CONTACTS 

SUBJECTS
Meeting Doctor at Kaiser Review Progress Develop Work Plans and Sche
CA 15-3 70 Rises from 60 Reversing Trend of Past 6 Months

0804 -
0804 -    ..
0805 - Summary/Objective
0806 -
080601 - Follow up ref SDS 58 0000, ref SDS 56 0000
080602 -
080603 - The doctor diagnosed metastatic cancer that requires immediate and
080604 - continuing treatment, based on pathology showing recurrence of cancer
080605 - has been established by biopsy from the neck. ref SDS 0 8R6M  Other
080606 - diagnostics using CA 15-3 and CT tests corroborate biopsy findings.
080607 - The doctor indicated that surgery, initially planned by Doctor Laio,
080608 - is not effective for metastatic cancer, and that Kaiser works with
080609 - both Stanford and UC Med Center in San Francisco for 2nd opinions to
080610 - backup initial analysis and recommendations by Kaiser for
080611 - participation in a trial of a new treatment.  The Doctor introduced
080612 - Rosalie, who submitted a patient consent form, and reviewed the
080613 - protocol for the trial of a new drug, Avastin, which The Doctor wants
080614 - Millie to consider for the next phase of treatments.  Cancer
080615 - treatments will be delayed for 2 weeks, while Millie is treated for
080616 - increased redness, diagnosed today as cellulitus, in the left breast,
080617 - where cancer first occurred two years ago.  During this treatment
080618 - period, Millie will review the consent form and then call Rosalie to
080619 - schedule a meeting on questions that result from review of the consent
080620 - documents, toward signing to participate in the trial.
080621 -
080622 -
080623 -
080624 -
080626 -  ..
0807 -
0808 -
0809 - Discussion
0810 -
081001 - Recovery Progress CA 15-3 Cancer Marker Rises from 60 to 70
081002 - CA 15-3 Cancer Marker Continues Strong Rise Consistent with Pathology
081003 -
081004 - Follow up ref SDS 55 SM6M, ref SDS 54 SM6M.
081005 -
081006 - Blood test reported during the meeting today showed CA 15-3 cancer
081007 - marker rose from 60 to 70, reversing small declines from 68 to 60 over
081008 - the past 6 months, to jump above the highest level previously recorded
081009 - since a prior high 18 months ago in June of 2002.  While still
081010 - nominally below a level that indicates treatment has failed, as
081011 - reported on 030220, ref SDS 46 ZL4X, since recurrence has been
081012 - confirmed by pathology on 040309, ref SDS 58 0001, this record of
081013 - persistent reports well above normal (31) seems like an indicator of
081014 - failed treatment, and aligns with The Doctor's comments on 030606
081015 - that elevated CA 15-3 requires attention. ref SDS 48 NE6F
081017 -           ..
081018 -          040315??....... 70 H............. 040318, ref SDS 0 SM6M
081019 -          040205......... 60 H............. 040211, ref SDS 55 SM6M
081020 -          031205......... 62 H............. 031205, ref SDS 54 SM6M
081021 -          030912......... 66 H............. 030915, ref SDS 52 SM6M
081022 -          030708......... 68 H............. 030710, ref SDS 51 SM6M
081023 -          030503......... 54 H............. 030508, ref SDS 47 SM6M
081024 -          030403......... 45 H............. 030508, ref SDS 47 SM6M
081025 -          030220......... 46 H............. 030220, ref SDS 46 5E6L
081026 -          030106......... 37 H............. 030109, ref SDS 44 SM6M
081027 -          021202......... 41 H?............ 021204, ref SDS 40 SP5G
081028 -          021102......... 36 H?............ 021113, ref SDS 39 Y65I
081029 -          021023......... 33 H?............ 021023, ref SDS 38 SQ5I
081030 -          020930......... 33 H?..29........ 021002, ref SDS 37 SQ5I
081031 -          020917......... 36 H?............ 020924, ref SDS 36 SQ5I
081032 -          020717......... 59 H?............ 020726, ref SDS 35 YN5K
081033 -          020629......... 75 H ............ 020705, ref SDS 33 UX6I
081034 -          020608........  67 H ............ 020614, ref SDS 29 0001
081035 -          020603........ 108 H ............ 020607, ref SDS 27 X67F
081036 -          020511........ 117 H ............ 020603, ref SDS 26 PJ4J
081037 -          020419......... 81 H ............ 020430, ref SDS 22 7N5H
081038 -          020321......... 85 H ............ 020405, ref SDS 11 6T8K
081039 -
081040 -
081041 -
081043 -  ..
0811 -
0812 -
0813 - Analysis
0814 -
081401 - Rise in CA 15-3 Cancer Marker Attributed to Trauma of Biopsy
081402 -
081403 - Follow up ref SDS 54 GJ5M, ref SDS 52 GJ5M.
081404 -
081405 - The doctor seemed to indicate today that the sudden and large rise
081406 - in CA 15-3 from 60 to 70, per above, ref SDS 0 KV59, relates more to a
081407 - reaction of the body to the biopsy process, reviewed below,
081408 - ref SDS 0 8R6M, than to a general indication of distant metastasis.
081409 -
081410 -     [On 040601 received results of CA 15-3 blood test on 040524;
081411 -     results show another rise, from 70 to 78, which is a little less
081412 -     than the rise today. ref SDS 71 2N5J
081414 -  ..
081415 - The doctor cited the CT results that show only two instances of
081416 - cancerous locations in the neck to support a conclusion that the
081417 - problem is localized to the neck. ref SDS 0 WB8Q
081418 -
081419 -
081420 -
0815 -

SUBJECTS
Cancer Cells Detected in Biopsy of Lumps in Neck Taken on 040303 by
Trial on New Cancer Treatment Double Blind Test Alternative Approach
Meeting with Doctor about Lump in left breast and Under Left Arm Cau
Patient Symptoms Guide Kaiser for Performing Treatment of Cancer Rel
Symptom New Lump Under Arms where Cancer Surgery Performed on 020312
Lump Under Left Arm Scar Tissue Cancer Harder to Touch Small Isolate
Recurrence Likely Due to High Risk Factors in Millie's Case Doctor P
Testing Indicates Presence of Cancer Activity but No Clinical Observ
No Clinical Observable Symptoms of Cancer Delays Commencement of Sec
Tests Shows No Evidence Progression Distant Metastasis Stable Condit
Treatment Cancer and Trial on New Cancer Treatment Double Blind Test
Metastatic Cancer Diagnosed Chemotherapy Treatment and Trial on New

2414 -
241501 -  ..
241502 - Treatment Scheduled to Recover from Cancer in Neck Lymph Nodes
241503 - Cancer Cells Reported in Biopsy of Lumps in Neck Treatment Scheduled
241504 - Chemotherapy Prescribed Surgery Not Effective for Lymph Node Cancer
241505 - Metastatic Cancer Diagnosed Chemotherapy Treatment Prescribed
241506 -
241507 - Follow up ref SDS 58 0001.
241508 -
241509 - The doctor explained that a pathology report on 040309 for the biopsy
241510 - of lymph nodes along the left side of the neck show cancerous cells
241511 - are on the same left side as the original cancer in the breast,
241512 - described as a "supraclavicular" location. ref SDS 58 0001  He
241513 - indicated this establishes the patient has metastatic cancer due to
241514 - recurrence, i.e., relapse, and noted that the rise in CA 15-3, per
241515 - above, ref SDS 0 GJ5M, in combination with recent CT scan tests align
241516 - with this diagnosis, per below. ref SDS 0 WB8Q  The biopsy report was
241517 - not submitted during the meeting.
241518 -
241519 -     [On 041210 diagnosis 2nd relapse of cancer, and first relapse of
241520 -     IBC. ref SDS 80 028N
241522 -  ..
241523 - On 030508 a request for biopsy was not performed on a growing lump
241524 - under the left arm causing discomfort, also, on the same side as
241525 - cancer in the left breast, which was periodically inflammed with a red
241526 - rash. ref SDS 47 7C98
241528 -      ..
241529 -     [On 040517 Millie diagnosed with inflammatory breast cancer,
241530 -     ref SDS 70 7D6F, research indicates that swelled lymph nodes under
241531 -     arm and in the neck above the collar bone are symptoms of IBC.
241532 -     ref SDS 70 M67I
241534 -      ..
241535 -     [On 040614 The Doctor diagnosis IBC, assigns stage IV
241536 -     treatment status for metastatic cancer. ref SDS 73 SZ3I
241538 -      ..
241539 -     [On 040713 The Doctor confirms diagnosis of metastatic cancer
241540 -     based on cancer in the neck. ref SDS 74 NK9H
241542 -      ..
241543 -     [On 041019 research at Stanford found study last year showing
241544 -     Avastin trial did not acheive progression-free survival.
241545 -     ref SDS 76 U647
241547 -      ..
241548 -     [On 050324 research indicates metastatic cancer involving regional
241549 -     lymph nodes, diagnosed today, ref SDS 0 8R6M, may be operable to
241550 -     reduce chances of relapse, which is different from "distant
241551 -     metastasis," that surgery cannot cure, but may play a palliative
241552 -     role, ref SDS 82 O84N, further explained from research on 050712.
241553 -     ref SDS 83 B65G
241555 -      ..
241556 -     [On 051121 primary care physician finds patient has no evidence of
241557 -     disease (NED) based on estensive testing with biopsy, PET, CA
241558 -     1503; prognosis is for future relapse due to diagnosis of
241559 -     metastatic cancer, and therefore mastectomy surgery on 051021 was
241560 -     palliation for furture relapse. ref SDS 85 LH7M
241561 -
241562 -
241564 -  ..
241565 - Bevacizumab Avastin Taxol Chemotherapy Drug Trial Recommended
241566 - Metastatic Cancer Established by Biopsy, CA 15-3, CT Tests
241567 - Recurrence Based on Biopsy Establishes Metastatic Disease Relapses
241568 -
241569 - The doctor described Millie's condition as officially "recurrence",
241570 - which may be similar to "progression," and "relapse," based on
241571 - discussions with the doctor on 031205. ref SDS 54 265M  Recurrence
241572 - changes the status of "stable" described previously, also, on 031205.
241573 - ref SDS 54 GJ5M  New evidence reviewed today establishes metastatic
241574 - cancer, related to the phrase "distant metastasis," reviewed
241575 - originally on 020321. ref SDS 7 FX5H
241576 -
241577 -     [On 040713 The Doctor confirms diagnosis of metastatic cancer
241578 -     based on cancer in the neck. ref SDS 74 NK9H
241580 -  ..
241581 - The report today aligns with expectations on 030615. ref SDS 48 NE4G
241583 -  ..
241584 - A month later on 030710 the doctor explained a theory of delaying
241585 - treatment when metastasis has been detected by testing, until physical
241586 - symptoms are experienced by the patient. ref SDS 51 FZ55
241588 -  ..
241589 - Today, as a result of findings in the pathology report on the neck,
241590 - per above, ref SDS 0 8R6M, the doctor ordered an aggressive, proactive
241591 - regimen to treat recurrence of cancer immediately by starting Millie,
241592 - beginning next week, in a clinical trial for bevacizumab (rhuMab VEGF
241593 - - commercially called Avastin - and complemented with Taxol, see
241594 - below. ref SDS 0 TG4M)  This confirms the doctor's message on 040309
241595 - that referral to the Taxol Avastin drug trial is the best course for
241596 - treating Millie's recurrence of breast cancer. ref SDS 58 WG7F
241598 -  ..
241599 - Millie asked if referral to a clinical trial is better than using
241600 - established drugs?   Why take chances with unproven treatments?
241602 -  ..
241603 - The doctor said that many complex factors are balanced prescribing
241604 - treatment for cancer.  The doctor prescribes treatment with the best
241605 - chance of being effective based on medical science and experience, and
241606 - which also minimizes side effects.  Patient status, type of cancer,
241607 - general health, blood counts, fitness, and emotional condition are all
241608 - considered, as explained during the meeting on 030606. ref SDS 48 P97J
241610 -  ..
241611 - There was discussion that older established drugs often have severe
241612 - side effects that are difficult for older patients to tolerate.  This
241613 - makes it difficult to prescribe dose levels that will be effective.
241615 -  ..
241616 - The doctor explained that clinical trials expand the doctor's "tool
241617 - kit" for oncology practice treating cancer.  Millie's status of
241618 - ER/PR/HER2 (triple) negative, reported on 020321, ref SDS 0 DG4J,
241619 - limits drugs for treatment.  Since treatment does not generally "cure"
241620 - metastatic disease, diagnosed today, per above, ref SDS 0 WA4H,
241621 - doctors must prescribe care that prolongs both life and quality of
241622 - life using drugs that contain cancer until measurable progression
241623 - shows a drug is no longer effective.  As cancer mutates defeating
241624 - treatment, switching through a limited number of drugs eventually
241625 - leads to death, explained previously on 030606. ref SDS 48 N27L  New
241626 - drugs available in clinical trials often have much less side effects,
241627 - so patients can tolerate a full dose to optimize effect treating
241628 - cancer.  Clinical trials also give doctors flexibility to hold
241629 - established drugs in reserve until and unless more severe conditions
241630 - arise, as explained a month later on 030710. ref SDS 51 FZ55  When
241631 - that occurs, established drugs like Navelbine and Gemzar have a better
241632 - chance of being effective.
241634 -  ..
241635 - Millie asked about chances of success with bevacizumab in a clinical
241636 - trial compared to other established drugs Kaiser can use?  What about
241637 - Taxol by itself?
241638 -
241639 -        [On 090423 0830 Doctor Hsu applies standard of care for
241640 -        oncology by delaying use of "2-bullets" with radiation and
241641 -        hyperthermia holding them in reserve while Doctor Rugo
241642 -        experiments with clinical trials to find "maintenance" drugs
241643 -        that treat Millie's cancer as a chronic disease. ref SDS 95
241644 -        UH3G
241646 -  ..
241647 - The doctor advised that prescribing referral today for a clinical
241648 - trial to treat Millie's first relapse of cancer (see below,
241649 - ref SDS 0 DK63) is supported by evidence from extensive testing that
241650 - indicates this regimen is likely effective for Millie's condition of
241651 - metastatic breast cancer.  Every patient is unique.  Patients may not
241652 - respond even to established drugs.  The doctor cited Millie's
241653 - progression of cancer after just 2 treatments with AC that required
241654 - changing the prescription to Taxotere, reported on 020603. ref SDS 26
241655 - WO4O  Increasing the pool of drugs through clinical trials increases
241656 - the doctor's chance of finding effective treatment.
241658 -  ..
241659 - The doctor explained oncology practice to prescribe treatment that has
241660 - the best chance of being effective.  Clinical trials provide cutting
241661 - edge technology for treating cancer have advantages.
241663 -  ..
241664 - Newer treatments coming online strive to target only cancer cells.
241665 - This reduces damage from side effects of older drugs that use a
241666 - systemic "shot gun" design, which causes low blood counts, nausea and
241667 - fatigue that make patients feel miserable to the point of giving up.
241668 - On 030606 the doctor described chemotherapy as "posion" that attacks
241669 - healthy cells, which must be tolerated in order to treat cancer.
241670 - ref SDS 48 JP7G  Reducing severe side effects enhances quality of life
241671 - and increases tolerance for higher dosages of treatment that prolong
241672 - life.  Clinical trials are therefore an important part of the doctor's
241673 - "tool kit" for patient care in oncology practice, discussed above.
241674 - ref SDS 0 DG4J  Previously on 020405 the doctor changed prescription
241675 - from Taxol to Taxotere, because Taxotere is a newer chemotherapy drug
241676 - that causes less side effects. ref SDS 11 IU9H  On 030109 Taxotere was
241677 - successful lowering CA 15-3 cancer marker dramatically to 37, after
241678 - rising to 117 in June 2002 during treatment with older, established
241679 - drugs (AC). ref SDS 44 GJ5M
241681 -      ..
241682 -     [On 041130 the doctor explained strategy for starting and changing
241683 -     protocols in treating relapse of IBC with a new drug trial.
241684 -     ref SDS 79 028N
241686 -      ..
241687 -     [On 041210 doctor prescribes treatment with referral to clinical
241688 -     trial. ref SDS 80 CF9F
241690 -      ..
241691 -     [On 070105 Millie relapsed again; the doctor made referral for
241692 -     treatment with cetuximab and carboplatin in a clinical trial at
241693 -     UCSF. ref SDS 91 PK7L
241695 -      ..
241696 -     [On 070830 UCSF and Kaiser working on billing issues for Millie's
241697 -     treatment with clinical trial at UCSF ordered by her doctor at
241698 -     Kaiser. ref SDS 92 T259
241700 -  ..
241701 - The Doctor explained that chemotherapy treatments with Taxol will be
241702 - once a week for three (3) weeks, then Millie will get a week off.  If
241703 - Millie is "randomized" to receive the trial drug, then Taxol
241704 - treatments will be supplemented with bevacizumab.
241705 -
241706 -     [On 041019 research at Stanford found study last year showing
241707 -     Avastin trial did not acheive progression-free survival.
241708 -     ref SDS 76 U647
241710 -  ..
241711 - Millie asked about side effects, and mentioned that treatments once a
241712 - month during 2002 caused severe tiredness for several days.  If
241713 - treatments occur once a week, this may severly limit ability to work.
241715 -  ..
241716 - The doctor explained that infusion treatments are given once a
241717 - week when recurrence is diagnosed, which is much more frequent than
241718 - treatments during the first phase for Stage II cancer.  To reduce the
241719 - rate of accumulating side effects from more frequent exposure,
241720 - patients get a lower dose of chemotherapy to treat recurrence,
241721 - compared to the dosage patients get when first treated for breast
241722 - cancer, as in Millie's case during 2002.  Kaiser's experience
241723 - indicates that a lower dose of chemotherapy reduces the impact on
241724 - ability to function normally.
241726 -  ..
241727 - The doctor advised that he will see Millie at least once a month
241728 - prior to the start of each treatment cycle to evaluate continued
241729 - participation in the trial, based on side effects and response to
241730 - treatment.
241731 -
241732 -        [...below, Rosalie reviews treatment regimine. ref SDS 0 P13J
241734 -         ..
241735 -        [On 040517 one regimen for treating IBC is a higher dose of
241736 -        chemotherapy. ref SDS 70 JK94
241738 -  ..
241739 - The doctor advised that after the meeting today Rosalie, who is the
241740 - protocol nurse, will come in and initiate paperwork to make the
241741 - necessary arrangements for referral to begin treatment next week in
241742 - the clinical trial.
241743 -
241744 -        [...below, subsequent examination led to diagnosis of possible
241745 -        cellulitis that will defer treatment for at least 2 weeks.
241746 -        ref SDS 0 IM6J
241748 -         ..
241749 -        [...below, meeting with Rosalie on getting started with review
241750 -        of consent procedures. ref SDS 0 BK8M
241752 -         ..
241753 -        [On 040407 Millie requested assistance expediting a 2nd opinion
241754 -        to ensure timely treatment. ref SDS 61 F49U
241756 -         ..
241757 -        [On 040407 Rosalie called and scheduled treatments to begin on
241758 -        040420. ref SDS 61 3S6L
241760 -         ..
241761 -        [On 040419 surgery for port catheter; biopsy taken. ref SDS 65
241762 -        0001
241764 -         ..
241765 -        [On 040420 Millie begins treatments. ref SDS 66 0001
241767 -         ..
241768 -        [On 040517 Kaiser submits pathology report that has diagnosis
241769 -        of inflammatory breast cancer, ref SDS 70 7D6F, research
241770 -        indicates that swelled lymph nodes in the neck above the collar
241771 -        bone, lumps under the arm, and redness in the breast are
241772 -        symptoms of IBC. ref SDS 70 M67I
241774 -         ..
241775 -        [On 040601 good news -- Millie indicates the lumps in the neck
241776 -        seem to have gotten smaller, even disappeared. ref SDS 71 DJ9N
241777 -
241778 -
241779 -
2418 -

SUBJECTS
PET Test Not Needed Because Cancer Limited to Neck Metastisis PET Te

2503 -
250401 -  ..
250402 - PET Test Not Needed Because Cancer Limited to Neck
250403 - Neck Only Evidence Distant Metastasis PET Testing Unnecessary
250404 - Metastisis PET Test Not Needed Because Cancer Limited to Neck
250405 -
250406 - Discussion of performing a PET scan to evaluate scope of the problem
250407 - resulted in understandings from the doctor today that there is strong
250408 - evidence the problem is localized in the neck, based on the fact that
250409 - lymph nodes in the neck, where recurrence of cancer has been detected
250410 - with biopsy, reported by Doctor Laio on 040309, ref SDS 58 0001, are
250411 - on the left side where the cancer originated in the left breast, and
250412 - further because the CT test reviewed today, reports finding cancer is
250413 - limited to the neck. ref SDS 0 WB8Q
250415 -  ..
250416 - We reviewed Doctor Laio's comments on 040303 that cancer from the
250417 - breast rarely travels to the neck, that more often cancer from the
250418 - lung causes distant metastasis in the neck area. ref SDS 57 SO3F
250420 -  ..
250421 - Does this experiential evidence suggest more rigorous testing to
250422 - determine the scope of the problem?
250424 -  ..
250425 - The doctor indicated that a PET scan is not needed nor prudent to
250426 - assess the degree of the problem to solve, perhaps indicating that,
250427 - regardless of the severity of the problem, the treatment would not
250428 - change.
250429 -
250430 -        [On 040517 research indicates that treatment for inflammatory
250431 -        breast cancer (IBC) may require a different regimine from other
250432 -        forms of breast cancer. ref SDS 70 JK94
250433 -
250434 -
250435 -
250436 -
250437 -
2505 -

SUBJECTS
Surgery Not Prescribed for Lymph Cancer Schedule Chemo Therapy Cance
Surgery Metastatic Cancer Not Good Treatment for Lymph Nodes in Neck

2704 -
270501 -  ..
270502 - Surgery Not Good Treatment for Metastatic Cancer Lymph Nodes in Neck
270503 - Lymph Nodes in Neck Surgery Not Good Treatment for Metastatic Cancer
270504 - Metastatic Cancer Lymph Nodes in Neck Surgery Not Good Treatment
270505 -
270506 - Reviewed surgery option to remove cancerous lymph nodes in the neck,
270507 - which the doctor concludes are "localized," ref SDS 0 HC5G, based
270508 - on discussions with Doctor Laio on 040303, who indicated that, even if
270509 - cancer was not detected, he planned to remove the 3 or 4 swelled lymph
270510 - nodes detected through clinical examination on 040303. ref SDS 57 Y193
270511 -
270512 -        [On 040517 "minutes" of Tumor Board meeting on 040416 show
270513 -        discussion occurred on surgery to remove lymph nodes if
270514 -        chemotherapy is not effective. ref SDS 70 KI3O
270516 -  ..
270517 - Surgery was an important part of treatment to remove the original
270518 - tumor and affected lymph nodes in a procedure on 020312, ref SDS 4
270519 - 0001, and again a few weeks later on 020327. ref SDS 9 0001  During a
270520 - meeting on 030321 Doctor Riley-Paull, who performed surgery, indicated
270521 - there would be continuing consultations to examine the patient, and
270522 - compare notes with the primary care physician, The Doctor.
270523 - ref SDS 8 029O  On 020408 Doctor Riley-Paull confirmed planning to
270524 - meet with Millie every 3 months for follow up on the original surgery.
270525 - ref SDS 12 WX4K
270527 -  ..
270528 - Would this be a good time for a follow up visit with the surgeon,
270529 - under Kaiser's recommendations to get additional input from a
270530 - different type of doctor who treats similar problems? see below.
270531 - ref SDS 0 8U3N  The left breast treated by Doctor Riley-Paull showing
270532 - signs of increased redness; treated with antibiotics. ref SDS 0 IM6J
270533 -
270534 -        [On 040517 "minutes" of Tumor Board meeting on 040416 show
270535 -        discussion occurred on surgery to remove lymph nodes if
270536 -        chemotherapy is not effective. ref SDS 70 KI3O
270538 -  ..
270539 - The doctor made a clinical examination of the swelled lymph nodes
270540 - in the neck, and commented that they seem slightly bigger and firmer
270541 - than during the examination on 040227. ref SDS 56 0001  The doctor
270542 - related these findings with the report on the CT test, shown below.
270543 - ref SDS 0 WB8Q
270544 -
270545 -        [On 040416 lumps in the neck seem bigger, and confirmed by new
270546 -        CT test. ref SDS 64 WQ46
270548 -         ..
270549 -        [On 040601 good news -- Millie indicates the lumps in the neck
270550 -        seem to have gotten smaller, even disappeared. ref SDS 71 DJ9N
270552 -  ..
270553 - The doctor indicated today that the type of cancer detected in
270554 - this case is metastatic cancer, per above, ref SDS 0 8R6M, which he
270555 - explained is more conducive to treatment with drugs rather than by
270556 - surgery.  As a result, the doctor does not plan to remove the
270557 - lymph nodes in the neck at this time, which confirms understandings
270558 - from the discussion with Doctor Laio on 040309.
270560 -         ..
270561 -        [On 040419 surgeon examined Millie and took a biopsy.
270562 -        ref SDS 65 789F
270564 -         ..
270565 -        [On 040429 pathology report on biopsy shows cancer requiring
270566 -        further surgery. ref SDS 68 C155
270568 -         ..
270569 -        [On 040517 Millie diagnosed with inflammatory breast cancer,
270570 -        ref SDS 70 7D6F, research indicates that swelled lymph nodes in
270571 -        the neck above the collar bone are symptoms of IBC. ref SDS 70
270572 -        M67I
270574 -         ..
270575 -        [On 040601 good news -- Millie indicates the lumps in the neck
270576 -        seem to have gotten smaller, even disappeared. ref SDS 71 DJ9N
270578 -  ..
270579 - This point can be aided by reference to authority.  What types of
270580 - cancer are possible, and where is the type of cancer identified in the
270581 - record showing surgery was helpful for the original diagnosis, based
270582 - on findings of suspicious lumps and biopsy, but not for the type of
270583 - cancer detected with new lumps, biopsy, CA 15-3 and CT tests?
270585 -         ..
270586 -        [On 040517 "minutes" of Tumor Board meeting on 040416 show
270587 -        discussion occurred on surgery to remove lymph nodes if
270588 -        chemotherapy is not effective. ref SDS 70 KI3O
270589 -
270590 -
270591 -
2706 -

SUBJECTS
Arm Lump Swelled Lymph Nodes Under Left Arm Seem Bigger Again
Lymph Node Lumps Under Arm Cushy Like Tip of Nose Do Not Have Charac
Arm Lump Swelled Lymph Nodes Under Left Arm Seem Bigger Again

3205 -
320601 -  ..
320602 - Lymph Nodes Swelled Under Arm Seem More Severe Today
320603 -
320604 - Follow up ref SDS 48 Y45M.
320605 -
320606 - The doctor examined the lump under Millie's left arm, where lymph
320607 - nodes were removed with surgery on 020312. ref SDS 4 Q78M
320609 -  ..
320610 - The doctor seemed to agree with Millie that the condition today
320611 - appears more severe or pronounced, i.e., there is a larger mass, than
320612 - was detected in previous CT tests that found on 030710 lymph nodes had
320613 - increased in size from 1 to 1.5 CM, ref SDS 51 VM7I, following
320614 - examinations on 030606, ref SDS 48 Y45M, and a month earlier on
320615 - 030508, ref SDS 47 7C9G, when Millie asked for a biopsy of red rash on
320616 - the left breast to check for cancer, dut to experience on 020202, when
320617 - a biopsy was ordered under similar conditions, and led to discovery of
320618 - cancer that required surgery. ref SDS 2 0001
320620 -  ..
320621 - Discussed further testing by taking a biopsy, which found cancer in
320622 - the neck, per above, ref SDS 0 8R6M, and/or performing a PET scan
320623 - test, which found previously cancer under the arm, reported on 020603,
320624 - leading to a change in treatment. ref SDS 26 0001  Can testing help
320625 - establish the scope of the problem based on new reports of increased
320626 - redness in the left breast, discussed below, ref SDS 0 IM6J, and now a
320627 - more severe lump under the left arm found by the doctor, in order to
320628 - target treatment?
320630 -  ..
320631 - The doctor indicated that pathology on the biopsy from the neck,
320632 - reported on 040309 establishes recurrence, per above, ref SDS 0 8R6M,
320633 - which is "localized" to the neck, also, per above, ref SDS 0 HC5G, and
320634 - so further testing with another biopsy and/or a PET scan to diagnose
320635 - the scope of the problem can be deferred at this time.
320636 -
320637 -     [On 040416 CT test does not seem to discuss lump under left arm.
320638 -     ref SDS 64 DL46
320640 -      ..
320641 -     [On 040517 Millie diagnosed with inflammatory breast cancer,
320642 -     ref SDS 70 7D6F, research indicates that swelled lymph nodes under
320643 -     arm and in the neck above the collar bone are symptoms of IBC.
320644 -     ref SDS 70 6M9H
320645 -
320646 -
320647 -
320648 -
3207 -

SUBJECTS
2nd Opinions Errors Ommissions Find Correct Mistakes Kaiser Requires

4903 -
490401 -  ..
490402 - 2nd Opinion Verify Scope of Problem and Treatment Planning
490403 -
490404 - Millie asked for help getting supplemental review, and cited recent
490405 - advertising by Stanford offering support for cancer patients, based on
490406 - the doctor's explanation of standard practice to get a broad base of
490407 - input, during the meeting on 030710. ref SDS 51 FZ55
490409 -  ..
490410 - The doctor explained collaboration between Kaiser and Stanford.  He
490411 - commended the cancer program at Stanford, and further cited very high
490412 - confidence in Doctor Hope Rugo's work in the Cancer Center at
490413 - University of California in San Francisco (UCSF) for getting a second
490414 - opinion in this case.  The doctor indicated there is a long wait at
490415 - UCSF for patients to see a doctor, and that he believes Kaiser
490416 - requires patients to pay $600 for a consultation to evaluate case
490417 - history that avoids costly mistakes on diagnosis and treatments.
490418 -
490419 -     [On 040602 Jeannie explains that Cancer Centers located in major
490420 -     medical teaching programs are sometimes better prepared to treat
490421 -     Inflammatory Breast Cancer (IBC), because IBC is a rare disease;
490422 -     mainstream oncology departments, like Kaiser, do not often
490423 -     encounter patients with IBC, but Cancer Centers have a lot of
490424 -     experience treating this disease. ref SDS 72 RZ4O
490426 -  ..
490427 - Kaiser's Healthwise Handbook reviewed on 990625 explains procedures
490428 - for obtaining supplemental review, ref OF 1 4266, to help verify
490429 - accuracy of analysis, reported on 990625, ref SDS 1 455N, and further
490430 - explains advantages from broadening analysis of diagnosis and
490431 - treatment planning based on patient profile and medical history by
490432 - collaborating with a different type of doctor who treats similar
490433 - problems. ref SDS 1 455N
490435 -  ..
490436 - On 020726 the doctor applied this guidance in making plans to consult
490437 - with the radiologist at Mt Diablo hospital for a 2nd opinion to backup
490438 - analysis in the Oncology Department at Kaiser. ref SDS 35 RQ9F
490440 -  ..
490441 - Today, the doctor recommended that, before consulting a Cancer Center,
490442 - Millie should first get 2nd opinion input from the Kaiser Tumor Board
490443 - on a work plan to recover from recurrent cancer, diagnosed today, per
490444 - above. ref SDS 0 WA4H
490446 -         ..
490447 -        [On 040409 Millie requested assistance expediting a 2nd opinion
490448 -        to ensure timely treatment, ref SDS 62 YC6X; Kaiser called
490449 -        later that day and offered four (4) choices, and Millie
490450 -        selected review by Kaiser's Tumor Board. ref SDS 62 7K4G
490452 -         ..
490453 -        [On 040414 Tumor Board hearing is scheduled for 040416,
490454 -        ref SDS 63 HS3O, and Millie will have a bone scan performed to
490455 -        support review by the Board. ref SDS 63 XY5K
490457 -         ..
490458 -        [On 040504 the doctor says Millie has inflammatory breast
490459 -        disease; was very unexpected because this affliction has not
490460 -        previously occurred in his practice. ref SDS 69 UR6M
490462 -         ..
490463 -        [On 041117 2nd opinion Doctor Benz recommends follow up contact
490464 -        Doctor Rugo for chemotherapy drug trials sponsored by UCSF.
490465 -        ref SDS 78 OV3T
490467 -         ..
490468 -        [On 050913 doctor objects that 2nd opinions delay mastectomy
490469 -        surgery for patient with secondary IBC, history of relapse, and
490470 -        pulmonary emboli. ref SDS 84 G44O
490472 -         ..
490473 -        [On 061226 Kaiser performing due diligence collaborating with
490474 -        Doctor Rugo at UCSF to consider drug trial potocols for
490475 -        Millie's patient profile. ref SDS 90 086H
490477 -  ..
490478 - In this case, the surgeon has been planning to have follow up
490479 - consultations, and so now might be a good time to get another "pair of
490480 - eyes" to look through the record and provide additional input to
490481 - assist the doctor's analysis in Oncology, per above. ref SDS 0 HC8M
490483 -             ..
490484 -            [On 060807 advice nurse recommends getting 2nd opinion
490485 -            right away for treatment, ref SDS 88 3J4O, because IBC is a
490486 -            rare, very aggressive cancer, goes through the patient like
490487 -            a hot knife through butter. ref SDS 87 7Q8H
490489 -             ..
490490 -            [On 060809 Kaiser makes referrals for 2nd opinions when the
490491 -            doctor does not feel confident. ref SDS 88 NT9X
490493 -  ..
490494 - An article in the Medical News published on May 15, 2000, ref OF 15
490495 - 0001, makes a similar point saying in part....
490496 -
490497 -      WebMD: What situations demand a second opinion? ref OF 15 5S48
490499 -       ..
490500 -      Groopman: Any time you have a very serious or life-threatening
490501 -      disease:
490502 -
490503 -          •  Where the treatment is very risky or toxic, ref OF 15 5S49
490504 -
490505 -          •  Where the diagnosis is not clear, the treatment is
490506 -             experimental, or there is no established consensus or Food
490507 -             and Drug Administration-approved treatment, ref OF 15 5S5R
490509 -              ..
490510 -          •  If you're considering participating in a trial for a new
490511 -             drug, ref OF 15 5S56
490513 -              ..
490514 -          •  If you're considering some new experimental approach or a
490515 -             procedure that involves using experimental instruments or
490516 -             devices. ref OF 15 5S58
490518 -  ..
490519 - The article continues...
490520 -
490521 -      WebMD: We all fear being the "demanding" patient. How should you
490522 -      ask for a second opinion? ref OF 15 5S63
490524 -       ..
490525 -      Groopman: I think we all want to be polite and civil and don't
490526 -      want to spark an adversarial relationship. Yet, I feel very
490527 -      strongly that any time a patient raises the issue of a second
490528 -      opinion, a physician should welcome and endorse it. ref OF 15
490529 -      TL5N
490531 -  ..
490532 - Groopman's perspective seems to align with Kaiser's policy reviewed on
490533 - 990625 supporting the time honored practice that...
490534 -
490535 -            An ounce of prevention is worth a pound of cure.
490536 -            ref SDS 1 455N
490538 -  ..
490539 - A case study on breast cancer diagnosis shows importance of verifying
490540 - pathology....
490541 -
490542 -      WebMD: A recent study of biopsy slides at Johns Hopkins published
490543 -      in the December 1999 issue of the journal Cancer showed a
490544 -      surprising rate of misdiagnoses. Is it realistic to ask for a
490545 -      second medical and lab or pathologist opinion? ref OF 15 TL9S
490547 -       ..
490548 -      Groopman: Always. Absolutely. I saw a woman recently who had
490549 -      sought three "second" opinions in Boston. She had been diagnosed
490550 -      with a breast cancer that was characterized by the genetic marker
490551 -      HER2, a marker for a very aggressive breast cancer. If staining
490552 -      of the tissue by a pathologist shows this, it means that you're
490553 -      eligible to be treated with a new medication called Herceptin.
490554 -      It also means you have a much more aggressive form of cancer and
490555 -      need chemotherapy immediately. ref OF 15 FJ59
490557 -       ..
490558 -      As part of my assessment, I sent the slides to our pathologist
490559 -      and he said, "I just don't think this is HER2. I think there may
490560 -      have been a technical error in the staining." We repeated the lab
490561 -      test and it was negative. She's done extremely well on hormones,
490562 -      which are not toxic, in contrast to a course of intensive
490563 -      chemotherapy -- without probable benefit -- and Herceptin, which
490564 -      wouldn't have worked for her. ref OF 15 TL51
490566 -  ..
490567 - In this case, there is a CT scan and a biopsy pointing to the same
490568 - problem, and so provides a cross-check.
490570 -  ..
490571 - Do these perspectives in combination with possible mixup in CT Scan
490572 - test reporting, reviewed below, ref SDS 0 ZE5O, suggest investing time
490573 - for further testing and review to verify pathology and diagnosis
490574 - toward determining the best course for treatment?
490576 -  ..
490577 - The doctor wants to meet with Millie in two weeks on 040402, and
490578 - these issues can be reviewed again.
490579 -
490580 -        [On 040407 Millie wants to inquire about getting a 2nd opinion.
490581 -        ref SDS 61 0001
490582 -
490583 -        [On 040409 Millie wrote to Rosalie requesting support for a 2nd
490584 -        opinion; later in the afternoon Debra called and explained
490585 -        Kaiser's Tumor Board procedure to provide additional opinion.
490586 -        ref SDS 62 HS3O
490588 -         ..
490589 -        [On 040414 Debra called and advised that the doctor has
490590 -        scheduled Millie to get a bone scan to support review by the
490591 -        Tumor Board. ref SDS 63 XY5K
490593 -         ..
490594 -        [On 040429 bone scan test performed at Kaiser in Walnut Creek.
490595 -        ref SDS 67 0001
490597 -         ..
490598 -        [On 040517 results of test were not submitted nor reviewed.
490599 -        ref SDS 70 GN6G
490600 -
490601 -
490602 -
490603 -
490604 -
490605 -
4907 -

SUBJECTS
PET Scan Findings Show Previous Metastatic Lymphadenopathy No Longer Ac
Metastasis New Nonspecific May be Post Treatment Trauma Inflammatory Ch
CT Scan Findings Show 2 New 1 CM Masses in Area of Prior Surgery for Ly
CT Scan Findings Show 1 CM Masses Increased to 1.5 CM 50% Growth
CT Scan Test Shows No Evidence Progression Distant Metastasis Stable Co
CT Scan Test Shows Evidence of Cancer Recurrence Localized in Neck O

5908 -
590901 -  ..
590902 - Cancer Neck Only Evidence of CT Scan Shows Distant Metastasis
590903 - CT Scan Shows Evidence of Distant Metastasis Carcinoma Only in the N
590904 -
590905 - Follow up ref SDS 54 LK5L, ref SDS 52 LK5L.
590906 -
590907 - The Doctor submitted results of a CT test on 040307, which was
590908 - ordered on 040227, ref SDS 56 LK5L, after Millie reported new lumps in
590909 - the neck on 040205, ref SDS 55 WP7L, and after treatment with
590910 - antibiotics failed to diminish the lumps. ref SDS 56 0001
590912 -      ..
590913 -     Patient
590916 -      ..
590917 -     CT of the Chest
590921 -      ..
590922 -     History
590924 -         ..
590925 -        Axillary and left cervical lymph node.
590926 -
590928 -      ..
590929 -     Findings
590930 -
590931 -        Comparison:  Prior CT of the chest and abdomen dated 031031.
590932 -
590933 -              Prior tests....
590934 -
590935 -              031031 reported on 031205.............. ref SDS 54 IG9K
590936 -              030626 reported on 030710.............. ref SDS 51 AL6N
590937 -              030428 reported on 030508.............. ref SDS 47 LK5L
590939 -          ..
590940 -         [On 040416 follow up CT test. ref SDS 64 7U9O
590942 -      ..
590943 -     Technique
590944 -
590945 -        Following administration of intravenous and oral contrast,
590946 -        contiguous axial images in 5 mm increments were obtained from
590947 -        the skull base to the upper pelvis.
590948 -
590950 -      ..
590951 -     Neck
590952 -
590953 -        Structures of the skull base appear normal.  The mandible is
590954 -        obscured by artifact from dental amalgam.  There is an 11 x 7
590955 -        mm node in the left posterior cervical triangle (image #28).
590956 -        There is an 11 x 9 mm node in the high left supraclavicular
590957 -        region (image #32).  A few subcentimeter nodes are seen along
590958 -        the jugular chains bilateralerly.
590960 -         ..
590961 -        The mucosal structures appear normal.  The salivary glands
590962 -        are unremarkable.  There is a nonspecific 5 mm low density
590963 -        lesion in the right lobe of the thyroid.
590964 -
590966 -      ..
590967 -     Chest
590968 -
590969 -        Stable postoperative changes are again noted in the left breast
590970 -        and axillary region.  Small left axilliary nodes are again seen
590971 -        without significant change in appearance.  A few small
590972 -        pretrachael nodes are again seen without significant change in
590973 -        appearance.  There is no evidence of mediastinal, hilar or
590974 -        right axillary adenopathy.
590975 -
590976 -            [On 040416 two of the "small left axiliary nodes" cited
590977 -            today are described as being 15 x 9 mm and 14 x 10 mm,
590978 -            ref SDS 64 GO6H, which are both about 40% larger than the
590979 -            nodes in the neck, ref SDS 0 WB8Q, that the biopsy says
590980 -            have cancer. ref SDS 0 8R6M
590982 -         ..
590983 -        Stable areas of scaring are again seen in the left lung apex.
590984 -        There is a tiny subpleural calcified module again seen in the
590985 -        right upper lobe.  There are a few small subpleural nodules in
590986 -        the right middle lobe without significant change in appearance.
590987 -        There is no evidence of new pulmonary nodule. There is no
590988 -        evidence of pleural effusion.
590990 -  ..
590991 - Previously, in the test on 031031 received on 031205 the CT test
590992 - reported findings of "skin thickening" in left breast. ref SDS 54 VM7I
590993 - This report appears to say this condition is "stable," but is not
590994 - entirely clear about correlations required, for example, in the test
590995 - on 030630 reviewed with the doctor on 030710. ref SDS 51 GJ69
590997 -  ..
590998 - CT test findings continue...
590999 -
591000 -     Abdomen & Pelvis
591001 -
591002 -        A stable cyst is again seen in the dome of the liver.  The
591003 -        liver is otherwise unremarkable.  Multiple spenic
591004 -        calcifications are again seen consistent with granulomas.  The
591005 -        gallbladder, pancreas and adrenals again appear normal.  Small
591006 -        low density lesions are again seen in the kidneys.  These are
591007 -        unchanged in appearance.  There is no evidence of free fluid in
591008 -        the abdomen.  There is no evidence of adenopathy.
591009 -
591011 -      ..
591012 -     Impression
591013 -
591014 -        There are two prominent nodes in the posterior cervical
591015 -        triangle of the neck and in the high left supraclavicular
591016 -        region as described above.  Other findings in the chest and
591017 -        abdomen appear stable compared to the prior study.
591018 -
591019 -
591020 -
591021 -
591025 -      ..
591026 -     Dictated           Dictation Transcribed
591027 -     DD:  040310        DT:  040311  PZW
591028 -     *************************************************************
591029 -
591030 -
591031 -
591032 -                         Great!
591034 -                      ..
591036 -                     Oncology
591038 -      ..
591039 -     RAD.REP
591040 -     MTZRAJ  031134 0921
591041 -
591042 -
591043 -
591044 -
5911 -

SUBJECTS
CT Scan Imaging Test Report Doctor Cannot Find Files on Kaiser Compu

6303 -
6304 - Analysis
630501 -  ..
630502 - Distant Metastasis Cancer Neck Only Evidence of CT Scan Shows
630503 - Computer Files Kaiser Cannot Find Medical Tests Cancer Locations
630504 - Mistakes Cannot Find Computer Files Cancer Locations Medical Tests
630505 - Medical Image Test CT Scan Cancer Locations Cannot Find Computer Files
630506 -
630507 - Millie asked about possible conflicts in prior CT test reports set out
630508 - in the record of the meeting on 031210, ref SDS 54 GJ69, and then
630509 - discussed with the doctor during the last meeting on 040227?
630510 - ref SDS 56 YE4F,
630512 -  ..
630513 - Today, The Doctor asked why the matter was not resolved on 040227?
630514 -
630515 -     [On 040517 "minutes" of Tumor Board meeting lucky to find on the
630516 -     computer; show consideration of "scans" and does not report
630517 -     resolving conflicts in reporting. ref SDS 70 W78I
630519 -  ..
630520 - Millie recalled that on 040227, the doctor indicated that Kaiser's
630521 - computers were malfunctioning, and so could not be accessed to
630522 - research the record at that time, so hopefully, today the equipment is
630523 - running to permit investigation. ref SDS 56 YE4F
630525 -  ..
630526 - During the meeting on 030508, a CT test dated 030428 found small lymph
630527 - nodes measuring less than 1 CM in size located in the left axilla that
630528 - were not present on the prior examination. ref SDS 47 VM8N  About 3
630529 - months later, when meeting with the doctor on 030710, the next CT test
630530 - dated 030626 showed lymph nodes in the left axilla had grown to 1.5
630531 - CM. ref SDS 51 VM7I  The following test on 031031 was received from
630532 - the doctor with a handwritten notation that said "great," for
630533 - favorable diagnosis, ref SDS 54 LK5L, but did not reconcile 50% growth
630534 - of lymphadenopathy from prior test report on 030710. ref SDS 54 GJ69
630535 -
630537 -  ..
630538 - Find Test Reports for Comparison Trend Analysis Fails
630539 -
630540 - The doctor looked through papers in Millie's medical chart file
630541 - folder.  He, also, examined Kaiser's computer.  He could not find
630542 - records for the tests on 030428 and on 030626 in the file folder nor
630543 - on the computer during the time available for the meeting today, so
630544 - this needs further research to determine the scope of current
630545 - problems.
630546 -
630547 -     [On 040402 accuracy medical practice paramount for patient care
630548 -     shown by audits for compliance with protocols. ref SDS 59 6E4K
630550 -      ..
630551 -     [On 040416 differences in describing test results increases the
630552 -     burden on physicians that lead to overlooking critical details.
630553 -     ref SDS 64 PTSX
630555 -      ..
630556 -     [On 040812 doctor explains conflicts in test reports reflects
630557 -     medical practice does not have requirements for accuracy that is
630558 -     common to engineering work. ref SDS 75 T761
630560 -      ..
630561 -     [On 060126 medical analyst cannot find prior report for PET scan
630562 -     test on 051005; caused failure to perform comparison and trend
630563 -     analysis with results of test on 060120. ref SDS 86 LC7N
630565 -      ..
630566 -     [On 061024 case study medical practice computer access limited
630567 -     even with everything on the computer, people can't find details
630568 -     stored in parts of the computer (software modules) that are not
630569 -     frequently used. ref SDS 89 JD9L
630571 -  ..
630572 - The doctor advised that, regardless of possible conflicts in prior
630573 - CT testing, the CT test report today showing that cancer is in the
630574 - neck establishes recurrance.  He feels that the focus should be for
630575 - Millie to begin chemotherapy treatments as soon as possible to arrest
630576 - progression of disease, wherever it may be occurring, as discussed
630577 - above. ref SDS 0 4U9F
630578 -
630579 -
630580 -
630581 -
6306 -

SUBJECTS
Redness of Breast Clinical Symptom of Cancer Relapse Occurred Briefl
Redness Returns to Left Breast Diagnosed as Cellulitus Treated with
Breast Softer Change May Indicate Recovery from Trauma of Surgery
Breast Redness Returns to Left Breast Diagnosed as Cellulitus Treate
Cancer Treatment Delayed Cellulitus Diagnosed Treated with Antibioti

6807 -
680801 -  ..
680802 - Chemotherapy Treatment Delayed to Treat Diagnosis of Cellulitus
680803 - Cellulitus Causes Redness of the Skin Treated with Antibiotics
680804 - Redness of Breast Treated for Cellulitus to Qualify for Avastin Trial
680805 -
680806 - Follow up ref SDS 51 7C6W, ref SDS 48 7C6W.
680807 -
680808 - After discussing findings of cancer from the biopsy of lymph nodes in
680809 - the neck, and prescribing immediate treatments, per above, ref SDS 0
680810 - PU6M, Millie asked the doctor to examin the left breast which looks
680811 - much worse, with redness spreading and getting darker, and so caused
680812 - the request for a meeting today ahead of the original schedule.
680814 -  ..
680815 - The doctor observed that severe redness has returned to the left
680816 - breast, originally treated for cancer with surgery on 020312.
680817 - ref SDS 4 0001
680819 -  ..
680820 - Millie advised that the left breast seems softer now.
680822 -  ..
680823 - The Doctor examined the breast and concurred.  The doctor noted
680824 - that this softening shows progress on recovery from persistant
680825 - thickening of the skin reported in the CT test last year on 030710.
680826 - ref SDS 51 GJ69  The doctor explained that recovery from skin
680827 - thickening, together with return of "redness" found today, ref SDS 0
680828 - IM6J, suggests the redness problem is cellulitus, and so prescribed
680829 - treatment with antibiotics over the next two weeks. Cellulitus was
680830 - previously diagonsed on 030109. ref SDS 44 0T6N
680832 -  ..
680833 - As shown above, there was discussion about asking for review of the
680834 - redness problem by the surgeon, who performed a procedure on the left
680835 - breast for further input on diagnosis and ideas for treatment.
680836 - ref SDS 0 HC8M
680838 -  ..
680839 - The doctor indicated that since swelled lymph nodes occurred on the
680840 - left side of the neck, and since cancer originally occurred in the
680841 - left breast, this record establishes recurrence, and no further
680842 - inquiry nor analysis is needed to determine a course of treatment.
680843 - The doctor used a phrase along the lines of "...walks like a duck,
680844 - quacks like a duck, so its a duck," evidently referring to recurrance
680845 - signaling metastatic disease.
680847 -  ..
680848 - The doctor explained that the "cellulitus problem" has to be treated
680849 - before starting chemotherapy, under the protocol for the Avastin
680850 - trial.  As a result, the doctor prescribed Keflex antibiotics for the
680851 - next two (2) weeks, that will delay start of chemotherapy treatments,
680852 - in order to avoid contaminating participation in the Avastin trial
680853 - program, explained by Rosalie, per below. ref SDS 0 DK5N
680854 -
680855 -      [On 040402 skin firmness, redness left breast persist; diagnosis
680856 -      changed from cellulitus to reaction from radiation treatments in
680857 -      July 2002; steriods prescribed to treat breast redness; patient
680858 -      cleared to begin chemotherapy treatments on Taxol and Avastin
680859 -      trial. ref SDS 60 IM6J
680861 -       ..
680862 -      [On 040416 redness left breast seems less severe, treatment for
680863 -      breast redness ended. ref SDS 64 IM6J
680865 -       ..
680866 -      [On 040419 following procedure to install port catheter, surgeon
680867 -      observed red rash during examination of left breast and performed
680868 -      a needle biopsy. ref SDS 65 789F
680870 -       ..
680871 -      [On 040429 the surgeion advised that the pathology report on the
680872 -      biopsy shows that some kind of new cancer has recurred in the
680873 -      left breast. ref SDS 68 F66N
680875 -       ..
680876 -      [On 040504 the doctor met with Millie for a few minutes prior to
680877 -      chemotherapy treatment and advised that the pathology report, on
680878 -      a biopsy taken on 040419, says inflammatory breast disease was
680879 -      found. ref SDS 69 WI8F
680881 -       ..
680882 -      [On 040517 the doctor met with Millie and submitted the pathology
680883 -      report on the biopsy; the diagnosis says inflammatory carcinoma,
680884 -      ref SDS 70 7D6F; research on the Internet found that inflammatory
680885 -      breast cancer is rare, affecting only 1% of patients, ref SDS 70
680886 -      TO7L; symptoms are swelled lymph nodes under the arm or in the
680887 -      neck, ref SDS 70 6M9H, redness of the breast, and thickening of
680888 -      the skin, ref SDS 70 S65H, which could be described as
680889 -      "firmness," originally reported on 030109. ref SDS 44 KW5F
680891 -       ..
680892 -      [On 041130 treatment of IBC delayed to search for new
680893 -      chemotherapy drug trial. ref SDS 79 ZQ8L
680894 -
680895 -
680896 -
680897 -
680898 -
6809 -

SUBJECTS
Blood Tests Painful Conditions Requires Higher Skilled Technician to
Port for New Treatments Administered Intravenously Avoids Pain and D

7304 -
730501 -  ..
730502 - Blood Tests Causing Painful Condition on Right Arm
730503 - Port to Support New Treatments Administered Intravenously
730504 -
730505 - Follow up ref SDS 54 CO3G.
730506 -
730507 - Millie reported painful experience from difficulty nurses in the Lab,
730508 - in the Infusion Clinic, and other technicians have had drawing blood
730509 - and making chemotherapy injections for treatment, and CT and PET scan
730510 - medical tests.  The doctor examined Millie's arm showing severely
730511 - swollen, black and blue condition from needle penetrations, reported
730512 - previously on 031205. ref SDS 54 CO3G
730513 -
730514 -     [On 041104 Doctor Kaufman ordered blood drawn without using the
730515 -     port catheter to avoid trauma to the arm. ref SDS 77 4S9K
730517 -      ..
730518 -     [On 050204 patient experiencing new needle trauma to right arm
730519 -     again from continuing blood tests for pulmonary emboli treatments,
730520 -     which are performed in the Kaiser Martinez clinic; staff are not
730521 -     trained to use the port; doctor wants treatments to continue.
730522 -     ref SDS 81 VG4H
730524 -  ..
730525 - There was no discussion of the doctor's suggestion to drink a lot
730526 - of water prior to having blood drawn, because evidently this causes
730527 - blood vessels to swell, so it is easier for the technician to locate
730528 - new areas to draw blood.
730530 -  ..
730531 - The doctor explained again that patients can ask the attending
730532 - technician for Kaiser to assign a higher skilled technician for
730533 - drawing blood in light of the condition caused by continuing
730534 - treatment.
730536 -  ..
730537 - The doctor indicated that blood cannot be drawn from Millie's left arm
730538 - in order to avoid trauma to the right arm, because Millie's cancer is
730539 - on her left side, with possible complications of lymphedema and
730540 - Cellulitis.  Additionally, Kaiser avoids drawing blood and IV
730541 - infusions in the legs and other areas.  This leaves only Millie's
730542 - right arm and hand available for needle penetrations.
730544 -  ..
730545 - The doctor explained that patients who get a lot of needle punctures
730546 - eventually need a port, because the body reacts to protect itself.
730547 - Needle puncture wounds cause scarring in the veins which reduce blood
730548 - flow.  Needle penetrations for IVs become more and more difficult to
730549 - find a vein with sufficient flow to draw blood and infuse treatments,
730550 - even for the most experienced nurses.  The IV process then become very
730551 - painful and harmful to the patient because the nurse cannot find a
730552 - vein.
730554 -  ..
730555 - The doctor noted that pain and suffering Millie has experienced from
730556 - harm observed today on the right arm caused by continued needle
730557 - punctures can therefore be avoided with a "port catheter" implanted
730558 - surgically.  Port catheters enable blood draws, tests, injections, and
730559 - infusion treatments with chemotherapy and other drugs, rather than
730560 - using conventional needle puncture methods to access veins through
730561 - skin on the right arm and hand, as was done by nurses in the Infusion
730562 - Clinic for tests and treatments in 2002.
730563 -
730564 -     [On 040402 Rosalie, Kaiser's Protocol Nurse for Clinical Trials,
730565 -     explained port catheter procedure, and schedule the work as
730566 -     outpatient minor surgery operation. ref SDS 59 V750
730568 -      ..
730569 -     [On 040414 Kaiser scheduled surgery to install the port on 040419,
730570 -     ref SDS 63 194J, a day before treatments are scheduled to begin on
730571 -     040420. ref SDS 62 K175
730573 -      ..
730574 -     [On 040419 port catheter installed at Kaiser in Martinez CA;
730575 -     reported a success, expecting to relieve trauma from needle
730576 -     punctures and penetrations for blood draws and IV infusion
730577 -     treatments for chemotherapy. ref SDS 65 PPSW
730579 -      ..
730580 -     [On 041104 Doctor Kaufman ordered blood drawn without using the
730581 -     port catheter to avoid trauma to the arm. ref SDS 77 4S9K
730583 -  ..
730584 - The Doctor explained that port catheters require nurses trained to
730585 - draw  blood with these mechanisms in a manner that does not
730586 - contaminate test samples.  Nurses trained to use a port catheter only
730587 - work in the chemotherapy department.  As a result, Millie must drive
730588 - to the hospital the day before treatments to have blood drawn from the
730589 - port.  If she goes to the Park Shadelands clinic nearby in Concord
730590 - they can only draw blood with a conventional needle that causes severe
730591 - trauma to the arm, per above. ref SDS 0 CO3G
730593 -  ..
730594 - The doctor will arrange with the surgery depratment for Millie to get
730595 - a port catheter implanted to solve problems of injury from needle
730596 - penetrations.
730597 -
730598 -     [On 040414 Kaiser scheduled surgery to install the port on 040419,
730599 -     ref SDS 63 194J, a day before treatments are scheduled to begin on
730600 -     040420. ref SDS 62 K175
730602 -      ..
730603 -     [On 050204 patient experiencing new needle trauma to right arm
730604 -     again from continuing blood tests for pulmonary emboli treatments,
730605 -     which are performed in the Kaiser Martinez clinic; staff are not
730606 -     trained to use the port; doctor wants treatments to continue.
730607 -     ref SDS 81 VG4H
730609 -      ..
730610 -     [On 080425 Millie experiencing trauma from needle penetrations for
730611 -     injecting CT test contrast medium. ref SDS 93 9W9I
730613 -      ..
730614 -     [On 080501 Brigid explained concerns at UCSF that risks of
730615 -     outpatient minor surgery to remove the current port and replace
730616 -     with a Power Port that is safer for CT contrast medium injections
730617 -     is greater risk than injury to the arm from excessive needle
730618 -     penetrations. ref SDS 94 R59F
730619 -
730620 -
730621 -
730622 -
730623 -
730624 -
7307 -

SUBJECTS
Avastin Meeting with Rosalie for Briefing on Trial Protocol Receive
Double Blind Test Placebo Not Protocol for Avastin Uses Randomized S
Treatment Cancer and Trial on New Cancer Treatment Double Blind Test
Treatment Cancer and Trial on New Cancer Treatment Double Blind Test
Avastin Meeting with Rosalie for Briefing on Trial Protocol Receive
Cancer Treatment Delayed Cellulitus Diagnosed Treated with Antibioti

7908 -
790901 -  ..
790902 - Avastin Meeting with Rosalie for Briefing on Trial Protocol
790903 -
790904 - Follow up ref SDS 58 WG80.
790905 -
790906 - After meeting the initial meeting, per above, ref SDS 0 PU6M, the
790907 - doctor introduced Rosalie to explain details of treatment.
790909 -  ..
790910 - Rosalie is the research nurse for oncology clinical trials, mentioned
790911 - in the doctor's telephone message last week on 040309. ref SDS 58 WG80
790913 -  ..
790914 - Rosalie explained the protocol for clinical trials to test Avastin
790915 - treatment for breast cancer.
790916 -
790917 -     [On 041019 research at Stanford found study last year showing
790918 -     Avastin trial did not acheive progression-free survival.
790919 -     ref SDS 76 U647
790921 -  ..
790922 - Rosalie submitted a consent document of 10 pages, ref OF 10 0001, for
790923 - Millie to review and sign in order to be included in the trial for
790924 - Avastin, which is called "bevacizumab (rhuMab VEGF) throughout the
790925 - consent document. e.g., ref OF 10 C594
790926 -
790927 -     [On 040402 Rosalie submitted a revised consent form for signature.
790928 -     ref SDS 59 BK8M
790930 -      ..
790931 -     [On 040402 Rosalie reviewed side effects to support patient
790932 -     signing concent to participate in the Avastin trial. ref SDS 59
790933 -     HS9X
790935 -      ..
790936 -     [On 040517 Millie reports severe coughing, shortness of breath,
790937 -     and heaviness in chest causing difficult breathing for several
790938 -     hours, listed as side effects of Avastin, ref SDS 70 RZ4I, and
790939 -     diagnosed as reaction to allergy; no treatment prescribed.
790940 -     ref SDS 70 AY5K
790942 -      ..
790943 -     [On 040812 Genentec, manufacturer of Avastin announces increased
790944 -     risk for pulminary emboli (blood clots); Millie reports family
790945 -     history of blood clot issues, and asks about report in connection
790946 -     with symptoms of coughing, difficult breathing, heaviness in
790947 -     chest; doctor interprets increased risk on Avastin trial related
790948 -     to personal history of blood clots, and so no change in treatment
790949 -     was prescribed. ref SDS 75 RZ4I
790951 -      ..
790952 -     [On 041104 Millie's symptoms of cough, shorness of breath, and
790953 -     heaviness in chest diagnosed due to blood clot (pulminary emboli)
790954 -     reported in CT test, and which is a side effect of Avastin
790955 -     (Bevacizumab) listed in the record on 040517, ref SDS 70 ML8J;
790956 -     Millie removed from Avastin trial; all cancer treatments
790957 -     suspended. ref SDS 77 N43I
790959 -  ..
790960 - Rosalie explained that Millie cannot commence treatment in the trial
790961 - until the doctor reports favorable results treating cellulitis over
790962 - the next two weeks, per above. ref SDS 0 IM6J
790963 -
790964 -     [On 040402 Rosalie schedule Millie for immediate treatments based
790965 -     on examination and instruction from The Doctor. ref SDS 59
790966 -     9739
790968 -      ..
790969 -     [On 040517 Millie diagnosed with inflammatory breast cancer,
790970 -     ref SDS 70 7D6F, research indicates IBC is aggresive and so
790971 -     spreads quickly; requires immediate treatment. ref SDS 70 YM3M
790973 -  ..
790974 - During the period for treatment of cellulitis, Millie can review the
790975 - consent documents...
790976 -
790977 -        1.  CONSENT TO PARTICIPATE IN A MEDICAL RESEARCH STUDY
790978 -            A RANDOMIZED PHASE III TRIAL OF PACLITAXEL VERSUS
790979 -            PACLITAXEL PLUS BEVACIZUMAB (RHUMAB BEFG) AS FIRST-LINE
790980 -            THERAPY FOR LOCALLY RECURRENT OR METASTATIC BREAST CANCER
790981 -            (CTSU E2100)
790982 -            ref OF 10 0001
790984 -             ..
790985 -        2.  AUTHORIZATION (PERMISSION)
790986 -            TO USE OR DISCLOSE IDENTIFIABLE HEALTH INFORMATION
790987 -            FOR RESEARCH
790988 -            ref OF 11 0001
790990 -             ..
790991 -        3.  Kaiser Permanente Medical Care Program
790992 -            Research Participant's Bill of Rights
790993 -            ref OF 12 0001
790994 -
790996 -  ..
790997 - Rosalie asked Millie to contact her next week about meeting to discuss
790998 - questions, and sign the documents authorizing consent, and which,
790999 - also, requires granting permission for research activities, including
791000 - distribution of personal identification and health information.
791001 - ref OF 10 0001
791003 -  ..
791004 - The protocol for the trial calls for 3 weeks of treatments once a
791005 - week, and then a week off. ref OF 10 UK34
791007 -  ..
791008 - Rosalie advised that Millie will be examined by the doctor at least
791009 - once a month prior to starting each new treatment cycle to evaluate
791010 - continued participation in the study based on progress of recovery and
791011 - impact of side effects, as further noted in the protocol. ref OF 10
791012 - UK54
791013 -
791014 -     [...confirms The Doctor's explanation, per above. ref SDS 0
791015 -     PU6M
791017 -      ..
791018 -     [On 040402 Rosalie submitted a revised consent form for signature.
791019 -     ref SDS 59 BK8M
791021 -      ..
791022 -     [On 040402 CT scan tests, and body fluids will be drawn and
791023 -     examined for diagnostics to monitor progress, and to guard against
791024 -     side effects on the Avastin/Taxol drug trial ref SDS 59 HS45
791026 -  ..
791027 - This schedule may permit Millie to carry through with prior plans to
791028 - vacation in July with her daughter, Pam, at a health spa in Arizona.
791029 - It would require coordinating the schedule so that one of the weeks
791030 - that is a "rest" period, could fall during the week that has been
791031 - previously scheduled for the vacation to the health spa.
791032 -
791033 -
791034 -
791035 -
791036 -
791037 -
7911 -