Welch Company
San Francisco, CA


S U M M A R Y


DIARY: October 27, 2009 08:30 AM Tuesday; Rod Welch

Millie meeting at Kaiser evaluate next treatment for 9th relapse cancer.

1...Summary/Objective
2...Medical Chart


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CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Millie and Pam met with Doctor Johnson in the Oncology Department at
040902 - Kaiser in Walnut Creek.
040904 -  ..
040905 - Doctor Johnson implemented planning in Millie's letter to the medical
040906 - team submitted last night with the agenda today.  In the examination
040907 - room, he called Millie's cell phone number to conference with Rod in
040908 - the ICU unit at the VA in San Francisco, 5, days after heart bypass
040909 - surgery performed on 091022 0700. ref SDS 10 01F9  Doctor Johnson used
040910 - the speaker phone, so everyone in the examination room at Kaiser could
040911 - participate in the call.
040913 -  ..
040914 - Doctor Johnson reported good news.
040916 -  ..
040917 - Millie's cancer marker dropped 50 points to CA 15-3 299 for the lab 2
040918 - weeks ago, and after increasing 50 points to CA 15-3 352 from the
040919 - prior test 4 weeks ago.
040921 -  ..
040922 - The doctor made an examination.
040924 -  ..
040925 - Doctor Johnson indicated there is evidence of stable to reducing IBC
040926 - lesions.
040928 -  ..
040929 - This seems to align with the drop in the cancer marker, but conflicts
040930 - somewhat with the letter to the medical team on 091019, reporting
040931 - evident progression of IBC, ref SDS 9 0Z9S, and the letter yesterday
040932 - reporting again patient observations that IBC seems to be progressing
040933 - on the left arm and other sites outside the radiation zones treated at
040934 - UCSF ending on 090317, and which aligned with rise of 50 points in the
040935 - prior test for the cancer marker CA 15-3 352, per above. ref SDS 0
040936 - DR6M
040938 -         ..
040939 -        [On 091112 0930 Doctor Johnson examined Millie and concurred
040940 -        with the report on 091019 that cancer is progressing, and so
040941 -        switched Millie to Navelbine chemotherapy, because the medical
040942 -        team still has not had time to find a targeted treatment for
040943 -        Millie that does not have difficult side effects. ref SDS 11
040944 -        H54F
040946 -  ..
040947 - Discussed goal of care for Millie is stable to improvement, under
040948 - Brigid's Rule that "stable is good" for treating cancer as a chronic
040949 - disease, reported on 070329 0800. ref SDS 1 M645
040951 -  ..
040952 - Doctor Johnson advised that since examination today indicates at this
040953 - time Millie seems at least stable, he orders continuing the current
040954 - Gemzar treatment regimen another cycle, possibly 2.
040956 -  ..
040957 - The doctor feels that this unexpected drop in cancer marker buys the
040958 - medical team another month or so to find the next treatment for
040959 - Millie's 9th relapse of cancer, and targeted to Millie's patient
040960 - profile listed in the record on 090213. ref SDS 2 ES7I
040962 -  ..
040963 - This requirement was discssed with Doctor Johnson during a meeting in
040964 - the cafeteria on 090909 1344. ref SDS 7 VF60
040966 -  ..
040967 - Doctor Johnson reported receiving Millie's letter to the medical team
040968 - on 090922 asking about progress at Kaiser collaborating with UCSF
040969 - reviewing follow on treatments for Millie, including PARP. ref SDS 8
040970 - NW6S
040972 -  ..
040973 - Doctor Johnson reported during the meeting today that he still has not
040974 - had time to coordinate with Doctor Rugo at UCSF on finding the next
040975 - treatment for Millie.  The doctor recalled meeting on 090909 and
040976 - feeling at that time that he had time to review 2nd opinion follow on
040977 - treatments for Millie, including PARP. ref SDS 7 QX88
040979 -  ..
040980 - During the meeting, Doctor Johnson advised that he has not received a
040981 - call nor corresondence from Doctor Rugo to implement UCSF's work plan
040982 - on 090716 for Doctor Rugo to collaborate with Doctor Johnon on
040983 - coordinating Millie's care recovering from medical mistakes at UCSF
040984 - that have caused Millie's cancer to spread, reported by Doctor Hsu on
040985 - 090609. ref SDS 5 W65W
040987 -  ..
040988 - Doctor Johnson further advised during the meeting today plans to work
040989 - with Doctor Rugo and her team at UCSF over the next few weeks to be
040990 - prepared for prescribing effective care treating Millie's cancer as a
040991 - chronic disease, when progression of IBC causes the 9th relapse, and
040992 - as explained by Doctor Rugo during the meeting at UCSF on 090616, when
040993 - at that time she reported that everybody at Kaiser and UCSF is "on
040994 - board" for treating Millie's cancer as a chronic disease, and for the
040995 - purpose of mitigating damage Millie suffered from medical mistakes
040996 - getting radiation treatment from UCSF on referral, and further
040997 - advising that Millie's treatment plan would next try a new line of
040998 - PARP agents "targeted" to treat only cancer, ref SDS 6 D647, similar
040999 - to cetuximab which was effective for nearly 2 years keeping Millie
041000 - "stable" under Brigid's rule, and with a high quality of daily life,
041001 - unlike her current stopgap treatment with Gemzar, which has achieved
041002 - stability, but has difficult side effects.
041004 -  ..
041005 - Thanked Doctor Johnson for continuing to support the medical team with
041006 - hard work required to treat Millie's cancer as a chronic disease,
041007 - which he first proposed on 080829, and as shown in the case study of
041008 - patient history discussed previously at Kaiser on 090325. ref SDS 3
041009 - L15M
041011 -  ..
041012 - With these understandings, ended conference call.  Doctor Johnson
041013 - completed his visit with Millie and Pam at Kaiser in Walnut Creek, and
041014 - the VA continued care in the ICU to recover from heart surgery in San
041015 - Francisco on 091022. ref SDS 10 01F9
041017 -  ..
041018 - Doctor Johnson explained to Millie after the call that Navelbine is
041019 - the only "Gold Standard" chemotherapy treatment he has left for
041020 - treating Millie's 9th relapse of cancer.
041022 -  ..
041023 - This aligns with prior understandings in the meeting on 090515, when
041024 - at that time, the doctor advised that Gemzar and Navelbine
041025 - chemotherapy agents are not appropriate for Millie's patient profile.
041026 - ref SDS 4 658J
041027 -
041028 -
041029 -
0411 -

SUBJECTS
Default Null Subject Account for Blank Record

0503 -
050401 -  ..
050402 - Medical Chart
050403 -
050404 - Mil received the doctor's report for the meeting today sent with
050405 - Kaiser's Knowledge Management system...
050406 -
050407 -    1.  Office Visit 10/27/09
050408 -        To: Mildred A Buck
050409 -        From: ROBERT ALLSTON JOHNSON MD
050410 -        Received: 10/27/09 9:07 AM
050412 -         ..
050413 -    2.  Patient presents with: RECHECK
050415 -         ..
050416 -    3.  History of Present Illness:
050417 -
050418 -        Mildred A Buck is a 73 Y female with a history of IBC of left
050419 -        breast who was initially diagnosed 03/04/02.  S/P AC x's 4 from
050420 -        04/23/02 through 07/01/02 followed by Taxotere ending 12/04/02.
050421 -        She had recurrent disease noted initially in the cervical LN's
050422 -        03/03/04.  On E2100 Study with Taxol/Avastin, but she had a PE
050423 -        noted on CT 11/03/2004.  Then, because of progression of
050424 -        disease, the patient was started on Taxotere and Xeloda
050425 -        4/15/05.  She had a total of 8 cycles ending 9/16/05.  She had
050426 -        a palliative left mastectomy performed 10/21/05.  Then her left
050427 -        chest lesions began expanding again.  The patient started
050428 -        Taxotere and Xeloda again 07/21/06 for 7 cycles.  She was
050429 -        started on a Clinical Trial 02/01/07 at UCSF and was randomized
050430 -        to the Erbitux only (no Carbo) Arm.  She had weekly Carboplatin
050431 -        added 03/13/08 because of progression of disease.  Her disease
050432 -        progressed again and she began a Phase I/II Study of Sunitinib
050433 -        (SU11248) at UCSF 11/14/08.  Lengthy discussion about current
050434 -        status and response to therapy. Because of cytopenia, MTX to be
050435 -        D/C'd and Sutent and CTX held and then dose reduced.  The
050436 -        patient started hyperthermia/XRT at UCSF 02/19/09 and completed
050437 -        it 03/17/09.  She has started the MPA Clinical Trial at UCSF
050438 -        06/16/09 but this has been D/C'd.  She started Gemzar 07/28/09
050439 -        and received Wk #1 Of Cycle #4 10/22/09.  She is here for FU.
050440 -        She is concerned that there is evidence of progression , now
050441 -        involving the right side of chest and breast.
050443 -         ..
050444 -    4.  Current medications:
050445 -        HYDROCODONE/ACETAMINOPH 5-5
050446 -        WARFARIN 4 MG TABLETS
050447 -        LUMIGAN 0.03% EYE DROPS (2.
050448 -        TIMOLOL MALEATE 0.5% EYE DR
050449 -        OXYCODONE W/APAP 5-325 MG T
050450 -        AEROCHAMBER Z-STAT/PLUS W/O
050451 -        QVAR 80 MCG ORAL INHALER
050452 -        ALBUTEROL HFA 90MCG ORAL IN
050453 -        GUAIFEN/CODEIN 100-10MG/5ML
050454 -        LORAZEPAM 1 MG TABLETS
050456 -         ..
050457 -    5.  Review of systems:
050458 -        Constitutional: Appetite and energy level are stable still able to walk
050459 -        Lafayette Reservoir.
050460 -        Eyes: Vision is OK.
050461 -        ENT: No nose bleeds.
050462 -        Cardiovascular: No SOB, palpitations or chest pain
050463 -        Respiratory: No hemoptysis or cough. Some DOE noted
050464 -        GI: Diarrhea resolved
050465 -        GU: No hematuria or dysuria
050466 -        Musculoskeletal: Left neck spasm and right shoulder pain
050467 -        Skin: Pruritis of chest wall
050468 -        Neurological: No confusion, sensory changes or motor weakness
050469 -        Psychiatric: Anxious
050471 -         ..
050472 -    6.  Physical Exam:
050473 -        ECOG Performance Score 0
050474 -        BP 138/81 | Pulse 72 | Temp (Src) 98.7 F (37.1 C) (Oral) | Wt 141 lb 9.6 oz
050475 -        (64.229 kg) | SpO2 99%
050476 -        Head: alopecia
050477 -        Eyes: normal conjunctiva
050478 -        Mouth: normal mucosa
050479 -        Lymph: no nodes palpable in neck, axillae or groin
050480 -        Breasts: evidence of progression of erythema to other breast
050481 -        Lungs: clear to percussion and auscultation
050482 -        Heart: regular without murmur or gallop
050483 -        Abd: soft with normal bowel sounds. No masses or organomegaly
050484 -        Ext: no edema
050485 -        Skin: no rashes or palpable masses
050486 -        Bones: no tenderness
050487 -        Neuro: awake, alert, and oriented. Moves all extremities well. Normal gait.
050489 -         ..
050490 -    7.  Lab:
050491 -        PT, Patient H 31.3 Sec
050492 -        PT INR 3.0 Ratio
050494 -         ..
050495 -    8.  WBC 5.3 K/uL
050496 -        RBC L 3.06 M/uL
050497 -        Hemoglobin L 9.2 g/dL
050498 -        Hematocrit L 28.7 %
050499 -        MCV 94 fL
050500 -        RDW H 20.2 %
050501 -        Plt 388 K/uL
050503 -         ..
050504 -    9.  CA 15-3
050505 -        -----------
050506 -        299 H
050507 -        343 H
050508 -        297 H
050509 -        302 H
050510 -        346 H
050511 -        335 H
050512 -        350 ?
050513 -        389 H
050514 -        289 H
050515 -        320 H
050516 -        271 H
050518 -         ..
050519 -   10.  PFT's 08/31/09
050520 -        - No obstruction
050521 -        - Good response to bronchodilators
050522 -        - Moderate decrease in diffusion capacity
050524 -         ..
050525 -   11.  Imaging:
050526 -        09/19/09 CT THORAX W CONTRAST - No pulmonary emboli on a technically good
050527 -        study. The lungs show multiple areas of groundglass opacity and multiple
050528 -        small areas of more confluent density. Tiny left pleural effusion. S/P left
050529 -        mastectomy. A few additional minor findings, as described above. Since July
050530 -        20, 2009 CT scan of the chest, there has been resolution of many of the
050531 -        pulmonary opacities but there are now many new ones, especially in the left
050532 -        lower lobe and in the right upper lobe. The left pleural effusion is much
050533 -        smaller. Otherwise, no change.
050535 -         ..
050536 -   12.  09/19/09 CHEST, SINGLE
050538 -         ..
050539 -   13.  07/31/09 RIBS, UNILATERAL, 2 VIEWS - Right ribs appear intact
050541 -         ..
050542 -   14.  07/20/09 CT THORAX W CONTRAST -
050543 -
050544 -        1.  Negative for pulmonary embolus.
050545 -
050546 -        2.  New small left pleural effusion.  No pleural enhancement or
050547 -            evidence of loculation.
050549 -             ..
050550 -        3.  Otherwise stable chest CT compared with recent examination
050551 -            from one month earlier.
050553 -         ..
050554 -   15.  06/12/09 CT THORAX, ABDOMEN, PELVIS W CONTRAST
050556 -         ..
050557 -   16.  06/12/09 CT NECK W CONTRAST
050559 -         ..
050560 -   17.  03/17/09 DXA BONE DENSITY, AXIAL -
050561 -
050562 -        1.  Bone mineral density calculated for the LUMBAR SPINE is
050563 -            statistically consistent with osteopenia.
050564 -
050565 -        2.  Bone mineral density calculated for the TOTAL HIP is
050566 -            statistically consistent with osteopenia.
050568 -         ..
050569 -   18.  01/29/09 SHOULDER, COMPLETE 2+ VIEWS
050571 -         ..
050572 -   19.  01/22/09 SHOULDER, COMPLETE 2+ VIEWS - Orthopedic follow up.
050573 -        See Orthopedic note for details.  S/P reduction of anterior
050574 -        shoulder dislocation.
050576 -         ..
050577 -   20.  01/22/09 SHOULDER, ONE VIEW - Dislocation, right shoulder.
050578 -        Fracture right humeral head
050580 -         ..
050581 -   21.  01/22/09 CT CERV SPINE W/O CONTRAST - Degenerative changes of
050582 -        the cervical spine without evidence of acute C spine fracture
050583 -        or loss in alignment.
050585 -         ..
050586 -   22.  01/22/09 CT HEAD W/O CONTRAST -
050587 -
050588 -        1.  No evidence of acute infarct or hemorrhage.
050589 -        2.  Sinus disease. Mild nasal septal deviation to the right.
050591 -         ..
050592 -   23.  Assessment:
050593 -        1. Metastatic breast cancer (IBC) lung, lymph node and chest wall;
050594 -        progression?
050595 -        2. Tolerating Gemzar; CA 15-3 is stable
050596 -        3. ACD stable
050597 -        4. DOE; due to radiation injury vs lymphangitic spread; stable
050598 -        5. Lymphedema stable
050599 -        6. Neck spasm
050601 -         ..
050602 -   24.  Plan:
050603 -        1. Continue Gemzar 750 mg/m2 iv q weekly x 3 weeks for one more cycle and then
050604 -        reassess
050605 -        2. Continue Neupogen 480 mcg to be given 24 hrs after each treatment x 2 days
050606 -        3. Continue serial CA 15-3's
050607 -        4. Then consider Navelbine in the future
050608 -        5. Add Robaxin
050609 -        6. RTC monthly prior to chemotherapy
050610 -
050614 -
050615 -
050616 -
050617 -
050618 -
050619 -
0507 -