CONTACTS 
0201 - University of California San Franci
020101 - Ms. Sheridan L. Tinker
020102 - New Patient Coordinator
020104 - Admissions

SUBJECTS
UCSF Meeting Doctor Benz 2nd Opinion
2nd Opinion UCSF Received on Millie's Condition Treatment Plans and
Surgery No Role Metastatic Surgery Doctor Benz Recommends Systemic C

0505 -
0505 -    ..
0506 - Summary/Objective
0507 -
050701 - Follow up ref SDS 28 0000. ref SDS 27 0000.
050702 -
050703 -
050704 -
050706 -  ..
050707 - Analyse Doctor Benz report, submit feedback to UCSF with corrections.
050708 -
050709 -            [On 041201 Kaiser proposes participating in a new trial
050710 -            that includes capecitabine. ref SDS 31 4P9L
050711 -
050712 -            [On 050819 submit request for 2nd opinion #2. ref SDS 46
050713 -            0001
050715 -             ..
050716 -            [On 050823 UCSF responded with referral to surgeons in
050717 -            Berkeley. ref SDS 47 AI8N
050719 -             ..
050720 -            [On 060725 submit request fo 2nd opinion #3. ref SDS 60
050721 -            YK6N
050723 -             ..
050724 -            [On 060809 schedule meeting at UCSF for 2nd opinion #3.
050725 -            ref SDS 62 0001
050727 -             ..
050728 -            [On 060821 meeting at UCSF Doctor Benz for 2nd opinion #3.
050729 -            ref SDS 63 0001
050731 -             ..
050732 -            [On 060929 receive 2nd opinion #3 from Doctor Benz at UCSF,
050733 -            during meeting at Kaiser. ref SDS 65 025H
050734 -
050735 -
050736 -
050737 -
050738 -
050740 -  ..
0508 -
0509 -
0510 - Progress
0511 -
051101 - Doctor Benz Submits 2nd Opinion from UCSF on Millie's Treatment
051102 -
051103 - Follow up ref SDS 28 6L9O, ref SDS 27 FV6I.
051104 -
051105 - Received ref DRT 2 0001 from Sheridan to Millie and responding to
051106 - Millie's request yesterday, ref DIP 6 0001, for the computer file on
051107 - the 2nd opinion issued by Doctor Benz.
051109 -  ..
051110 - Sheridan says...
051111 -
051112 -        Millie,
051113 -
051114 -        I was able to copy from the University system, but there is no
051115 -        program that allows for this to happen gracefully.  The text,
051116 -        therefore is often not spaced properly, to which I extend my
051117 -        apologies.  The report is quite long and I do not have the
051118 -        facilities to repair it.  See below attachment. ref DRT 2 0001
051120 -  ..
051121 - The computer file received from Sheridan is misformatted with the left
051122 - margin corrupted, and there is no paragraphing, just 7 pages of
051123 - continuous text.  Took about 60 minutes to construct a functional
051124 - document.
051125 -
051126 -     [On 041201 ask Michael to provide computer file on 2nd opinion
051127 -     from Stanford. ref SDS 32 V76T
051129 -      ..
051130 -     [On 060929 1643 another 2nd opinion from Doctor Benz had normal
051131 -     formatting. ref SDS 66 2L8K
051133 -  ..
051134 - Millie also received in the mail, ref DRT 1 0001 from Doctor Benz,
051135 - which is a printed document addressed to...
051136 -
051138 -
051139 - ..., the primary care physician in the Oncology Department at Kaiser
051140 - in Walnut Creek.  This document is not signed, and is the 2nd opinion
051141 - from UCSF prepared by Doctor Benz.
051142 -
051143 -     [On 041209 received 2nd opinion from Stanford. ref SDS 34 KU4F
051145 -  ..
051146 - Addressing the document to the primary care physician conflicts with
051147 - instructions to UCSF on 041018, which asked that the opinion be
051148 - submitted only to Millie for distribution at her discretion.
051149 - ref SDS 22 L37J
051150 -
051151 -     [On 041209 2nd opinion from Stanford makes same mistake ignoring
051152 -     customer requirements. ref SDS 34 WY9I
051154 -  ..
051155 - Doctor Benz says in his opinion letter...
051156 -
051157 -    1.  Dear Doctor...
051158 -
051159 -        Thank you for the opportunity of providing this consultation
051160 -        and second medical oncology opinion on this 68-year-old patient
051161 -        who, in March of this year, was found to have metastatic breast
051162 -        cancer after her original primary diagnosis of stage IIB breast
051163 -        cancer made two years earlier. ref DRT 1 0001
051165 -  ..
051166 - During the meeting on 041018, Doctor Benz seemed to say that Millie's
051167 - current diagnosis of IBC a year or so after initial idanosis of stage
051168 - IIB, would today be diagnosed as stage III under UCSF policies and
051169 - practice. ref SDS 21 EO3Y  Diagnosis of stage III cancer is not
051170 - presented in the 2nd opinion received today.
051171 -
051172 -            [see below, Doctor Benz confirms notice on 041018 that
051173 -            Millie's patient history does not offer a role for surgery.
051174 -            ref SDS 0 OU4U
051176 -  ..
051177 - Doctor Benz continues...
051178 -
051179 -    2.  Her history is well known to you, but briefly, she had been
051180 -        receiving surveillance mammography on a yearly basis, but in
051181 -        the early part of 2002 she noticed a walnut-sized lesion
051182 -        developing at the 12 o'clock position of her left breast.
051183 -        Apparently a mammogram was negative, but ultrasound was
051184 -        positive and a left breast core biopsy performed of a 3 x 4 cm
051185 -        mobile node revealed a high-grade infiltrating ductal cancer
051186 -        whose biomarkers were estrogen receptor and progesterone
051187 -        receptor negative, with 0% immunostaining, HER-2/neu negative
051188 -        and with a DNA index of 1.6. ref DRT 1 IQ6H
051190 -         ..
051191 -    3.  On 03/12/2002, she had a left breast sentinel node procedure
051192 -        along with a left axillary dissection and left breast
051193 -        lumpectomy.  A 2-cm high-grade invasive ductal carcinoma with
051194 -        associated high-grade DCIS was excised, although with positive
051195 -        margins.  The sentinel node was positive, with pericapsular and
051196 -        extracapsular invasion of the breast cancer and three
051197 -        additional axillary nodes were all positive for the metastatic
051198 -        breast cancer.  There was no angiolymphatic invasion.
051199 -        ref DRT 1 IQ72
051201 -         ..
051202 -    4.  On 03/27/2004, surgical re-excision was performed to obtain
051203 -        clear margins. ref DRT 1 IQ82
051205 -  ..
051206 - Surgical re-excision was actually performed 2 years earlier on 020327,
051207 - ref SDS 8 0001, as discussed during the meeting with the doctor on
051208 - 041018. ref SDS 21 EN69
051210 -  ..
051211 - Doctor Benz continues...
051212 -
051213 -    5.  The patient was started on a course of adjuvant chemotherapy in
051214 -        late April, and this was planned to be four cycles of
051215 -        Adriamycin-Cytoxan followed by four cycles of taxane.  However,
051216 -        a CA15.3 marker performed on 05/05/2004 was noted to be
051217 -        markedly elevated at 85, upper limit of normal being 31, and
051218 -        after two cycles of Adriamycin-Cytoxan, there was no apparent
051219 -        improvement in this tumor marker.  Thus, the oncologist
051220 -        switched to Taxotere and six cycles of Taxotere treatment were
051221 -        given to conclude the adjuvant chemotherapy in early December
051222 -        of 2002. ref DRT 1 IQ84
051224 -         ..
051225 -    6.  Radiation therapy to the chest, left axilla, and periclavicular
051226 -        fossae on the left side was performed beginning on 07/08/2002.
051227 -        ref DRT 1 IQ94
051229 -         ..
051230 -    7.  The patient had other staging procedures at the time of
051231 -        diagnosis, including a bone scan which was negative, normal
051232 -        chemistry except for the CA15.3 tumor marker, normal brain MRI,
051233 -        bone scan that was repeated and showed only evidence of what
051234 -        was considered degenerative change in the L5 vertebra.
051235 -        ref DRT 1 IQ99
051237 -         ..
051238 -    8.  A CT scan performed on 04/09/2004 which showed only a small
051239 -        liver cyst and a small lung calcified granuloma, and a PET scan
051240 -        that was performed on 05/29/2004 that was suspicious for four
051241 -        focal hypermetabolic lesions persistent in the left axilla and
051242 -        consistent with metastatic nodal involvement.
051244 -         ..
051245 -    9.  The PET scan was repeated on 12/18/2002 and showed reduced
051246 -        activity in the left axillary metastasis.  However, the
051247 -        appearance of the hypermetabolic region in the apex of the left
051248 -        lung that was thought to be possibly postradiation changes and
051249 -        a suspicious eleventh rib and L5 vertebral lesion.  This second
051250 -        PET scan was at the conclusion of the adjuvant chemotherapy and
051251 -        at a time when the CA15.3 had normalized, I believe.
051252 -        ref DRT 1 IQ53
051254 -  ..
051255 - Report on PET scan test performed 021218 and received from the doctor
051256 - at Kaiser on 030109 says in part...
051257 -
051258 -            Also, new are mild diffuse increased uptakes at the region
051259 -            of the left axilla as well as the left upper chest wall
051260 -            both anteriorly and posteriorly including the left
051261 -            supraclavicular region.  No other significant finding.
051262 -            ref SDS 10 L66M
051264 -  ..
051265 - CA 15-3 cancer marker on 030109 was elevated to 37, approximately 10
051266 - points above 29, listed as "normal," at that time; this was down from
051267 - 41, a month earlier, but began a long steady rise to 78 in July 2004,
051268 - when the marker began falling under the Avastin Taxol trial.
051269 -
051271 -         ..
051272 -        IBC Rash Waxed Waned During 2003 Symptoms Misdiagnosed
051273 -
051274 -
051275 - Doctor Benz 2nd opinion continues...
051276 -
051277 -   10.  The patient noticed, within two months of going off adjuvant
051278 -        chemotherapy, that she was developing a rash on her left
051279 -        breast.  There were attempts to treat this with antibiotics,
051280 -        and the rash waxed and waned.  There was another attempt to
051281 -        treat this with steroid pills.  Again, the rash waxed and
051282 -        waned.  By late 2003, she had almost 90% of her left breast
051283 -        involved in this rash, and in early 2004, began to notice lumps
051284 -        in the posterior portion of her left neck. ref DRT 1 IQ55
051285 -
051286 -            [On 041202 Kaiser diagnoses cellulitus again.
051287 -            ref SDS 33 IP7O
051289 -             ..
051290 -            [On 061227 CA 15-3 74 significant rise, erratic change
051291 -            after slight decline following 3rd relapse, reflects IBC
051292 -            rash wax and wane; doctor reports probably represents
051293 -            progression metastatic disease. ref SDS 70 UF3I
051295 -  ..
051296 - This account conveys complexity of patient history noted by the doctor
051297 - during the meeting at UCSF on 041018. ref SDS 21 QU6F
051299 -  ..
051300 - The gist of the account by Doctor Benz aligns with patient memory
051301 - presented on 041018 discussing events 2 years earlier, and further
051302 - that Doctor Benz was unable to access the actual record of patient
051303 - history on the computer, also, reported on 041018. ref SDS 21 EN5L
051304 - Case history reported on 040517, ref SDS 16 OT5L, cites the record on
051305 - 030109 when the primary care physician made the first observance of a
051306 - slight rash on the left breast, which was treated for cellulitus.
051307 - ref SDS 10 KW5F  Months later at the end of May, the patient was
051308 - alarmed by a sudden flare up of red rash on the left breast, and so
051309 - requested an emergency meeting.  The doctor examined the problem on
051310 - 030606, and further noticed skin thickening.  Diagnosis was reaction
051311 - to radiation. ref SDS 11 7C6W  Rising discomfort from swelled lymph
051312 - nodes in the left axillary was diagnosed as scar tissue from surgery
051313 - on 020312. ref SDS 11 Y45M
051315 -  ..
051316 - Doctor Benz construction of "wax-and-wain" in the 2nd opinion
051317 - describes IBC symptoms during 2003, which were believed to deserve
051318 - minimal attention, based on understandings the rash was benign, as
051319 - further described in the record on 041019, ref SDS 23 TX36  In March
051320 - 2004 after getting out of the shower, increased severity of the rash
051321 - was pointed out, and this then became an issue for further inquiry
051322 - with the doctor during a meeting at Kaiser on 040318, shown by the
051323 - chronology listed on 040517. ref SDS 16 YY84
051324 -
051325 -            [On 050922 final draft of second opinion #2 contains same
051326 -            erroneous report on evolution of IBC discovery, ref SDS 52
051327 -            6E8K, possibly due to reliance on the Benz report.
051328 -            ref SDS 52 WO4O
051330 -  ..
051331 - The meeting on 040318 primarily responded to new findings from a
051332 - biopsy on the neck, which required scheduling new treatments in the
051333 - Avastin trial.  There was no urgency by the patient on investigating
051334 - the rash at that time, because there was nothing in the record showing
051335 - it was inflammatory breast cancer (IBC).  This was reinforced by the
051336 - diagnosis on 040318 that the rash was the return of cellulitus, and
051337 - was only significant because it further delayed starting chemotherapy
051338 - treatment. ref SDS 15 IM6J
051340 -  ..
051341 - Doctor Benz continues...
051342 -
051343 -   11.  On 03/03/2004, she had a left neck FNA in the node at the
051344 -        posterior triangle which showed metastatic breast cancer, and
051345 -        on 04/19/2004, she had a left breast punch biopsy within the
051346 -        rash area of her left breast which showed metastatic breast
051347 -        cancer with extensive dermal lymphatic involvement consistent
051348 -        with inflammatory breast cancer.  At this time, her CA15.3 was
051349 -        between 70 and 80 and the patient was enrolled in a clinical
051350 -        protocol in which Taxol was administered on a once-a-week times
051351 -        three basis with 1/4 weeks rest, and in association with
051352 -        Avastin 10 mg/kg infused on the first and third weeks.  On this
051353 -        protocol, the patient's rash improved and CA15.3 has declined
051354 -        to near normal levels. ref DRT 1 EJ6N
051355 -
051356 -            [On 060929 Benz #2 opinion received on 060929 does not
051357 -            mention discovering IBC from biopsy on 040419. ref SDS 66
051358 -            WY4I
051360 -         ..
051361 -   12.  She is presently in the midst of her seventh cycle of this
051362 -        Taxol- Avastin protocol and her last CA15.3 value of 10/07/2004
051363 -        was 39.  Her CT scan which had been performed every couple of
051364 -        months this past year has showed marked decline in the multiple
051365 -        posterior cervical, axillary and high supraclavicular lymph
051366 -        nodes.  Her last CT scan of 09/21/2004 shows no evidence of any
051367 -        lymph node greater than 7 mm in diameter.  She still has some
051368 -        persistent redness of the left breast and claims that her
051369 -        activity level is about 75% of normal on the present clinical
051370 -        therapy protocol. ref DRT 1 SJ4F
051372 -         ..
051373 -   13.  The patient's risk factors for breast cancer include onset of
051374 -        menses at age 13. She has had three pregnancies.  First
051375 -        full-term pregnancy was at age 18.  She entered menopause in
051376 -        the late 40s, when she developed hot flashes and started
051377 -        estrogen replacement therapy which she took for  nearly two
051378 -        decades, and these were discontinued at the time of her breast
051379 -        cancer diagnosis in 2002.  She took birth control pills in her
051380 -        20s for five or six years. ref DRT 1 RF5G
051382 -         ..
051383 -   14.  She is a former smoker, less than one pack per day.  She
051384 -        currently drinks one to four alcoholic beverages per week.  She
051385 -        does not use recreational drugs. ref DRT 1 RF5P
051387 -         ..
051388 -   15.  She is a non-Hispanic Caucasian and not of Ashkenazi Jewish
051389 -        descent. ref DRT 1 RF6K
051391 -         ..
051392 -   16.  She has no family history of breast cancer.  She has a maternal
051393 -        grandfather who was a smoker who died of lung cancer.  She has
051394 -        a maternal aunt who died of liver cancer. She has a sister and
051395 -        twin brothers, none of whom have developed cancer. Mother and
051396 -        father died at an early age, each of heart attack and
051397 -        pneumonia. ref DRT 1 RF6O
051399 -  ..
051400 - Pulmonary emboli and blood clot problems may require elevated concern
051401 - in light of CT test findings reported on 041104, ref SDS 26 RZ4I,
051402 - following the meeting with Doctor Benz on 041018.
051404 -  ..
051405 - Kaiser was notified on 040812 of mother's death from pulmonary
051406 - thrombosis at age 40, and of Millie's son's hospitalization for
051407 - pulmonary emboli at age 49.
051409 -  ..
051410 - Millie reported pulmonary emboli symptoms to UCSF during the
051411 - examination on 041018, ref SDS 21 LX96,
051412 -
051413 -          [On 041104 Millie diagnosed pulmonary emboli CT test, removed
051414 -          from cancer treatment Avastin Taxol drug trial. ref SDS 26
051415 -          RZ4I
051417 -  ..
051418 - Doctor Benz continues...
051419 -
051420 -   17.  PAST MEDICAL HISTORY:
051421 -
051422 -        Hysterectomy.  Other than that, she is on no current
051423 -        prescription medications beyond those prescribed as part of her
051424 -        clinical protocol. ref DRT 1 1E7G
051426 -         ..
051427 -   18.  ALLERGIES:
051429 -         ..
051430 -        She has no known allergies. ref DRT 1 9D7W
051432 -         ..
051433 -   19.  REVIEW OF SYSTEMS:
051434 -
051435 -        Positive for fatigue secondary to her chemotherapy, past and
051436 -        present. ref DRT 1 H18O
051438 -         ..
051439 -   20.  She wears corrective lenses. ref DRT 1 9D8G
051441 -         ..
051442 -   21.  She claims that she may have early signs of glaucoma, but she
051443 -        is not taking any medications for this. ref DRT 1 9D8K
051445 -         ..
051446 -   22.  She has had nosebleeds and voice changes which have been side
051447 -        effects from her chemotherapy treatments. ref DRT 1 9D8P
051448 -
051450 -         ..
051451 -        Pulmonary Embolism UCSF Recommends Kaiser Investigate Symptoms
051452 -        Cough Heavy Chest Shortness of Breath Not Addressed 2nd Opinion
051453 -
051454 -   23.  She has had some asthma and wheezing, breathing problems and
051455 -        chronic cough while she has been on the Avastin and Taxol
051456 -        therapy.  This is unclear and is being investigated.  This has
051457 -        sometimes been associated with shortness of breath but has not
051458 -        severely limited her activities. ref DRT 1 SC8J
051460 -  ..
051461 - Coughing, heavy chest, continual throat clearing, and shortness of
051462 - breath were discussed with Doctor Benz on 041018. ref SDS 21 LX96  At
051463 - that time, the doctor seemed to suggest investigation for lung cancer,
051464 - ref SDS 21 LX42, but does not mention consideration for lung cancer in
051465 - the 2nd opinion, per above. ref SDS 0 OT5Q
051467 -  ..
051468 - The doctor's reference to cough, fatigue, shortness of breath problems
051469 - "being investigated" is not supported by the record.  Kaiser delay
051470 - investigating chronic symptoms was the reason for seeking a 2nd
051471 - opinion, as reported on 040909, ref SDS 18 M14J, and reported again on
051472 - 041005. ref SDS 19 H46M
051473 -
051474 -            [On 041104 Kaiser reports blood clots found in CT test on
051475 -            041028 caused coughing and heavy chest conditions due to
051476 -            pulmonary emboli side effects of Avastin chemotherapy;
051477 -            patient removed from clincal trial, and all treatment was
051478 -            stopped. ref SDS 26 N43I
051480 -  ..
051481 - Doctor Benz recommends continuing on Avastin/Taxol trial causing
051482 - persistent side effects over 6 months that relate to pulmonary emboli,
051483 - per below. ref SDS 0 OU5P
051484 -
051485 -            [On 041209 Stanford 2nd opinion recommends continuing on
051486 -            Avastin/Taxol trial and further cites patient's persistent
051487 -            side effects related to pulmonary emboli. ref SDS 34 XS4I
051489 -  ..
051490 - On 041104 patient diagnosed with pulmonary emboli shown by blood clot
051491 - evident in CT image taken on 041103 diagnosed as cause of coughing,
051492 - heaviness in chest, shortness of breath, beginning on 040517; patient
051493 - was therefore removed from Taxol Avastin trial. ref SDS 26 RZ4I
051495 -  ..
051496 - Since the CT test on 041103 was out of sequence, and was advanced by
051497 - 1.5 months, this suggests that Doctor Benz may have informally
051498 - notified Kaiser by telephone call to "investigate" patient's chronic
051499 - symptoms of pulmonary emboli.  There is no other explanation of the
051500 - doctor's construction:  "this is... being investigated". ref SDS 0
051501 - OT5Q
051503 -             ..
051504 -            [On 050922 Doctor Bailey recommends hypercoagulable state
051505 -            work up for pulmonary emboli risks of blood clots during
051506 -            proposed mastectomy surgery. ref SDS 52 XD9X
051508 -             ..
051509 -            [On 051007 Kaiser surgery department cites patient extreme
051510 -            high risk for complications from mastectomy surgery due to
051511 -            history of treatment for pulmonary emboli. ref SDS 53 635M
051513 -             ..
051514 -            [On 051007 Kaiser removes Millie from treatment for
051515 -            pulmonary emboli, which conflicts with policy to treat
051516 -            cancer patients for life. ref SDS 53 GC6K
051518 -             ..
051519 -            [On 060722 patient learns eldest son (age 52) hospitalized
051520 -            for relapse pulmonary emboli; doctor test son and finds
051521 -            genetic disposition for pulmonary emboli. ref SDS 58 3D9T
051523 -             ..
051524 -            [On 060722 case study patient pulmonary emboli symptoms,
051525 -            testing, discovery, and treatment show Millie high risk for
051526 -            pulmonary emboli and for recurrence, ref SDS 58 6G6O;
051527 -            research indicates 45% of recurrence for pulmonary emboli
051528 -            die, ref SDS 58 BI5J, presenting a "wicked problem,"
051529 -            because symptoms are common to other conditions that are
051530 -            not life threatening. ref SDS 58 346F
051532 -             ..
051533 -            [On 060724 Kaiser notified of Millie's family history
051534 -            showing genetic disposition for pulmonary emboli.
051535 -            ref SDS 59 NL5Q
051537 -             ..
051538 -            [On 060825 meeting with doctor at Kaiser, no action on
051539 -            pulmonary emboli. ref SDS 64 9W4L
051541 -             ..
051542 -            [On 060929 Millie reports fatigue and shortness of breath;
051543 -            doctor orders CT test for pulmonary emboli. ref SDS 65 B56N
051545 -             ..
051546 -            [On 060930 Millie notified date of test advanced; she goes
051547 -            to Kaiser for CT test. ref SDS 67 MI5I
051549 -             ..
051550 -            [On 061002 primary care physician leaves message that CT
051551 -            test is positive for pulmonary emboli; Millie must resume
051552 -            treatment previously ended on 051007. ref SDS 68 MI5I
051554 -  ..
051555 - Doctor Benz continues...
051556 -
051557 -   24.  She has no gastrointestinal complaints.  She has no significant
051558 -        weight loss problems.  She has no neurologic complaints.  She
051559 -        has had some loss in libido but no other change in
051560 -        genitourinary or hormonal problems. ref DRT 1 4C9F
051562 -         ..
051563 -   25.  She has a poorly healed punch biopsy site in the left breast
051564 -        associated with the erythema in her left breast. ref DRT 1 4C9L
051565 -
051566 -            [On 041130 examination after treatment stopped on 041104
051567 -            shows sore from punch biopsy worsens and festering.
051568 -            ref SDS 30 JU6N
051570 -             ..
051571 -            [On 050520 punch biopsy sore heals substantially after 2
051572 -            treatments with Taxotere and capecitabine (Xeloda), begun
051573 -            on 050415. ref SDS 42 6T5G
051575 -         ..
051576 -   26.  She has had hair loss in the past and at present on her
051577 -        chemotherapy. ref DRT 1 4C9Q
051579 -         ..
051580 -   27.  She has had some sleep difficulty. ref DRT 1 4C4K
051582 -         ..
051583 -   28.  PHYSICAL EXAMINATION:
051584 -
051585 -        The patient appears her stated age, with normal vitals, and is
051586 -        in no acute distress.  She weighs 140 pounds.  Blood pressure
051587 -        of 141/82, peripheral pulse 71 and regular.  Oral temperature
051588 -        98.7 degrees.  She is here in attendance with her ex-husband,
051589 -        who has been very supportive of her through her disease
051590 -        process.  She is wearing a wig; beneath the wig, she has
051591 -        sporadic baldness with generalized hair thinning.  No evidence
051592 -        of scalp lesions.  Her pupils are equal, round, reactive to
051593 -        light and accommodation.  EOMs intact. Oropharynx clear.
051594 -        ref DRT 1 XW6K
051596 -         ..
051597 -   29.  Neck is without adenopathy or thyromegaly.  She has vague
051598 -        sensation of fullness in the left supraclavicular fossa, but I
051599 -        can palpate no discrete lymph nodes. The chest shows generally
051600 -        clear lung fields and cardiac exam by auscultation. ref DRT 1
051601 -        HO4G
051603 -         ..
051604 -   30.  The right breast is within normal limits to palpation and
051605 -        inspection with normal nipple-areolar complex and no evidence
051606 -        of right axillary or right periclavicular adenopathy.
051607 -        ref DRT 1 0H4L
051609 -         ..
051610 -   31.  The left breast, on the other hand, has somewhat distorted
051611 -        nipple-areolar complex.  She has a circumferential erythematous
051612 -        pattern with areas of peau d'orange consistent with
051613 -        inflammatory breast cancer.  She has areas of induration in the
051614 -        lower quadrants of the breast, and there is in the six o'clock
051615 -        position the punch biopsy which is incompletely healed.
051616 -        ref DRT 1 0H5K
051618 -  ..
051619 - Reference to peau d'orange aligns with research on IBC reported
051620 - 040517. ref SDS 16 BO3N  Finding "...areas of peau d'orange" further
051621 - aligns with understandings reported on 041018. ref SDS 21 V18I
051622 -
051623 -            [On 041209 Stanford 2nd opinion describes "poorly healed"
051624 -            biopsy site. ref SDS 34 O23X
051626 -             ..
051627 -            [On 050727 surgeon at Kaiser finds significant regression
051628 -            of IBC symptoms after 5 cycles of treatment with Taxoter
051629 -            and capecitabine (Xeloda), recommended by Doctor Benz,
051630 -            ref SDS 45 YY7F; begin due diligence to evaluate surgical
051631 -            solution, ref SDS 45 O85O; develop criteria for patient to
051632 -            consider approval of masectomy. ref SDS 45 VL4O
051634 -  ..
051635 - Doctor Benz continues...
051636 -
051637 -   32.  She has no tenderness or open skin lesions in the left breast.
051638 -        I can feel no adenopathy in the left axilla or the
051639 -        infraclavicular fossa on the left.  She has the radiation
051640 -        tattoos evident.  Abdomen is benign, with no organomegaly,
051641 -        fluids or masses palpable.  Extremities show full joint range
051642 -        of motion, no edema.  Symmetric pulses and reflexes
051643 -        bilaterally. ref DRT 1 LG6G
051645 -         ..
051646 -   33.  I see no other significant skin changes in the extremities.
051647 -        ref DRT 1 5G6N
051649 -         ..
051650 -   34.  Neurologic exam: Mental status and cerebellar function, cranial
051651 -        nerves grossly intact, as is peripheral motor and sensory
051652 -        function. ref DRT 1 PY6N
051654 -         ..
051655 -   35.  ASSESSMENT AND RECOMMENDATIONS:
051656 -
051657 -        It appears that at the time of 2002 when she was staged as
051658 -        having a 2-cm T2N1 with 4 involved nodes, or stage IIB breast
051659 -        cancer, she was placed on an aggressive adjuvant chemotherapy
051660 -        regimen and this was modified due to the lack of response in
051661 -        the tumor marker, and perhaps also to abnormalities detected on
051662 -        the PET scan.  By these markers, there was some evidence of
051663 -        improvement on the Taxotere portion of this adjuvant
051664 -        chemotherapy regimen.  The patient completed radiation therapy
051665 -        and her primary surgical therapy was adequate in all respects.
051666 -        ref DRT 1 CG33
051668 -  ..
051669 - The gist of the report on this matter is accurate.  Changing treatment
051670 - was driven by elevated CA 15-3 testing, and PET scan findings of
051671 - cancer, which caused an inferrance that the initial treatment was
051672 - failing, as shown in the patient history listed on 040517. ref SDS 16
051673 - SU9W  This decision may have erred, since CA 15-3 dropped in the next
051674 - test, which was prior to start of a different chemotherapy treatment,
051675 - suggesting that the initial treatment began to produce a favorable
051676 - response for the patient, and that difficulties handling testing data
051677 - caused inaccurate assesment. ref SDS 16 SU47  The patient continued to
051678 - respond favorably to the new treatment.
051680 -  ..
051681 - On 041019 the change in treatments during 2002 may provide
051682 - opportunities for future treatments, if needed. ref SDS 23 BV6K
051684 -  ..
051685 - Doctor Benz continues...
051686 -
051687 -   36.  However [on 030109], it was very ominous that within two months
051688 -        of finishing her adjuvant chemotherapy, the left breast
051689 -        erythema which was ultimately diagnosed as inflammatory breast
051690 -        cancer arose, and waxed and waned but did not fully disappear,
051691 -        and by the early portion of this year, it was also manifest
051692 -        with posterior cervical adenopathy and by CT scan evidence of
051693 -        involved lymph nodes of the left neck, supraclavicular and
051694 -        axillary regions. ref DRT 1 WF4L
051696 -         ..
051697 -   37.  However, it seems that there has been response to her clinical
051698 -        protocol consisting of the other taxane, paclitaxel, in
051699 -        combination with investigational agent Avastin, and she has now
051700 -        had seven monthly cycles of this combination therapy and has
051701 -        objective and clinical evidence of response, although with the
051702 -        persistent erythema in the left breast and some residual peau
051703 -        d'orange, it would be difficult to state that she has had a
051704 -        complete response, even with near-normalization of her CA15.3
051705 -        and lack of CT evidence of discrete residual lymph nodes.
051706 -        ref DRT 1 WF55
051707 -
051708 -
051709 -
0518 -

SUBJECTS
Cancer Likely to Progress Chemotherapy Best Treatment Taxotere Capec

0603 -
060401 -         ..
060402 -        Avastin (Bevacizumab) Taxol Continue Drug Trial Treatment
060403 -        Surgery No Role for Cure Palliative Treatment Only Option
060404 -        Palliative Treatment Only Surgery Option No Cure Available
060405 -
060406 -   38.  I have recommended to the patient and her ex-husband that she
060407 -        continue on this regimen until there is objective evidence of
060408 -        progression beyond even a rising tumor marker. ref DRT 1 K56G
060410 -  ..
060411 - Recommending continuing Avastin/Taxol chemotherapy trial does not
060412 - address persistent and increasing side effects cited by Doctor Benz,
060413 - which seem related to pulmonary emboli, per above. ref SDS 0 OT5Q
060414 -
060415 -           [On 041104 patient was removed from Taxol Avastin trial
060416 -           due to report in CT test showing pulmonary emboli
060417 -           (blood clot), which had not been seen in prior tests,
060418 -           and which did not appear on any subsequent tests.
060419 -           Patient began immediate treatment with cumodin.
060420 -           ref SDS 26 N43I
060422 -            ..
060423 -           [On 041209 Stanford 2nd opinion recommends continuing on
060424 -           Avastin/Taxol trial and further cites patient's persistent
060425 -           side effects related to pulmonary emboli. ref SDS 34 XS4I
060427 -  ..
060428 - Doctor Benz continues...
060429 -
060430 -   39.  I have reinforced the notion that she has metastatic breast
060431 -        cancer with inflammatory breast cancer in the left breast, and
060432 -        I do not see any role for surgery, and I suspect that there
060433 -        would be no tolerance for additional radiation therapy.
060434 -        ref DRT 1 K567
060436 -  ..
060437 - This aligns with understandings during the meeting at UCSF on 041018,
060438 - ref SDS 21 NZ6H; and, further supports comment by the primary care
060439 - physician in the oncology department during a meeting at Kaiser on
060440 - 040812. ref SDS 17 SE61
060441 -
060442 -            [On 090312 0800 UCSF calculated Millie could tolerate more
060443 -            radiation at lower dose to combine with hyperthermia for
060444 -            accomplishing local control after Millie's IBC suffers
060445 -            severe progression of disease, shown by rising CA 15-3 303
060446 -            cancer marker, ref SDS 73 F866; interim review after 3
060447 -            weeks of radiation and hyperthermia indicates favorable
060448 -            response to treatment toward accomplishing local control.
060449 -            ref SDS 73 AH6L
060451 -             ..
060452 -            [On 090312 0800 Doctor Hsu seems to indicate Millie will
060453 -            have no tolerance for more radiation within the defined
060454 -            treatment ares, and after treatments end on 090317; this
060455 -            leaves open possibility of radiation if IBC appears in
060456 -            areas outside the currently defined treatment areas.
060457 -            ref SDS 73 F973
060459 -  ..
060460 - At that time on 041018, the doctor seemed to indicate UCSF policies
060461 - and practice present Millie for stage III cancer, ref SDS 21 EO3Y,
060462 - which is not set out in the 2nd opinion received today.
060464 -  ..
060465 - There is seeming conflict with understanding from meeting with Doctor
060466 - Guardino at Stanford on 041019, who indicated surgery may be an option
060467 - after further recovery from IBC. ref SDS 23 TX96
060468 -
060469 -     [On 041209 2nd opinion received from Stanford says that surgery
060470 -     may be possible after regression of inflammatory breast condition;
060471 -     there is no opinion on staging. ref SDS 34 SN97
060473 -      ..
060474 -     [On 041210 doctor proposes surgery to treat IBC; case study
060475 -     reviews history considering surgery for Millie. ref SDS 35 ZV5J
060477 -      ..
060478 -     [On 050324 research yielded a professional comment that IBC is not
060479 -     always inoperable, which seems to present a bias against surgery
060480 -     that may align with Doctor Benz. ref SDS 38 TN76
060482 -      ..
060483 -     [On 050324 research indicates metastatic cancer involving regional
060484 -     lymph nodes, diagnosed on 040318, ref SDS 15 8R6M, may be operable
060485 -     to reduce chances of relapse, which is different from "distant
060486 -     metastasis," that surgery cannot cure, but may play a palliative
060487 -     role, ref SDS 38 O84N, further explained from research on 050712.
060488 -     ref SDS 44 B65G
060490 -      ..
060491 -     [On 050712 research indicates surgery can be a treatment option
060492 -     for stage III cancer, and is generally not attempted for stage IV
060493 -     cancer patients, who instead receive palliative treatment,
060494 -     ref SDS 44 B65G, as proposed by Doctor Benz today.
060496 -      ..
060497 -     [On 050819 letter to UCSF requests 2nd opinion on whether to have
060498 -     surgery in Millie's case. ref SDS 46 PC5R
060500 -      ..
060501 -     [On 050823 UCSF makes referral to surgeons, which may indicate
060502 -     there is now a role for surgery in Millie's case. ref SDS 47 AI8N
060504 -      ..
060505 -     [On 050913 Kaiser recommends immediate mastectomy surgery for
060506 -     local control. ref SDS 51 X645
060508 -      ..
060509 -     [On 051007 Kaiser recommends patient approve mastectomy treatment
060510 -     for left breast and for the purpose of "palliation." ref SDS 53
060511 -     IV4G
060513 -      ..
060514 -     [On 051021 Kaiser performs left breast mastectomy surgery.
060515 -     ref SDS 54 0001
060517 -      ..
060518 -     [On 051027 Kaiser reports biopsy reports no evidence of IBC in
060519 -     removed tissue. ref SDS 54 LH6O
060521 -      ..
060522 -     [On 060623 Kaiser diagnoses IBC recurrence. ref SDS 56 025H
060524 -      ..
060525 -     [On 070130 UCSF indicates mastectomy surgery for Millie's patient
060526 -     profile was a good choice with 20% chance of success. ref SDS 71
060527 -     JK5N
060528 -
060529 -
060530 -
0606 -

SUBJECTS
Default Null Subject Account for Blank Record
Cancer Likely to Progress Chemotherapy Best Treatment Taxotere Capec

0704 -
070501 -         ..
070502 -        Cancer Likely to Progress Chemotherapy Best Treatment
070503 -        Taxotere Capecitabine Systemic Treatment with Disease Progress
070504 -
070505 -
070506 - Doctor Benz continues...
070507 -
070508 -   40.  I indicated that whether she were to discontinue her current
070509 -        chemotherapy protocol or continue it, sooner or later her
070510 -        disease will again progress, and likely spread, and at that
070511 -        time, there would be other chemotherapy options open to her,
070512 -        including capecitabine, another form of liposomal anthracycline
070513 -        known as Doxil, or combinations in couplets involving such
070514 -        agents as Gemzar. ref DRT 1 K574
070516 -  ..
070517 - Research on the Internet explains Doxil applies liposomal technology
070518 - that seems intended to treat a form of aids -- Kaposi's -- but treats
070519 - skin problems, and so may address IBC...
070520 -
070521 -              http://www.atdn.org/simple/doxil.html
070523 -  ..
070524 - Liposomal anthracycline chemotherapy for HIV-1 seems to be components
070525 - of doxil....
070526 -
070527 -              http://www.aegis.com/conferences/bhiva/2002/P53.html
070528 -
070530 -  ..
070531 - Doxil and Taxol were combined in a study to treat breast cancer...
070532 -
070533 -              http://www.usc.edu/hsc/info/pr/ccr/96fall/update.html
070535 -  ..
070536 - Doxil by itself seemed to have failed in a study to treat soft tissue
070537 - sarcoma...
070538 -
070539 -              http://annonc.oxfordjournals.org/cgi/content/abstract/9/10/1131
070541 -  ..
070542 - Forecast that disease cannot be cured, and so will eventually progress
070543 - aligns with understandings during the meeting at UCSF on 041018
070544 - calling for continuous treatment of cancer symptoms. ref SDS 21 LX7L
070546 -  ..
070547 - Previously, the primary care physician at Kaiser made a similar
070548 - representation on 030606. ref SDS 11 NE4G  At that time on 030606 the
070549 - doctor explained cancer mutates which resists treatment. ref SDS 11
070550 - N27L An article last year received on 031010 explains that 50% of
070551 - breast cancer patients relapse within two (2) years. ref SDS 13 IM6N
070552 -
070553 -            [On 041201 Kaiser proposes participating in a new trial
070554 -            that includes capecitabine. ref SDS 31 4P9L
070556 -             ..
070557 -            [On 041209 Doctor Guardino at Stanford 2nd opinion
070558 -            indicates possible role for surgery. ref SDS 34 SN97
070560 -             ..
070561 -            [On 050727 follow up examination by surgeon shows biopsy
070562 -            wound fully healed, and IBC has healed sufficiently for
070563 -            surgery after 4 treatments with Taxotere and capecitabine.
070564 -            ref SDS 45 CK7N  Patient asks about criteria for deciding
070565 -            on surgery based on 2nd opinion from Doctor Benz.
070566 -            ref SDS 38 YW6M
070568 -             ..
070569 -            [On 050826 surgeon in Kaiser's Oakland office explains
070570 -            mastectomy surgery for patients with metastatic cancer
070571 -            limited to regional disease and no evidence of distant
070572 -            metastasis fits a curative treatment model for stage III
070573 -            cancer. ref SDS 48 947O
070575 -  ..
070576 - Doctor Benz continues...
070577 -
070578 -   41.  Her success with taxanes would indicate that capecitabene-
070579 -        Taxotere or Gemzar-Taxotere combinations might be considered
070580 -        upon disease progression. ref DRT 1 K57E
070582 -  ..
070583 - The doctor's reference to success with taxanes refers to Millie's
070584 - improvement on 020628 after switching from AC to Taxotere. ref SDS 9
070585 - QB22
070586 -
070587 -            [On 041104 Kaiser reports dramatic improvement patient CA
070588 -            15-3 cancer marker drops to normal for 1st time in 3 years,
070589 -            ref SDS 26 GJ5M; CT test shows no evidence of cancer,
070590 -            ref SDS 26 Q49F; Kaiser ends treatment of IBC with Taxol
070591 -            Avastin trial due to report of pulmonary emboli in a CT
070592 -            test, ref SDS 26 N438; plans to begin new treatment for IBC
070593 -            as soon as possible. ref SDS 26 WT60
070595 -             ..
070596 -            [On 041230 participation in new trial with capecitabine was
070597 -            cancelled due to administrative issue, ref SDS 36 028N,
070598 -            relapse diagnosed following treatment lapse since 041021,
070599 -            ref SDS 36 025H; new work plan to try AC for qualifying to
070600 -            participate in drug trial using Capecitabine. ref SDS 36
070601 -            7W4K
070603 -             ..
070604 -            [On 050104 treatments with AC begin. ref SDS 37 0001
070606 -             ..
070607 -            [On 050329 Kaiser tried to qualify Millie for another
070608 -            clinical trial by prescribing more treatment with
070609 -            Adriamicyn Cytoxyn (AC); this failed when IBC worsens, CA
070610 -            15-3 rises to over 100; Kaiser switches prescription to
070611 -            Taxotere and capecitabine, ref SDS 39 AW5G, recommended by
070612 -            Benz at UCSF, per above. ref SDS 0 OU6S
070614 -             ..
070615 -            [On 050415 Taxotere capecitabene (Xeloda) treatment begins,
070616 -            ref SDS 41 407N, per recommendation by Doctor Benz at UCSF
070617 -            on 041117, ref SDS 0 OU6S, and following guidance from
070618 -            Kaiser pharmacist on 050415. ref SDS 41 PS6X
070620 -             ..
070621 -            [On 050520 dramatic improvement; after 2 cycles of
070622 -            treatment the spread and severity of inflamation, and the
070623 -            firmness of skin have all receded to near normal, CA 15-3
070624 -            drops to 65; side effects of peeling, blistering feet
070625 -            reduce level of treatment by 25%. ref SDS 43 887S
070627 -             ..
070628 -            [On 060807 disease progresses beginning new cycle of
070629 -            capecitabine and Taxotere; patient asks Kaiser about follow
070630 -            on treatment with Gemzar and Taxotere. ref SDS 61 SL4P
070632 -             ..
070633 -            [On 060929 Benz follow up 2nd opinion proposes treatment
070634 -            with Gemzar or Navelbine combined with capeticabine.
070635 -            ref SDS 66 WR3Y
070637 -             ..
070638 -            [On 070510 another patient treated at UCSF wtih cetuximab
070639 -            and Carboplatin was switched to Gemzar after 10 months
070640 -            treatment on cetuximab carboplatin clinical study.
070641 -            ref SDS 72 FK4G
070642 -
070643 -
070644 -
070645 -
0707 -

SUBJECTS
HER2/neu Negative Endocrine Herceptin Not Available for Millie's Sta

0903 -
090401 -         ..
090402 -        HER2/neu Negative Endocrine Herceptin Not for Millie's Status
090403 -
090404 -
090405 -   42.  Given the total lack of hormonal responsiveness, there is no
090406 -        point to the use of endocrine therapy, nor would she be a
090407 -        candidate for Herceptin, given the HER-2/neu negativity.
090408 -        However, other small molecule kinase inhibitors as part of a
090409 -        protocol would certainly be warranted if she were eligible for
090410 -        such studies. ref DRT 1 K586
090412 -  ..
090413 - This aligns with the report on 020321 where the doctor listed the
090414 - patient her2/neu negative as a factor in treatment. ref SDS 7 YF5M
090415 -
090416 -           [On 050907 doctor recommends retesting for status change
090417 -           that could have a huge impact on treatment options,
090418 -           illustrated by Doctor Benz's 2nd opinion today. ref SDS 49
090419 -           TX6J
090421 -            ..
090422 -           [On 060428 status change reviewed with rising evidence of
090423 -           cancer relapse. ref SDS 55 ZR6J
090425 -            ..
090426 -           [On 060711 primary care physician submits document
090427 -           identified as biospy performed on 040419, and showing no
090428 -           status change, ref SDS 57 AR4X, which was not originally
090429 -           rendered in the report submitted on 040517. ref SDS 16 736K
090430 -
090431 -
090432 -
090433 -
090434 -
090435 -
090436 -
0905 -

SUBJECTS
2nd Opinion Consultation Follow Up UCSF on Eligibility for Future Pr

1603 -
160401 -  ..
160402 - UCSF Offers Further Consultation on Eligibility for Future Protocols
160403 -
160404 - Follow up ref SDS 15 AW6M.
160405 -
160406 - Doctor Benz continues...
160407 -
160408 -   43.  The only study presently at UCSF includes Avastin in
160409 -        combination with Tarceva, and thus she would not be eligible
160410 -        given her present therapy with Avastin, but this may change in
160411 -        several months' time, and one might inquire of my
160412 -        co-investigator here at UCSF, Dr. Hope Rugo, for her possible
160413 -        eligibility into newer UCSF protocols for metastatic breast
160414 -        cancer. ref DRT 1 U48H
160416 -  ..
160417 - Previously, on 040318 primary care physician credited Doctor Hope and
160418 - the work at UCSF for 2nd opinions on treatment for Millie. ref SDS 15
160419 - HC6O
160420 -
160421 -            [On 041209 Doctor Guardino offered similar additional
160422 -            consultation to follow up on 2nd opinion presented by the
160423 -            Cancer Center at the Stanford Medical Center. ref SDS 34
160424 -            HS6L
160426 -             ..
160427 -            [On 050324 surgeon at Kaiser recommended getting additional
160428 -            opinions on performing surgery for a masectomy to treat
160429 -            pockets of resistance to chemotherapy causing worsening
160430 -            IBC. ref SDS 38 FN6I
160432 -             ..
160433 -            [On 050520 Millie asks Kaiser about new treatment trial at
160434 -            UCSF. ref SDS 42 L27G
160436 -             ..
160437 -            [On 050823 Millie asks UCSF about new treatment trial at
160438 -            UCSF. ref SDS 47 7I5Y
160440 -             ..
160441 -            [On 050909 Doctor Bailey discussed a drug trial conducted
160442 -            by Doctor Parks at UCSF that might benefit Millie and fit
160443 -            her patient profile. ref SDS 50 AL3N
160445 -             ..
160446 -            [On 060711 Millie relapses; primary care physician
160447 -            coordinating with protocol nurse to find drug trials that
160448 -            may arrest progression of disease. ref SDS 57 ED4K
160450 -             ..
160451 -            [On 060929 another UCSF 2nd opinion on 3rd IBC relapse
160452 -            proposes Millie qualifies for 2 UCSF drug trials.
160453 -            ref SDS 66 UI9K
160455 -             ..
160456 -            [On 061226 Kaiser performing due diligence collaborating
160457 -            with Doctor Rugo at UCSF to consider drug trial potocols
160458 -            for Millie's patient profile. ref SDS 69 086H
160460 -             ..
160461 -            [On 070130 Millie starting treatment at UCSF on clinical
160462 -            study with cetuximab; Doctor Rugo advised that UCSF has
160463 -            other drug trials on clinical study which Millie qualifies
160464 -            to treat her IBC, if disease progresses with cetuximab drug
160465 -            trial. ref SDS 71 TG5G
160467 -         ..
160468 -   44.  Thank you for the opportunity to participate in the care of
160469 -        this lovely but unfortunate woman. ref DRT 1 E49F
160470 -
160471 -
160472 -
160473 -
160474 -
160475 -
160476 -
160477 -
160478 -
160479 -
160480 -
160481 -
160482 -
160483 -
160484 -
160485 -
1605 -