treatment Recover IBC 6th Relapse on Referral

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 52 0000, ref SDS 45 0000.
040502 -
040503 - Excellent meeting with Doctor Joe Hsu, and his colleague Doctor Linda
040504 - Chang; very experienced treating IBC, with good knowledge of Millie's
040505 - history, well briefed by Doctor Rugo. ref SDS 0 O47G  Meeting was
040506 - hurried with fast discussion. ref SDS 0 PQVT  Doctor Hsu was aware of
040507 - Millie's pulmonary embolism. ref SDS 0 P33M  Millie reported
040508 - lymphedema recurrence this morning. ref SDS 0 9Y5I  Doctor Hsu
040509 - carefully reviewed prior radiation treatments in 2002. ref SDS 0 PN8H
040510 - Patient history discovering IBC was requested today, ref SDS 0 O534,
040511 - along with background on lymphadenopathy. ref SDS 0 7H64  Initial
040512 - planning discussed 2 hyperthermia treatments per week for 4 weeks.
040513 - ref SDS 0 LT6K  Examination disclosed IBC more complex, severe
040514 - problem, ref SDS 0 FQ8W, requires 4-5 treatments for 4 - 6 weeks, and
040515 - will use "lower dose" radiation to complement hyperthermia, rather
040516 - than doxil. ref SDS 0 PR8J  Palpation found rising lymphadenopathy
040517 - again in left supraclavicular; seemed to discuss treating systemic
040518 - cancer with lower dose radiation. ref SDS 0 OH88  Side effects sound
040519 - minor; there was no discussion today of remedies to mitigate side
040520 - effects. ref SDS 0 GM4N  Prognosis indicates a good chance achieve
040521 - local control of IBC, so that systemic treatment can become effective
040522 - again. ref SDS 0 1R5M  Work plan next step is CT test to lay out IBC
040523 - fields for treatment working with a physicist technician, and this
040524 - will be scheduled as soon as possible. ref SDS 0 0399
040525 -
040526 -            [On 090209 Millie meets with UCSF medical team in the
040527 -            Radiation Oncology Department for testing and planning of
040528 -            radiation and hypertherapy treatments. ref SDS 56 9R61
040530 -             ..
040531 -            [On 090219 Millie begins radiation and hyperthermia
040532 -            treatment to accomplish local control of IBC 6th relapse.
040533 -            ref SDS 60 428F
040535 -             ..
040536 -            [On 090220 1548 received UCSF memo from Chris dated 090209
040537 -            that describes scope of work, some treatment planning, and
040538 -            references discussions with Millie. ref SDS 62 DH3H
040539 -
040540 -
040541 -
040542 -
0406 -

SUBJECTS
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0503 -
0504 - Progress
050501 -  ..
050502 - Lymphedema Recurrence Left Arm Increased Pressure Right Arm Injured
050503 -
050504 - This morning in the cafeteria waiting to visit Radiation Oncology at
050505 - 0830, about 0643 Millie reported rising lymphedema in the left arm
050506 - again, previously reported on 090201. ref SDS 44 KN4S  She did not
050507 - wear the prosthetic sleeve this morning, because it is hard to remove
050508 - and put back on for examination.  Evident cause of lymphedema is over
050509 - exertion using the left arm getting in and out of bed, because the
050510 - right arm is healing from dislocated shoulder.
050512 -  ..
050513 - We saw Laura and her mom, Clara, in the cafeteria.  Laura looked
050514 - lovely, and sounded very strong and energetic, recovering under Doctor
050515 - Rugo's care from a very low ebb just a few weeks ago.  Clara was
050516 - pleased that today is the last day of her treatment with Herceptin.
050517 - Very unusual for a mother and daughter to have cancer at the same
050518 - time.  Fortunately, Clara's cancer at this stage is well controlled,
050519 - so she is able to help her daughter deal with more difficult recovery.
050520 -
050521 -
050522 -
0506 -

SUBJECTS
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0603 -
060401 -  ..
060402 - Documentation Signed Radiation Oncology Department
060403 -
060404 - Millie went to the Radiation Oncology Department on the basement
060405 - floor.  The receptionist office is clearly marked after exiting from
060406 - the elevator.
060408 -  ..
060409 - Met Missy, the receptionist.
060411 -  ..
060412 - Missy said that Krshna is still out of the office.  Jennette, who did
060413 - excellent work on Tuesday expediting Millie's care on Tuesday, 090203,
060414 - ref SDS 52 KL8X, was not available for even a few seconds to express
060415 - appreciation for job well done arranging for Millie's care in time to
060416 - be effective.
060418 -  ..
060419 - Missy provided the following patient identification...
060420 -
060424 -            COPAY:  0
060425 -            FSC '39
060426 -            Plan:  Kaiser Senior   2Y5V
060432 -  ..
060433 - Millie signed the following forms on advice of her doctors at Kaiser
060434 - and UCSF that this is required to get urgent care needed quickly...
060435 -
060436 -        1.  Authorization for release of health information
060437 -            UCSF Medical Center
060438 -
060439 -            This form has nothing filled out on the purpose of
060440 -            release, who is authorized to release information, nor what
060441 -            can be released.  The duration of authoization is not
060442 -            entered; there is a default of 12 months.
060444 -             ..
060445 -            Millie signed and dated the document 090205 0930.
060447 -             ..
060448 -        2.  Terms and Conditions of Service:
060449 -            Admission Medical Services and Financial Agreement
060451 -             ..
060452 -            Millie signed and dated the document 090205.
060454 -             ..
060455 -            Witness signed, but the signature is illegible.
060457 -             ..
060458 -        3.  Medication List
060459 -
060460 -            This is a copy of a pink form prepared by Doctor Hsu during
060461 -            the examination and in consultatio with Millie.  The form
060462 -            is very difficult to read.  Seems to say...
060464 -             ..
060465 -            Coumadine                     4 mg          Daily
060466 -            Vicodin                       5 mg          4 - 6 Hours
060467 -            Tylenol extra strength      500 mg          As needed
060468 -
060470 -             ..
060471 -            Treatment Alergies
060473 -             ..
060474 -            Tegaderm ???
060475 -
060476 -
0605 -

SUBJECTS
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0703 -
0704 - 0840
070501 -  ..
070502 - 4th Floor Receptionist Lobby
070503 -
070504 - After filling out forms in the Radiation Oncology Department in the
070505 - basement, Missy took us to the 4th floor to sign-in for meeting with
070506 - Doctor Hsu.
070507 -
070508 -
070509 -
0706 -

SUBJECTS
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0803 -
0804 - 0913
080501 -  ..
080502 - Vitals Elevated May Reflect Continuing Pain Emotional Trauma Worry
080503 -
080504 - Millie was called from the reception waiting area and moved to an
080505 - examination room.
080507 -  ..
080508 - Vitals were taken in the hallway, similar to work on the 2nd floor.
080510 -  ..
080511 - Millie's vitals were elevated, something like 184 78 and pulse 63,
080512 - and temperature about 97,8.
080514 -  ..
080515 - Pulse 63 is a moderatly good sign that effects of sunitinib have begun
080516 - to subside, where pulse was routinely below 50 for several months.
080517 -
080518 -
080519 -
0806 -

SUBJECTS
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0903 -
0904 - 0924
090501 -  ..
090502 - Examination Review Patient History IBC Bleeding Nodularity No Puss
090503 -
090504 - Linda Chan did an initial interview and examination.
090505 -
090506 - Reviewed Millie's patient history, submitted on 090121 for referral to
090507 - Radiation Oncology. ref SDS 37 NU5H
090509 -  ..
090510 - Linda had documentation that appeared to have been prepared by Doctor
090511 - Rugo, but not sure.  Linda used the documents to guide questions
090512 - during the meeting.  She entered handwritten notations in the margins
090513 - for clarification of treatment history, also listed on 090121.
090514 - ref SDS 37 H16M
090515 -
090516 -        [On 090209 0018 Linda commended in letter to medical team on
090517 -        meeting at UCSF 090205. ref SDS 55 736V
090519 -  ..
090520 - During brief examination of IBC, Linda asked if any of the few IBC
090521 - nodules that appeared to have burst and bled, had puss flow from the
090522 - wounds?  Linda gave an example of seeing puss soiled clothing?
090524 -  ..
090525 - Millie seemed to say that so far, she has not seen evidence of puss.
090527 -  ..
090528 - Linda left the room to brief Doctor Hsu.
090529 -
090530 -
090531 -
0906 -

SUBJECTS
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1003 -
1004 - 0943
100501 -  ..
100502 - UCSF Radiation Oncology Doctor Hsu Strong Credentials Hyperthermia
100503 -
100504 - Doctor Hsu introduced himself and was supported by Linda during the
100505 - meeting.
100507 -  ..
100508 - The doctor has a distinguished career, graduating from John Hopkins
100509 - School of Medicine in 1991, focusing on cancer and radiation oncology,
100510 - shown in the UCSF profile...
100511 -
100512 -              http://www.ucsfhealth.org/adult/cgi-bin/prd.cgi?action=DISPLAYDOCTOR&doctorid=1405
100514 -  ..
100515 - UCSF Radiation Oncology also presents Doctor Hsu's credentials...
100516 -
100517 -              http://radonc.ucsf.edu/faculty/physicians/hsu_i.html
100518 -
100519 -
100520 -
1006 -

SUBJECTS
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1103 -
110401 -  ..
110402 - Medical Team Collaboration Facilitated Electronic Communication
110403 - Electronic Communication Facilitates Doctor Patient Partnership
110404 -
110405 - During the meeting today, Doctor Hsu submitted an email address for
110406 - communication, which was requested in Millie's letter to the medical
110407 - team on 090202, ref SDS 49 C95U, and cited for causing delayed
110408 - communication coordinating care on 090203. ref SDS 53 YQ6S
110410 -  ..
110411 - Doctor Hsu advised that he had received from Doctor Rugo relevant
110412 - correspondence the past week or so on progression of Millie's cancer,
110413 - as listed in "Background" for the record on 090203 1444. ref SDS 53
110414 - O66O
110416 -  ..
110417 - Millie thanked Doctor Hsu for advancing her care, implementing Doctor
110418 - Rugo's request in her letter to Doctor Hsu on 090202, reporting that
110419 - Millie needed urgent treatment quickly. ref SDS 47 V47L  Today, Millie
110420 - expressed hope that advancing work at UCSF 3 weeks from 090219 to
110421 - today, will enable treatment in time to be effective recovering from
110422 - 7th relapse of cancer, reported in Millie's letter to the medical team
110423 - on 090203. ref SDS 53 6Q3J
110425 -  ..
110426 - Doctor Hsu appologized for delays getting started.  He expressed
110427 - confidence that the Radiation Oncology Department can expedite
110428 - treatment for Millie to recover from the 7th relapse despite delays
110429 - starting treatment.
110431 -  ..
110432 - The doctor was very professional and thorough conducting the meeting.
110433 - Discussion was hurried, reflecting UCSF having added Millie to the
110434 - schedule for this morning, 3 weeks ahead of initial plan for meeting
110435 - on 090219, reported by Krshna on 090202. ref SDS 48 PRUQ
110437 -  ..
110438 - Hurried discussion makes comprehension difficult, fragmented, and
110439 - uncertain, especially for a stage IV cancer patient, with a dislocated
110440 - right shoulder, and lymphedema flaring up in the left arm.  Doctor
110441 - Chang helped Doctor Hsu remember details, with both taking notes.
110442 -
110443 -
110444 -
1105 -

SUBJECTS
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1203 -
120401 -  ..
120402 - Medication Primarily Coumadin for PE All Chemotherapy Ended 090122
120403 -
120404 - Patient medication at this time is simplified, because all
120405 - chemotherapy was ended with Glenna's call on 090122, ref SDS 39 AT6N,
120406 -
120407 -
120408 -
120409 -
120410 -
1205 -

SUBJECTS
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1303 -
130401 -  ..
130402 - UCSF Well Briefed Patient History Asks about Pulmonary Embolism
130403 -
130404 - Doctor Hsu seemed well briefed on Millie's pulmonary embolism,
130405 - diagnosed at UCSF by Doctor Benz 2nd opinion consultation on 041018,
130406 - and cooborated by CT test at Kaiser on 041103.  The next day on 041104
130407 - Millie was taken off chemotherapy treatment with bevacizumab and
130408 - Taxoter, ref SDS 17 RZ4I, and started treatment with Coumadin
130409 - (warfarin). ref SDS 17 Q57K  Today, Doctor Hsu was not aware that
130410 - Coumadin (warfarin) was stopped on 051007 to prepare Millie for
130411 - mastectomy surgery on 051021. ref SDS 20 RZ4I  On 060930 Millie was
130412 - ordered to resume Coumadin, because CT test discovered PE recurrence,
130413 - reported on 061012. ref SDS 26 294Q
130415 -  ..
130416 - The doctor commented today Millie was lucky to survive PE recurrence.
130418 -  ..
130419 - Research on 060722 indicated 45% of patients who suffer pulmonary
130420 - embolism recurrence do not survive. ref SDS 24 BI5J
130421 -
130422 -
130423 -
130424 -
1305 -

SUBJECTS
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1403 -
140401 -  ..
140402 - Radiation History Assess Viablity Lower Dose Radiation Planned Today
140403 -
140404 - Doctor Hsu advised that UCSF will treat Millie with hyperthermia and
140405 - radiation, rather than Doxil, discussed further below. ref SDS 0 EY5F
140406 -
140407 -        [...below, research indicates hyperthermia typically provided
140408 -        with other treatments, including radiation. ref SDS 0 5Y5I
140410 -  ..
140411 - The doctor asked about Millie's radiation treatments in 2002?  The
140412 - doctor asked where the work was performed, and who was the attending
140413 - physician?
140415 -  ..
140416 - Some authorities seem to indicate that hyperthermia can be more
140417 - effective, when the patient has received prior radiation.  The source
140418 - has been difficult to identify.
140420 -  ..
140421 - Would be helpful for UCSF to comment on how patient radiation history
140422 - will influence getting treatment with hyperthermia and radiation,
140423 - including expectations for success, and risks of injury at this time.
140424 -
140425 -            [On 090331 2047 after completing radiation begun on 090219
140426 -            and ending on 090317 Millie went hiking and for the first
140427 -            time ever she experienced shortness of breath that lasted
140428 -            an entire lap (2.75 miles) at Lafayette Reservoir.
140429 -            ref SDS 67 Q69Q
140431 -             ..
140432 -            [On 090403 0748 Millie reports to medical team a new
140433 -            problem of difficult breathing. ref SDS 68 UV4X
140435 -             ..
140436 -            [On 090403 1324 Doctor Hsu concerned about Millie getting
140437 -            pneumonia caused by side effects of radiation and
140438 -            hyperthermia treatments for 6th relapse of IBC; recommends
140439 -            Millie request examination by primary care physician at
140440 -            Kaiser. ref SDS 69 XZ6I
140442 -  ..
140443 - Millie's patient history shows...
140444 -
140445 -    1.  Radiation at Mt Diablo hospital in Concord on referral from
140446 -        Kaiser in Walnut Creek.
140447 -
140448 -        Attending physician:  Doctor Mioni
140450 -         ..
140451 -        Orientation meeting on 020708, ref SDS 1 0001, disclosed that
140452 -        initial treatment plan using radiation over 4 weeks, was
140453 -        increased to 6 weeks 5-days per week. ref SDS 1 AN6I
140455 -         ..
140456 -    2.  Radiation first treatment on 020723. ref SDS 2 0001
140458 -         ..
140459 -        On 020726, after the first three treatments, the primary care
140460 -        physician met with Millie at Kaiser and asked about side
140461 -        effects.  At that time, Millie reported no side effects.
140462 -        ref SDS 3 YO52  Primary care physician explained that radiation
140463 -        was increased because Millie's condition seems more complex
140464 -        than most stage II breast cancer cases. ref SDS 3 MO37
140466 -         ..
140467 -    3.  Radiation completed on 020910, reported in the record on
140468 -        020924. ref SDS 4 0J7H
140470 -         ..
140471 -        The period from starting radiation on 020723 to completion on
140472 -        020910 seems to be 6 weeks.
140474 -         ..
140475 -    4.  UCSF opinion presented by Doctor Benz for examination on 041018
140476 -        advised surgery would not be effective, and further suspected
140477 -        Millie would have no tolerance for additional radiation
140478 -        therapy, reported in the record on 041117. ref SDS 18 OU4U
140479 -        Kaiser prescribed surgery on 050915, ref SDS 19 5T5N, and was
140480 -        performed on 051021, ref SDS 21 EG5L, with biopsy showing no
140481 -        evidence of IBC, reported on 051027. ref SDS 22 616P  On 060711
140482 -        Millie was diagnosed with IBC recurrence. ref SDS 23 025H
140484 -  ..
140485 - Doctor Hsu asked about radiation layout marks?
140487 -  ..
140488 - Millie explained that some were removed with left breast mastectomy
140489 - surgery on 051021. ref SDS 21 0001
140491 -  ..
140492 - The doctor seemed say he found several marks, including the neck, and
140493 - the upper back.
140494 -
140495 -
140496 -
1405 -

SUBJECTS
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1503 -
150401 -  ..
150402 - IBC Symptoms Reported PET Scan Test 021218 Diagnosed Biopsy 040419
150403 -
150404 - Doctor Hsu asked today for the first evidence of IBC?
150406 -  ..
150407 - Case study of patient history on 040517 shows full history discovering
150408 - IBC disease. ref SDS 16 S66O  Highlights include...
150409 -
150410 -    1.  Primary care physician concerned Millie
150411 -        did not respond to adjuvent treatment,
150412 -        and so increased radiation
150413 -        from 4 to 6 weeks.................... 020726, ref SDS 3 MO37
150415 -         ..
150416 -        No signs of rash were reported in the
150417 -        record at that
150418 -        time................................. 020726, ref SDS 3 2F5J
150420 -         ..
150421 -    2.  Examination noted rise of cancer marker
150422 -        after completion of phase II
150423 -        chemotherapy with
150424 -        Taxotere............................. 021206, ref SDS 5 SM6M
150425 -        Swelling in left axilla.............. 021206, ref SDS 5 KW5F
150426 -        Thickened skin observed during
150427 -        examination disgnosed as scar tissue
150428 -        from surgery on 020312, and from
150429 -        radiation completed on
150430 -        020910............................... 021206, ref SDS 5 SG7J
150432 -         ..
150433 -    3.  Examination presented results PET scan
150434 -        test on 021218 may in retrospect
150435 -        present 3 symptoms of
150436 -        IBC.................................. 030109, ref SDS 6 L66M
150437 -        PET scan test Test "Impression" lists
150438 -        3 symptoms of IBC as most likely
150439 -        "post-radiation
150440 -        changes"............................. 030109, ref SDS 6 GJ69
150442 -         ..
150443 -    4.  Doctor observed left breast inflammation
150444 -        and rash, attributed to radiation side
150445 -        effects, as stated in the PET test
150446 -        report............................... 030109, ref SDS 6 KW5F
150447 -        Diagnosed Cellulitis and prescribed
150448 -        Keflex............................... 030109, ref SDS 6 0T6N
150450 -         ..
150451 -    5.  Millie requested emergency meeting with
150452 -        doctor to investigate sudden rise rash and
150453 -        inflammation on the left breast; at
150454 -        meeting a week later, doctor found
150455 -        condition had
150456 -        subsided............................. 030606, ref SDS 7 7C6W
150458 -         ..
150459 -    6.  CT test on 030626 findings reported during
150460 -        meeting with doctor shows skin thickening
150461 -        on left breast may be side effects of
150462 -        radiation, and notes invasion of dermal
150463 -        lymphatics from known breast
150464 -        cancer can present
150465 -        similarly............................ 030710, ref SDS 8 VM7I
150466 -        recommends correlate
150467 -        clinically........................... 030710, ref SDS 8 GJ69
150469 -         ..
150470 -    7.  CT test on 030625 finds lymph nodes in left
150471 -        axilla increased 50%, discussed with
150472 -        doctor during meeting at
150473 -        Kaiser............................... 030710. ref SDS 8 XX4G
150475 -         ..
150476 -    8.  Millie complains stiff neck and lump
150477 -        left supclavicular................... 040207, ref SDS 9 WP7L
150479 -         ..
150480 -    9.  Biopsy performed at Kaiser left
150481 -        supraclavicular...................... 040303, ref SDS 10 VF77
150483 -         ..
150484 -   10.  Pathology biopsy on 040303 left
150485 -        supraclavicular shows
150486 -        cancer cells......................... 040309, ref SDS 11 WG7F
150488 -         ..
150489 -   11.  Doctor observes severe redness
150490 -        in left breast that led request
150491 -        for early meeting.................... 040318, ref SDS 12 IM6J
150492 -        Diagnosis cellulitus................. 040318, ref SDS 12 PY4N
150493 -        Treatment antibiotics delays
150494 -        start of chemotherapy until
150495 -        after antibiotics clear
150496 -        cellulitus........................... 040318, ref SDS 12 PY5H
150498 -         ..
150499 -   12.  Doctor observes redness
150500 -        persists............................. 040402, ref SDS 13 IM6J
150501 -        Diagnosis changed from cellulitus
150502 -        to reaction from radiation
150503 -        treatments given in August 2002...... 040402, ref SDS 13 8T5O
150504 -        Treatment steroid and cleared
150505 -        to commence chemotherapy with
150506 -        taxol and bevacizumab (Avastin)...... 040402, ref SDS 13 SY6J
150508 -         ..
150509 -   13.  Doctor examined left breast and
150510 -        reported findings that redness
150511 -        in left breast reduced slightly,
150512 -        so treatment for reaction to
150513 -        radiation treatments in 2002
150514 -        was ended............................ 040416, ref SDS 14 IM6J
150516 -         ..
150517 -   14.  Biopsy taken on left breast
150518 -        at request of patient after
150519 -        minor surgery to install
150520 -        port catheter for getting
150521 -        chemotherapy treatments.............. 040419, ref SDS 15 789F
150523 -         ..
150524 -   15.  Diagnosis in Pathology report on biopsy
150525 -        performed 040419 shows metastatic Carcinoma
150526 -        involving dermal lymphmatics consistent
150527 -        with inflammatory carcinoma of the breast;
150528 -        pathology
150529 -        report handed to patient during
150530 -        meeting at Kaiser evaluate
150531 -        treatment with bevacizumab
150532 -        and Taxotere......................... 040517, ref SDS 16 7D6F
150533 -
150534 -
150535 -
1506 -

SUBJECTS
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1603 -
160401 -  ..
160402 - Lymphadenopathy Original Left Axilla Resolved
160403 - Supraclavicular Left Side Biopsy 081022 Resoved CT Test 081230
160404 -
160405 - During the meeting, Doctor Hsu asked about patient history of
160406 - lymphadenopathy?
160408 -  ..
160409 - The doctor was well briefed on patient history of biopsy that found
160410 - cancer in the left suparclavicular at Kaiser on 040303. ref SDS 10
160411 - VF77
160413 -  ..
160414 - Millie explained that on 040309 Kaiser reported results of biopsy on
160415 - 040303 was positive for recurrence. ref SDS 11 0001  At that time,
160416 - nobody knew about IBC, as shown in the study above. ref SDS 0 ET4M
160418 -  ..
160419 - Doctor Hsu asked what happened since then?
160421 -  ..
160422 - The next report of lymphadenopathy occurred 10 months after starting
160423 - treatment at UCSF on 070201...
160424 -
160425 -    1.  CT tests have tracked 3 nodes in the right
160426 -        axilla that have been stable +/- 1 CM
160427 -        for the past year, shown by study
160428 -        for the test on 081107
160429 -        reported............................. 081112. ref SDS 31 RM6I
160431 -         ..
160432 -    2.  Lynn Beach in Doctor Rugo's office at UCSF
160433 -        2nd floor Breast Care Clinic
160434 -        palpated node in left
160435 -        supraclavicular...................... 080821, ref SDS 27 4C6O
160437 -         ..
160438 -    3.  Primary care physician, Doctor Johnson,
160439 -        Kaiser Walnut Creek Oncology Department
160440 -        concurred there was swelling in
160441 -        left supraclavicular................. 080829, ref SDS 28 RP8T
160443 -         ..
160444 -    4.  Doctor Rugo observed rising IBC on Millie's
160445 -        breastbone area; FNA ordered to
160446 -        evaluate node in left
160447 -        supraclavicular...................... 081016, ref SDS 29 J36R
160449 -         ..
160450 -    5.  Biopsy on 081022 was reported positive
160451 -        for breast cancer recurrence
160452 -        the next day......................... 081023. ref SDS 30 4Q9Q
160454 -         ..
160455 -    6.  CT test on 081107 shows several small nodes
160456 -        in the right supclavicular findings
160457 -        reviewed in the record on............ 081113, ref SDS 32 OO6M
160459 -         ..
160460 -    7.  CT test on 081107 shows lymphadenopathy
160461 -        single large node in the left supraclavicular
160462 -        which previously tested positive in biopsy
160463 -        on 081022, and findings for CT test
160464 -        on 081107 were reviewed
160465 -        on 081113............................ 081113, ref SDS 32 5O6N
160467 -         ..
160468 -    8.  Sunitinib clinical study started with
160469 -        cyclcophosphamide and Methotrexate
160470 -        treatment started.................... 081114, ref SDS 33 505G
160472 -         ..
160473 -    9.  Examination on 081126 showed node in left
160474 -        supraclavicular seemed smaller,
160475 -        reported on.......................... 081202 ref SDS 34 AT3S
160476 -        observed significant reduced IBC
160477 -        indicating response to
160478 -        treatment............................ 081202, ref SDS 34 YJ3G
160480 -         ..
160481 -   10.  Examination showed near elimination
160482 -        of IBC rash.......................... 081218, ref SDS 35 GF8S
160483 -        palpation left supraclavicular found
160484 -        no swelling.......................... 081218, ref SDS 35 GF9R
160486 -         ..
160487 -   11.  CT test on 081230 reports node in left
160488 -        supraclavicular no longer visible;
160489 -        but examination shows IBC
160490 -        increased dramatically on
160491 -        breastbone area...................... 090108. ref SDS 36 UC4H
160492 -
160493 -
160494 -
1605 -

SUBJECTS
Default Null Subject Account for Blank Record

1703 -
170401 -  ..
170402 - Distant Metastasis No Internal Spread of Cancer
170403 - IBC Only Problem to Solve No Evidence Metastatic Disease
170404 -
170405 - Doctor Hsu asked if cancer has spread internally, and whether Millie
170406 - is being treated with chemotherapy for distant metastatis?
170408 -  ..
170409 - The primary care physician at Kaiser, Doctor Johnson, called a few
170410 - weeks ago on 090123 to encourage immediate treatment at UCSF for
170411 - Millie's 6th relapse of IBC. ref SDS 40 OZ6N   During the call, Doctor
170412 - Johnson seemed to indicate that the only evidence of internal cancer
170413 - from PET and CT scan testing over Millie's 8 years of treatment is in
170414 - the right axilla, and left supraclavicular, which are both symptoms of
170415 - IBC.  Therefore, Millie's only cancer to solve is IBC. ref SDS 40 8K6K
170416 - This is shown in the case history discussed during the meeting today,
170417 - per above. ref SDS 0 O534
170419 -  ..
170420 - Due to rapid progression of IBC, Doctor Rugo ended Millie's systemic
170421 - treatments with sunitinib on 090122. ref SDS 39 AT6N  A week later on
170422 - 090129 the doctor prescribed treatment for Millie's 6th relapse of IBC
170423 - with hyperthermia and Doxil in order to achieve local control,
170424 - reported in Millie's letter to the medical team on 090130. ref SDS 43
170425 - 4S8O
170427 -  ..
170428 - IBC observed during examination today, per below, ref SDS 0 FQ8W, is
170429 - Millie's only cancer, and has been progressing without treatment since
170430 - 090122, pending start of radiation and hyperthermia.
170431 -
170432 -
170433 -
170434 -
170435 -
170436 -
1705 -

SUBJECTS
Default Null Subject Account for Blank Record

1803 -
180401 -  ..
180402 - CT Test Layout IBC Fields for Treatment Plan
180403 - Hyperthermia Treatment Plan 4-5-days per Week for 4 - 6 Weeks
180404 - Complex Severe IBC Requires Robust Treatment Plan Timely Action
180405 -
180406 - Doctor Hsu advised that hyperthermia protocol for Millie will take 2
180407 - treatments a week for 4 weeks.  The first step is to meet next week
180408 - with a physicist technician, who will help the doctor "layout" IBC
180409 - sites with a CT test and xrays, and then use the layout of IBC sites
180410 - to develop a treatment plan for each site.
180411 -
180412 -            [On 090209 1347 Millie met with Doctor Hsu and his team in
180413 -            the UCSF Radiology Oncology Department for laying out
180414 -            treatment zones, and performing CT tests to develop the
180415 -            work plan. ref SDS 56 0G5I
180417 -  ..
180418 - Millie asked Doctor Hsu to coordinate with Kaiser ordering the CT test
180419 - and xrays today?  Kaiser has performed outstanding case management,
180420 - but complexity of communications delays coordinating Kaiser support
180421 - for Millie's care on referral to UCSF.
180423 -  ..
180424 - The doctor seemed to indicate that severity of Millie's condition
180425 - presented in Doctor Rugo's letter to the medical team on 090202 saying
180426 - urgent treatment is needed quickly, ref SDS 50 Y15J, requires
180427 - deference to doctor discretion performing CT and xray tests at UCSF
180428 - for medical necessity.  Doing radiology tests at UCSF gives the doctor
180429 - immediate control to direct the work for laying out treatment fields.
180430 - Doctor Hsu feels that coordinating to do these tests in another
180431 - facility would put Millie at risk of not recovering from her 6th
180432 - relapse of IBC.
180433 -
180434 -            [On 090209 1347 deference to doctor discretion was applied
180435 -            to move Millie's arm in order to perform CT scans and xrays
180436 -            needed to plan treatment for recovering from 6th relapse of
180437 -            IBC, and despite Kaiser policy that the arm should be
180438 -            immobolized to heal from separated shoulder, and if
180439 -            movement is reqired, then orthopedics department should
180440 -            collaborate on the maneuver. ref SDS 56 E663
180442 -             ..
180443 -            [On 090213 1140 case study shows coordinating case
180444 -            management for Millie's care has increased exponentially
180445 -            for each relapse the past 8 years. ref SDS 58 IG5O
180447 -  ..
180448 - Research on 090203 indicates hyerthermia practice uses a PET/CT scan
180449 - to identify IBC sites for laying out treatment. ref SDS 51 6F4N
180451 -  ..
180452 - Research on 090129 found hyperthermia is approved by the FDA for
180453 - holistic alternative treatment of IBC. ref SDS 42 BR57
180455 -  ..
180456 - UCSF publishes explanation of hyperthermia that says in part...
180457 -
180458 -        UCSF Radiation Oncology (date unclear)
180459 -
180460 -              http://radonc.ucsf.edu/treatment_programs/hyperthermia.html
180461 -
180462 -        Hyperthermia
180464 -         ..
180465 -        Hyperthermia refers to the use of heat treatments to kill
180466 -        cancer cells. Hyperthermia enhances the effects of other
180467 -        cancer treatments, so it is almost always given in combination
180468 -        with radiation therapy, chemotherapy, or both. The beneficial
180469 -        effects of hyperthermia have been documented in clinical
180470 -        trials that included patients with tumors of the brain, head
180471 -        and neck, breast, cervix, rectum, bladder, and patients with
180472 -        melanoma. It is particularly useful for treatment of recurrent
180473 -        cancer in an area of the body that has already received
180474 -        radiation therapy.
180475 -
180476 -            [...above, UCSF planning to provide hyperthermia treatment
180477 -            for Millie combined with radiation; asks about Millie'
180478 -            history of prior radiation. ref SDS 0 PN8H
180480 -         ..
180481 -        Hyperthermia is most often used to treat tumors that are close
180482 -        to the surface of the body. A special device called a surface
180483 -        applicator is applied to the region of the tumor. That area is
180484 -        heated to a temperature of 43oC (109oF) for approximately one
180485 -        hour. Hyperthermia treatments are given within one hour of
180486 -        radiation therapy or chemotherapy. Hyperthermia can also be
180487 -        used to treat deeper tumors when combined with high dose rate
180488 -        brachytherapy (HDR) (link). The HDR catheters are used for
180489 -        internal radiation treatments and for temperature
180490 -        measurements.
180492 -         ..
180493 -        We have the largest and most versatile hyperthermia program on
180494 -        the west coast. Our hyperthermia team tailors treatment to
180495 -        meet the needs of each individual patient.
180497 -         ..
180498 -        Hyperthermia Team
180500 -         ..
180501 -        Joe Hsu, MD
180502 -        Chris Diederich, PhD
180503 -        Naome Schechter, MD
180504 -        Sue S Yom, MD
180506 -  ..
180507 - Discussed expediting treatment doing layout this morning, and starting
180508 - treatment later today or tomorrow in order to prevent IBC from
180509 - cascading out of control spreading to other areas, e.g., lungs,
180510 - pancreas, colon, etc.  Doctor Rugo's letter on 090202 reported
180511 - Millie's condition is urgent and requires treatment quickly.
180512 - ref SDS 50 Y15J
180513 -
180514 -
180516 -  ..
180517 - Examination Finds Complex Severe IBC Requires Immediate Traetment
180518 - Complex Severe IBC Requires Robust Treatment Plan Timely Action
180519 -
180520 - Doctor Hsu examined Millie's IBC.
180522 -  ..
180523 - He prepared small sketches of IBC locations in the notepad used to jot
180524 - down key points during discussion.  The doctor diagrammed the main IBC
180525 - sites to organize understandings from the meeting, and plan scope of
180526 - work.
180528 -  ..
180529 - Doctor Hsu observed bleeding seepages and puss from concentration of
180530 - IBC nodules that looked like a wound in the breastbone area, noted
180531 - previously by Doctor Rugo during examination on 090129, cited in
180532 - Millie's letter to the medical team on 090130, ref SDS 43 TZ6H, and
180533 - also reported in Millie's letter to the team on 090130, ref SDS 43
180534 - 4S8O, but now today significantly increased advancing toward the neck,
180535 - across the left chest, and somewhat onto the right breast.
180537 -  ..
180538 - The doctor asked if coloration on the upper left arm was bruising from
180539 - the dislocated shoulder?
180541 -  ..
180542 - Millie showed the right arm with very heavy brusing from dislocated
180543 - shoulder on 090122. ref SDS 38 CW6J  Doctor Hsu was startled seeing
180544 - severity and extent of bruising on the upper shoulder and arm, noting
180545 - he has never seen anything like this, and made the connection with
180546 - Millie being on Coumadin blood thinner for pulmonary embolism, which
180547 - likely accounts for elevated bruising.
180549 -  ..
180550 - Millie explained guidance from the Orthopedic Department during a
180551 - meeting at Kaiser on 090129 that the right arm should not be moved
180552 - above the elbow for another 2 weeks. ref SDS 41 FN8N
180554 -  ..
180555 - Today, during examination, the doctor was careful not to move the
180556 - right arm abruptly.  He noted that his team may need an orthopedic
180557 - specialist to assist positioning Millie's arm for the CT testing and
180558 - xrays to plan hyperthermia treatments for recovering from IBC, per
180559 - above. ref SDS 0 LT6K
180560 -
180561 -        [On 090209 1347 Doctor Hsu and the medical team was forced to
180562 -        manipulate Millie's right arm and shoulder in order to perform
180563 -        radiology tests to layout fields for Millie's radiation
180564 -        treatment to recover from cancer. ref SDS 56 MN4L
180566 -  ..
180567 - Inflammation on upper left arm is IBC.  This has been stable to
180568 - lessening IBC compared to conditions before starting sunitinib
180569 - treatment on 081114.  Unlike the breastbone area where sunitinib
180570 - failed, other IBC sites even today show stable to slow progression of
180571 - disease.
180573 -  ..
180574 - Doctor Hsu feels Millie's breastbone with oozing IBC wound, and IBC
180575 - flowing onto the right breast, on the abdomen, the entire left side of
180576 - her chest, flowing up toward the neck, and down and toward the back,
180577 - and separately on the left arm present a much more severe and complex
180578 - treatment problem than initially expected.
180579 -
180580 -        [On 090209 1347 meeting with Doctor Hsu for CT and Xray tests
180581 -        to layout treatment fields, and guide development of molds for
180582 -        radiation; severity of Millie's IBC complicates design and
180583 -        construciton of molds, which requires extra time that delays
180584 -        starting treatment until 090219. ref SDS 56 TW7O
180586 -         ..
180587 -        [On 090212 0017 Millie's letter to the medical team reports IBC
180588 -        is getting more severe, ref SDS 57 1N3X, asks for advice on
180589 -        home care patient can initiate to slow progression of disease,
180590 -        and requests starting treatment with hyperthermia in a few days
180591 -        rather than wait until molds are designed and built for
180592 -        radiation. ref SDS 57 1N4Q
180593 -
180594 -
180595 -
180596 -
1806 -

SUBJECTS
Default Null Subject Account for Blank Record

1903 -
190401 -  ..
190402 - Doxil Changed to Radiation with Hyperthermia to Treat Complex IBC
190403 - Lower Dose Radiation with Hyperthermia Recover Severe IBC Condition
190404 -
190405 - Doctor Hsu advised today that delay starting treatment, reported on
190406 - 090130 1722, ref SDS 43 AY8Q, and subsequent delays noted by Doctor
190407 - Rugo's letter notifying the medical team on 090202 that Millie needs
190408 - urgent treatment, ref SDS 50 Y15J, have caused Millie's cancer to
190409 - progress too far for hyperthermia with Doxil to be effective.
190410 - prescribed by Doctor Rugo in the UCSF treatment plan on 090129 (cited
190411 - in Millie's letter to the medical team the next day on 090130,
190412 - ref SDS 43 HK3V).  This aligns with Doctor Johnson's many warnings to
190413 - the medical team that Millie's cancer has mutated into a very
190414 - aggressive disease that requires immediate treatment, reported most
190415 - recently 2 weeks ago on 090123 1326. ref SDS 40 RK6O
190417 -  ..
190418 - Doctor Hsu advised that advancing severity of Millie's cancer now most
190419 - evident in the breastbone area, see examination above, ref SDS 0 FQ8W,
190420 - requires more aggressive treatment.  Therefore UCSF has changed the
190421 - work plan from hyperthermia with cheotherapy (Doxil), to "lower dose"
190422 - radiation, see discussion above. ref SDS 0 PN8H
190424 -  ..
190425 - The doctor explained that Millie will get 4 treatments per week, and
190426 - duration will increase from 2 - 3 weeks to 4 - 6 weeks, subject
190427 - further review of Millie's prior radiation treatment history, also,
190428 - discussed above. ref SDS 0 HS8N
190430 -  ..
190431 - Changing from Doxil to lower dose radiation may align with the 2nd
190432 - opinion from Doctor Benz on 060929. ref SDS 25 WR3Y
190434 -  ..
190435 - Doctor Hsu distinguished "lower dose" from "low dose" radiation,
190436 - indicating Millie will get the former, rather than "low dose"
190437 - radiation.  The doctor asked earlier in the meeting about Millie's
190438 - patient history getting radiation for breast cancer, per above.
190439 - ref SDS 0 PN8H
190441 -  ..
190442 - Research on 090129 indicates hyperthermia is approved by the FDA as an
190443 - alterntive treatment for IBC. ref SDS 42 BR57
190444 -
190445 -        [On 090218 1205 Millie's letter to the medical team requests
190446 -        explanation of treatment plan using hyperthermia and radiation
190447 -        for recovering local control of IBC. ref SDS 59 TH5W
190449 -         ..
190450 -        [On 090219 during meeting with Doctor Hsu and Chris at UCSF
190451 -        requested medical orders for Millie's ratiation and
190452 -        hyperthermia treatments, similar to Chemotherapy Orders issued
190453 -        to the Infusion Clinic for Millie's care the past 2 years.
190454 -        ref SDS 60 4254
190456 -         ..
190457 -        [On 090220 0157 Millie's letter to the medical team confirms
190458 -        request today for an explanation of the treatment plan,
190459 -        including the doctor's orders for radiation and hyperthermia
190460 -        treatments, similar to Chemotherapy Orders Millie received for
190461 -        care in the Infusion Clinic. ref SDS 61 EA4Q
190463 -         ..
190464 -        [On 090220 1548 Millie received notes of a planning meeting at
190465 -        UCSF on designing her treatment for IBC wtih lower dose
190466 -        radiation and hyperthermia. ref SDS 62 PR4Y
190468 -         ..
190469 -        [On 090220 1548 paper received from UCSF describes
190470 -        hyperthermia combined with ionizing radiation provides
190471 -        effective treatment even for mutated cancer cells that
190472 -        resist treatment with chemotherapy. ref SDS 62 00FS  Since
190473 -        hyperthermia combined with radiation and/or chemotherapy,
190474 -        ref SDS 62 0129, "kills" cancer cells, ref SDS 62 00EI,
190475 -        this does not seem to fit the model of "palliation" as mere
190476 -        relief from suffering while cancer progresses toward near
190477 -        term demise. "Killing" cancer cells through heat sounds
190478 -        like aggressive curative therapy. ref SDS 62 GK6F
190479 -
190480 -
190481 -
190482 -
190483 -
190484 -
1905 -

SUBJECTS
Default Null Subject Account for Blank Record

2003 -
200401 -  ..
200402 - Left Supraclavicular Swelling Recurrence Finding Examination Today
200403 - Recurrence Lymphadenopathy Left Supraclavicular Palpation Found Today
200404 -
200405 - During examination today, Doctor Hsu palpated the lymph node in the
200406 - left suparclavicular saying it has now increased in size again, with
200407 - the rise of IBC on the chest.
200408 -
200409 -        [On 090213 1140 Doctor Johnson primary care physician at Kaiser
200410 -        in Walnut Creek palpated lymphadenopathy in left
200411 -        supraclavicular, confirming Doctor Hsu's findings today on
200412 -        090205. ref SDS 58 4M5I
200414 -         ..
200415 -        [On 090325 0830 examination at Kaiser finds reduced
200416 -        lymphadenopathy in left supraclaficular a week after completing
200417 -        radiation and hyperthermia treatment at UCSF. ref SDS 66 P36J
200419 -  ..
200420 - Doctor Hsu seemed to indicate that lower dose radiation and
200421 - hyperthermia can treat systemic cancer in both the right axillary, and
200422 - the node in the left supraclavicular.
200423 -
200424 -
200425 -
2005 -

SUBJECTS
Default Null Subject Account for Blank Record

2103 -
210401 -  ..
210402 - Side Effects Possible Scaling on Chest Similar to Sun Burn
210403 -
210404 - The doctor noted that extensive scope of Millie's IBC rash could cause
210405 - side effects with lower dose radiation and hyperthermia that leave a
210406 - mild "burning" condition, with the skin pealing, similar to getting a
210407 - sun burn.
210409 -  ..
210410 - Previously, on 081016 discussion of side effects from sunitinib
210411 - treatment sounded mild, and easily tolerated. ref SDS 29 N94W
210413 -  ..
210414 - Research indicates that side effects of radiation are sometimes
210415 - treated with Vitamin E plus pentoxifylline (Trental).  Can this or
210416 - something else help prevent severe side effects of hyperthermia
210417 - protocol?
210418 -
210419 -        [On 090206 Millie received letter presenting Vitamin E with
210420 -        pentoxifylline. ref SDS 54 SJ6R
210422 -         ..
210423 -        [On 090209 0018 Millie's letter to medical team asks about
210424 -        treating side effects from radiation and hyperthermia with
210425 -        Vitamine and pentoxifylline. ref SDS 55 745R
210427 -         ..
210428 -        [On 090218 1205 Millie asks medical team for feedback on
210429 -        treatment for side effects, and whether Vitamin E plus
210430 -        pentoxifylline is a solution, since this will require
210431 -        coordination with Gloria to adjust Coumadin treatments for
210432 -        Millie's pulmonary embolism. ref SDS 59 TH7V
210434 -         ..
210435 -        [On 090312 0800 Doctor Hsu discloses that severe side
210436 -        effects from radiation and hyperthermia, which were
210437 -        reported on 090310 to look worse than IBC, ref SDS 63
210438 -        O56X, will be treated beginning on 090317 after ending
210439 -        treatment with cream, ref SDS 64 F860; the doctor did
210440 -        not discuss Vitamin E plus pentoxifylline (Trental),
210441 -        ref SDS 64 6P8K, but proposed providing "cream" to treat
210442 -        radiation side effects. ref SDS 64 F852
210444 -         ..
210445 -        [On 090317 Millie receives Silvadene Cream 1% from Doctor
210446 -        Hsu, ref SDS 65 M442, and also received instructions from
210447 -        Miranda for application, including an orientation for
210448 -        bandaging to recover from expanding sores caused by
210449 -        radiation and hyperthermia treatments. ref SDS 65 ET46
210450 -
210452 -  ..
210453 - Prognosis Favorable for Local Control Evident Scope Expanding IBC
210454 -
210455 - Doctor Hsu seemed confident that lower dose radiation and hyperthermia
210456 - will successfully treat all or most IBC disease now evident from
210457 - observation today.
210459 -  ..
210460 - After hyperthermia accomplishes local control, systemic treatment can
210461 - maintain Millie's vitality by preventing recurrence.  The doctor
210462 - noted that hyperthermia helps avoid recurrence.
210464 -  ..
210465 - There is a question about treating lymphadenopathy, per Doctor Hsu's
210466 - finding today of rising nodes in left supraclavicular, ref SDS 0 OH88,
210467 - and patient history showing continuing CT tests showing nodes in right
210468 - axilla, per above. ref SDS 0 UG44
210469 -
210471 -  ..
210472 - Work Plan Begin Treatment in Time to Be Effective
210473 -
210474 -
210475 -    1.  Doctor Hsu explained that after the meeting this morning, he
210476 -        will consult with a physicist technician on scope of Millie's
210477 -        radiation and hyperthermia treatment based on sketches prepared
210478 -        during the meeting today. ref SDS 0 FQ8W
210480 -         ..
210481 -    2.  Doctor Hsu or a colleague will call Millie to schedule the
210482 -        earliest time for doing the CT test layout process, so that
210483 -        treatment can begin immediately, based on findings of
210484 -        accelerating disease, observed during the meeting today.
210485 -        ref SDS 0 R29M  The doctor asked how soon Millie can be
210486 -        available for the CT test layout step?
210488 -         ..
210489 -    3.  Millie advised that her time is the "doctor's time".
210490 -        Everything in Millie's schedule is subordinate to this task,
210491 -        because if treatment is not commenced in time to be effective,
210492 -        there will be no time left for anything else.  She is prepared
210493 -        to meet with Doctor Hsu and the physiciast technician any time
210494 -        at their first opportunity.
210496 -         ..
210497 -    4.  Doctor Hsu will work on making timely arranements for Millie's
210498 -        treatment.
210499 -
210500 -
210501 -
210502 -
210503 -
210504 -
210505 -
210506 -
210507 -
210508 -
2106 -