THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net
S U M M A R Y
DIARY: May 17, 2004 12:00 PM Monday;
Rod Welch
Meeting Kaiser start 2nd cycle Avastin; pathology report diagnosis IBC.
1...Summary/Objective
2...Schedule Treatments on Friday Maintain Doctor Patient Continuity
3...Backup Doctor Requests Primary Care Physician Conduct Examination
4...Recovery Progress CA 15-3 Cancer Marker Rises from 60 to 70
5...CA 15-3 Cancer Marker Continues Strong Rise Consistent with Pathology
6...Rise in CA 15-3 Cancer Marker Attributed to Trauma of Biopsy
7...Bone Scan Test Results Not Available Today
8...Breathing Problem Continuous Coughing for Several Hours Due to Allergy
9...Lumps Under Arm Seem Less Severe Today
10...Dilemma Better Medical Practice Expands Scope of Infirmities to Treat
11...Case Study Lumps Under Left Arm Connecting Dots in Time for Treatment
12...Lumps in Neck Seem Less Severe Today
13...Painful Neck May Result from Favorable Effect of Cancer Treatments
14...Pathology Report on Biopsy of Left Breast Received from Kaiser
15...Redness Breast Seems Less Severe; Skin Seems Softer after Treatments
16...Pathology Report on Biopsy Diagnosis Inflammatory Breast Cancer IBC
17...Inflammatory Breast Cancer IBC Diagnosed in Pathology Report on Biopsy
18...Lymph Nodes Swelled in Neck and Under the Arm Symptoms IBC
19...Inflammatory Breast Cancer (IBC) Rare 1% Needs Prompt Treatment
20...Misdiagnosis IBC as Infection Treated Antibiotics Common Mistake
21...Symptoms Redness Thickening Skin Lumps in the Neck and Under the Arm
22...IBC Rare Aggressive Cancer Longevity 18 Months
23...IBC Diagnosis Hard Cannot Detect Image Tests Rash Thick Skin Lymph Nodes
24...Redness Rash Skin Thickening Swollen Lymph Nodes Symptoms IBC
25...CT PET Tests Cannot Detect IBC CA 15-3 Test Diagnostic Tracks IBC
26...IBC Not Detectable Image PET CT Test Swelled Lymph Nodes May Occur
....Treatment IBC Aggressive Chemotherapy Possibly Surgery Radiation
....Inflammatory Breast Cancer Treated Aggressively
....Chemotherapy Surgery Radiation Common Treatment Regimen for IBC
....Mastectomy Increases Chances Inflammatory Breast Cancer to Relapse
....Masectomy 4 Types Most Common Modified Radical Masectomy MRM
....Risks of Masectomy Commonly Very Safe Surgery
....Skin Graft Required Rare Complication to Repair Skin Loss
....Lymph Nodes Removed Under Arm Pit Causes Side Effects
....Axillary Dissection Removing Lymph Nodes Stiffness Swelling Numb
....Chemotherapy High Dose Treatment for Inflammatory Breast Cancer
....Prognosis Inflammatory Breast Cancer Average Survival 18 Months
....New Treatments Extend Survival To 5 Years Chemotherapy Radiation
27...Red Rash Inflammation Left Breast Case Study
28...IBC Case Study Inflammatory Breast Cancer Red Rash Left Breast
29...Medical Intelligence Connecting Dots in Time for Effective Treatment
30...Case Study Red Rash Left Breast Connecting Dots in Time for Treatment
........Treatment Taxotere and Bevacizumab
........Treatment resumed with Andrimiacin
........Treatment changed from AC to Taxotere
........Mastectomy surgery performed to remove
31...Issues Arising from Research on IBC and Record in Millie's Case
32...Work Plan to Aggressively Treat IBC
33...Lessons Learned to Improve Medical Practice and Research
34...Complex Patient History Lucky to Find Record of Tumor Board Hearing
35...Lucky to Find Tumor Board Minutes File Cursory Analysis
36...2nd Opinion Verify Scope of Problem and Treatment Planning
37...Tumor Board Cursory Report Lesson Learned Deminimus 2nd Opinion
.....................Tumor Board Minutes
....Tumor Board Report Requires Support Showing What was Reviewed
....CA 15-3 Key Criteria Patient Progress Reviewed by Tumor Board
....Surgery Proposed by Tumor Board to Remove Lymph Nodes If Necessary
....Radiation Left Neck Post-surgery Recommended by Tumor Board
38...Tumor Board Re-hearing Consider New Evidence Deferred
39...Tumor Board Follow Up Review Address New Information
40...Cancer Neck Only Evidence of CT Scan Shows Distant Metastasis
41...CT Scan Shows Evidence of Distant Metastasis Carcinoma Only in the N
42...Distant Metastasis Cancer Neck Only Evidence of CT Scan Shows
43...Port Catheter Working Well Solves Prior Problems Using Needles
44...Disability Sick Leave Extended Due to Complications of Recurrence
ACTION ITEMS..................
Click here to comment!
1...Pending issues to discuss with the doctor on diagnosis and
2...Work Plan to perform following tasks...
3...Lesson learned need review to improve health care...
CONTACTS
SUBJECTS
Schedule Treatments on Friday So that Millie Can Meet with Doctor Jo
Meeting Doctor at Kaiser Progress Review Treatment Planning Cancer R
0604 -
0604 - ..
0605 - Summary/Objective
0606 -
060601 - Follow up ref SDS 72 0000. ref SDS 67 0000.
060602 -
060603 - Patient cleared for next cycle using Avastin and Taxol in a trial
060604 - protocol. Diagnosis in the pathology report received today on a
060605 - biopsy taken from the left breast shows inflammatory breast cancer
060606 - (IBC). ref SDS 0 6T5G Research indicates IBC is a rare, aggressive
060607 - cancer that spreads quickly, ref SDS 0 TO7L; average longevity in one
060608 - account is 18 months. ref SDS 0 EE7I Treatment may use a high dose of
060609 - chemotherapy, mastectomy surgery and possibly radiation. ref SDS 0
060610 - JK94 Prior to the report today on IBC, on 040318 the doctor
060611 - prescribed immediate chemotherapy to treat recurrence of breast
060612 - cancer. At that time, treatment was delayed to treat redness of the
060613 - left breast for infection. ref SDS 0 YC5W Chemotherapy, as part of a
060614 - drug trial for Avastin, was later begun on 040420, with planning for
060615 - mastectomy surgery pending response to the Avastin trial. Good news
060616 - today from clinical examination found that lumps under the left arm
060617 - and in the neck seem smaller, ref SDS 0 MW8J, and that the left breast
060618 - skin seems softer and less red, ref SDS 0 IM6J, indicating positive
060619 - response to treatment. Tumor board "minutes" were received today
060620 - showing cursory review of patient history, and no reconciliation of
060621 - conflicts in medical tests. ref SDS 0 AW6M Tumor board endorsed
060622 - current treatment plan, and added options to consider further
060623 - radiation, and further surgery to remove lymph nodes. ref SDS 0 F77M
060625 - ..
060626 - Two (2) case studies reported today indicate more rigorous tests and
060627 - anlaysis are needed in order to support the present course.
060629 - ..
060630 - Case study on the lump under the arm shows that biopsy, ref SDS 0
060631 - SU7G, and PET scan tests have successfully diagnosed cancer,
060632 - ref SDS 0 SU9W, and that clinical examination and CT tests overlooked
060633 - the lump under the arm, lost track of size, and explained symptoms of
060634 - IBC as post operative scar tissue that did not require treatment.
060636 - ..
060637 - Case study on rash, inflammation, redness and thickening of skin on
060638 - the left breast, indicate patient was at risk for IBC, beginning about
060639 - 18 months ago on 021206. ref SDS 0 S66O Since average longevity of
060640 - IBC is 18 months, which has now expired, and since a research regimen
060641 - for treating IBC calls for a high dose of chemotherapy, ref SDS 0
060642 - JK94, while Millie is getting a low dose of Taxol, timely review of
060643 - pending issues to establish the scope of the problem, and confirm
060644 - treatment is critical. ref SDS 0 S79G During the meeting with the
060645 - doctor scheduled for on 040614 a work plan can be developed to address
060646 - pending issues. ref SDS 0 5Q5L At an appropriate time lessons learned
060647 - can be reviewed. ref SDS 0 PW8F
060648 -
060649 - [On 040601 lumps in neck seem to have nearly disappeared.
060650 - ref SDS 84 BG41
060652 - ..
060653 - [On 040607 Millie seems to be getting tired, and she experienced
060654 - another severe coughing spell, following exercise, which
060655 - previously did not have this effect. ref SDS 86 0001
060657 - ..
060658 - [On 040610 request guidance from Jeannie based on experience
060659 - recovering fron IBC diagnosed 5 years ago. ref SDS 87 0001
060661 - ..
060662 - [On 040610 planning submitted that assists the doctor to be
060663 - prepared for meeting on 040614 to review diagnosis and treatment.
060664 - ref SDS 88 OA4P
060666 - ..
060667 - [On 040614 meeting start 3rd cycle Avastin trial Kaiser confirms
060668 - diagnosis IBC; doctor explains patient will face difficult
060669 - dilemma. ref SDS 89 0001
060670 -
060671 -
060672 -
060673 -
060675 - ..
0607 -
0608 -
0609 - Discussion
0610 -
061001 - Schedule Treatments on Friday Maintain Doctor Patient Continuity
061002 - Backup Doctor Requests Primary Care Physician Conduct Examination
061003 -
061004 - The meeting today was regularly scheduled as part of the protocol for
061005 - the Avastin drug trial.
061007 - ..
061008 - Initially, Doctor Rakesh Bhutani, MD, met with Millie and saw the
061009 - issues listed on the marking board for review today...
061010 -
061011 - Neck pain for several hours................ ref SDS 0 8R6M
061012 - Breathing problem, coughing last night
061013 - for several hours.......................... ref SDS 0 RZ4I
061014 - CA 15-3 Diagnostic Test.................... ref SDS 0 GJ5M
061015 - Breast redness, biopsy mastectomy
061016 - surgery schedule........................... ref SDS 0 6T5G
061017 - Bone Scan results.......................... ref SDS 0 L34N
061018 - Tumor Board report......................... ref SDS 0 MB7F
061019 - Lumps in neck clinical examination......... ref SDS 0 8R6M
061020 - Lumps under arm clinical examination....... ref SDS 0 MW8J
061021 - Disability sick leave...................... ref SDS 0 AK3J
061023 - ..
061024 - After reviewing the agenda, Doctor Bhutani said he would check on the
061025 - report from the Tumor Board, and left the room. He returned a few
061026 - minutes later and advised that he asked the primary care physician to
061027 - conduct the meeting today, based on prior knowledge of pending issues,
061028 - even though the primary care phycician is, also, the Chief of the
061029 - Oncology Department, and so normally does not see patients in the
061030 - Clinic on Mondays. Doctor Bhutani then left the room.
061032 - ..
061033 - About 10 minutest later, Millie's primary care physician arrived to
061034 - conduct the meeting.
061036 - ..
061037 - The doctor indicated an error occurred with the Scheduling Department.
061039 - ..
061040 - The doctor cited the importance of continuity in the doctor patient
061041 - partnership for effective treatment, reflecting Kaiser's policies for
061042 - good care, reviewed on 990625, ref SDS 3 4185, and illustrated by
061043 - Doctor Bhutani's experience today encountering issues that require
061044 - knowledge of prior history from a careful review of the patient
061045 - medical file. ref SDS 0 SM6M
061047 - ..
061048 - The doctor advised that Doctor Bhutani is the deputy director of the
061049 - clinic, and was assigned for the meeting today, because the doctor
061050 - does not work in the Clinic on Monday and Tuesday. The schedule for
061051 - Millie to receive treatment on Tuesday, therefore, conflicts with the
061052 - trial protocol requirement for the doctor to make an examination prior
061053 - to beginning of each new cycle of treatments, i.e., every 4 weeks, in
061054 - order to evaluate progress and side effects.
061056 - ..
061057 - The doctor will visit with the Scheduling department to correct
061058 - the dates, so that doctor/patient continuity in maintained in the
061059 - record going forward. Shifting the treatment day to Friday, fits
061060 - requirements to meet with the doctor when he is working in the clinic,
061061 - and will provide two days recovery over the weekend for starting work
061062 - on Mondays.
061063 -
061064 - [On 040525 Rosalie advised that the doctor requested a change
061065 - in the dates Millie gets treatment so that the doctor can
061066 - maintain doctor patient continuity; Rosalie asks Millie to call
061067 - and remind about the doctor's planning near the date for
061068 - starting the next cycle of treatments, so that the schedule can be
061069 - changed to accommodate the days of the week that the doctor
061070 - works in the chemotherapy clinic. ref SDS 83 HI52
061071 -
061072 -
061073 -
061074 -
061075 -
0611 -
SUBJECTS
CA 15-3 70 Rises from 60 Reversing Trend of Past 6 Months
CA 15-3 Test Ordered by the doctor Based on Reliance by Tumor Bo 08
0804 -
080501 - ..
080502 - Recovery Progress CA 15-3 Cancer Marker Rises from 60 to 70
080503 - CA 15-3 Cancer Marker Continues Strong Rise Consistent with Pathology
080504 -
080505 - Follow up ref SDS 72 SM6M, ref SDS 67 SM6M.
080507 - ..
080508 - There were no new blood tests reported today on CA 15-3.
080510 - ..
080511 - 040311......... 70 H............. 040211, ref SDS 65 SM6M
080512 - 040205......... 60 H............. 040211, ref SDS 61 SM6M
080513 - 031201......... 62 H............. 031205, ref SDS 60 SM6M
080514 - 030912......... 66 H............. 030913, ref SDS 58 SM6M
080515 - 030708......... 68 H............. 030710, ref SDS 57 SM6M
080516 - 030503......... 54 H............. 030508, ref SDS 53 SM6M
080517 - 030403......... 45 H............. 030403, ref SDS 53 SM6M
080518 - 030220......... 46 H............. 030220, ref SDS 52 5E6L
080519 - 030106......... 37 H............. 030109, ref SDS 50 SM6M
080520 - 021202......... 41 H?............ 021204, ref SDS 46 SP5G
080521 - 021102......... 36 H?............ 021113, ref SDS 45 Y65I
080522 - 021023......... 33 H?............ 021023, ref SDS 44 SQ5I
080523 - 020930......... 33 H?..29........ 021002, ref SDS 43 SQ5I
080524 - 020917......... 36 H?............ 020924, ref SDS 42 SQ5I
080525 - 020717......... 59 H?............ 020726, ref SDS 41 YN5K
080526 - 020629......... 75 H ............ 020705, ref SDS 39 UX6I
080527 - 020608........ 67 H ............ 020614, ref SDS 35 0001
080528 - 020603........ 108 H ............ 020607, ref SDS 33 X67F
080529 - 020511........ 117 H ............ 020603, ref SDS 32 PJ4J
080530 - 020419......... 81 H ............ 020430, ref SDS 27 7N5H
080531 - 020321......... 85 H ............ 020405, ref SDS 16 6T8K
080532 -
080533 -
080534 -
080536 - ..
0806 -
0807 -
0808 - Analysis
0809 -
080901 - Rise in CA 15-3 Cancer Marker Attributed to Trauma of Biopsy
080902 -
080903 - Follow up ref SDS 72 GJ5M, ref SDS 67 GJ5M.
080904 -
080905 - There were no new test results to review for CA 15-3; the doctor
080906 - ordered CA 15-3 blood work that will be included with tests today,
080907 - which precede treatments starting up again tomorrow.
080909 - ..
080910 - The "minutes" of the Tumor Board submitted today cite reliance on CA
080911 - 15-3 testing for evaluation of the case. ref SDS 0 4R59
080912 -
080913 - [On 040601 received results of CA 15-3 blood test on 040524;
080914 - shows another rise, from 70 to 78, which is a little less than
080915 - the rise on 040318. ref SDS 84 2N5J
080916 -
080917 -
080918 -
080919 -
080920 -
0810 -
SUBJECTS
Meeting the doctor 040517 Results Bone Scan Test Results Not Sub 08
Bone Scan Test Results Not Submitted Meeting the doctor 040517 09
1004 -
100501 - ..
100502 - Bone Scan Test Results Not Available Today
100503 -
100504 - Follow up ref SDS 77 0000, ref SDS 70 XY5K.
100505 -
100506 - On 040318 planning was developed to make a careful review verifying
100507 - pathology, diagnosis and treatment. ref SDS 65 8U6O On 040409 Debra
100508 - called and explained Kaiser's Tumor Board procedure to provide a 2nd
100509 - opinion. ref SDS 69 HS3O On 040414 Debra called back to schedule a
100510 - bone test for additional input that enables thorough review by the
100511 - Tumor Board. ref SDS 70 XY5K
100513 - ..
100514 - Previously, on 020628 results of prior bone scan test on 020613 were
100515 - reviewed by the doctor and appeared negative for cancer problems.
100516 - ref SDS 37 QA6L
100518 - ..
100519 - On 040429 a follow up bone scan test was performed at Kaiser.
100520 - ref SDS 77 DJ5K
100522 - ..
100523 - During the meeting today, results of the test were not submitted nor
100524 - discussed. Below, the "minutes" of Tumor Board meeting say "scans"
100525 - were reviewed by the Board, but since the hearing occurred on 040416
100526 - and the bone scan was taken on 040429, this suggests the Tumor Board
100527 - did not review the bone scan test results. ref SDS 0 MB7F
100529 - ..
100530 - Pending issues...
100531 -
100532 - 1. The doctor report results of bone scan test.
100533 -
100534 - 2. Tumor Board amend report to reflect results of bone scan test.
100535 - ref SDS 0 HN4N
100536 -
100537 -
100538 -
100539 -
100540 -
100541 -
1006 -
SUBJECTS
Breathing Problem Continuous Coughing for Several Hours Reaction to
1403 -
140401 - ..
140402 - Breathing Problem Continuous Coughing for Several Hours Due to Allergy
140403 -
140404 - Millie explained an episode last night that has never occurred
140405 - previously, where for several hours she was coughing because breathing
140406 - was very difficult with heaviness in the chest.
140408 - ..
140409 - Eventually, she had to sit up in order to sleep.
140411 - ..
140412 - On 040318 Rosalie submitted consent documents on Taxol and Avastin
140413 - trial. ref SDS 65 TG4M Side effects were reviewed by Rosalie during a
140414 - follow up meeting on 040402, ref SDS 66 HS9X, that cites side effects
140415 - which may relate to coughing, difficulty breathing, and heaviness in
140416 - the chest...
140417 -
140418 - • Shortness of breath, ref OF 10 CE47
140420 - ..
140421 - The doctor advised that Millie's symptoms are likely a reaction to an
140422 - allergy of some kind, rather than a side effect to Avastin, so there
140423 - is nothing to worry about.
140425 - ..
140426 - Mild to severe allergic reaction is a side effect of Taxol.
140427 - ref OF 10 UK90 On 040420 the nurse explained that pre-treatment drugs
140428 - are given to prevent allergic reaction. ref SDS 75 V17B The doctor
140429 - feels this regimen will control allergic reations that patients must
140430 - tolerate in order to benefit from chemotherapy to treat cancer.
140431 -
140432 - [On 040601 the record of treatment reports there have been no
140433 - further episodes of difficulty breathing and coughing, as reported
140434 - today. ref SDS 84 X44L
140436 - ..
140437 - [On 040607 extended coughing to clear a scratchy throat for about
140438 - 18 hours resulting in sore throat, reported in connection with
140439 - hiking and following a meal. Aspirin seems to have helped.
140440 - ref SDS 86 0001
140442 - ..
140443 - [On 040614 shortness of breath, coughing gets worse, ref SDS 89
140444 - RZ4I; coughing cited by doctor as side effect of Avastin
140445 - treatments, cough medicine prescribed. ref SDS 89 R433
140447 - ..
140448 - [On 040812 Genentec, manufacturer of Avastin announces increased
140449 - risk from Avastin for pulminary emboli (blood clots); Millie
140450 - reports family history of blood clot issues, and asks about report
140451 - in connection with symptoms of coughing, difficult breathing,
140452 - heaviness in chest; doctor interprets increased risk on Avastin
140453 - trial related to personal history of blood clots, and so no change
140454 - in treatment was prescribed. ref SDS 92 RZ4I
140456 - ..
140457 - [On 041005 Millie suffers nose bleed, cough, heavy chest; doctor
140458 - cites CT tests for 6 months do not show pulmonary embolism, so
140459 - continues bevacizumab and Taxol treatment for breast cancer,
140460 - because examination shows Millie is recovering from IBC,
140461 - ref SDS 94 RZ4I;
140463 - ..
140464 - [On 041005 Millie notifies doctor of planning to get 2nd opinion
140465 - on worsening symptoms. ref SDS 94 H46M
140467 - ..
140468 - [On 041018 symptoms presented to Doctor Benz at UCSF for 2nd
140469 - opinion. ref SDS 96 LX96
140471 - ..
140472 - [On 041104 day before on 041103 doctor ordered emergency CT test
140473 - same day at 2000 hours at night. ref SDS 98 NL4N
140475 - ..
140476 - [On 041104 coughing and heaviness in chest diagnosed due to blood
140477 - clot (pulminary emboli) reported in CT test, and which is a side
140478 - effect of Avastin (Bevacizumab) listed in the record on 040517,
140479 - ref SDS 0 ML8J; Millie removed from Avastin trial; all cancer
140480 - treatments suspended. ref SDS 98 N43I
140482 - ..
140483 - [On 041104 Kaiser prescribed warfarin (Coumadin) to treat Millie
140484 - for the rest of her life to prevent pulmonary embolism.
140485 - ref SDS 98 4Y9G
140487 - ..
140488 - [On 041230 CT test on 041217 says pulmonary embolism is no
140489 - longer visualized. ref SDS A4 PW3K
140491 - ..
140492 - [On 050729 patient again reports difficult breathing, heavy chest;
140493 - xrays ordered; CT tests does not indicate pulmonary emboli; doctor
140494 - cites drop in physical fitness due to lack of exercise caused by
140495 - side effects of chemotherapy. ref SDS B8 JV63
140497 - ..
140498 - [On 061020 1640 Kaiser discloses that tests to check for pulmonary
140499 - embolism require a special form of CT test using thin slice
140500 - technology, ref SDS D6 S56G; not ordering CT tests using thin
140501 - slice technology explains why multiple tests in 2004 delayed
140502 - diagnosis of pulmonary embolism for 6 months. ref SDS 94 OG3I
140503 -
140504 -
140505 -
140506 -
140507 -
1406 -
SUBJECTS
Meeting with Doctor about Lump in left breast and Under Left Arm Cau
Swelling Left Side Under Left Arm Likely Caused by Draining Lymph No
Symptom New Lump Under Arms where Cancer Surgery Performed on 020312
Pea-like Cluster and Firmness Indicates Cancerous Lumps Not Present
Arm Lump Swelled Lymph Nodes Under Left Arm Seem Bigger Again Testin
Lumps Under Arm Swelled Lymph Nodes Symptom Inflammatory Breast Canc
2108 -
210901 - ..
210902 - Lumps Under Arm Seem Less Severe Today
210903 -
210904 - Follow up ref SDS 65 HC7F, ref SDS 54 Y45M.
210905 -
210906 - Millie indicated that the lump under the left arm seems a little
210907 - smaller today.
210909 - ..
210910 - The doctor examined the lump and concurred that it seems smaller,
210911 - which may reflect positive response to treatment, since the
210912 - examination on 040318. ref SDS 65 HC7F Seems to align with smaller
210913 - lumps in the neck, reported below. ref SDS 0 3R6O
210914 -
210915 - [On 040713 doctor examines lump under left arm and reports that
210916 - swelling seems significantly reduced, indicating favorable
210917 - response to treatment. ref SDS 90 RW9H
210919 - ..
210920 - Not sure how this relates to the CT test reviewed on 040416.
210921 - ref SDS 72 LK5L
210923 - ..
210924 - Research reported today, following diagnosis of inflammatory breast
210925 - cancer (IBC), found that swelled lymph nodes under the arm are one of
210926 - several symptoms that may indicate IBC. ref SDS 0 6M9H
210927 -
210928 -
210929 -
210930 -
2110 -
SUBJECTS
Case Study Lump Under Arm Left Side Swelled Lymph Nodes Symptom IBC
3303 -
330401 - ..
330402 - Dilemma Better Medical Practice Expands Scope of Infirmities to Treat
330403 - Case Study Lumps Under Left Arm Connecting Dots in Time for Treatment
330404 -
330405 - The "knowledge management" dilemma of advances in medical practice
330406 - expanding diagnostic and treatment capabilities reduces time available
330407 - for deliberative analysis, causing critical details to fall outside
330408 - limited span of attention, was reviewed on 020221. ref SDS 6 Y27F
330409 -
330410 - [...see below case study redness left breast inflammation symptom
330411 - IBC previously treated as cellulitus. ref SDS 0 S66O
330413 - ..
330414 - [On 060722 "wicked problems" common in medical practice
330415 - illustrated by delayed diagnosis of pulmonary emboli. ref SDS C9
330416 - 5I3H
330418 - ..
330419 - Evolving conditions of more patients, expanding issues to treat, and
330420 - options for treatment collides with limited time available to see
330421 - patients. Managing this conflict requires commitment to the doctor -
330422 - patient partnership for leveraging the time of experts like Millie's
330423 - doctor and the Kaiser team.
330424 -
330425 - [On 060809 case study evaluate Kaiser reputation medical
330426 - mistakes lessons learned improve health care. ref SDS D3
330427 - K65K
330429 - ..
330430 - Background on the lump under the left arm shows....
330431 -
330432 - 1. Lump reported under left arm......... 020208, ref SDS 5 0001
330433 - Biopsy............................... 020304, ref SDS 7 0001
330434 - Pathology shows cancer............... 020306, ref SDS 8 0001
330435 - Surgery removes tumor and
330436 - cancerous lymph nodes; cancer
330437 - found "out of capsule"............... 020312, ref SDS 9 7V61
330438 -
330439 - [On 040614 the doctor reported difficulty accessing
330440 - this case study on the Internet of the lump under the left
330441 - arm. ref SDS 89 RW9H
330443 - ..
330444 - 2. Chemotherapy scheduled using
330445 - Adriamycin and Cytoxan (AC)
330446 - over 4 months........................ 020405, ref SDS 16 6SWS
330448 - ..
330449 - 3. Chemotherapy begins.................. 020425, ref SDS 24 0001
330451 - ..
330452 - 4. Chemotherapy treatment
330453 - deferred due to low blood
330454 - test reports; Meeting with
330455 - doctor - CT test shows
330456 - many cysts; PET scan test
330457 - ordered.............................. 020513, ref SDS 29 0001
330459 - ..
330460 - 5. PET scan shows cancer under
330461 - left arm causing discomfort
330462 - aligns with dramatic rise
330463 - in CA 15-3 to 117, consistent
330464 - with original biopsy showing
330465 - cancer out of capsule................ 020603, ref SDS 32 0001
330467 - ..
330468 - 6. Taxotere chemotherapy treatment
330469 - prescribed replace Adriamycin
330470 - (AC) and Cytoxan because CA 15-3
330471 - rising, and PET test shows
330472 - expanding cancer..................... 020603, ref SDS 32 WO4O
330474 - ..
330475 - 7. CA 15-3 test taken before
330476 - switching to Taxotere shows
330477 - significant drop to 65,
330478 - indicating response to prior
330479 - treatment with Adriamycin
330480 - (AC) and Cytoxan was beginning
330481 - to be effective...................... 020614, ref SDS 35 0001
330483 - ..
330484 - 8. Meeting the doctor
330485 - CA 15-3 testing shows
330486 - unexpected results because
330487 - patient is not responding
330488 - to chemotherapy treatments
330489 - using Taxotere....................... 020628, ref SDS 37 QB7H
330491 - ..
330492 - 9. Good news, CA 15-3 dropped;
330493 - the doctor concerned
330494 - about erratic CA 15-3
330495 - test results......................... 020726, ref SDS 41 0001
330497 - ..
330498 - 10. 2nd phase chemotherapy
330499 - concludes; CA 15-3 continues
330500 - rising; patient reports mild,
330501 - occassional discomfort from
330502 - new swelling under left arm
330503 - where cancerous lymph nodes
330504 - were removed on 020312, and
330505 - condition was "out of capsule"
330506 - -- swelling diagnosed as
330507 - drainage from surgery 9 months
330508 - earlier when lymph nodes were
330509 - removed.............................. 021206, ref SDS 47 KW5F
330511 - ..
330512 - 11. Patient reports increased
330513 - discomfort under left arm,
330514 - along left side; clinical
330515 - examination under the left
330516 - arm found no scar tissue to
330517 - explain discomfort reported
330518 - by patient........................... 030109, ref SDS 50 KW5F
330520 - ..
330521 - 12. PET test on 021218 compared to
330522 - study on 020502; previously
330523 - noted multifocal hypermetabolic
330524 - findings in the left axilla
330525 - are no longer visiualized,
330526 - indicates cancer activity may
330527 - be reduced or ended.................. 030109, ref SDS 50 GJ55
330529 - ..
330530 - 13. PET test on 021218 reported new
330531 - mild diffuse increased uptakes
330532 - at the region of the left axilla
330533 - may align with report of increased
330534 - discomfort under left arm, and
330535 - previous report on 021206 of new
330536 - mild discomfort from new
330537 - swelling under left arm.............. 030109, ref SDS 50 L66M
330539 - ..
330540 - 14. Patient reports lump under left
330541 - arm where surgery was performed
330542 - to remove infected lymph nodes
330543 - and cancer was found out of
330544 - capsule; doctor cannot detect
330545 - lump, diagnosis scar tissue
330546 - from surgery and reaction to
330547 - radiation............................ 030508, ref SDS 53 7C84
330549 - ..
330550 - 15. CT test report finds 2 lymph
330551 - nodes less than 1 CM in
330552 - left axilla that were not
330553 - present in prior exam................ 030508, ref SDS 53 VM8N
330555 - ..
330556 - 16. Biopsy discussed to investigate
330557 - new swelled lymph nodes; decide
330558 - to wait for next CT test............. 030508, ref SDS 53 7C98
330560 - ..
330561 - 17. Patient requests meeting to
330562 - investigate growing lump under
330563 - left arm causing discomfort
330564 - during exercise; doctor found
330565 - lump with clinical examination,
330566 - commented that 2 1 CM swelled
330567 - lymph nodes reported in CT
330568 - test on 030508 are deeper in
330569 - the body than lumps indicated
330570 - by clinical examination;
330571 - diagnosis was scar
330572 - tissue............................... 030606, ref SDS 54 Y45M
330574 - ..
330575 - 18. CT scan finds persistant dermal
330576 - (skin) thickening left breast;
330577 - notes that invasion of the dermal
330578 - lymphatics from known breast
330579 - cancer can present similarly;
330580 - left axillary adenopathy nodes
330581 - measuring 1.5 cm, a 50% increase
330582 - from prior study; findings
330583 - attributed to radiation treatment
330584 - a year earlier; recommends to
330585 - correlate clinically................. 030710, ref SDS 57 VM7I
330587 - ..
330588 - 19. CA 15-3 68 - 30% rise and
330589 - clinical correlation of CT
330590 - test findings with examination
330591 - attributes patient symptoms to
330592 - reaction from prior radiation
330593 - treatment a year
330594 - earlier.............................. 030710, ref SDS 57 7C6W
330596 - ..
330597 - 20. Patient requests PET scan test
330598 - to determine emerging problems,
330599 - and take proactive action;
330600 - doctor recommends PET scan not
330601 - needed, orders CT scan test in
330602 - 2 months............................. 030915, ref SDS 58 7C6W
330604 - ..
330605 - 21. Patient condition described as
330606 - "stable" based on halt in rise
330607 - of CA 15-3 and favorable CT
330608 - test........ ........................ 031205, ref SDS 60 GJ5M
330610 - ..
330611 - 22. CT test characterized as
330612 - "great" by doctor.................... 031205, ref SDS 60 LK5L
330614 - ..
330615 - 23. CT test says relatively stable
330616 - examination since 030626 with
330617 - slight decrease in size of a
330618 - few left axillary lymph nodes;
330619 - does not seem to correlate with
330620 - prior reports of 2 1.5 CM lymph
330621 - nodes in left axilla................. 031205, ref SDS 60 GJ69
330623 - ..
330624 - 24. Metastatic cancer recurrence
330625 - diagnosed based on biopsy
330626 - of swelled lymph nodes in the
330627 - neck, in combination with CA
330628 - 15-3 blood test, and CT test
330629 - report............................... 040318, ref SDS 65 8R6M
330631 - ..
330632 - 25. CT test says there is an 11 x
330633 - 7 mm node in the left posterior
330634 - cervical triangle. There is
330635 - 11 x 9 mm node in the high
330636 - left supraclavicular region
330637 - A few subcentimeter nodes are
330638 - seen along the jugular chains
330639 - bilateralerly. There is no
330640 - express finding of cancer............ 040318, ref SDS 65 WB8Q
330642 - ..
330643 - 26. Clinical examination found
330644 - lump under arm more severe;
330645 - discussed taking biopsy, or
330646 - PET scan test, which previously
330647 - detected cancer on 020603, in
330648 - order to determine scope of
330649 - patient problems in light of
330650 - increased redness in left
330651 - breast; determination to
330652 - treat for recurrence without
330653 - biopsy nor PET scan to
330654 - investigate scope of the
330655 - problem............................. 040318, ref SDS 65 HC7F,
330657 - ..
330658 - 27. CT test says small left
330659 - axilliary nodes are again
330660 - seen without significant
330661 - change in appearance................. 040318, ref SDS 65 VM7I
330663 - ..
330664 - 28. CT test marked not finalized
330665 - describes post operative
330666 - multiple axillary lymph nodes,
330667 - the largest on the right
330668 - measuring 15 x 9 mm and
330669 - the largest on the left
330670 - measuring 14 x 10 mm.
330671 - Post operative changes are
330672 - again noted within the left
330673 - axillary region and the breast.
330674 - No significant mediastinal or
330675 - hilar lymphadenopathy is
330676 - appreciated.......................... 040416, ref SDS 72 7V3R
330678 - ..
330679 - 29. Lymph nodes in chest seem much
330680 - larger than lymph nodes in
330681 - neck that a biopsy showed
330682 - was cancerous........................ 040416, ref SDS 72 DL3W
330684 - ..
330685 - 30. CT test report marked "not
330686 - finalized" language unclear
330687 - on disposition of lymph nodes
330688 - in left axilla that grew from
330689 - 1 to 1.5 CM in the report
330690 - on 030710............................ 040416, ref SDS 72 DL46
330692 - ..
330693 - 31. Left breast examined following
330694 - surgery to install port catheter
330695 - for chemotherapy; biopsy taken
330696 - to diagnose redness problem.......... 040419, ref SDS 74 789F
330698 - ..
330699 - 32. The surgeon advises that
330700 - pathology report on biopsy
330701 - shows cancer in left breast;
330702 - patient requests clarification
330703 - on type of cancer.................... 040429, ref SDS 78 J757
330705 - ..
330706 - 33. Pathology report submitted to
330707 - patient on biopsy of left breast
330708 - shows diagnosis inflammatory
330709 - breast cancer (IBC).................. 040517, ref SDS 0 6T5G
330711 - ..
330712 - 34. IBC is a rare form of cancer;
330713 - aggressive, spreads quickly,
330714 - average longevity 18 months
330715 - requires early, specialized
330716 - treatment............................ 040517, ref SDS 0 TO7L
330718 - ..
330719 - 35. Research found that lumps under
330720 - arm and lumps in the neck are
330721 - listed as symptoms of IBC along
330722 - with redness and thickening
330723 - of skin.............................. 040517, ref SDS 0 6M9H
330725 - ..
330726 - 36. Doctor explains the version
330727 - of CT test submitted on 040416
330728 - was final version, and that
330729 - notice in the report that an
330730 - addendum exists is a mistake......... 040517, ref SDS 0 LK5L
330732 - ..
330733 - 37. Doctor reports clinical
330734 - examination indicates lump
330735 - under left arm seems smaller
330736 - showing response to treatment
330737 - which indicates lump may have
330738 - been cancer rather than scar
330739 - tissue and other post
330740 - operative response................... 040517, ref SDS 0 MW8J
330742 - ..
330743 - 38. Doctor examines left axilla and
330744 - commented the lump seems to be
330745 - getting smaller, indicating
330746 - favorable response to treatment...... 040713, ref SDS 90 MW8J
330748 - ..
330749 - 39. Patient reports lumps under left
330750 - arm seem to be getting smaller
330751 - indicating response to
330752 - treatment............................ 040812, ref SDS 92 MW8J
330754 - ..
330755 - 40. Doctor examines left axilla and
330756 - commented the lump continues to
330757 - get smaller.......................... 040909. ref SDS 93 MW8J
330759 - ..
330760 - 41. Patient reports lumps under left
330761 - arm seem to be getting smaller
330762 - indicating response to
330763 - treatment............................ 041005, ref SDS 94 MW8J
330765 - ..
330766 - 42. CT test shows subcentimeter
330767 - mediastinal and axillary lymph
330768 - nodes, none pathologic by size
330769 - criteria............................. 041104, ref SDS 98 MW8J
330771 - ..
330772 - 43. Patient reports lump under left
330773 - arm seems to have disappeared;
330774 - doctor examins under left arm
330775 - and finds no evidence of cancer
330776 - activity............................ 041104, ref SDS 98 MW8J
330778 - ..
330779 - 44. Patient experiences no discomfort
330780 - nor feelings of lumpiness under
330781 - left arm............................. 041130, ref SDS A0 MW8J
330783 - ..
330784 - 45. Patient experiences no discomfort
330785 - nor feelings of lumpiness under
330786 - left arm............................. 041210, ref SDS A2 MW8J
330788 - ..
330789 - 46. Patient reports slight discomfort
330790 - from awareness of lumpiness under
330791 - left arm; which is a change from
330792 - prior examination on
330793 - 041210............................... 041230, ref SDS A4 MW8J
330795 - ..
330796 - 47. Patient reports continuing feeling
330797 - of lumpiness and discomfort under
330798 - left arm............................. 050204, ref SDS A7 MW8J
330800 - ..
330801 - 48. Patient experiences occassional
330802 - tingling for a few days along
330803 - the left forearm..................... 050418, ref SDS B3 KE6Q
330805 - ..
330806 - 49. Doctor examines right and left
330807 - axilla; reports slight lumpiness
330808 - on left side, consistent with
330809 - surgery and radiation side effects;
330810 - patient does not complain of
330811 - tingling on left side reported
330812 - earlier on 050418 because tingling
330813 - subsided by 050422; patient reports
330814 - no discomfort on right or left
330815 - axilla............................... 050422, ref SDS B4 MW8J
330817 - ..
330818 - 50. Major swelling left axilla
330819 - diagnosed as possibly lymphedema
330820 - plan for evaluation with PET scan
330821 - test................................. 060106, ref SDS C2 MW8J
330823 - ..
330824 - 51. Swelling recedes significantly in
330825 - left axilla without treatment; PET
330826 - scan test on 060120 shows no
330827 - lymphadenopathy; CA 15-3 drops
330828 - slightly to 33, well below danger
330829 - level of 39; defer further action
330830 - to diagnose and treat left axilla
330831 - until after next PET test in
330832 - April................................ 060217, ref SDS C3 MW8J
330834 - ..
330835 - 52. PET scan test on 060414 no findings
330836 - lymphadenopathy left axillary
330837 - indicates NED for this region unless
330838 - analyst failed to make an actual
330839 - review............................... 060428, ref SDS C4 MW8J
330841 - ..
330842 - 53. CT Test 060505 no findings presented
330843 - left axillary; may indicate are clear
330844 - of recognizable cancer, or that
330845 - analyst overlooked this
330846 - region............................... 060523, ref SDS C6 Q95L
330848 - ..
330849 - 54. Pulmonary emboli recurrence while
330850 - off coumadin treatment ended on
330851 - 051007, patient falls with fatigue
330852 - and shortness of breath; injures
330853 - middle finger; left arm and hand
330854 - swell rapidly with complications
330855 - of lemphedema following left breast
330856 - mastectomy on 051021 supported by
330857 - ending treatment for pulmonary
330858 - embolism on
330859 - 051007............................... 060914, ref SDS D4 ZQ5I
330861 - ..
330862 - 55. Cellulitus diagnosed left arm
330863 - inflammed and severely swelled
330864 - complications of lymphedema
330865 - attributed in part to trauma from
330866 - fall on 060914; patient hospitalized
330867 - 5 days, released with home
330868 - treatment for another 10 days
330869 - antibiotics.......................... 061027, ref SDS D7 V759
330871 - ..
330872 - 56. CT test 060930 makes no findings
330873 - of lymphadenopathy for left axilla,
330874 - indicating region is clear of
330875 - cancer............................... 061012, ref SDS D5 2967
330876 -
330878 - ..
330879 - This record shows that CT tests identify masses and nodes, and in some
330880 - cases estimate the size. Not clear that CT test reports actually
330881 - identify cancer. Biopsy and PET tests identify cancer. The history
330882 - of elevated CA 15-3 in this case, that attracted attention, reported
330883 - on 030710, ref SDS 54 NE6F, suggest greater reliance on PET scan and
330884 - biopsy, noted by the doctor on 040504. ref SDS 79 UR6M
330885 -
330886 -
330887 -
330888 -
330889 -
330890 -
330891 -
330892 -
330893 -
3309 -
SUBJECTS
Lumps Neck Seem to Have Become Softer Smaller Suggest Possible Favor
4003 -
400401 - ..
400402 - Lumps in Neck Seem Less Severe Today
400403 - Painful Neck May Result from Favorable Effect of Cancer Treatments
400404 -
400405 - Follow up ref SDS 72 8R6M, ref SDS 67 8R6M.
400406 -
400407 - Millie reported an episode about a week or so ago where for several
400408 - hours, she experienced severe pain and stiffness in her neck.
400410 - ..
400411 - The doctor explained these symptoms may reflect favorable effects
400412 - of chemotherapy treatments, begun on 040420. ref SDS 75 V17B
400413 - Chemotherapy attacks cancer which would shrink lumps in the neck that
400414 - were found to be cancerous reported on 040318. ref SDS 65 8R6M
400416 - ..
400417 - The doctor made a clinical examination of the two (2) lumps in the
400418 - neck, and indicated that the lumps seem less firm and smaller today,
400419 - than when they were originally noticed on 040211, ref SDS 61 WP7L,
400420 - which later led to discovery of cancer recurrence on 040318.
400421 - ref SDS 65 8R6M Millie agreed that she feels the lumps now seem less
400422 - pronounced. The doctor indicated that reduced swelling of lymph
400423 - nodes, while causing some discomfort, as Millie reports, could, also,
400424 - indicate favorable results from treatment, and further cautioned that
400425 - it is still early in the treatment regimen to be sure about results.
400426 -
400427 - [On 040601 lumps in neck seem to have disappeared. ref SDS 84 DJ9N
400429 - ..
400430 - Research reported today, following diagnosis of inflammatory breast
400431 - cancer (IBC), found that swelled lymph nodes in the neck are one of
400432 - several symptoms that may indicate IBC. ref SDS 0 6M9H
400433 -
400434 -
400435 -
400436 -
400437 -
4005 -
SUBJECTS
Redness Returns to Left Breast Diagnosed as Cellulitus Treated with
Breast Softer Change May Indicate Recovery from Trauma of Surgery
Diagnosis Changed from Cellulitus to Radiation Reaction Treated with
Cancer Treatment Delayed Cellulitus Diagnosed Treated with Antibioti
Breast Redness Returns to Left Breast Diagnosed as Cellulitus Treate
Breast Redness Diagnosis Changed from Cellulitus to Radiation Reacti
Biopsy Pathology Report Diagnosed Inflammatory Breast Cancer Submitt
Pathology Report on Biopsy Diagnosed Inflammatory Breast Cancer Subm
Treatment Chemotherapy Mastectomy Surgery Radiation Initially Reduce
5611 -
561201 - ..
561202 - Pathology Report on Biopsy of Left Breast Received from Kaiser
561203 - Redness Breast Seems Less Severe; Skin Seems Softer after Treatments
561204 -
561205 - Follow up ref SDS 72 IM6J, ref SDS 65 IM6J.
561206 -
561207 - Today, the doctor submitted a pathology report that was discussed
561208 - briefly a few weeks ago, but not submitted to Millie, just prior to
561209 - Millie getting chemotherapy treatment on 040504. ref SDS 79 WI8F The
561210 - report explains findings from a biopsy taken on 040419 at Kaiser's
561211 - hospital in Martinez, CA, by the surgeon. ref SDS 74 1572 Two (2)
561212 - weeks ago, during a meeting on 040429 at Kaiser in the Walnut Creek
561213 - surgery clinic, the surgeon advised that the biopsy was positive for
561214 - cancer; however, as on 040504, the pathology report was not submitted,
561215 - and the type of cancer was not explained at that time. ref SDS 78 C155
561216 -
561217 - [On 040607 Millie learned Kaiser may have diagnosed inflammatory
561218 - breast cancer (IBC), and this is a rare, aggressive disease.
561219 - ref SDS 86 MP6H
561221 - ..
561222 - [On 040614 the doctor diagnoses Inflammatory Breast Cancer
561223 - (IBC), ref SDS 89 6T5G, and changed treatment stage from II to IV.
561224 - ref SDS 89 6M9H
561226 - ..
561227 - [On 060711 Doctor submits another part of the pathology report
561228 - that was not provided today, because additional training,
561229 - learning, and experience are required to access another part of
561230 - Kaiser's computer system, and it shows no status change for HER2
561231 - Neu negative, which suggests treatments for cancer are limited for
561232 - Millie. ref SDS C8 RK4L
561234 - ..
561235 - On 040429 the surgeon planned to request clarification from the lab on
561236 - the type of cancer to determine any relationship with the original
561237 - tumor. ref SDS 78 J757 The pathology report today seems to support
561238 - the surgeon's analysis that this is a new outbreak of cancer,
561239 - ref SDS 78 IE6K, relative to the original tumor treated with surgery
561240 - on 020312. ref SDS 9 0001
561242 - ..
561243 - During the meeting today, the doctor did not read the pathology report
561244 - to Millie, and the dynamics of the meeting, with many issues to
561245 - review, per above, ref SDS 0 X15N, did not allow time for Millie to
561246 - read through the report. The doctor explained that a special kind of
561247 - cancer was found, and may have used the acronym "IBC" - memory is of
561248 - something more like "IFB," per meeting on 040504. ref SDS 79 UR6M The
561249 - doctor mentioned "inflammatory breast disease." There was no
561250 - explanation and no discussion, and so no significance was associated
561251 - during the meeting to the pathology report, because the finding of
561252 - cancer had already been disclosed by the surgeon on 040429,
561253 - ref SDS 78 F66N, and, also, by the doctor on 040504. ref SDS 79 WI8F
561254 -
561255 - [On 040607 Millie learned Kaiser may have diagnosed inflammatory
561256 - breast cancer (IBC), and this is a rare, aggressive disease.
561257 - ref SDS 86 MP6H
561259 - ..
561260 - [On 051027 surgeon reports biopsy on mastectomy surgery finds
561261 - "funny stuff," which was later determined to diagnose DCIS, which
561262 - research on the Internet indicates has raises diagnostic and
561263 - treatment issues. ref SDS C1 HB4M
561265 - ..
561266 - Millie commented that her breast seems to be getting softer, noted
561267 - previously on 040318. ref SDS 65 J49F
561269 - ..
561270 - The doctor examined Millie's breast, and indicated that the degree of
561271 - redness seems to have receded, which, along with reducing the size of
561272 - lumps in the neck, per above, ref SDS 0 8R6M, may reflect favorable
561273 - results, after the first cycle of 3 treatments: 2, with Taxol and
561274 - Avastin, and 1 with only Taxol, which began on 040420. ref SDS 75 9Z5J
561275 - Reducing redness toward elimination of "inflamed" condition was cited
561276 - by the surgeon on 040429 as a condition for performing a mastectomy
561277 - operation, ref SDS 78 SD7F, mentioned, as well, by the doctor on
561278 - 040504. ref SDS 79 MG8G
561279 -
561280 - Later, research on the Internet indicates chemotherapy and
561281 - mastectomy are common treatments for inflammatory breast cancer.
561282 - ref SDS 0 YM3M
561284 - ..
561285 - The doctor cautioned that clinical examination at this stage is
561286 - very preliminary, and that actual response to treatment takes rigorous
561287 - testing.
561288 -
561289 - [On 040607 Millie seems to be getting tired, and she experienced a
561290 - severe coughing spell, following exercise, which previously did
561291 - not have this effect. ref SDS 86 0001
561292 -
561293 -
561295 - ..
561296 - Pathology Report on Biopsy Diagnosis Inflammatory Breast Cancer IBC
561297 - Inflammatory Breast Cancer IBC Diagnosed in Pathology Report on Biopsy
561298 -
561299 - After meeting with the doctor, the pathology report received during
561300 - the meeting was reviewed. Since the doctor advised that Millie has
561301 - contracted another form of cancer, ref SDS 0 Y16I, research was
561302 - performed on the Internet to learn about IBC. Research yielded a
561303 - number of sources that describe a problem called "Inflammatory Breast
561304 - Cancer" (IBC), reviewed below. ref SDS 0 6M9H
561305 -
561306 - [On 040607 Millie learned Kaiser may have diagnosed inflammatory
561307 - breast cancer (IBC), and this is a rare, aggressive disease.
561308 - ref SDS 86 MP6H
561310 - ..
561311 - [On 051027 surgeon reports biopsy on mastectomy surgery finds
561312 - "funny stuff," which was later determined to diagnose DCIS, which
561313 - research on the Internet indicates has raises diagnostic and
561314 - treatment issues. ref SDS C1 HB4M
561316 - ..
561317 - [On 060711 Doctor submits another part of the pathology report
561318 - that was not provided today, because additional training,
561319 - learning, and experience are required to access another part of
561320 - Kaiser's computer system, and it shows no status change for HER2
561321 - Neu negative, which suggests treatments for cancer are limited for
561322 - Millie. ref SDS C8 RK4L
561324 - ..
561325 - The report for the biopsy on 040419 and received today says...
561326 -
561327 - Patient Provider Category View FR Date To Date
561339 -
561340 - ** Walnut Creek Medical Center **
561342 - ..
561343 - SP Final RPT
561345 - ..
561346 - Specimen
561348 - ..
561349 - Skin, Left Breast
561351 - ..
561352 - Diagnosis
561354 - ..
561355 - Metastatic Carcinoma involving dermal lymphmatics consistent with
561356 - inflammatory carcinoma of the breast.
561358 - ..
561359 - This diagnosis aligns with CT scan test last year on 030626 and
561360 - received on 030710 showing persistant dermal thickening of the left
561361 - breast; invasion of the dermal lymphatics from known breast cancer can
561362 - present similarly. ref SDS 57 VM7I Previously, on 030109 the doctor
561363 - submitted a PET scan test performed on 020218 that shows findings for
561364 - all three (3) symptoms of IBC. ref SDS 50 L66M
561365 -
561366 - [...see below, lessons learned #2 on limited time to read
561367 - medical test findings. ref SDS 0 VG6U
561369 - ..
561370 - [On 040614 the doctor diagnoses Inflammatory Breast Cancer
561371 - (IBC), ref SDS 89 6T5G, and changed treatment stage from II to
561372 - IV. ref SDS 89 6M9H
561374 - ..
561375 - [On 051021 after 18 months of treatment biopsy on 051012
561376 - negative for inflammatory carcinoma. ref SDS C0 544N
561378 - ..
561379 - [On 060428 read medical test findings - case study doctors
561380 - limited time prevents reading findings to correlate
561381 - clinically for discovering symptomatic trends that enable
561382 - proactive case management; there is only enough time to
561383 - read summaries that present the gist of findings.
561384 - ref SDS C5 VG5L
561386 - ..
561387 - [On 060711 IBC relapse 2nd time, and following mastectomy
561388 - surgery 9 months earlier on 051021. ref SDS C8 8Y7O
561390 - ..
561391 - Pathology report continues...
561392 -
561393 - 040421 nh
561396 - ..
561397 - Clin History
561399 - ..
561400 - History
561402 - ..
561403 - History of breast cancer on left side. Red discoloration.
561405 - ..
561406 - Gross Desc
561408 - ..
561409 - Received is a punch biopsy of gray-white skin measuring 0.4 cm in
561410 - diameter and 0.5 cm in thickness. Bisected. All, 1, (rj)
561411 - DSF/prv
561413 - ..
561414 - Resource ID: 0098685
561416 - ..
561417 - PAT.RES <Shift F9> For complete Lab Results MTZRXB 040517 1231
561418 -
561419 - [On 060711 Doctor submits another part of the pathology report
561420 - that was not provided today, because additional training,
561421 - learning, and experience are required to access another part of
561422 - Kaiser's computer system, and it shows no status change for
561423 - HER2 Neu negative, which suggests treatments for cancer are
561424 - limited for Millie. ref SDS C8 RK4L
561425 -
561426 -
561427 -
561428 -
5615 -
SUBJECTS
Inflammatory Breast Cancer IBC Rare 1% of Cases Aggressive Spreads Q
6903 -
690401 - ..
690402 - Lymph Nodes Swelled in Neck and Under the Arm Symptoms IBC
690403 - Inflammatory Breast Cancer (IBC) Rare 1% Needs Prompt Treatment
690404 - Misdiagnosis IBC as Infection Treated Antibiotics Common Mistake
690405 - Symptoms Redness Thickening Skin Lumps in the Neck and Under the Arm
690406 -
690407 - A few days after the meeting today, research on the Internet for
690408 - inflammatory carcinoma of the breast, diagnosed in the pathology
690409 - report, per above, ref SDS 0 7D6F, found a website for IBC Support...
690410 -
690411 - http://www.ibcsupport.org/
690413 - ..
690414 - [On 040602 Jeannie suggested the IBC website. ref SDS 85 RZ6F
690416 - ..
690417 - [On 050712 further research for natural remedies to
690418 - supplement medical treatments. ref SDS B6 4P62
690420 - ..
690421 - Symptoms of IBC....
690423 - ..
690424 - Swollen lymph nodes under the arm or above the collarbone on the
690425 - same side as inflammed (red, erythema), and thickened skin (peau
690426 - d'orange) on the breast are symptoms of IBC, per below. ref SDS 0
690427 - S65H
690429 - ..
690430 - Review on 030109 of PET scan testing on 021218 found mild diffuse
690431 - increased soft tissue activities in the left axilla, left upper chest
690432 - wall, and supraclavicular regions, ref SDS 50 L66M, and were
690433 - attributed at that time to post-radiation symptoms. ref SDS 50 GJ69
690434 - During the same meeting on 030109, the doctor observed inflammation of
690435 - the left breast. ref SDS 50 KW5F This new symptom was treated for
690436 - cellulitus. ref SDS 50 0T6N Later, on 030710 a follow up CT test
690437 - reported dermal (skin) thickening and alerts that breast cancer can
690438 - present similarly. ref SDS 57 VM7I
690440 - ..
690441 - On 040402 the protocol nurse reported that Kaiser audits reports for
690442 - accuracy to strengthen proactive management of diagnosis and treatment
690443 - that prevents small changes in body chemestry from cascading into
690444 - major problems. ref SDS 66 6E4K What do the audits show in Millie's
690445 - case?
690447 - ..
690448 - Millie reported lumps in the neck above the collarbone on 040211, and
690449 - was treated with antibiotics for an infection. ref SDS 61 WP7L On
690450 - 040318 the doctor found that the lump under the left arm seemed
690451 - bigger. ref SDS 65 HC7F Earlier, on 021206, when the lump first
690452 - reappeared under the left arm where surgery was performed 9 months
690453 - earlier, the diagnosis was drainage from the initial surgery,
690454 - ref SDS 47 KW5F; later on 030508 the lump was described as scar tissue
690455 - from the initial operation in early 2002. ref SDS 53 7C84
690457 - ..
690458 - [On 040713 the doctor cited lumps in neck of IBC patient as
690459 - only evidence of metastic cancer. ref SDS 90 X43W
690460 -
690462 - ..
690463 - IBC Rare Aggressive Cancer Longevity 18 Months
690464 -
690465 - Further research found the Imigins website...
690466 -
690467 - http://imaginis.com/breasthealth/inflammatory.asp?mode=1
690468 -
690469 - ...that has the following report dated on 010328 saying...
690470 -
690471 - Inflammatory breast cancer is a rare form of rapidly advancing
690472 - breast cancer that usually accounts for less than 1% of all breast
690473 - cancer diagnoses. Inflammatory breast cancer is a form of invasive
690474 - breast cancer that progresses quickly and should be differentiated
690475 - by physicians from other forms of advanced breast cancer with
690476 - similar characteristics.
690477 -
690478 - [...IBC longevity 18 months, very poor prognosis, see below.
690479 - ref SDS 0 EE7I
690481 - ..
690482 - [On 040614 doctor confirms diagnoses (IBC), ref SDS 89 6T5G;
690483 - changes treatment protocol from stage II to most severe stage
690484 - IV, ref SDS 89 6M9H; tells Millie to get her affairs in order
690485 - with only months to live. ref SDS 89 I385
690487 - ..
690488 - [On 060807 report IBC is a very bad disease that goes through
690489 - the patient like a hot knife through butter. ref SDS D1 7Q8H
690491 - ..
690492 - Inflammatory breast cancer causes the breast to appear swollen and
690493 - inflamed. This appearance is often but not always caused when
690494 - cancer cells block the lymphatic vessels in the skin of the breast,
690495 - preventing the normal flow of lymph fluid and leading to reddened,
690496 - swollen and infect-looking breast skin-hence the designation
690497 - "inflammatory" breast cancer. ref OF 17 S018
690499 - ..
690500 - [On 040607 Millie learned Kaiser may have diagnosed inflammatory
690501 - breast cancer (IBC), and this is a rare, aggressive disease.
690502 - ref SDS 86 0001
690504 - ..
690505 - [On 061228 research MD Anderson says IBC is hard to diagnose,
690506 - common image testing does not identify IBC. ref SDS E0 H99F
690508 - ..
690509 - Another source says...
690510 -
690511 - Inflammatory Breast Cancer Help Website - Signs and Symptoms
690512 -
690513 - http://www16.brinkster.com/ibcsymptoms/
690515 - ..
690516 - Inflammatory Carcinoma, also known as Inflammatory Breast Cancer
690517 - (IBC), is an advanced and accelerated form of breast cancer that is
690518 - automatically staged as Stage IIIb or IV (within the range of Stage
690519 - I to Stage IV), and IBC is usually not detected by mammograms or
690520 - ultrasounds.
690522 - ..
690523 - It requires immediate aggressive treatment with chemotherapy prior
690524 - to surgery and is treated differently than more common types of
690525 - breast cancer.
690527 - ..
690528 - On 030606 the doctor noted that Millie's case requires close attention
690529 - to signs of redness and rising CA 15-3 for starting treatments and
690530 - switching chemotherapy in time to prevent cancer from cascading out of
690531 - control. ref SDS 54 N27L
690533 - ..
690534 - IBC Help article continues...
690535 -
690536 - IBC has a higher risk of recurrence than other types of breast
690537 - cancer. It is the most lethal of the breast cancers, but an early
690538 - diagnosis and quick start of treatment improves the chances of
690539 - survival. Chemotherapy is usually begun within days of diagnosis.
690540 - With new and upcoming treatment protocols, there is always hope of
690541 - long-term survival.
690542 -
690543 - [On 040614 the doctor diagnoses IBC, explains this is a
690544 - serious condition that requires aggressive, prompt stage IV
690545 - cancer treatment. ref SDS 89 6M9H
690547 - ..
690548 - [On 041230 case study of CT testing for Millie indicates no
690549 - distant metastatis; objective to provide timely treatment of
690550 - IBC to stabalize patient and prevent disease from spinning out
690551 - of control. ref SDS A4 XV7M
690553 - ..
690554 - [On 050324 surgeon advises that chemotherapy must cure IBC from
690555 - left breast in advance of surgery, and discloses having minimal
690556 - experiance performing masectomy on IBC patients (maybe once in
690557 - 5 years), responding to primary care physician's request for
690558 - surgery to treat "pockets of resistance" to chemotherapy.
690559 - ref SDS A9 QJ44
690561 - ..
690562 - [On 050712 further research for natural remedies to supplement
690563 - medical treatments. ref SDS B6 4P62
690565 - ..
690566 - [On 060711 IBC relapse 2nd time, and following mastectomy
690567 - surgery 9 months earlier on 051021. ref SDS C8 8Y7O
690568 -
690569 -
690570 -
690571 -
6906 -
SUBJECTS
IBC Not Detectable CT PET Scans Image Tests Except Common Symptoms S
7803 -
780401 - ..
780402 - IBC Diagnosis Hard Cannot Detect Image Tests Rash Thick Skin Lymph Nodes
780403 - Redness Rash Skin Thickening Swollen Lymph Nodes Symptoms IBC
780404 - CT PET Tests Cannot Detect IBC CA 15-3 Test Diagnostic Tracks IBC
780405 - IBC Not Detectable Image PET CT Test Swelled Lymph Nodes May Occur
780406 -
780407 - Research on Imigins website continues...
780408 -
780409 - Breast redness (erythema), thickened skin, and swollen lymph nodes
780410 - are primary symptoms. ref OF 17 H67H Another website cites swollen
780411 - lymph nodes in the axillary area (underarm) or the supraclavicular
780412 - area (above the collarbone). Itching, discomfort, bruise that does
780413 - not heal,
780414 -
780415 - http://www.ibchelp.org/symptoms/
780417 - ..
780418 - With inflammatory breast cancer, the breast skin has a thick,
780419 - pitted appearance that is classically described as "peau d'orange"
780420 - (resembling an orange peel). Sometimes the skin develops ridges and
780421 - small bumps that resemble hives. ref OF 17 QX6M
780423 - ..
780424 - Since image testing with CT and PET scans cannot detect IBC, only CA
780425 - 15-3 can track progression of disease and response to treatment.
780426 - Thickened skin may be detected or overlooked by CT and PET scan image
780427 - tests, but, if so, the condition may not be reported as IBC, nor
780428 - anything that sounds like "thickened skin." For example, on 030109
780429 - review of PET test on 021218 reported finding "mild diffuse increased
780430 - uptakes at the left upper chest wall." ref SDS 50 L66M At that time,
780431 - the doctor described "firmness" attributable to reaction from
780432 - radiation treatment, ref SDS 50 KW5F, and possible cellulitis.
780433 - ref SDS 50 0T6N Another example, a CT test reviewed on 030710 cites
780434 - dermal thickening of the left breast, ref SDS 57 VM7I, which is
780435 - another way of describing skin thickening presented in the research
780436 - that identifies IBC, per above. ref SDS 0 S65H
780438 - ..
780439 - [On 041019 Doctor Guardino at Stanford Medical Center described
780440 - "peau d'orange" coloration is a symptom of IBC. ref SDS 97 TX93
780442 - ..
780443 - [On 041117 Doctor Benz at UCSF Medical Center 2nd opinion
780444 - report describes "peau d'orange as a symptom of IBC.
780445 - ref SDS 99 OU5T
780447 - ..
780448 - [On 060711 case study CT and PET scan test findings IBC
780449 - symptoms dermal and skin thickening, lymphadenopathy in left
780450 - axillary and supraclavicular. 060711, ref SDS C8 YU6M
780452 - ..
780453 - [On 061228 research MD Anderson says IBC is hard to diagnose,
780454 - common image testing does not identify IBC. ref SDS E0 H99F
780456 - ..
780457 - Research continues...
780458 -
780459 - Inflammatory breast cancer can sometimes be mistaken by patients
780460 - and physicians as a breast infection because its symptoms, and the
780461 - rapidity with which they appear (sometimes within weeks) resemble
780462 - those associated with infections. However, while most breast
780463 - infections will respond to antibiotics, inflammatory breast cancer
780464 - will not. In fact, symptoms of inflammatory breast cancer do not
780465 - usually get better or worse as infections do. If symptoms persist
780466 - more than two or three weeks despite treatment, further testing and
780467 - a breast biopsy....
780469 - ..
780470 - http://imaginis.com/breasthealth/biopsy/
780471 -
780472 - ...should be performed to determine whether cancer is present.
780473 - ref OF 17 H67H
780475 - ..
780476 - This aligns with the doctor's comments on 040504 advising that
780477 - normally a biopsy would be prescribed after symptoms persist following
780478 - use of antibiotics. ref SDS 79 UR6M
780479 -
780480 -
780481 -
780482 -
780483 -
7805 -
SUBJECTS
Inflammatory Breast Cancer Rare 1% of Cases Aggressive Spreads Quick
Treatment IBC Chemotherapy Masectomy (Surgery) Radiation How Inflamm
8104 -
810501 - ..
810502 - Treatment IBC Aggressive Chemotherapy Possibly Surgery Radiation
810503 - Inflammatory Breast Cancer Treated Aggressively
810504 - Chemotherapy Surgery Radiation Common Treatment Regimen for IBC
810505 - Mastectomy Increases Chances Inflammatory Breast Cancer to Relapse
810506 -
810507 - Inflammatory breast cancer is an aggressive cancer that can grow
810508 - and spread quickly. If the inflammatory cancer has not spread
810509 - beyond the breast, a mastectomy (removal of the entire breast) may
810510 - be performed to remove the tumor. ref OF 17 M54M
810511 -
810512 - http://imaginis.com/breasthealth/mastectomy.asp
810514 - ..
810515 - Types of mastectomy are discussed below. ref SDS 0 1371
810517 - ..
810518 - However, because inflammatory breast cancer involves lymphatic
810519 - vessels of the skin, mastectomy can increase the chances for the
810520 - cancer to recur (since the skin is stitched together after
810521 - mastectomy). ref OF 17 JPXW
810522 -
810523 - http://imaginis.com/breasthealth/bcrecurrence.asp
810525 - ..
810526 - Therefore, other treatment options (most commonly, chemotherapy)
810527 - ...are usually considered before surgery. ref OF 17 JF6G
810529 - ..
810530 - [On 041019 Stanford recommends aggressive treatment with
810531 - continuous chemotherapy. ref SDS 97 HX5H
810533 - ..
810534 - [On 050324 research yielded a professional comment that IBC is
810535 - not always inoperable, ref SDS A9 TN76, which seems to present
810536 - a bias against surgery that may align with Doctor Benz at
810537 - UCSF, who discouraged surgery in a 2nd opinion received on
810538 - 041117. ref SDS 99 OU5P
810540 - ..
810541 - [On 050712 further research for natural remedies to supplement
810542 - medical treatments. ref SDS B6 4P62
810544 - ..
810545 - [On 040812 doctor indicates patients with IBC need not
810546 - necessarily be treated with surgery for IBC. ref SDS 92 T75L
810548 - ..
810549 - [On 041018 Doctor Benz commented during a meeting at UCSF for
810550 - a 2nd opinion that surgery was once a common solution for IBC;
810551 - he feels surgery is not an effective solution for Millie.
810552 - ref SDS 96 NZ6H
810554 - ..
810555 - [On 041210 doctor proposes surgery to treat IBC, and case study
810556 - reviews history considering surgery for Millie. ref SDS A2 ZV5J
810558 - ..
810559 - Chemotherapy is often administered to inflammatory breast cancer
810560 - patients before local treatment, ref OF 17 AB3F, (such as
810561 - mastectomy or radiation...
810563 - ..
810564 - After mastectomy surgery, patients with inflammatory breast cancer
810565 - are usually treated with additional chemotherapy followed by
810566 - radiation therapy to the chest wall. ref OF 17 B53F
810567 -
810568 - http://imaginis.com/breasthealth/radio_bctreatment.asp
810570 - ..
810571 - This fits the model discussed with the surgeon on 040429, and this
810572 - afternoon with the doctor, per above. ref SDS 0 735H
810573 -
810574 - [On 050324 surgeon advises that chemotherapy must cure IBC from
810575 - left breast in advance of surgery, and discloses having minimal
810576 - experiance performing masectomy on IBC patients (maybe once in
810577 - 5 years), responding to primary care physician's request for
810578 - surgery to treat "pockets of resistance" to chemotherapy.
810579 - ref SDS A9 QJ44
810581 - ..
810582 - [On 090129 2143 research shows treatment of IBC with radiation
810583 - ref SDS E6 NJ6H, is used with hyperthermia, ref SDS E6 9O5F,
810584 - was prescribed along with Doxil chemotherapy for Millie at UCSF
810585 - earlier on 090129, reported on 090130. ref SDS E7 HK3V
810587 - ..
810588 - Treatment with chemotherapy and mastectomy fits the surgeon's planning
810589 - on 040429, ref SDS 78 SD7F, and the doctor mentioned on 040416 that
810590 - the Tumor Board suggested trying radiation after chemotherapy.
810591 - ref SDS 72 2U5V
810592 -
810593 -
810595 - ..
810596 - Masectomy 4 Types Most Common Modified Radical Masectomy MRM
810597 -
810598 -
810599 - Another source says...
810600 -
810601 - Inflammatory Breast Cancer Help Website - Surgery
810602 -
810603 - http://www.ibchelp.org/mrm.html
810605 - ..
810606 - Most IBC patients will receive a Modified Radical Mastectomy (MRM)
810607 - after they receive their adjuvant (before surgery) chemotherapy.
810608 - Some IBC patients will opt for a Prophylactic (preventative)
810609 - Mastectomy for their unaffected breast, and that will usually be a
810610 - Total (or Simple) Mastectomy. IBC patients are rarely given a
810611 - Radical Mastectomy.
810613 - ..
810614 - There are four (4) general types of masectomy...
810615 -
810616 - 1. A Subcutaneous Mastectomy removes the entire breast, but leaves
810617 - the nipple and areola (the pigmented circle around the nipple)
810618 - in place.
810620 - ..
810621 - 2. A Total (or Simple) Mastectomy is the removal of the whole
810622 - breast, but not the lymph nodes under the arm (axillary nodes).
810623 - This is often done as a Prophylactic Mastectomy for the
810624 - non-affected breast of the IBC patient. A prophylactic
810625 - mastectomy greatly reduces, but does not eliminate the risk of
810626 - breast cancer.
810628 - ..
810629 - 3. A Modified Radical Mastectomy (MRM) is the removel of the whole
810630 - breast and most of the lymph nodes under the arm (axillary
810631 - nodes). Removal of these lymph nodes is called an axillary
810632 - dissection. This is the standard surgery for the IBC breast.
810634 - ..
810635 - 4. A Radical Mastectomy involves removal of the chest wall muscles
810636 - (pectorals) in addition to the breast and axillary lymph nodes,
810637 - but it is rarely used today.
810638 -
810640 - ..
810641 - Risks of Masectomy Commonly Very Safe Surgery
810642 -
810643 - Mastectomy is a very safe surgery, and most patients recover well
810644 - with no complications; but as with any surgery, there are risks.
810645 - The risks of any surgery are bleeding, infection, and injury to
810646 - nearby tissues. Some post-operative pain and soreness is expected,
810647 - but can usually be effectively treated with pain medication. There
810648 - will also be a scar on the chest wall.
810649 -
810651 - ..
810652 - Skin Graft Required Rare Complication to Repair Skin Loss
810653 -
810654 - The risks related specifically to the removal of the breast include
810655 - a compromised blood supply to the skin of the chest wall, which may
810656 - cause loss of some skin. In extreme circumstances, this
810657 - complication may require a skin graft, but this is very rare.
810658 - There is also a risk of bleeding into the space where the breast
810659 - used to be. Sometimes a second operation is required to control
810660 - bleeding, but this is also uncommon.
810661 -
810662 - [On 050324 skin grafts discussed with surgeon as possible
810663 - solution for masectomy to resolve dilemma where pockets of
810664 - resistance to chemotherapy prevent full recovery of IBC, as a
810665 - predicate to surgery, raised by primary care physician.
810666 - ref SDS A9 F14N
810667 -
810669 - ..
810670 - Lymph Nodes Removed Under Arm Pit Causes Side Effects
810671 - Axillary Dissection Removing Lymph Nodes Stiffness Swelling Numb
810672 -
810673 - There are risks specifically related to removing the nearby lymph
810674 - nodes (axillary dissection):
810675 -
810676 - 1. Many patients experience shoulder stiffness after removal of
810677 - the lymph nodes in the armpit. This stiffness improves over
810678 - time, especially with exercise and physical therapy.
810680 - ..
810681 - 2. A fluid collection, called a seroma, may collect in the armpit.
810682 - This is relatively common and usually resolves on its own, but
810683 - may require needle drainage.
810685 - ..
810686 - 3. Since the axillary (armpit) lymph nodes normally drain excess
810687 - fluid from the arm, the removal of these can result in
810688 - postoperative swelling of the arm on the same side as the
810689 - breast which is removed. This swelling (called lymphedema) is
810690 - uncommon, but when it occurs, it can be a persistent problem
810691 - and carries an increased risk of infection.
810692 -
810693 - [On 060106 patient reports new swelling, large bulge under
810694 - left axillary; initial diagnosis is lymphedema, ref SDS C2
810695 - S164; research indicates lymphedema is serious, and there
810696 - is no cure. ref SDS C2 SS6K
810698 - ..
810699 - 4. There are some important nerves in the area of the axillary
810700 - lymph nodes that are at risk during surgery. Many patients
810701 - will have a numb patch on the inside of the arm after surgery.
810702 - Nerves to muscles of the back and chest wall are also at risk,
810703 - but your surgeon will make every effort to protect these nerves
810704 - during surgery.
810705 -
810707 - ..
810708 - Research on Imigins website continues...
810709 -
810711 - ..
810712 - Chemotherapy High Dose Treatment for Inflammatory Breast Cancer
810713 -
810715 - ..
810716 - A common regimen, as of the date of the report in April 2001, using a
810717 - "high-dose" of chemotherapy with CAF (cyclophosphamide, doxorubicin,
810718 - and fluorouracil), reported in research shown above, ref SDS 0 JK94,
810719 - is not being followed in this case. Millie is participating in a
810720 - trial of bevacizumab (rhuMab VEGF - Avastin), that is given to the
810721 - patient once a week with a low dose of Taxol, reported on 040318,
810722 - ref SDS 65 PU6M, prior to the diagnosis of IBC today.
810724 - ..
810725 - http://imaginis.com/breasthealth/radio_bctreatment.asp
810727 - ..
810728 - [On 040601 dose of chemotherapy using Taxol has been
810729 - consistently lowered to accomodate Millie's low blood counts.
810730 - ref SDS 84 Q659
810732 - ..
810733 - Is CAF out of date - is Taxol and Avastin at least an equivalently
810734 - aggressive, "high dose" research treatment?
810736 - ..
810737 - Does the new diagnosis create a more complex scenario that requires
810738 - review of the current treatment regimen, by people with more
810739 - experience treating IBC, because IBC is an aggressive cancer that
810740 - spreads quickly, ref SDS 0 YM3M, and because IBC is a rare disease
810741 - which is not encountered often in oncology departments?
810742 -
810743 - [...below, issues to review with the doctor for verifying
810744 - treatment regimen. ref SDS 0 S79G
810746 - ..
810747 - [...below, questions for Tumor Board on reviewing and revising
810748 - recommendations. ref SDS 0 8K5M
810749 -
810750 -
810751 -
810752 -
8108 -
SUBJECTS
Prognosis Inflammatory Breast Cancer Average Survival 18 Months
8203 -
820401 - ..
820402 - Imigins website continues...
820404 - ..
820405 - Prognosis Inflammatory Breast Cancer Average Survival 18 Months
820406 - New Treatments Extend Survival To 5 Years Chemotherapy Radiation
820407 -
820408 - Because inflammatory breast cancer is an advanced cancer...
820409 -
820410 - http://imaginis.com/breasthealth/metastatic.asp
820411 -
820412 - ...it has been associated with a poor prognosis (expected outcome).
820413 - Past statistics have shown the average survival rate of
820414 - inflammatory breast cancer to be approximately 18 months.
820415 -
820416 - [...above, IBC is a rare, aggressive cancer. ref SDS 0 TO7L
820418 - ..
820419 - [On 060807 report IBC is a very bad disease that goes through
820420 - the patient like a hot knife going through butter. ref SDS D1
820421 - 7Q8H
820423 - ..
820424 - However, recent studies have shown that advancements in treatment
820425 - may help to extend the survival time for women with inflammatory
820426 - breast cancer. Using chemotherapy, surgery (mastectomy), and
820427 - radiation, the average five-year survival rate is currently 40%.
820428 - Physicians are hopeful that advances in treatment will continue to
820429 - improve the prognosis for women diagnosed with inflammatory breast
820430 - cancer. ref OF 17 GL4N
820431 -
820432 - [On 040607 Millie learned Kaiser may have diagnosed
820433 - inflammatory breast cancer (IBC), and this is a rare,
820434 - aggressive disease. ref SDS 86 MP6H
820435 -
820436 -
820437 -
820438 -
8205 -
SUBJECTS
Case Study Redness Inflammation Breast Left Side Symptoms Where Canc
9403 -
940401 - ..
940402 - Red Rash Inflammation Left Breast Case Study
940403 - IBC Case Study Inflammatory Breast Cancer Red Rash Left Breast
940404 - Medical Intelligence Connecting Dots in Time for Effective Treatment
940405 - Case Study Red Rash Left Breast Connecting Dots in Time for Treatment
940406 -
940407 - This case study complements study on the lump under the left arm which
940408 - has been treated separately until discovery today that both are
940409 - symptoms of IBC, per above, ref SDS 0 LS3L, further reflecting the
940410 - Knowledge Management dilemma inherent to medical practice, also
940411 - discussed above. ref SDS 0 SU7G
940413 - ..
940414 - Research indicating four (4) symptoms of IBC -- inflammation, red rash
940415 - on the breast, stiff, thickened skin, lumps under arm (axilla), and in
940416 - the neck, see above, ref SDS 0 6M9H, have been mistakenly treated for
940417 - other maladies in Millie's case beginning 2 years ago on 021206. This
940418 - patient history shows IBC is difficult to diangose, because other more
940419 - common medical problems have similar symptoms. Misdiagnosis delays
940420 - treatment for IBC, making recovery very difficult...
940421 -
940422 - [On 060722 "wicked problems" causing Knowledge Management
940423 - dilemmas are common in medical practice illustrated by
940424 - delayed diagnosis of pulmonary embolism. ref SDS C9 5I3H
940425 -
940426 - 1. primary care physician concerned Millie
940427 - did not respond normally to adjuvent
940428 - treatment; complex beast cancer case,
940429 - rising CA 15-3 and so increased
940430 - radiation from 4 to 6
940431 - weeks................................ 020726, ref SDS 41 MO37
940432 - No signs of rash were reported in
940433 - the record at that time.............. 020726, ref SDS 41 2F5J
940435 - ..
940436 - 2. Stiff, thickened skin left breast
940437 - found during examination at Kaiser
940438 - attributed to scar tissue from surgery
940439 - on 020312, and to radiation
940440 - treatments ended on
940441 - 020910 .............................. 021206, ref SDS 47 SG7J
940442 - Swelling in left axilla.............. 021206, ref SDS 47 KW5F
940443 - Cancer marker rises.................. 021206, ref SDS 47 SM6M
940445 - ..
940446 - 3. Doctor observes red rash
940447 - coloration and firmness of
940448 - left breast.......................... 030109, ref SDS 50 KW5F
940449 - Diagnosis cellulitus................. 030109, ref SDS 50 0T6N
940450 - Treatment antibiotics................ 030109, ref SDS 50 GK7T
940452 - ..
940453 - 4. PET test on 021218 reported new
940454 - mild diffuse increased uptakes
940455 - at the region of the left axilla,
940456 - left upper chest wall, and left
940457 - supraclavicular regions may give
940458 - early warning of IBC symptoms
940459 - to explain doctor finding red
940460 - rash on on left breast, patient
940461 - discomfort under left arm,
940462 - and later finding cancer lymph
940463 - nodes on left side of
940464 - neck................................. 030109, ref SDS 50 L66M
940466 - ..
940467 - 5. Clinical examination under
940468 - the left arm found no scar
940469 - tissue to explain discomfort
940470 - reported by patient.................. 030109, ref SDS 50 KW5F
940472 - ..
940473 - 6. Doctor observed red rash
940474 - reduced indicating effective
940475 - treatment with antibiotics........... 030220, ref SDS 52 0T6N
940477 - ..
940478 - 7. Patient reports lump under left
940479 - arm where surgery was performed
940480 - to remove infected lymph nodes
940481 - and cancer was found out of
940482 - capsule; doctor cannot detect
940483 - lump, diagnosis scar tissue
940484 - from surgery and reaction to
940485 - radiation............................ 030508, ref SDS 53 7C84
940487 - ..
940488 - 8. CT test report finds 2 lymph
940489 - nodes less than 1 CM in
940490 - left axilla that were not
940491 - present in prior exam................ 030508, ref SDS 53 VM8N
940493 - ..
940494 - 9. Biopsy discussed to investigate
940495 - new swelled lymph nodes; decide
940496 - to wait for next CT test............. 030508, ref SDS 53 7C98
940498 - ..
940499 - 10. Patient requests emergency meeting for
940500 - examination severe rash and inflammation
940501 - of left breast, and larger lumps
940502 - under left arm causing
940503 - discomfort during
940504 - exercise............................. 030606, ref SDS 54 7C6W
940506 - ..
940507 - 11. Doctor observed severe redness
940508 - which had led to early meeting
940509 - for examination had reduced on
940510 - the day of the examination, no
940511 - treatment prescribed................. 030606, ref SDS 54 MM6J
940513 - ..
940514 - 12. Doctor found definite lump with
940515 - clinical palpation
940516 - examination.......................... 030606, ref SDS 54 N66U
940518 - ..
940519 - 13. Lump found by clinical examination closer
940520 - to the surface than 2 new swelled lymph
940521 - nodes reported in CT test on 030508,
940522 - and diagnosis of these lumps is
940523 - scar tissue from from surgery
940524 - 14 months earliery on
940525 - 020312............................... 030606, ref SDS 54 N66J
940527 - ..
940528 - 14. Steady rise in CA 15-3 has
940529 - doctor's attention................... 030606, ref SDS 54 NE7L
940531 - ..
940532 - 15. Patient asks again for biopsy and PET
940533 - scan testing to start treatment before
940534 - conditions become to difficult to
940535 - control; doctor decides to wait for
940536 - results of CT test at end of June
940537 - to assess need for further biopsy
940538 - and PET scan testing................. 030606, ref SDS 54 P97J
940540 - ..
940541 - 16. Potential for recurrence in this case
940542 - has always been viewed as high; getting
940543 - close scrutiney by Kaiser's medical
940544 - team................................. 030606, ref SDS 54 NE4G
940546 - ..
940547 - 17. CT scans from test on 030626 finds
940548 - left axillary adenopathy nodes measures
940549 - 1.5 cm or less similar to former study;
940550 - slight increase in reticulation
940551 - of left axillary
940552 - fat.................................. 030710, ref SDS 57 VM7I
940554 - ..
940555 - 18. CT test on 030626 findings persistant
940556 - left breast skin thickening may be from
940557 - radiation therapy, but notes invasion
940558 - of dermal lymphatics from known breast
940559 - cancer can present similarly; doctor
940560 - advised to "correlate
940561 - clinically".......................... 030710, ref SDS 57 GJ69
940563 - ..
940564 - Research today shows persistant skin
940565 - thickening symptom of inflammatory
940566 - breast cancer (IBC). ref SDS 0 S65H
940568 - ..
940569 - 19. Doctor cites CT test showing persistent
940570 - left breast and chest wall skin thickening
940571 - may be from radiation therapy, and so
940572 - decides not to perform biopsy to
940573 - check for cancer recurrence
940574 - planned on 030508, and a
940575 - few weeks ago on
940576 - 030606............................... 030710, ref SDS 57 7C6W
940578 - ..
940579 - 20. No discussion of CT test seeming
940580 - to report that lumps under the
940581 - arm have increased in size
940582 - from 1 CM to 1.5 CM.................. 030710, ref SDS 57 XX4G
940584 - ..
940585 - 21. Persistent stiffness and discomfort in
940586 - left side of neck; xray ordered for
940587 - evaluation........................... 030915, ref SDS 58 H84F
940589 - ..
940590 - 22. Lymph nodes swelled in neck
940591 - near collarbone, led to
940592 - request for meeting with
940593 - doctor............................... 040211, ref SDS 61 WP7L
940594 - Diagnosis infection.................. 040211, ref SDS 61 S15G
940595 - Treatment antibiotics................ 040211, ref SDS 61 6S6N
940597 - ..
940598 - 23. Lymph nodes swelling persists
940599 - in neck, biopsy ordered.............. 040227, ref SDS 62 0001
940601 - ..
940602 - 24. The doctor advises that
940603 - pathology report on biopsy
940604 - found swelled lymph nodes
940605 - in the neck are cancer............... 040318, ref SDS 65 8R6M
940606 - Diagnosis reccurrence................ 040318, ref SDS 65 WA4H
940607 - Treatment immediate chemotherapy
940608 - prescribed........................... 040318, ref SDS 65 PU6M
940610 - ..
940611 - 25. PET test rejected to assess
940612 - scope of metastasis because
940613 - CT tests show problem limited
940614 - to the neck.......................... 040318, ref SDS 65 HC5G
940616 - ..
940617 - 26. Doctor observes severe redness
940618 - in left breast that led request
940619 - for early meeting.................... 040318, ref SDS 65 IM6J
940620 - Diagnosis cellulitus................. 040318, ref SDS 65 PY4N
940621 - Treatment antibiotics delays
940622 - start of chemotherapy until
940623 - after antibiotics clear
940624 - cellulitus........................... 040318, ref SDS 65 PY5H
940626 - ..
940627 - 27. Doctor observes redness
940628 - persists............................. 040402, ref SDS 67 IM6J
940629 - Diagnosis changed from cellulitus
940630 - to reaction from radiation
940631 - treatments given in August 2002...... 040402, ref SDS 67 8T5O
940632 - Treatment steroid and cleared
940633 - to commence chemotherapy with
940634 - taxol and bevacizumab (Avastin)...... 040402, ref SDS 67 SY6J
940636 - ..
940637 - 28. Doctor examined left breast and
940638 - reported findings that redness
940639 - in left breast reduced slightly,
940640 - so treatment for reaction to
940641 - radiation treatments in 2002
940642 - was ended............................ 040416, ref SDS 72 IM6J
940644 - ..
940645 - 29. Biopsy taken on left breast
940646 - at request of patient after
940647 - minor surgery to install
940648 - port catheter for getting
940649 - chemotherapy treatments.............. 040419, ref SDS 74 789F
940651 - ..
940652 - 30. Treatments begin using Taxol and
940653 - trial protocol using bevacizumab
940654 - (Avastin)............................ 040420, ref SDS 75 9Z5J
940656 - ..
940657 - 31. The surgeon reports
940658 - pathology on biopsy of left
940659 - breast taken on 040419 found
940660 - cancer of some kind; will
940661 - require mastectomy after 4 - 6
940662 - cycles of chemotherapy to treat
940663 - redness of left breast; no
940664 - disclosure of IBC.................... 040429, ref SDS 78 J757
940666 - ..
940667 - 32. The doctor meets patient
940668 - in Chemotherapy Clinic during
940669 - treatment, explains normally
940670 - biopsy is ordered when breast
940671 - redness observed, but invariably
940672 - results are negative, so biopsy
940673 - was not ordered on 030508, on
940674 - 030606, and on 040318; IBC was
940675 - therefore overlooked, but
940676 - maintained there is no change in
940677 - treatment; and, there was no
940678 - disclosure to patient of IBC......... 040504, ref SDS 79 WI8F
940680 - ..
940681 - 33. Diagnosis in Pathology report on
940682 - biopsy shows metastatic Carcinoma
940683 - involving dermal lymphmatics
940684 - consistent with inflammatory
940685 - carcinoma of the breast; pathology
940686 - report handed to patient during
940687 - meeting with no explanation of
940688 - IBC.................................. 040517, ref SDS 0 7D6F
940690 - ..
940691 - 34. Research shows symptoms for
940692 - inflammatory breast cancer (IBC)
940693 - are redness, thickening of
940694 - skin and swelled lymph nodes
940695 - in the neck and under the arm;
940696 - which first began to appear
940697 - on 021206, ref SDS 0 2F4G, per
940698 - above................................ 040517, ref SDS 0 6M9H
940700 - ..
940701 - 35. Patient formally notified
940702 - of diagnosis for IBC................. 040614, ref SDS 89 6T5G
940704 - ..
940705 - 36. Stage IV assigned changed from
940706 - prior stage IIA treatment
940707 - protocol............................. 040614, ref SDS 89 6M9H
940709 - ..
940710 - 37. Dilemma patient must decide
940711 - to have surgery to reduce risk
940712 - of recurrence, or lose treatment
940713 - in Avastin trial, PET test not
940714 - approved to study scope of
940715 - problem.............................. 040614, ref SDS 89 JK8L
940717 - ..
940718 - 38. Tumor Board did not review IBC
940719 - symptoms, doctor recommends
940720 - against re-hearing based on
940721 - pathology report diagnosing
940722 - IBC.................................. 040614, ref SDS 89 4R59
940724 - ..
940725 - 39. Bone scan shows no evidence
940726 - metastatic cancer.................... 040713, ref SDS 90 L34N
940728 - ..
940729 - 40. Metastatic cancer diagnosed
940730 - based solely on lumps in neck
940731 - which are symptoms of IBC............ 040713, ref SDS 90 8R6M
940733 - ..
940734 - 41. CT test on 040710 reviewed shows
940735 - no report of cancer; lumps in
940736 - neck, under arm significantly
940737 - decreased............................ 040811, ref SDS 91 WV66
940739 - ..
940740 - 42. Patient advised surgery not
940741 - necessarily recommended
940742 - treatment for IBC.................... 040812, ref SDS 92 T75L
940744 - ..
940745 - 43. Conflicts in medical tests not
940746 - resolved with precision of
940747 - engineering.......................... 040812, ref SDS 92 T761
940749 - ..
940750 - 44. CA 15-3 falls to normal for first
940751 - time in 3 years reverses 3 month
940752 - rise to 49 by falling
940753 - to 39................................ 041014, ref SDS 95 2N5J
940755 - ..
940756 - 45. IBC rash inflammation left breast nearly
940757 - gone (slight coloration) findings 2nd
940758 - opinion consultation Doctor Benz
940759 - UCSF................................. 041018, ref SDS 96 V18I
940761 - ..
940762 - Treatment Taxotere and Bevacizumab
940763 - (Avastin) clniical trial ended because
940764 - patient diagnosed pulmonary embolism
940765 - after 6 months of symptoms; 041021
940766 - last treatment for IBC............... 041104, ref SDS 98 0001
940768 - ..
940769 - 46. Emergency room hospital treatment
940770 - IBC symptoms red rash inflammation
940771 - temperature suddenly increase;
940772 - resolved reaction to antibiotic
940773 - treatment of persistant
940774 - biopsy wound for
940775 - cellulitus........................... 041202, ref SDS A1 0001
940777 - ..
940778 - 47. IBC red rash on left breast worsening
940779 - after removing patient from treatment
940780 - due to side effects of pulmonary embolism
940781 - and 2 months delay starting new
940782 - treatment while searching for
940783 - clinical trial....................... 041210, ref SDS A2 025H
940785 - ..
940786 - 48. IBC red rash on left breast much worse
940787 - after nearly 3 months off treatment
940788 - searching for clinical
940789 - trial................................ 041230, ref SDS A4 025H
940791 - ..
940792 - Treatment resumed with Andrimiacin
940793 - Cytoxin (AC)......................... 050104, ref SDS A5 407N
940795 - ..
940796 - 49. Surgery mastectomy impossible; IBC red
940797 - rash inflammation spreads beyond
940798 - left breast toward
940799 - neck................................. 050107, ref SDS A6 IS5N
940801 - ..
940802 - 50. IBC on left breast inflammation
940803 - may show both regression in some
940804 - places, and might be worse;
940805 - progress indeterminate............... 050204, ref SDS A7 025H
940807 - ..
940808 - 51. IBC on left breast inflammation now
940809 - spreading, and cancer blisters suddenly
940810 - occur, signal rising IBC
940811 - activity............................. 050311, ref SDS C6 025H
940813 - ..
940814 - 52. IBC rash inflammation left breast worsens
940815 - advances further toward neck; cancer
940816 - sores visible on
940817 - breast............................... 050324, ref SDS A9 YY7F
940819 - ..
940820 - Treatment changed from AC to Taxotere
940821 - and capecitatine (Xeloda) recommended
940822 - in 2nd opinion by Doctor Benz at
940823 - UCSF................................. 050329, ref SDS B0 AW5G
940824 -
940825 - Treatment begins Taxotere and
940826 - capecitabine (Xeloda)................ 050415, ref SDS B2 407N
940828 - ..
940829 - 53. IBC rash inflammation left breast dramatic
940830 - subsidance 1st time since 041104; cancer
940831 - sores seem fully "dried up";
940832 - miraculous recovery and
940833 - improvement.......................... 050520, ref SDS B5 025H
940835 - ..
940836 - 54. Inflammation left breast full regression;
940837 - skin coloration and texture near
940838 - normal 1st time in
940839 - 18 months............................ 050727, ref SDS B7 YY7F
940841 - ..
940842 - Mastectomy surgery performed to remove
940843 - tissue previously infected with
940844 - IBC.................................. 051021, ref SDS C0 EG5L
940846 - ..
940847 - 55. Red rash left breast signals IBC relapse,
940848 - wide mastectomy may not have been wide
940849 - enough; resume chemotherapy pending
940850 - verify recovery from
940851 - pneumonia............................ 060623, ref SDS C7 025H
940853 - ..
940854 - 56. IBC worsening chest looks like red beet;
940855 - notify Kaiser treatment with Taxotere
940856 - and capecitabine failing, request
940857 - instructions on going ahead
940858 - with next cycle scheduled
940859 - for 060810........................... 060806, ref SDS D0 OJ7S
940861 - ..
940862 - 57. Red rash IBC seems to subside; backup
940863 - doctor decides to test delayed response
940864 - to treatment rather than conclude
940865 - failure; decide to continue
940866 - treatment Taxotere and
940867 - capecitabine (Xeloda)................ 060808, ref SDS D2 VO6G
940869 - ..
940870 - 58. IBC inflammation red rash left breast
940871 - complications of lymphedema from
940872 - mastectomy surgery compounded by
940873 - broken finger 2 months
940874 - earlier.............................. 061027, ref SDS D7 V79M
940876 - ..
940877 - 59. Examination IBC rash spreading on
940878 - left breast area..................... 061110, ref SDS D8 025H
940880 - ..
940881 - 60. IBC spreads right breast............. 061204, ref SDS D0 I93X
940883 - ..
940884 - 61. Remarkable improvement............... 061204, ref SDS D9 2P8U
940886 - ..
940887 - 62. IBC worsening spreads to
940888 - right breast......................... 070105, ref SDS E1 J44H
940890 - ..
940891 - 63. IBC spreads to stomach and back
940892 - seems less intense................... 070130, ref SDS E2 M68J
940894 - ..
940895 - 64. IBC spreads left arm, but intensity
940896 - still subsiding...................... 070222, ref SDS E3 B64F
940898 - ..
940899 - 65. IBC spreads right arm?? intensity
940900 - clearly subsiding, CA 15-3
940901 - falls dramatically................... 070301, ref SDS E4 LB5L
940903 - ..
940904 - 66. Left arm intensity suddenly increases
940905 - significantly; treatment for Cellulitis
940906 - prescribed; but rash subsides quickly
940907 - without treatment back
940908 - to low condition of
940909 - IBC.................................. 070330, ref SDS E5 7C7G
940911 - ..
940912 - 67. Rash right upper chest suddenly appears;
940913 - treatment for Cellulitis prescribed;
940914 - but rash quickly subsides without
940915 - treatment; no biopsy performed
940916 - to determine pathology of new
940917 - rash................................. 070330, ref SDS E5 583G
940918 -
940919 -
940920 -
940921 -
9410 -
SUBJECTS
Issues Pending Verify Diagnosis IBC Review Treatment Regimen Taxol A
Treatment IBC Review Verify Regimen Taxol Avastin Trial Credentials
9604 -
960501 - ..
960502 - Issues Arising from Research on IBC and Record in Millie's Case
960503 -
960504 - Pending issues to discuss with the doctor on diagnosis and
960505 - treatment....
960506 -
960507 - [On 040610 planning submitted to the doctor to prepare
960508 - for meeting on 040614 reviewing diagnosis and treatment.
960509 - ref SDS 88 OA4P
960511 - ..
960512 - [On 040614 the doctor reported his computer was down,
960513 - so he was not able to review pending issues from the prior
960514 - meeting on 040517. ref SDS 89 RU5F
960515 -
960516 - 1. What are implications for longevity of 18 months listed in the
960517 - research, per above, ref SDS 0 0141, in relation to original
960518 - symptoms reported on 030109? ref SDS 48 KW5F, and again on
960519 - 030606? ref SDS 52 7C6W
960521 - ..
960522 - 2. What are implications for longevity of 18 months for
960523 - Inflammatory Breast Cancer under the current treatment, in
960524 - relation to typically prescribed treatments, shown in the
960525 - research today, per above? ref SDS 0 JK94
960527 - ..
960528 - 3. How does diagnosis of inflammatory carcinoma of the left breast
960529 - (IBC), shown in the pathology report of a biopsy taken on
960530 - 040419, per above, ref SDS 0 7D6F, influence treatment in
960531 - relation to the clinical trial for Avastin that calls for a low
960532 - dose of Taxol chemotherapy, reported on 040318, ref SDS 65
960533 - VJ46, which appears to conflict with a common regimen that
960534 - calls for a high dose of chemotherapy using other drugs, shown
960535 - by research listed above? (see pending action items)
960536 - ref SDS 0 JK94
960538 - ..
960539 - 4. The research cites advances in treatment may help to extend
960540 - survival, ref SDS 0 0141, and in this case Millie is in a trial
960541 - of Avastin, beginning on 040420. ref SDS 0 MP6G Does this
960542 - preclude trying other ways of treating inflammatory breast
960543 - cancer, e.g., see research today? ref SDS 0 JK94
960545 - ..
960546 - 5. What "surgery" is contemplated from the minutes of the meeting
960547 - by the Tumor Board on 040416? ref SDS 0 KI3O
960548 -
960549 - a. Doctor Laio discussed surgery
960550 - to remove infected lymph nodes
960551 - in the neck...................... 040309, ref SDS 63 Y193
960553 - ..
960554 - b. The surgeon discussed
960555 - mastectomy surgery, which was
960556 - after the Tumor Board met on
960557 - 040416, so this could not have
960558 - been in the minds of board
960559 - members.......................... 040429, ref SDS 78 C155
960561 - ..
960562 - 6. Is further testing required to accurately diagnose other issues
960563 - that need analysis for prescribing treatment? ref SDS 0 SU7G
960564 - and ref SDS 0 2F4G
960566 - ..
960567 - 7. What experience treating IBC does the Oncology Department in
960568 - Kaiser's Walnut Creek hospital have?
960569 -
960570 - How many IBC cases have been treated in the past 5 years by
960571 - the team at Walnut Creek?
960573 - ..
960574 - How many IBC cases have been treated in the past 5 years
960575 - under the doctor's supervision as the chief of
960576 - Hermatology/Ontology for the Diablo Service Area of Kaiser
960577 - Permanente Medical Group, reported in the Spring 2002
960578 - edition of Member News, reviewed on 020321? ref SDS 12 MK4J
960580 - ..
960581 - What treatment regimen has Kaiser adopted for IBC?
960583 - ..
960584 - How does this differ from the regimen found in research
960585 - today, per above? ref SDS 0 JK94
960587 - ..
960588 - What results has Kaiser achieved treating IBC?
960589 -
960590 - How many patients who contracted IBC 5 years ago are
960591 - still surviving?
960592 -
960594 - ..
960595 - 8. Should Kaiser consult and/or refer the patient to other
960596 - "experts" and/or to a Cancer Center for diagnosis and targeted
960597 - treatment plans, based on diagnosis today of IBC? see above.
960598 - ref SDS 0 YN3L
960600 - ..
960601 - On 040318 the doctor cited working relationships with
960602 - Cancer Centers and Stanford and at Cal. ref SDS 65 AW6M
960604 - ..
960605 - 9. Is the treatment currently prescribed the best course?
960606 -
960607 - How does the current treatment of low dose of Taxol given 3
960608 - times a week in combination with Avastin given 2 times a week,
960609 - correlate with research today citing a research treatment using
960610 - a high dose of chemothearpy? ref SDS 0 JK94
960612 - ..
960613 - What treatment options are available under the record in this
960614 - case? ref SDS 0 JK6J
960615 -
960617 - ..
960618 - 10. What criteria will be used to monitor progress?
960620 - ..
960621 - 11. What other steps will be tried in the event of poor progress?
960622 -
960623 -
960624 -
960625 -
9607 -
SUBJECTS
Work Plan to Treat IBC
9703 -
970401 - ..
970402 - Work Plan to Aggressively Treat IBC
970403 -
970404 - Pending issues, listed above, ref SDS 0 S79G, can be addressed with
970405 - Work Plan to perform following tasks...
970406 -
970407 - [On 040610 planning submitted to the doctor to prepare
970408 - for meeting on 040614 reviewing diagnosis and treatment.
970409 - ref SDS 88 OA4P
970410 -
970411 - 1. Assignments.
970412 -
970413 - Kaiser's team care practice marshal resources of doctors,
970414 - staff, equipment and consultants to immediately address pending
970415 - issues under the doctor's leadership. ref SDS 0 S79G
970417 - ..
970418 - What skills are needed and who is available with experience
970419 - treating IBC?
970421 - ..
970422 - Can Tumor Board members contribute to review the record and
970423 - perform analysis?
970425 - ..
970426 - 2. Verify diagnosis of IBC.
970427 -
970428 - At this time all that has been submitted is a pathology report.
970429 - ref SDS 0 7D6F
970431 - ..
970432 - Diagnosis should be formalized to state whether IBC is being
970433 - treated, or that this is a false alarm, and that the current
970434 - treatment is adequate.
970435 -
970436 - [On 040614 the doctor advised that the pathology handed
970437 - to the patient today is the only formal notice of diagnosis
970438 - on IBC that Kaiser provides to the patient. ref SDS 89 HE6H
970440 - ..
970441 - 3. Testing with CT, PET and biopsy to determine scope of problem,
970442 - and that positive response is or is not occurring under current
970443 - treatment regimen using Taxol and the Avastin trial.
970445 - ..
970446 - There is now a history of 2 cycles. Is this sufficient to
970447 - assess whether a low dose of Taxol combined with the Avastin
970448 - trial drug should be continued, or switched to treat for IBC?
970450 - ..
970451 - 4. Review by Tumor Board to support doctor and patient partnership
970452 - by addressing pending issues. ref SDS 0 S79G
970454 - ..
970455 - Validate diagnosis and treatment plan.
970457 - ..
970458 - Establish criteria for determining when to change the
970459 - treatment.
970461 - ..
970462 - 5. Cancer Center review to validate treatment plan or recommend
970463 - alternate course based on broader experience with IBC.
970464 -
970465 -
970466 -
970467 -
970468 -
970469 -
970470 -
9705 -
SUBJECTS
IBC Diagnosis Treatment Lessons Learned Patient History Improve Medi
A603 -
A60401 - ..
A60402 - Lessons Learned to Improve Medical Practice and Research
A60403 -
A60404 - Often there is a tendency to say that if the patient comes through no
A60405 - harm no foul, so don't bother to check the record for improving tools
A60406 - and practice. Two (2) case histories may yield lessons learned that
A60407 - strengthen the doctor patient partnership for diagnosis and treatment
A60408 - of a lump under the arm, ref SDS 0 SU7G, and recognizing IBC from
A60409 - emerging symptoms. ref SDS 0 S66O This analysis supports review of
A60410 - Kaiser Papers on 020221, ref SDS 6 EG4K, including Knowledge
A60411 - Management dilemma that successful care increases demands for still
A60412 - better care to treat rare medical problems that occur in an aging
A60413 - population, ref SDS 6 Y27F, also, cited above on challenges of quality
A60414 - care. ref SDS 0 SU7G
A60415 -
A60416 - [On 041019 additional lessons learned from 2nd opinion
A60417 - process by Stanford. ref SDS 97 TX4K
A60419 - ..
A60420 - [On 041019 request review by Stanford. ref SDS 97 U369
A60422 - ..
A60423 - [On 060809 case study evaluate Kaiser reputation medical
A60424 - mistakes lessons learned improve health care. ref SDS D3 K65K
A60426 - ..
A60427 - Lesson learned need review to improve health care...
A60429 - ..
A60430 - 1. Can doctor's expertise be further leveraged to save lives,
A60431 - time, money by implementing Kaiser's requirements in the
A60432 - Healthwise Handbook on maintaining patient history in the
A60433 - Medical Chart with an intelligence support role to strengthen
A60434 - analysis in test reporting so that trends and conflicts are
A60435 - more readily apparent, similar to reporting for CA 15-3, per
A60436 - example above? ref SDS 0 087J
A60438 - ..
A60439 - One technique easily implemented with current technology is a
A60440 - simple spreadsheet uniquely identifying each swelled lymph
A60441 - node, or other "mass" that is of potential concern, including
A60442 - "scar tissue," and track the size over time in constant units,
A60443 - i.e., millimeters, or centimeters so that trends are readily
A60444 - apparent.
A60446 - ..
A60447 - Can CAD technology provide a 3-dimensional construct of the
A60448 - body showing location and size of nodes, with ability to zoom
A60449 - and and out, and supplemented with a spreadsheet that shows
A60450 - numerical trend analysis, supplemented by narrative comments of
A60451 - the doctor who reviews scans? Multiple sources provide cross
A60452 - checks to avoid mistakes.
A60454 - ..
A60455 - Blood and other tests should do the same.
A60457 - ..
A60458 - On 020726 the doctor reported that trend analysis on CA 15-3
A60459 - was helpful in deciding to switch chemotherapy drugs, and to
A60460 - submit the case to the Tumor Board for supplemental review.
A60461 - ref SDS 0 SU9W
A60463 - ..
A60464 - 2. Reading test reports with multiple findings doctors do not have
A60465 - enough time to correlate clinically with complex patient
A60466 - history, and so rely on first impressions getting the gist of
A60467 - problems from reading only the "Impression" summary; case study
A60468 - on 040416 shows pathology reports for medical tests vary widely
A60469 - in quality, detail, and thoroughness of analysis, including
A60470 - omitting comparisons, and further describe the same issue with
A60471 - different terminology, which greatly increases the risk that a
A60472 - busy doctor will overlook critical trends for diagnosis
A60473 - requiring timely treatment. ref SDS 72 PTSX
A60474 -
A60475 - [On 040812 the doctor said that medical tests are not
A60476 - examined with precision used in engineering to reconcile
A60477 - differences and conflicts in reports. The doctor said
A60478 - that doctors do not have enough time to review conflcits in
A60479 - test reports. The primary care physician who visits
A60480 - directly with patients expects the specialists who prepare
A60481 - reports to reconcile differences. ref SDS 92 T761
A60483 - ..
A60484 - [On 060428octor did not have enough time to read PET scan
A60485 - test findings of "likely esophagitis." ref SDS C4 PR9J
A60487 - ..
A60488 - [On 060428 read medical test findings - case study doctors
A60489 - limited time prevents reading findings to correlate
A60490 - clinically for discovering symptomatic trends that enable
A60491 - proactive case management; there is only enough time to
A60492 - read summaries that present the gist of findings.
A60493 - ref SDS C5 VG5L
A60495 - ..
A60496 - [On 061020 doctor did not have enough time to read findings
A60497 - of enlarged right ventricle in CT test that complicated
A60498 - diagnosis of pulmonary embolism. ref SDS D6 3Z9N
A60500 - ..
A60501 - 3. Does the record showing clinical examination and CT testing did
A60502 - not diagnose cancer, suggest greater reliance on biopsy and PET
A60503 - scan to meet requirements for treating IBC, especially with
A60504 - elevated CA 15-3. ref SDS 0 VH5J Does the record of
A60505 - conflicting format, structure, variance in language,
A60506 - terminology and descriptions, e.g., on 030508, ref SDS 53 VM7W,
A60507 - and disparities in comparison figures and analysis, illustrated
A60508 - by the record on 040416 suggest skeptical reliance on CT tests
A60509 - pending improvements? ref SDS 72 PTSX and ref SDS 72 GO8J
A60510 -
A60511 - [On 040811 CT test on 040710 does not account for another 2
A60512 - lymph nodes. ref SDS 91 WW6N
A60514 - ..
A60515 - [On 060428 PET scan test language unclear reporting patient
A60516 - history. ref SDS C4 634G
A60518 - ..
A60519 - 4. Does the record in this case suggest refinements to criteria
A60520 - for diagnosis of inflammatory breast cancer? ref SDS 0 2F4G
A60521 - Should this record be submitted to a board or other body that
A60522 - reviews case histories to determine diagnosis criteria, for
A60523 - example on the meaning of "persistent" redness and skin
A60524 - thickening? What additional guidance can be offered to help
A60525 - doctors commence treatment in time to be effective?
A60527 - ..
A60528 - 5. Can diagnosis be aided by listing on the wall of a patient
A60529 - examination room common symptoms for high risk cancers, like
A60530 - inflammatory breast cancer (IBC) that occurs rarely, but
A60531 - spreads quickly, so there is less time to recover from
A60532 - oversight?
A60534 - ..
A60535 - 6. Can diagnosis of high risk cancer be aided by obtaining a
A60536 - biopsy early, when symptoms are only preliminary, as in this
A60537 - case on 030109, later on 030606, on 030710, and on 040318,
A60538 - where the meaning of "persistent" might be uncertain to a busy
A60539 - doctor?
A60541 - ..
A60542 - 7. Does Kaiser have a research department where a case history of
A60543 - organizational memory can be used for teaching and professional
A60544 - events?
A60545 -
A60546 - a. Lump under arm case study............. ref SDS 0 OW3I
A60547 -
A60548 - b. Redness thickened skin
A60549 - case study............................ ref SDS 0 S66O
A60551 - ..
A60552 - 8. Does the patient's good fortune to overcome average survival of
A60553 - 18 months, suggest grounds for researchers to investigate
A60554 - factors of genetics, life-style, diet, exercise, etc., that may
A60555 - yield guidance for helping other patients, based on the record
A60556 - that initial symptoms of IBC were first noticed on 030109?
A60557 - ref SDS 0 2F4G
A60559 - ..
A60560 - 9. Does Kaiser liaison with teaching institutions to improve
A60561 - quality of care through case history to educate doctors and
A60562 - staff with continual learning, called out in management
A60563 - standards, reviewed on 950721? ref SDS 1 2846
A60565 - ..
A60566 - 10. Does the record in this case present opportunities for
A60567 - improving the doctor patient partnership that enables better
A60568 - care for patients and less stress on doctors, reviewed on
A60569 - 990625? ref SDS 3 4185
A60571 - ..
A60572 - 11. The Walnut Creek Kaiser clinic has a computer room on the
A60573 - ground floor; does this present a way to educate patients about
A60574 - IBC scenarios, and about communication methods that can assist
A60575 - doctors in treating patients?
A60577 - ..
A60578 - 12. Should the record in this case be provided on the Internet for
A60579 - patients and physicians to learn about IBC scenarios, and
A60580 - methods for improving communication.
A60582 - ..
A60583 - 13. Could there have been a better chance of earlier diagnosis with
A60584 - consequent increased chances for successful treatment and
A60585 - longer survival, by using the "ping pong" communication method
A60586 - recommended by Kaiser's Healthwise Handbook, reviewed on
A60587 - 990625, calling for doctors to review the patient's record of
A60588 - meetings in order to clarify understandings, refine accuracy of
A60589 - meaning and be reminded of pending action items? ref SDS 3 3190
A60591 - ..
A60592 - 14. Can Communication Metrics strengthen the professional quality
A60593 - of Tumor Board work product, by enabling more thorough review
A60594 - and findings linked to the original record and to published
A60595 - standards, while building a knowledge library that aids
A60596 - deliberations for diagnosis and treatment recommendations,
A60597 - which meaningfully assist decision making by the doctor and
A60598 - patient partnership?
A60600 - ..
A60601 - 15. How can Communication Metrics using SDS be modified to better
A60602 - serve the doctor patient partnership under Kaiser's team care
A60603 - concept?
A60605 - ..
A60606 - 16. How can the power of Communication Metrics to "connect the
A60607 - dots" be implemented to better support medical research and
A60608 - patient care?
A60610 - ..
A60611 - 17. How can Kaiser gain more experience to assess value added of
A60612 - Communication Metrics and refine implementation to meet
A60613 - management, administrative and medical care needs?
A60615 - ..
A60616 - 18. Does the impending explosion of new patients over the next 10
A60617 - years require technology that augments intelligence to improve
A60618 - personal and organizational memory, which can only be solved by
A60619 - integrating new skills, new technology and leadership with a
A60620 - broader vision, as set out in NWO? ref OF 32 4305
A60621 -
A60622 -
A60623 -
A60624 -
A60625 -
A60626 -
A60627 -
A60628 -
A60629 -
A607 -
SUBJECTS
Tumor Board Minutes 2nd Hearing Verify Scope of Problem and Treatmen
2nd Opinion Metastatic Cancer Treatment Chemotherapy New Trial Drug
600 Dollars Patients Must Pay for 2nd Opinion Metastatic Cancer Trea
Tumor Board Minutes Lost 1st Hearing Millie's Case Doctor Cannot Fin
AT06 -
AT0701 - ..
AT0702 - Complex Patient History Lucky to Find Record of Tumor Board Hearing
AT0703 - Lucky to Find Tumor Board Minutes File Cursory Analysis
AT0704 - 2nd Opinion Verify Scope of Problem and Treatment Planning
AT0705 - Tumor Board Cursory Report Lesson Learned Deminimus 2nd Opinion
AT0706 -
AT0707 - Follow up ref SDS 72 AW6M, ref SDS 65 AW6M.
AT0708 -
AT0709 - On 040409 Millie's letter requested a 2nd opinion. ref SDS 67 HS3O
AT0710 - Debra called later that day, and explained that Kaiser offers review
AT0711 - by a Tumor Board to support objectives for a 2nd opinion to guide the
AT0712 - doctor and patient partnership in deciding on treatment. ref SDS 67
AT0713 - 7K4G At that time, Millie agreed to get input from the Tumor Board.
AT0715 - ..
AT0716 - On 040416 the doctor reported having met with the Tumor Board, and
AT0717 - that there was discussion of radiation to complement chemotherapy
AT0718 - treatments. At that time, Millie requested a copy of the report on
AT0719 - the Tumor Board's work and recommendations. ref SDS 72 OI5F
AT0721 - ..
AT0722 - The doctor came into the examination room today and submitted two (2)
AT0723 - pieces of paper that have a title...
AT0724 -
AT0725 - Tumor Board Minutes
AT0727 - ..
AT0728 - The doctor said that Millie's patient history is getting pretty
AT0729 - complex, cited previously on 020726. ref SDS 41 MO37 He feels it was
AT0730 - lucky to find files on Kaiser's' computer for the Tumor Board Minutes
AT0731 - submitted today. The doctor explained that finding information in
AT0732 - Kaiser's Knowledge Base is not fast and easy, so he was pleased to be
AT0733 - able to submit the report today.
AT0734 -
AT0735 - [On 041222 the radiologist reported that tumor board hearings are
AT0736 - conducted by conversation, with no written records at Mt Diablo
AT0737 - hospital, and that this is typical for industry work product on
AT0738 - tumor board activities. ref SDS A3 E55G
AT0740 - ..
AT0741 - [On 061020 primary care physician feels patient profile has
AT0742 - too many issues for a 5-year medical case of secondary
AT0743 - inflammatory breast cancer (IBC), cellulitus, lymphedema,
AT0744 - pulmonary embolism, broken finger. ref SDS B8 MO4K
AT0746 - ..
AT0747 - This aligns with the doctor's report on 020726 that results of the
AT0748 - Tumor Board meeting on Millie's case could not be found, ref SDS 41
AT0749 - WF42, and were never submitted to the patient. Similarly, the date
AT0750 - when radiation treatments began could not be found at that time,
AT0751 - ref SDS 41 4Y5I, and later on 030109 the doctor could not find the
AT0752 - date when radiation treatments ended to analyse and diagnose cancer
AT0753 - relapse. ref SDS 50 GK51
AT0754 -
AT0755 - Will the new knowledge management system, demonstrated by the
AT0756 - doctor on 040504, ref SDS 80 HP57, put the patient medical chart in
AT0757 - a computer file to make it fast and easy for the doctor to find
AT0758 - relevant information when needed?
AT0760 - ..
AT0761 - Millie reported this problem at work on 960406. ref SDS 2 5922
AT0763 - ..
AT0764 - The first page of the Tumor Board minutes received today lists the
AT0765 - names of about 10 people. We need this document to complete the
AT0766 - record.
AT0768 - ..
AT0769 - The second page of the "minutes" received today says....
AT0771 - ..
AT0772 - Page 2 RE: TUMOR BOARD MINUTES FIRDAY APRIL 16, 2004
AT0774 - ..
AT0777 - ..
AT0778 - Case presented by [the doctor]. The patient is a 68 year-old
AT0779 - female with diagnosis of metastatic breast cancer who is requesting
AT0780 - a clinical trial using Taxol and Avastin.
AT0782 - ..
AT0783 - There is no evidence that members of the Tumor Board had read even a
AT0784 - summary of patient history, nor any of recent history on IBC.
AT0785 - ref SDS 0 S66O
AT0786 -
AT0787 -
AT0788 -
AT0789 -
AT0790 -
AT08 -
SUBJECTS
Tumor Board Surgery Proposed Before Irradiation Left Neck Tumor Boar
Tumor Board Report Requires Support Showing What was Reviewed Poor Q
CA 15-3 Key Criteria Patient Progress Reviewed by Tumor Board
Surgery Proposed by Tumor Board Recommends Left Neck Irradiation Pos
BD06 -
BD0701 - ..
BD0702 - Tumor Board Report Requires Support Showing What was Reviewed
BD0703 - CA 15-3 Key Criteria Patient Progress Reviewed by Tumor Board
BD0704 - Surgery Proposed by Tumor Board to Remove Lymph Nodes If Necessary
BD0705 - Radiation Left Neck Post-surgery Recommended by Tumor Board
BD0706 -
BD0708 - ..
BD0709 - "Minutes" of Tumor Board hearing received from the doctor today
BD0710 - continue...
BD0711 -
BD0712 - In March of 2002 she presented with a T1, N2 breast cancer was
BD0713 - treated with two cycles of AC followed by taxotere. She was
BD0714 - switched because there appeared to be a delayed response to therapy
BD0715 - and there was a rise in the CA 15-3 titer. Post chemotherapy she
BD0716 - went to a low of 33 on her CA 15-3 titer. She received radiation
BD0717 - therapy to the breast, axillary apex and supraclavicular ofssa.
BD0718 - Most recently she has developed new left cervical lymph node
BD0719 - reoccurrence.
BD0721 - ..
BD0722 - On 030508 the doctor reviewed guidelines published by ASCO that
BD0723 - says CA 15-3 is not recommended for assessing progress of cancer.
BD0724 - ref SDS 53 M28G
BD0725 -
BD0726 - [On 050812 patient history prepared for 2nd opinion. ref SDS B9
BD0727 - UF4J
BD0728 -
BD0730 - ..
BD0731 - Tumor Board Re-hearing Consider New Evidence Deferred
BD0732 -
BD0733 - The doctor advised that the Tumor Board did not consider findings in
BD0734 - the pathology report on IBC, submitted today, per above, ref SDS 0
BD0735 - 6T5G, because the hearing on 040416 occurred a few days prior to the
BD0736 - biopsy taken on 040419, and at a time the red inflammed breast
BD0737 - condition was diagnosed as Cellulitis, which is unrelated to cancer,
BD0738 - reported on 040318. ref SDS 65 IM6J
BD0740 - ..
BD0741 - Millie asked about a re-hearing to consider new data in the biopsy
BD0742 - report? Can the Tumor Board help develop strategy for treatment of
BD0743 - major change in patient profile?
BD0745 - ..
BD0746 - The doctor indicated re-submission of the case in order for the Tumor
BD0747 - Board to consider the biopsy report showing IBC, which was released
BD0748 - after the date of the original hearing, is not required because the
BD0749 - surgeon reviewed the pathology report with the patient on 040429, and
BD0750 - the doctor discussed it with the patient on 040504. ref SDS 79 VN7N
BD0752 - ..
BD0753 - Millie asked about presenting understandings by the surgeon and the
BD0754 - primary care physician to the Tumor Board for additional support and
BD0755 - refining ideas on treatment strategy and planning?
BD0757 - ..
BD0758 - The doctor feels this should be deferred until the next meeting. He
BD0759 - was not scheduled for the meeting today, and so has very limited time,
BD0760 - as related at the start of the meeting, per above. ref SDS 0 X177
BD0761 -
BD0762 - [On 040614 the doctor proposed not asking Tumor Board to revise
BD0763 - findings and recommendations based on evidence available prior to
BD0764 - the hearing on 040419, but not submitted, and then confirmed by a
BD0765 - new diagnosis of IBC, until after a few months to assess response
BD0766 - to treatment on the Avastin and Taxol chemothrapy trial protocol.
BD0767 - ref SDS 89 4R59
BD0769 - ..
BD0770 - Tumor Board "minutes" continue...
BD0771 -
BD0772 - Discussion was held and the prior scans were reviewed. The patient
BD0773 - has been placed on a clinical trial.
BD0775 - ..
BD0776 - The question is should she get the left neck irradiation. This
BD0777 - could be done post surgery.
BD0779 - ..
BD0780 - This part of Tumor Board minutes appear to support "surgery" planned
BD0781 - on 040429, ref SDS 78 SD7F, and supported by the doctor on 040504.
BD0782 - ref SDS 79 MG8G Planning in the Board's report to give radiation
BD0783 - treatment to the left neck reflects understandings at the time of the
BD0784 - hearing that cancer had relapsed in the neck, based on the biopsy
BD0785 - taken on 040303, and reported on 040309, noted by the doctor during
BD0786 - the meeting on 040416, and which is another symptom of IBC, reported
BD0787 - today, ref SDS 0 N23J, adding to prior findings which were confirmed
BD0788 - by the biopsy taken 040419 that diagnosed IBC. ref SDS 0 7D6F
BD0789 -
BD0790 - [On 040812 doctor indicates surgery may not be appropriate
BD0791 - treatment for IBC in Millie's case, further compounding dilimma
BD0792 - presented to the patient on 040614. ref SDS 92 T75L
BD0794 - ..
BD0795 - [On 041130 patient requests Tumor Board review following major
BD0796 - change in the case. ref SDS A0 YR8F
BD0798 - ..
BD0799 - [On 041210 doctor proposes surgery to treat IBC; case study
BD0800 - reviews history considering surgery for Millie. ref SDS A2 ZV5J
BD0802 - ..
BD0803 - [On 041222 meeting with the doctor at Mt Diablo hospital
BD0804 - radialogy clinic has no plans for radiation treatments, unless
BD0805 - there is further surgery. ref SDS A3 8F6O
BD0807 - ..
BD0808 - [On 050324 surgeon to recommend follow up Tumor Board review
BD0809 - for establishing criteria to perform surgery on recoverying
BD0810 - from IBC. ref SDS A9 O85O
BD0812 - ..
BD0813 - [On 051021 surgery left mastectomy wide area to treat IBC,
BD0814 - ref SDS C0 EG5L, IAW planning in Tumor Board report 040416,
BD0815 - received 040517, per above, ref SDS 0 VH7H
BD0817 - ..
BD0818 - [On 060428 post surgery PET scan test shows FDG SUV 4.5 left
BD0819 - supraclavicular, ref SDS C4 OX68, clinical examination finds no
BD0820 - swelled lymph nodes; no patient complaint; contrast CT test
BD0821 - ordered. ref SDS C4 8R6M
BD0822 -
BD0823 -
BD0825 - ..
BD0826 - Tumor Board minutes continue...
BD0827 -
BD0828 - It was felt if there was no response to chemotherapy then the
BD0829 - patient might have a removal of all the lymph nodes involved.
BD0831 - ..
BD0832 - [On 040601 good news -- Millie indicates the lumps in the neck
BD0833 - seem to have gotten smaller, even disappeared. ref SDS 84 DJ9N
BD0835 - ..
BD0836 - The Board's discussion that lack of response to chemotherapy might
BD0837 - lead to treatment with surgery to remove lymph nodes, follows up
BD0838 - review with the doctor on 040318, ref SDS 65 HC5N, explaining that
BD0839 - metastatic cancer is more conducive to treatment with drugs,
BD0840 - ref SDS 65 HC6K, and citing prior discussion with Doctor Laio on
BD0841 - 040309. ref SDS 64 HD5N
BD0842 -
BD0843 -
BD0844 -
BD0845 -
BD09 -
SUBJECTS
Tumor Board New Information IBC Diagnosis Follow Up Review Address I
Tumor Board Procedures Patient Support Doctor Patient Partnership Su
2nd Opinion Verify Scope of Problem and Treatment Planning Tumor Boa
BI05 -
BI0601 - ..
BI0602 - Tumor Board Follow Up Review Address New Information
BI0603 -
BI0604 - Additional issues flowing from the Tumor Board report that require
BI0605 - review and comment....
BI0606 -
BI0607 - [On 040610 planning submitted to the doctor to prepare
BI0608 - for meeting on 040614 reviewing diagnosis and treatment.
BI0609 - ref SDS 88 OA4P
BI0610 -
BI0611 - 1. Tumor Board procedures...
BI0612 -
BI0613 - a. Where are procedures that guide work by the Tumor Board and
BI0614 - how are procedures conveyed to the patient in time to
BI0615 - support proceedings?
BI0617 - ..
BI0618 - On 040416 this information was requested, but has not yet
BI0619 - been submitted. ref SDS 72 OI5F How can this be followed
BI0620 - up in time for the next hearing?
BI0621 -
BI0622 - [On 041222 the radiologist explained common tumor board
BI0623 - procedures, ref SDS A3 VA7I; for example, hearings are
BI0624 - conducted by conversation, with no written records at
BI0625 - Mt Diablo hospital, and this is typical for industry
BI0626 - work product on tumor board activities. ref SDS A3 E55G
BI0628 - ..
BI0629 - b. How does the patient support the work of the Tumor Board
BI0630 - under Kaiser's team care concept for doctor patient
BI0631 - partnership to optimize quality of care, reviewed on
BI0632 - 990625? ref SDS 3 4185
BI0634 - ..
BI0635 - c. How is the Board constituted and who speaks for the Board;
BI0636 - is there a chairman, is someone designated as the lead
BI0637 - subject matter expert (SME) for each case?
BI0639 - ..
BI0640 - d. Who prepares the record of proceedings? Does the Tumor
BI0641 - Board have an administrator? Does each member of the board
BI0642 - sign off on the report?
BI0644 - ..
BI0645 - e. How are dissents or alternate opinions recorded?
BI0647 - ..
BI0648 - f. How is the Board's analysis connected to the record to show
BI0649 - alignment, and how are recommendations linked to authority
BI0650 - and case history that can be checked for relevance and
BI0651 - accuracy to avoid mistakes?
BI0653 - ..
BI0654 - g. Who reviews the record to ensure professional work, e.g.,
BI0655 - coherence, accuracy, completeness, effectiveness in helping
BI0656 - the doctor and the patient determine the best course of
BI0657 - action?
BI0659 - ..
BI0660 - h. What follow up occurs by the Board to implement ideas and
BI0661 - recommendations, and to make appropriate adjustments to
BI0662 - treatment recommendations when new information shows the
BI0663 - initial course of action set by the Board was incorrect or
BI0664 - incomplete, based on the record at Enron showing the Board
BI0665 - of Directors issued a lot of directions, but had no
BI0666 - mechanism to follow up, reported on 020204? ref SDS 4 KM4F
BI0668 - ..
BI0669 - i. How are findings incorporated into Kaiser's lessons learned
BI0670 - for continuous learning and professional improvement?
BI0672 - ..
BI0673 - 2. What did the Board find is the scope of problems the patient
BI0674 - confronts, and based on what evidence, e.g., were "scans" the
BI0675 - only part of the medical chart reviewed?
BI0677 - ..
BI0678 - 3. What findings were made by the Tumor Board from "prior scans,"
BI0679 - noted in the report? ref SDS 0 F77M
BI0681 - ..
BI0682 - Did the Board successfully resolve the apparent mixup in CT
BI0683 - scan reports reviewed with the doctor on 040318?
BI0684 - ref SDS 65 ZE5O
BI0686 - ..
BI0687 - Did the Board conclude that the CT test received by the patient
BI0688 - on 040416 that is marked "...not finalized," is actually the
BI0689 - final version, as reported today, shown below? ref SDS 0 LK5L
BI0691 - ..
BI0692 - 4. Was trend analysis used on scan results, blood work and other
BI0693 - diagnostics, similar to CA 15-3 reported in this record shown
BI0694 - above? ref SDS 0 087J
BI0696 - ..
BI0697 - 5. How were "scans" interpreted in relation to clinical
BI0698 - observations, patient symptoms, diagnosis, treatments and
BI0699 - response reported in the medical chart, and summarized above.
BI0700 - ref SDS 0 2F4G
BI0702 - ..
BI0703 - 6. How does diagnosis of inflammatory carcinoma of the left breast
BI0704 - (IBC) shown in the pathology report for a biopsy taken on
BI0705 - 040419, following the Board's meeting on 040416, and received
BI0706 - today by the patient, per above, ref SDS 0 7D6F, influence
BI0707 - treatment planning in the Board's "minutes," ref SDS 0 F77M,
BI0708 - based on the doctor's report today that these symptoms were not
BI0709 - presented to the Board, per above, ref SDS 0 K48O How does the
BI0710 - pathology report impact participation in the clinical trial
BI0711 - that calls for a low dose of Taxol chemotherapy, reported on
BI0712 - 040318, ref SDS 65 VJ46, which appears to conflict with a
BI0713 - common regimen that calls for a high dose of chemotherapy using
BI0714 - other drugs, shown by research listed above? (see pending
BI0715 - action items) ref SDS 0 JK94
BI0717 - ..
BI0718 - 7. How does the bone scan test performed on 040429, reported
BI0719 - above, ref SDS 0 L34N, impact pathology, diagnosis and
BI0720 - treatment recommendations by the Board?
BI0721 -
BI0722 -
BI0723 -
BI0724 -
BI0725 -
BI0726 -
BI0727 -
BI08 -
SUBJECTS
Metastasis New Nonspecific May be Post Treatment Trauma Inflammatory Ch
PET Scan Findings Show Previous Metastatic Lymphadenopathy No Longer Ac
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 Test Final Version Marked Addendum Pending To Be Finalized Mistak
CT Test Analysis on 040416 Finding Cancer Metastasis Limited to Neck
BT09 -
BT1001 - ..
BT1002 - Cancer Neck Only Evidence of CT Scan Shows Distant Metastasis
BT1003 - CT Scan Shows Evidence of Distant Metastasis Carcinoma Only in the N
BT1004 -
BT1005 - Follow up ref SDS 72 LK5L, ref SDS 67 LK5L.
BT1006 -
BT1007 - Millie asked the doctor for the final version of the CT test
BT1008 - report submitted on 040416, ref SDS 72 HX4K, and which is marked "not
BT1009 - finalized." ref SDS 72 EG57
BT1011 - ..
BT1012 - The doctor looked on Kaiser's computer and printed a report. He
BT1013 - left the examination room and retrieve the CT test report from the
BT1014 - printer located in the common area at the front of the clinic.
BT1016 - ..
BT1017 - The doctor submitted another copy of the same report received on
BT1018 - 040416. The doctor advised that the bold notice printed multiple
BT1019 - times throughout the report saying....
BT1020 -
BT1021 - ** A D D E N D U M E X I S T S B U T N O T F I N A L I Z E D**
BT1023 - ..
BT1024 - ...is a mistake, because the report is actually finalized, but someone
BT1025 - forgot to publish a version without the notice.
BT1027 - ..
BT1028 - This resolves the action item in the record on 040416. ref SDS 72 WE92
BT1029 -
BT1030 -
BT1032 - ..
BT1033 - Distant Metastasis Cancer Neck Only Evidence of CT Scan Shows
BT1034 -
BT1035 - Follow up ref SDS 72 WE7N, ref SDS 67 ZE5O.
BT1036 -
BT1037 - Inflammatory breast cancer (IBC) diagnosed in the pathology report
BT1038 - today amends analysis on 040416 that cancer recurrence is limited to
BT1039 - the neck. ref SDS 72 WE7N
BT1040 -
BT1041 -
BT1042 -
BT1043 -
BT1044 -
BT1045 -
BT1046 -
BT1047 -
BT11 -
SUBJECTS
Blood Tests Painful Conditions Requires Higher Skilled Technician to
Port for New Treatments Administered Intravenously Avoids Pain and D
Port Will Provide Partial Releif from Excessive Needle Insertions in
C005 -
C00601 - ..
C00602 - Port Catheter Working Well Solves Prior Problems Using Needles
C00603 -
C00604 - Follow up ref SDS 70 CO3G, ref SDS 65 CO3G.
C00605 -
C00606 - Millie reported that the port catheter installed on 040419 has worked
C00607 - well, beginning on 040427, ref SDS 76 0001, to prevent prior trauma
C00608 - from excessive use of needles for drawing blood and administering
C00609 - chemotherapy infusion treatments.
C00610 -
C00611 - [On 040518 Millie schedules the chemotherapy clinic to draw blood
C00612 - for the Avastin trial using the port catheter, after a big welt
C00613 - occurs from having blood drawn using conventional needle methods in
C00614 - the Kaiser Lab. ref SDS 82 Q65L
C00616 - ..
C00617 - [On 040518 Mary needed three (3) tries to connect the infusion
C00618 - tubing to the port catheter. ref SDS 82 EB7J
C00619 -
C00620 -
C00621 -
C00622 -
C00623 -
C007 -
SUBJECTS
Disability Leave to be Extended Due to Complications of Cancer Submi
C103 -
C10401 - ..
C10402 - Disability Sick Leave Extended Due to Complications of Recurrence
C10403 -
C10404 - There was discussion about the effect of new diagnosis that identifies
C10405 - inflammatory breast cancer (IBC) reported today, ref SDS 0 7D6F, and
C10406 - consequent uncertainties about treatment and progress of disease.
C10408 - ..
C10409 - The doctor indicated a return to work should be delayed until
C10410 - there is more knowledge showing recovery is underway, and that will
C10411 - likely occur after mastectomy surgery, which will decided in a few
C10412 - months. The doctor asked Millie to request that the Kaiser Business
C10413 - Office prepare documents that extend sick leave until September, and
C10414 - these will be submitted to him for signature.
C10415 -
C10416 -
C10417 -
C10418 -
C10419 -
C10420 -
C10421 -
C10422 -
C10423 -
C10424 -
C105 -