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1...Stanford patient history omits report on 020321 showing patient met
2...Patient history is presented out of sequence for chronology, without
3...Stanford patient history omits report on 021206 of new swelling under
4...Stanford patient history omits report on 030109 that primary care
5...The date of May 3, 2003 is not significant in patient history.
6...Stanford patient history omits report on 030606 patient requested a
7...Stanford patient history omits report on 040309 that head and neck
8...Stanford patient history omits report on 040318 when doctor diagnosed
9...Stanford patient history omits report on 040402 when the doctor
10...Stanford patient history omits report on 040416 when the doctor
11...Stanford patient history describes work on 040419 incorrectly.
12...Stanford patient history omits report on 040429 when the surgeon met
13...Stanford patient history omits report on 040517 when the doctor
14...Stanford patient history omits report on 040614 when the doctor
15...Missing value of "13 mm" shown as "_________" in Stanford's patient
16...Stanford patient history omits report on 040812 when the doctor
17...Stanford patient history omits report on 041005 when the doctor
18...Stanford patient history omits report on 041007 when patient received
19...Metastatic cancer finding based on what evidence and against which
CONTACTS
SUBJECTS
2nd Opinion Received Stanford Assessment and Plan Diagnosis Patient
Late Submission 2nd Opinion Conflicts with Original Notice of Submis
2nd Opinion Received Stanford Medical Center Stanford Hospital and C
Addressed 2nd Opinion to Kaiser Conflicts with Patient Referral Hiri
2nd Opinion Received from Doctor Guardino at Stanford Cancer Center
1107 -
1107 - ..
1108 - Summary/Objective
1109 -
110901 - Follow up ref SDS 42 0000, ref SDS 37 0000.
110902 -
110903 - Stanford's 2nd opinion recommends continuing with Avastin trial.
110904 - ref SDS 0 O28T Six (6) week delay receiving the opinion frustrated
110905 - timely change to Adriamycin Cytoxan (AC) chemotherapy, ref SDS 0 SN88,
110906 - after negative response to Avastin on 041104, a week or so after
110907 - meeting at Stanford. ref SDS 0 WY5H Doctor Guardino's well written
110908 - opinion presents a very accurate chronology of patient history with
110909 - few mistakes, given only a short time to review a complex record
110910 - extending over many years. ref SDS 0 OW4T There is no evident impact
110911 - of errors and ommissions in Stanford's report, however, corrections
110912 - may be useful for future consultations, which Stanford graciously
110913 - offers to support. ref SDS 0 HS6L
110914 -
110915 - [On 041210 Kaiser received Stanford's 2nd opinion; there was no
110916 - discussion, ref SDS 44 IM5H; patient scheduled to begin new drug
110917 - trial for treatment of IBC with Novel Epothilones BMS-247550 Plus
110918 - Capecitabene.
110920 - ..
110921 - [On 041230 primary care physician meets with patient and discovers
110922 - worsening IBC conditions after no treatment since 041104,
110923 - ref SDS 47 CW53; Kaiser elects to resume treatment based on
110924 - Stanford recommendations using Adriamycin/Cytoxan chemotherapy.
110925 - ref SDS 47 IM5H
110927 - ..
110928 - [On 051008 Peggy is being treated by Doctor Guardino for breast
110929 - cancer; first meeting is early November 2005. ref SDS 67 KS8H
110931 - ..
110932 - [On 051108 letter to Doctor Guardino commending work on 2nd
110933 - opinion, reporting results of implementation, and noting
110934 - opportunity for Peggy to get high quality treatment from the
110935 - doctor. ref SDS 70 KS5N
110936 -
110937 -
110938 -
110940 - ..
1110 -
1111 -
1112 - Progress
1113 -
111301 - Stanford 2nd Opinion Accurate Comprehensive within Industry Norms
111302 - Treatment Lapse 5 Weeks Conflicts Stanford Advice Maintain Treatment
111303 - Late Submission 2 Months Conflicts Advice Patient Take Prompt Action
111304 -
111305 - Received ref DRT 1 0001 copy of a printed letter from Stanford to the
111306 - oncologist at Kaiser, and reporting the meeting at Stanford on 041019.
111307 - ref SDS 37 0001 Took 3 - 4 hours to transcribe and proof-read for a
111308 - work product ready for analysis. The main recommendation is to
111309 - continue the current treatment. ref SDS 0 XS4I Errors and omissions
111310 - in patient history are within industry norms, reported on 990912,
111311 - ref SDS 1 0001, and later on 991221 citing a study on communication
111312 - challenges in healthcare and medical practice. ref SDS 2 0001
111313 - Stanford's error rate aligns with Kaiser's work product reviewed on
111314 - 041014, ref SDS 36 T49J, and compares favorably with UCSF, reported on
111315 - 041117. Lack of timely electronic communication, reported on 041201,
111316 - ref SDS 41 RT3N, increases time and expense for intelligence support,
111317 - and prevents correction and clarification through feedback to increase
111318 - accuracy. ref SDS 40 6L9O
111319 -
111320 - [On 050819 did not ask Stanford for follow up on the next
111321 - 2nd opinion, because timely, accurate communication was
111322 - essential. ref SDS 58 AI8N
111324 - ..
111325 - [On 050826 changed practice for next 2nd opinion project;
111326 - added doctor/patient partnership to refine accuracy and
111327 - scope of 2nd opinion with review and feedback on 1st draft.
111328 - ref SDS 60 R445
111330 - ..
111331 - [On 050907 Doctor Shim's 2nd opinon on referral at Kaiser
111332 - demonstrates challenge of accuracy in medical practice, and
111333 - this was corrected through timely feedback. ref SDS 61 TY7M
111335 - ..
111336 - [On 050914 Doctor Grissom's 2nd opinion demonstrated added
111337 - value from doctor/patient partnership correcting erroneous
111338 - first impressions through feedback, ref SDS 62 XX6U, and
111339 - through collaboration refining presentation that aids
111340 - implementation. ref SDS 62 XX4R
111342 - ..
111343 - [On 050918 Doctor Bailey's 2nd opinion illustrated benefits
111344 - using doctor/patient partnership for refining accuracy,
111345 - ref SDS 63 FH5I, and presentation that facilitates
111346 - implementation. ref SDS 63 4R43
111348 - ..
111349 - [On 051108 Millie sent a letter commending Doctor Guardino
111350 - after successfull surgery on 051021, discussed in part by
111351 - the doctor in her opinion received on 041209. ref SDS 70
111352 - 3H7K
111354 - ..
111355 - Stanford's report complements the 2nd opinion from UCSF received on
111356 - 041117. ref SDS 40 6L9O
111357 -
111369 -
111370 - 1. Dear Doctor....
111371 -
111372 - We had the pleasure of meeting your patient, ...at the Breast
111373 - Oncology Clinic at Stanford University on October 19, 2004.
111374 - Please allow us to review her history and physical findings for
111375 - our records. ref DRT 1 EX6H
111377 - ..
111378 - A 2nd opinion was requested in a letter to Stanford on 041002 that set
111379 - objectives for a consultation. ref SDS 33 K138 The letter from
111380 - Stanford today shows good professional response in meeting some of the
111381 - objectives. This can be improved by setting out in the 2nd opinion
111382 - letter a reference to the originating document, and listing the major
111383 - objectives presented for referral to address in the opinion.
111385 - ..
111386 - Receiving the 2nd opinion today conflicts with understandings during
111387 - the meeting at Stanford on 041019 that a report would be issued within
111388 - 2 weeks, ref SDS 37 BV8N, to support recommendations for prompt action
111389 - when changes occur in treatment, confirmed in Doctor's letter received
111390 - today, as shown below. ref SDS 0 SN8P
111392 - ..
111393 - Receiving copy of 2nd opinion today, 6 weeks after meeting at Stanford
111394 - on 041019, conflicts with patient's request on 041020 for timely
111395 - submission to support meeting with Kaiser scheduled for 041104.
111396 - ref SDS 38 0001 Meeting at Kaiser on 041104 changed patient status by
111397 - no longer receiving treatment on the Avastin trial. This required
111398 - advice for determination of next steps, which was the purpose of
111399 - hiring Stanford for an opinion, as set out in the letter to Stanford
111400 - on 041002. ref SDS 33 K138 Stanford's opinion recommends continuous
111401 - treatment, ref SDS 0 XS4I, and immediate change to new treatment, when
111402 - the current treatment is no longer effective, as occurred on 041104.
111403 - ref SDS 39 N43I However, Kaiser stopped treatment and has not
111404 - switched to another treatment. As a result, 5 week delay receiving
111405 - the 2nd opinion withheld from Kaiser conflicts with advice in the
111406 - opinion to maintain continuous treatment.
111407 -
111408 - [On 041230 primary care physician meets with patient and
111409 - discovers worsening IBC conditions after no treatment since
111410 - 041104, ref SDS 47 CW53; Kaiser elects to resume treatment
111411 - based on Stanford recommendations. ref SDS 47 IM5H
111413 - ..
111414 - Addressing the 2nd opinion to Kaiser conflicts with instructions to
111415 - Stanford in the patient's letter dated 041002 requesting an
111416 - examination and 2nd opinion. ref SDS 33 K138 This instruction is
111417 - restated in the record of the meeting on 041019, ref SDS 37 ER8O,
111418 - which further expressly states that Stanford may send a copy of the
111419 - report to Kaiser, even though Kaiser failed make referral and failed
111420 - to pay for the report. ref SDS 37 BV8N The record for the meeting on
111421 - 041019 was submitted to Stanford on 041030. ref SDS 38 0001
111423 - ..
111424 - Previously, on 041117 UCSF made the same mistake, indicating systemic
111425 - problems meeting customer requirements, ref SDS 40 4Q3H, rather than
111426 - endemic to Stanford alone.
111427 -
111428 -
111429 -
111430 -
111431 -
1115 -
SUBJECTS
Lumps Neck Only Evidence Metastatic Cancer Symptom IBC
Lumps Neck Nearly Gone Clinical Examination Doctor Confirms No Other
Metastic Cancer Not Supported in Stanford's 2nd Opinion Imaging Test
1605 -
160601 - ..
160602 - Metastic Cancer Not Supported in Stanford's 2nd Opinion
160603 -
160604 - Stanford 2nd opinion continues...
160605 -
160606 - 2. IDENTIFICATION: A 68-year old female with a history of stage
160607 - IIB (T2 N1) carcinoma of the left breast status post lumpectomy
160608 - with lymph node dissection, chemotherapy, and radiation therapy
160609 - now with metastatic carcinoma and inflammatory carcinoma of the
160610 - left breast. ref DRT 1 1G6N
160611 -
160612 - [On 050324 research indicates metastatic cancer involving
160613 - regional lymph nodes, diagnosed on 040318, ref SDS 22 8R6M,
160614 - may be operable to reduce chances of relapse, which is
160615 - different from "distant metastasis," that surgery cannot
160616 - cure, but may play a palliative role, ref SDS 51 O84N,
160617 - further explained from research on 050712. ref SDS 54 B65G
160619 - ..
160620 - A study from Stanford's report shows testing consistently found no
160621 - evidence of distant mestastasis....
160623 - ..
160624 - Stanford 2nd opinion continues...
160625 -
160626 - Sentinel node biopsy displayed
160627 - capsular extension of the tumor.
160628 - 3 out of 3 additional nodes
160629 - were positive for metastatic
160630 - disease.......................... 020312, ref SDS 0 OW7W
160632 - ..
160633 - Primary care physician and
160634 - oncologist reports metastatic
160635 - cancer could not be diagnosed
160636 - based on available information
160637 - in relation to AJCC Staging
160638 - guidance; further testing
160639 - needed to determine metastatic
160640 - disease.......................... 020321, ref SDS 0 E84L
160642 - ..
160643 - Whole body skeletal sinography
160644 - demonstrating no significant
160645 - skeletal abnormalites
160646 - suggestive of metastatic
160647 - disease.......................... 020402, ref SDS 0 OW4S
160649 - ..
160650 - CT of abdomen demonstrated no
160651 - adenopathy....................... 020409, ref SDS 0 OW5R
160653 - ..
160654 - PET scan demonstrates four
160655 - (#4) focal hypermetabolic
160656 - findings in the left axilla
160657 - consistent with metastic
160658 - disease.......................... 020529, ref SDS 0 OX4X
160660 - ..
160661 - MRI of the brain rules out
160662 - metastatic disease............... 020617, ref SDS 0 OX6V
160664 - ..
160665 - MRI of lumbar spine rules out
160666 - metastatic disease............... 020713, ref SDS 0 OX7T
160668 - ..
160669 - PET scan reported possible
160670 - bone metastatis.................. 021218, ref SDS 0 OX4W
160672 - ..
160673 - Radiographs cervical spine,
160674 - demonstrate no evidence of
160675 - metastatic disease............... 030915, ref SDS 0 OY7W
160677 - ..
160678 - Primary care physician
160679 - diagnosed metastatic cancer
160680 - based on rise in CA 15-3,
160681 - and discovery of cancerous
160682 - lymph nodes in the neck,
160683 - also consistent with IBC
160684 - not yet diagnosed................ 040318, ref SDS 0 OZ3U
160686 - ..
160687 - Participation in trial of
160688 - paclitaxel and bevacizumab
160689 - (Taxol and Avastin) required
160690 - finding of metastatic breast
160691 - cancer........................... 040400, ref SDS 0 OZ4X
160693 - ..
160694 - Bone scan finds no evidence
160695 - metastasis....................... 040429, ref SDS 0 OZ6Y
160697 - ..
160698 - Primary care physician and
160699 - oncologist indicates lumps in
160700 - neck positive for cancer on
160701 - 040309 and since reduced by
160702 - treatment to below visibility
160703 - with testing is sole evidence
160704 - of metastatic cancer; also,
160705 - evidence of IBC.................. 040812, ref SDS 0 UF9M
160706 -
160707 -
160708 -
160709 -
160710 -
160711 -
1608 -
SUBJECTS
Patient History Stanford Lists Chronology Based on Case Studies and
1703 -
170401 - ..
170402 - Patient History Tumor Removed Left Breast 020312 Out of Capsule
170403 -
170404 - Stanford excellent work listing patient history with very few errors
170405 - applying case studies, and discussion with customer on 041019, and
170406 - further applies Kaiser's extensive reports of testing, and doctor
170407 - notes from the medical chart. ref SDS 37 WR9F Stanford's 2nd opinion
170408 - cites frustrations working with a complex record to understand disease
170409 - for diagnosis and prescribing treatment. ref SDS 0 O27S Stanford's
170410 - insistance on accuracy during the examination on 041019, ref SDS 37
170411 - BV92, is supported by the following review...
170413 - ..
170414 - Stanford 2nd opinion continues...
170415 -
170416 - 3. HISTORY OF THE PRESENT ILLNESS:
170417 -
170418 - 1. February 8 2002
170419 -
170420 - As per the patient, she reports an approximately two-month
170421 - history of left breast mass and progressive axillary
170422 - swelling, detected on self-exam prompting a visit to her
170423 - pirmary medical care physician.
170425 - ..
170426 - 2. February 18 2002
170427 -
170428 - As per the patient, she underwent a mammography that
170429 - failed to show any abnormalities. ref DRT 1 0055
170431 - ..
170432 - 3. March 4 2002
170433 -
170434 - The patient underwent a needle localized left breast core
170435 - biopsy at the 12 o'clock position at the,
170436 - Kiser Permanente Walnut Creek Medical Center. This was
170437 - prompted by a history of a 3 x 4 cm reported nonmobile
170438 - (highly suspicious for cancer) left breast mass at the 12
170439 - o'clock position with 2.5 cm axillary adenopathy. The
170440 - pathology was subsequently demonstrated to be consistent
170441 - wtih infiltrating carcinoma. The sample was shown to be
170442 - by immunohistochemistry negative for estrogen receptor (ER
170443 - negative), progesterone receptor (PR negative), and
170444 - HER2/neu (HER2/neu negative). The sample was also shown
170445 - to be aneuploid with a borderline MIB-1 proliferation
170446 - index of 16%. ref DRT 1 0062
170447 -
170449 - ..
170450 - 4. March 12 2002
170451 -
170452 - The patient underwent a lumpectomy with Tc-99m localized
170453 - lymph scintillography at Kaiser Permanente Walnut Creek.
170454 - At this time a 7 x 7.7 x 4 cm lumpectomy specimen was
170455 - removed containing a well-circumscribed tumor measuring 2
170456 - x 2 x 2 cm. The tumor was described as inflitrating,
170457 - poorly differentiated, ductal carcinoma; tumor was stated
170458 - to be present at the superior anterior margin, ductal
170459 - carcinoma in situ, comedo and cribriform types, high
170460 - nuclear grade (aggregating to approxomately 4 mm), ductal
170461 - carcinoma in situ approximately 4 mm from the medial
170462 - margin. The sentinel node biopsy displayed capsular
170463 - extension of the tumor. As well, 3 out of 3 additional
170464 - nodes were positive for metastatic disease showing tumor
170465 - involving the capsule without extracapsular extension.
170466 - There was no evidence of angiolymphatic involvement.
170467 - ref DRT 1 JS4J
170469 - ..
170470 - On 020312 the surgeon reported that lymph nodes appeared cancerous.
170471 - ref SDS 3 7V61
170473 - ..
170474 - Stanford patient history continues...
170475 -
170476 - 5. March 21, 2002
170478 - ..
170479 - Stanford patient history omits report on 020321 showing patient met
170480 - primary care physician and oncologist, who submitted the pathlogy
170481 - reort for surgery on 020312, ref SDS 0 OW7W, and pointed out the part
170482 - that says metastatic carcinoma tumor infiltrating through the capsule
170483 - into the peri-nodal fatty tissue, left breast sentinel lymph node.
170484 - ref SDS 4 4U8X
170486 - ..
170487 - At that same time, on 020321 the doctor highlighted the section in the
170488 - AJCC Cancer Staging Handbook on page 163, and then further observed
170489 - that there was not enough information to assess whether there is
170490 - actually distant metastasis, that this would be determined based on
170491 - further testing. ref SDS 4 FX5H
170493 - ..
170494 - Stanford patient history continues...
170495 -
170496 - 6. March 27 2002
170497 -
170498 - The patient underwent re-excision for the (positive)
170499 - margins encountered in her previous lumpectomy. The
170500 - pathology confirmed no residual carcinoma following wide
170501 - re-excision. ref DRT 1 JS62
170502 -
170504 - ..
170505 - 7. April 2, 2002
170506 -
170507 - The patient underwent a whole body skeletal sinography
170508 - demonstrating no significant skeletal abnormalites
170509 - suggestive of metastatic disease. However, there were
170510 - some degenerative changes diffusely involving the spine
170511 - and multiple joints of the extremities. ref DRT 1 JT3P
170512 -
170514 - ..
170515 - 8. April 9, 2002
170516 -
170517 - CT of the abdomen demonstrated no adenopathy but did show
170518 - a 1 cm cyst in the dome of the liver, which has been
170519 - positive and stable throughout all subsequent scans.
170520 - ref DRT 1 JT3Y
170521 -
170523 - ..
170524 - 9. April 5, 2002
170525 -
170526 - As per patient, she began Adriamycin/Cytoxan chemotherapy.
170527 - She received two cycles that were complicated by
170528 - neutropenia. The AC regimen was terminated after two
170529 - cycles because of rising CA 15-3. ref DRT 1 JT4X
170531 - ..
170532 - Patient history is presented out of sequence for chronology, without
170533 - evident purpose.
170535 - ..
170536 - Patient history shows that on 020710 treatment was changed to Taxotere
170537 - prior to completing planned treatments with Adriamycin/Cytoxan
170538 - chemotherapy due to dramatic rise in CA 15-3 and findings in PET scan
170539 - imaging showing advancing cancer. ref SDS 0 OX5Y
170540 -
170541 - [...see below Stanford recommends trying Adriamycin
170542 - Cytoxan chemotherapy again. ref SDS 0 SN88
170544 - ..
170545 - [On 041230 primary care physician meets with patient and
170546 - discovers worsening IBC conditions after no treatment
170547 - since 041104, ref SDS 47 CW53; Kaiser elects to resume
170548 - treatment based on Stanford recommendations. ref SDS 47
170549 - IM5H
170551 - ..
170552 - Stanford patient history continues...
170553 -
170554 - 10. April 12, 2002
170555 -
170556 - Baseline radionucleotide ventriculogram at rest is
170557 - performed for baseline evaluation before Adriamcycin
170558 - chemotherapy. Test strip shows ejection fraction of 68%.
170559 - ref DRT 1 JT57
170561 - ..
170562 - 11. May 13, 2002
170563 -
170564 - The patient undergoes thoracic and lumbar spine
170565 - radiographs to confirm degenerative change seen on bone
170566 - scan (April 2, 2002). No ostoblastic or osteolytic
170567 - lesions identified. ref DRT 1 JT6U
170568 -
170570 - ..
170571 - 12. May 29, 2002
170572 -
170573 - The patient undergoes PET of glucose metabolism for a
170574 - rising CA 15-3, negative bone scan, and negative CT for
170575 - re-staging. The exam demonstrates four (#4) focal
170576 - hypermetabolic findings in the left axilla consistent with
170577 - metastic disease. There is also borderline update at L4
170578 - and L5. ref DRT 1 JT76
170580 - ..
170581 - Left axilla sounds like confirmation of sentinal node biopsy under the
170582 - left arm reported on 020312, ref SDS 0 OW7W, discussed with oncologist
170583 - on 020321, as requiring additional testing to establish distant
170584 - metastasis. ref SDS 0 E84L On 040517 research found that cancer under
170585 - the arm and in the neck are symptoms of IBC. ref SDS 0 MA3N
170587 - ..
170588 - Stanford patient history continues...
170589 -
170590 - 13. June 10, 2002
170591 -
170592 - As per patient, she begins four treatments of Taxotere
170593 - chemotherapy. ref DRT 1 JT87
170595 - ..
170596 - On 020603 the doctor prescribes Taxotere to replace Adriamycin/Cytoxan
170597 - chemotherapy because CA 15-3 jumped dramatically to 117, and PET scan
170598 - report shows expanding cancer. ref SDS 5 4X5K Treatment with Taxotere
170599 - began on 020610. ref SDS 6 MR5I
170601 - ..
170602 - Stanford patient history continues...
170603 -
170604 - 14. June 17, 2002
170605 -
170606 - The patient undergoes an MRI of the brain with gadolinium
170607 - to rule out metastatic disease. The study demontrastes
170608 - normal MRI of brain. ref DRT 1 JT9S
170609 -
170611 - ..
170612 - 15. July 13, 2002
170613 -
170614 - The patient undergoes MRI of the lumbar spine to rule out
170615 - metastatic disease. The study showns multilevel mild
170616 - lumbar spondylosis, particularly at L4 and L5; without
170617 - evidence of metastic disease. ref DRT 1 JT41
170618 -
170620 - ..
170621 - 16. August 7, 2002
170622 -
170623 - The patient undergoes left rib radiograph for pain. No
170624 - rib abnormalities detected. ref DRT 1 EY5F
170625 -
170627 - ..
170628 - 17. July 2002 to August 2002
170629 -
170630 - As per patient, she underwent radiation therapy to the
170631 - breast, axilla, and supraclavicular regions for stage IIB
170632 - (T2 N1) cancer of the left breast. ref DRT 1 JT5X
170634 - ..
170635 - On 020708 meeting at Mt Diablo on planning radiation treatments.
170636 - ref SDS 7 0001 Radiation treatment started on 020723. ref SDS 8 0001
170637 - Radiation completed on 020910, reported during the meeting at Kaiser
170638 - on 020924. ref SDS 9 0J7H
170640 - ..
170641 - Stanford patient history continues...
170642 -
170643 - 18. September 2, 2002
170644 -
170645 - As per patient, she undergoes four more cycles of
170646 - Taxotere. ref DRT 1 JT65
170648 - ..
170649 - On 020924 treatment scheduled for phase II chemotherapy using
170650 - Taxotere. ref SDS 9 0J7H
170652 - ..
170653 - Phase II chemtherapy treatments with Taxotere begin on 021002.
170654 - ref SDS 10 0001
170656 - ..
170657 - Stanford patient history continues...
170658 -
170659 - 19. December 6, 2002
170661 - ..
170662 - Stanford patient history omits report on 021206 of new swelling under
170663 - left arm, ref SDS 11 KW5F, which is listed as a symptom of IBC in
170664 - research reported on 040517, ref SDS 28 6M9H, and is further listed in
170665 - the case study chronology, also, reported on 040517, ref SDS 28 2F4G,
170666 - which was submitted to Stanford on 041019, ref SDS 37 KH5G, and was
170667 - reviewed with Stanford's team during the meeting on that date.
170668 - ref SDS 37 WR9F
170670 - ..
170671 - Stanford patient history continues...
170672 -
170673 - 20. December 18, 2002
170674 -
170675 - The patient undergoes body PET of glucose metabolism for
170676 - follow up evaluation post-treatment. When compared with
170677 - the previous exam (May 2002) the left axillary nodes are
170678 - no longer active. There are mild diffuse increased soft
170679 - tissue activities in the left axilla, upper chest wall,
170680 - and supraclavicular regions, likely to be post-radiation
170681 - changes. There are new hypermetabolic findings in the
170682 - left eleventh rib, representing early bone metastasis
170683 - versus acute post-traumatic change. There is more
170684 - prominent irregular increased uptake noted in the
170685 - posterior L5 vertebrae bilaterally. ref DRT 1 JU3T
170687 - ..
170688 - PET test may align with patient report to physician on 021206 of mild,
170689 - occasional discomfort from new lump under left arm, and with
170690 - subsequent report on 030109 of increased discomfort under left arm and
170691 - along the left side, and with initial report by physician of red
170692 - coloration in left breast.
170694 - ..
170695 - "Metastasis" was investigated with bone scan on 030410, and found no
170696 - evidence of actual matastasis. ref SDS 0 OZ6Y
170698 - ..
170699 - Stanford patient history continues...
170700 -
170701 - 21. January 9, 2003
170702 -
170703 - As per patient, she notes firmness of the left breast with
170704 - some skin color changes. She saw her primary care
170705 - physician who gave her a presumptive diagnosis of
170706 - cellulitus and given antibiotics. ref DRT 1 JU4Y
170708 - ..
170709 - Stanford patient history omits report on 030109 that primary care
170710 - physician, who is, also, the oncologist observed red coloration during
170711 - examination, which had not been noticed nor reported by the patient
170712 - because this was not a subject of interest. ref SDS 12 KW5F
170714 - ..
170715 - During the meeting on 030109, patient reported continuing stiffness in
170716 - the neck. ref SDS 12 II34
170718 - ..
170719 - Stanford patient history omits report on 030109 of increased
170720 - discomfort under left arm, and along the left side, and increased
170721 - fatigue. ref SDS 12 KW5F
170723 - ..
170724 - Clinical symptoms may align with PET test report on 021228 which
170725 - Stanford cites finding new mild diffuse uptake in the left axilla
170726 - region, left supraclavicular, and left upper chest region. ref SDS 0
170727 - OX4W
170729 - ..
170730 - Stanford patient history continues...
170731 -
170732 - 22. January 28, 2003
170733 -
170734 - The patient undergoes CT of the chest. The study
170735 - demonstrates no left axillary lymphadenopathy. There is
170736 - evidence of parenchyml-based irregular opacities in the
170737 - left lung suggestive of post-radiation changes.
170738 - ref DRT 1 02RX
170739 -
170741 - ..
170742 - 23. February 20, 2003
170743 -
170744 - As per patient, she is again seen by physicians this time
170745 - for evaluation of her left breast cellulitis with some
170746 - improvement in redness after completing antibiotics. The
170747 - patient continues to complain of waxing and waning skin
170748 - changing through the rest of her duration of history.
170749 - ref DRT 1 JU68
170751 - ..
170752 - 24. April 28, 2003
170753 -
170754 - The patient undergoes CT of the chest, this time
170755 - demonstrating two small, less than 1 cm, and lymph nodes
170756 - in the left axilla, not present on the previous exam dated
170757 - January 28, 2003. ref DRT 1 JU7W
170759 - ..
170760 - CT test performed on 030428, report received from the doctor during
170761 - meeting on 030508 citing 2 new 1 cm lymph nodes. ref SDS 13 VM8N
170763 - ..
170764 - Stanford patient history continues...
170765 -
170766 - 25. May 3, 2003
170767 -
170768 - The patient again complains of increased redness in the
170769 - left breast and increase in the axillary swelling.
170770 - ref DRT 1 JU8V
170772 - ..
170773 - The date of May 3, 2003 is not significant in patient history.
170774 -
170775 -
170776 - 26. June 6, 2003
170778 - ..
170779 - Stanford patient history omits report on 030606 patient requested a
170780 - meeting and reported to the doctor sudden increased redness in the
170781 - left breast. Doctor commented that colortion seems normal (on the
170782 - date of the meeting, a week after patient requests an unscheduled
170783 - meeting to evaluate redness issue). ref SDS 14 7C6W Doctor observed
170784 - thickened skin on left breast, which was attributed to surgery scar
170785 - tissue and reaction to radiation treatment. ref SDS 14 016M
170787 - ..
170788 - Stanford patient history continues...
170789 -
170790 - 27. June 26, 2003
170791 -
170792 - As per patient, she undergoes CT of chest, this time
170793 - demonstrating increase in the size of the previous noted
170794 - axillary lymph node to 1.5 cm with some skin thickening
170795 - noted. ref DRT 1 JU9T
170797 - ..
170798 - On 030710 doctor submits report for CT test performed on 030626.
170799 - ref SDS 15 VM7I
170801 - ..
170802 - CT test report further says that invasion of the dermal lymphatics
170803 - from known breast cancer can present similarly, correlate clinically.
170804 - ref SDS 15 VM7I
170806 - ..
170807 - Stanford patient history continues...
170808 -
170809 - 28. September 15, 2003
170810 -
170811 - The patient undergoes radiographs of the cervical spine,
170812 - four views, which demonstrate no evidence of metastatic
170813 - disease. ref DRT 1 JU4S
170815 - ..
170816 - 29. October 6, 2003
170817 -
170818 - The patient undergoes yearly bilateral mammograms
170819 - demonstrating lumpectomy changes in the left breast,
170820 - otherwise no mammographic evidence of malignancy.
170821 - ref DRT 1 JU5Q
170823 - ..
170824 - 30. October 31, 2003
170825 -
170826 - CT of the chest and abdomen is performed demonstrating
170827 - irregular densities in the upper half of the left breast
170828 - with distortion changes consistent with post-surgical
170829 - change. There is thickening of the overlying skin. There
170830 - is an ill-defined density in the left axilla appearing
170831 - similar to previous exam. A few of the left axillary
170832 - lymph nodes have decreased in size compared to the June 6,
170833 - 2003, exam. ref DRT 1 JU6P
170835 - ..
170836 - On 031205 doctor submits to patient the report on CT test which was
170837 - performed on 031031, and includes a handwritten assesment of "Great,"
170838 - ref SDS 17 LK5L,
170840 - ..
170841 - The CT report on 031031 does not mention disposition of 2 1.5 cm nodes
170842 - presented in the prior report received on 030710, ref SDS 17 GJ69, and
170843 - dated 030626, cited above. ref SDS 0 OY6X
170845 - ..
170846 - Stanford patient history continues...
170847 -
170848 - 31. February 2004
170849 -
170850 - As per patient, she self-palpated two left neck lumps and
170851 - upon seeing primary care physician given antibiotics.
170852 - ref DRT 1 03PR
170854 - ..
170855 - On 040211 patient meets with doctor to report discovery of lumps in
170856 - the neck; lumps are diagnosed as temporarily inflamed lymph nodes, and
170857 - treated with antiobotics. ref SDS 18 WP7L
170859 - ..
170860 - Stanford patient history continues...
170861 -
170862 - 32. March 3, 2004
170863 -
170864 - The patient continues to appreciate left neck mass. The
170865 - patient undergoes fine needle sapiration of both left
170866 - posterior triangle lymph nodes with pathology consistent
170867 - with breast primary. ref DRT 1 JV34
170869 - ..
170870 - On 040227 the doctor found that treatment prescribed on 040211 did not
170871 - relieve lumps in the neck. The doctor then ordered an examination by
170872 - a head and neck specialist. ref SDS 19 0001
170874 - ..
170875 - On March 3, 2004 patient meets with head and neck specialist. The
170876 - doctor discovered 2 or 3 more lumps than previously recognized.
170877 - ref SDS 20 VF77 A biopsy was performed, ref SDS 20 Y171, and the
170878 - patient was advised that good practice is to perform surgery to remove
170879 - swelled lymph nodes even if found not to be cancerous. ref SDS 20 Y193
170881 - ..
170882 - Stanford patient history continues...
170883 -
170884 - 33. March 7, 2004
170885 -
170886 - The patient undergoes CT scan of the neck, chest, and
170887 - abdomen demonstrating an 11.7 mm node in the left
170888 - posterior cervical triangle. There is also an 11 x 9 mm
170889 - lymph node in the high left supracalvicular region. There
170890 - are a few sub-centimeter nodules seen along the jugular
170891 - chain bilaterally. There is no evidence at this time of
170892 - axillary adenopathy. ref DRT 1 JV49
170893 -
170895 - ..
170896 - 34. March 9, 2004
170898 - ..
170899 - Stanford patient history omits report on 040309 that head and neck
170900 - specialist notified the patient that the pathology report on the
170901 - biopsy for lumps in the neck showed cancer. ref SDS 21 0001
170903 - ..
170904 - The doctor advised that the oncologist and primary care physician
170905 - decided against surgery to remove infected lymph nodes in the neck,
170906 - and that chemotherapy treatment would be used. ref SDS 21 HD5N
170908 - ..
170909 - Stanford patient history continues...
170910 -
170911 - 35. March 18, 2004
170913 - ..
170914 - Stanford patient history omits report on 040318 when doctor diagnosed
170915 - metastatic cancer based on rise in CA 15-3, and discovery of cancerous
170916 - lymph nodes in the neck, also, reported by CT test. ref SDS 22 8R6M
170918 - ..
170919 - Immediate treatment was prescribed by particiapting in a drug trial
170920 - for Taxol and Avastin, beginning the following week. ref SDS 22 PU6M
170922 - ..
170923 - Patient requests examination of increased redness in left breast.
170924 - Doctor observes severe redness. Cellulitus diagnosed. Antibotics
170925 - prescribed for two (2) weeks that delay start of chemotherapy
170926 - treatments. ref SDS 22 IM6J
170928 - ..
170929 - Patient advises that skin on left breast seems softer. Doctor
170930 - attributes improvement to evidence of cellulitus. ref SDS 22 KT4N
170931 -
170933 - ..
170934 - Stanford patient history continues...
170935 -
170936 - 36. April 2004
170937 -
170938 - As per patient, she consented to treatment according to
170939 - CTSU E2100: A randomized phase III trial of paclitaxel
170940 - versus paclitaxel plus bevacizumab (Rhumab VEGF) as first
170941 - line therapy for locally recurrent or metastatic breast
170942 - cancer. She was reportedly randomized to group A,
170943 - receiving paclitaxel weekly for three weeks with a
170944 - one-week rest along with the bevacizumab once every two
170945 - weeks, constituting one cycle. ref DRT 1 JV7S
170947 - ..
170948 - Metastatic cancer requirement for participation in Avastin trial.
170949 -
170951 - ..
170952 - Stanford patient history continues...
170953 -
170954 - 37. April 2, 2004
170956 - ..
170957 - Stanford patient history omits report on 040402 when the doctor
170958 - observed increased redness, indicating lack of response to antibiotic
170959 - treatment, and so changed diagnosis from cellulitus to reaction caused
170960 - by radiation therapy in August 2002. ref SDS 24 IM6J
170962 - ..
170963 - Changed diagnosis permitted patient to begin chemotherapy treatment
170964 - with participation in Taxol and Avastin trial. ref SDS 24 8T6M
170965 - Protocol nurse scheduled patient to begin treatment, ref SDS 23 9739,
170966 - after another CT test, because delay for treatment of cellulitus
170967 - extended the date of the prior CT test on 040307 outside trial
170968 - requirements. ref SDS 23 HS45
170970 - ..
170971 - Protocol nurse explains changes to trial parameters, ref SDS 23 JP82
170972 - Side effects are also discussed, ref SDS 23 HS9X, and patient signs
170973 - consent to participate in trial protocoal for Taxol and Avastin.
170974 - ref SDS 23 HS9X
170976 - ..
170977 - Stanford patient history continues...
170978 -
170979 - 38. April 10, 2004
170980 -
170981 - The patient undergoes a CT of the head, neck, chest,
170982 - abdomen and pelvis. This study demonstrates a 13 x 7 mm
170983 - node within the left posterior cervical triangle. As well
170984 - as an 11 x 10 mm node in the high left supraclavicular
170985 - region without significant change from previous exam. The
170986 - report also comments on multiple axillary nodes, the
170987 - largest on the right measuring 15 x 9 mm and the largest
170988 - on the left measuring 14 x 10 mm. ref DRT 1 JV6P
170990 - ..
170991 - 39. April 16, 2004
170993 - ..
170994 - Stanford patient history omits report on 040416 when the doctor
170995 - submitted the report for CT test on 040410, ref SDS 25 HX4K, during a
170996 - meeting at Kaiser. Doctor advises that test findings of cancer are
170997 - limited to the neck, ref SDS 25 WE7N
170999 - ..
171000 - Breast examination reported reduced redness in left breast, so
171001 - treatment of reacation to radiation therapy was ended. ref SDS 25 IM6J
171003 - ..
171004 - Patient notified she would be treated with bevacizumab (Rhumab VEGF),
171005 - also called Avastin, and that treatment would begin on 040420.
171006 - ref SDS 25 2T65,
171007 -
171009 - ..
171010 - 40. April 19, 2004
171011 -
171012 - The patient undergoes left breast skin punch biopsy
171013 - demonstrating involvement of the dermal lymphatics
171014 - consistent with inflammatory carcinoma of the breast.
171015 - ref DRT 1 JV8S
171017 - ..
171018 - Stanford patient history describes work on 040419 incorrectly.
171020 - ..
171021 - Patient underwent a regularly scheduled procedure to install a port
171022 - catheter for chemotherapy threatments. After this procedure was
171023 - performed, the patient asked the surgeon, who had done the original
171024 - surgery on the left breast on 020312, ref SDS 0 OW7W, about currently
171025 - increasing redness of the left breast. The surgeon advised that the
171026 - left breast had not been examined during installation of the port
171027 - chatheter, because this work was performed above the right breast.
171028 - The surgeon then examined the left breast, reviewed the patient
171029 - history on Kaiser's computer, and then performed the punch biopsy.
171030 - ref SDS 26 789F
171032 - ..
171033 - Results of the punch biopsy were not presented on 040419, and were
171034 - later reported to the patient on 040429, without mention of
171035 - inflammatory carcinoma, nor of IBC in any form or expression.
171036 - ref SDS 0 TV6M
171038 - ..
171039 - Stanford patient history continues...
171040 -
171041 - 41. April 29, 2004
171042 -
171043 - The patient underwent a whole body bone scan, again with
171044 - no evidence of metastic disease with increased activity in
171045 - the posterolateral aspect of L5 and no uptake in the
171046 - region of the PET-positive region involving the eleventh
171047 - rib. There was mention of minor nonspecific asymmetry
171048 - involving the right sternoclabicular region. ref DRT 1
171049 - JV9T
171051 - ..
171052 - Bone scan appears to complement and adjust impression from PET scan
171053 - report on 021228 by finding no evidence of bone metastasis. ref SDS 0
171054 - OX4W
171056 - ..
171057 - Stanford patient history omits report on 040429 when the surgeon met
171058 - with the patient and advised that the pathology report for the biopsy
171059 - taken on 040419 was positive for skin cancer, and would require a
171060 - masectomy. ref SDS 27 F66N
171062 - ..
171063 - The pathology report stating inflammatory breast cancer (IBC) was not
171064 - shown nor submitted to the patient.
171066 - ..
171067 - Stanford patient history continues...
171068 -
171069 - 42. May 17, 2004
171071 - ..
171072 - Stanford patient history omits report on 040517 when the doctor
171073 - submitted the pathology report for the biopsy taken on 040419.
171074 - ref SDS 28 6T5G Subsequent independent review following the meeting
171075 - discovered diagnosis in the report of inflammatory breast cancer
171076 - (IBC), ref SDS 28 YN3L, including diagnosis, treatment, and longevity
171077 - issues. Following the meeting, independent research indicates that
171078 - redness in breast, cancer under the affected arm, and cancer on
171079 - affected side of the neck are symptoms of IBC. ref SDS 28 6M9H
171081 - ..
171082 - Examination indicates favorable response to treatment shown by reduced
171083 - redness. ref SDS 28 WD8N
171085 - ..
171086 - Stanford patient history continues...
171087 -
171088 - 43. June 14, 2004
171090 - ..
171091 - Stanford patient history omits report on 040614 when the doctor
171092 - diagnosed IBC, ref SDS 29 6T5G, and changes staging from IIB to IV.
171093 - ref SDS 29 6M9H
171095 - ..
171096 - Examination indicates continuing favorable response to treatment shown
171097 - by rise in CA 15-3 beginning to slow, ref SDS 29 GJ5M, reduced redness
171098 - in left breast, and reduced swelling of lumps in the neck. ref SDS 29
171099 - 735H
171101 - ..
171102 - Stanford patient history continues...
171103 -
171104 - 44. July 7, 2004
171105 -
171106 - The patient undergoes CT of the neck and chest status post
171107 - three cycles of paclitaxel plus bevacizumab for evaluation
171108 - of treatment. When compared with the April 10, 2004, exam
171109 - there is interval decrease in the left posterolateral
171110 - retro-sternocleidomastoid node, now 4 mm versus ________
171111 - mm previously. The left scalene node now measures 4 mm
171112 - versus 14 mm previously. The largest lymph node in the
171113 - left axilla now measures 8 MM versus 18 mm previously and
171114 - the largest right axillary node now measures 9 mm versus
171115 - 18 mm previously. ref DRT 1 JV4U
171117 - ..
171118 - Missing value of "13 mm" shown as "_________" in Stanford's patient
171119 - history for CT test dated 040707 is shown in the record on 040811
171120 - receiving the test report from the doctor. ref SDS 31 WV66
171121 -
171123 - ..
171124 - Stanford patient history continues...
171125 -
171126 - 45. July 13, 2004
171127 -
171128 - As per patient, repeat bone scan demonstrates no evidence
171129 - of metastatic disease. ref DRT 1 JV5Y
171130 -
171132 - ..
171133 - 46. August 12, 2004
171135 - ..
171136 - Stanford patient history omits report on 040812 when the doctor
171137 - discussed findings in the the CT test performed on 040707, and
171138 - indicated that all testing shows favorable response to treatment,
171139 - including CA 15-3 that fell to near normal, and that lumps in neck
171140 - originally reported on 040211, and which have since disappeared, are
171141 - only evidence of metastatic cancer. ref SDS 32 T761
171143 - ..
171144 - Patient asks about swelled lymph nodes reported in the CT test on
171145 - 040410, which are missing in the report for the subsequent test on
171146 - 040710. ref SDS 32 LQ5L
171148 - ..
171149 - Doctor advised that medical practice does not require precision used
171150 - for engineering. ref SDS 32 LQ67
171152 - ..
171153 - Patient asks for decision factors on continuing, changing, or ending
171154 - treatment, and about surgery option, previously cited in the Tumor
171155 - Board report. ref SDS 32 T75L
171157 - ..
171158 - Doctor cites dilemma from fluctuating CA 15-3, leading to plans for
171159 - PET testing, and a 2nd opinion. ref SDS 32 4I6I
171161 - ..
171162 - Stanford patient history continues...
171163 -
171164 - 47. September 21, 2004
171165 -
171166 - Repeat CT of neck, chest, abdomen and pelvis demonstrates
171167 - improvement in cervical adenopathy with no node greater
171168 - than 7 mm. There is stable postoperative change in the
171169 - left axilla but no adenopathy. ref DRT 1 JV6U
171170 -
171172 - ..
171173 - 48. October 5, 2004
171175 - ..
171176 - Stanford patient history omits report on 041005 when the doctor
171177 - reported that steadily rising CA 15-3 cancer marker conflicts with CT
171178 - test report for 040921 showing no adenopathy, and therefore presents a
171179 - dilemma. ref SDS 34 GJ5M
171181 - ..
171182 - 49. October 19, 2004
171183 -
171184 - The patient presents to Stanford Breast Oncology Clinic
171185 - for evaluation and recommendations regarding therapy.
171186 - ref DRT 1 JW3V
171188 - ..
171189 - Stanford patient history omits report on 041007 when patient received
171190 - test report showing that CA 15-3 has fallen for the first time in 3
171191 - years to 39, which is the high end of "normal." ref SDS 35 2N5J
171193 - ..
171194 - Report on visit to Stanford is reported in the record on 041019.
171195 - ref SDS 37 0001
171196 -
171197 -
171198 -
171199 -
1712 -
SUBJECTS
Breast Risk Factors Medical History Minimal Throughout Long Life Med
Breast Cancer Risk Factors Medical History Minimal Throughout Long L
Risk of Relapse Factors in Millie's Case Doctor Paying Close Attenti
2005 -
200601 - ..
200602 - Breast Cancer Risk Factors Medical History Minimal Over Long Life
200603 - Medical History Minimal Throughout Long Life with Breast Risk Factors
200604 -
200605 - Stanford 2nd opinion continues...
200606 -
200607 - 4. PAST MEDICAL HISTORY, ref DRT 1 JW44
200608 -
200609 - 1. As above.
200611 - ..
200612 - 2. Tubal ligation.
200614 - ..
200615 - 3. Bladder repair for incontinence.
200617 - ..
200618 - 4. Ankle surgery.
200620 - ..
200621 - 5. Hysterectomy.
200622 -
200624 - ..
200625 - 5. ALLERGIES: NO KNOWN DRUG ALLERGIES. ref DRT 1 JW57
200627 - ..
200628 - 6. MEDICATIONS:, ref DRT 1 JW58
200629 -
200630 - 1. Cough medicine.
200631 -
200632 - 2. Taxol.
200633 -
200634 - 3. Avastin (bevacizumab).
200636 - ..
200637 - 4. Eyedrops.
200638 -
200640 - ..
200641 - 7. BREAST CANCER RISK FACTORS:
200642 -
200643 - The patient underwent menarche at age 14. She is G3, P3, with
200644 - her first child being born at the age of 19. She breast fed
200645 - all her children. She reports a five to six-year interval
200646 - history of oral contraceptive pills. She experienced menopause
200647 - at age 50. She has a 15-17 year history of hormone replacement
200648 - therapy (no Provera due to her hysterectomy), which was ceased
200649 - with the diagnosis of breast cancer. ref DRT 1 JW68
200651 - ..
200652 - 8. FAMILY HISTORY:
200654 - ..
200655 - The patient denies a family history of breast, ovarian, or
200656 - colon cancer. ref DRT 1 JW77
200658 - ..
200659 - 9. SOCIAL HISTORY:
200661 - ..
200662 - The patient lives in Concord with her common-law husband who
200663 - accompanies her today. ref DRT 1 JW8Q
200665 - ..
200666 - 10. HABITS:
200668 - ..
200669 - The patient admits to a remote history of tobacco use with only
200670 - occassional social alchol use. ref DRT 1 JW8U
200672 - ..
200673 - 11. REVIEW OF SYSTEMS
200675 - ..
200676 - The patient admits to fatigue with stable weight and appetite.
200677 - She specifically denies headaches, fever, chills, nausea and
200678 - vomitting. She admits to episodic shortness of breath and
200679 - occassional nonproductive cough. She complains of waxing and
200680 - waning breast erythema and swelling. She otherwise denies any
200681 - symptoms on exhaustive review of systems. ref DRT 1 E54F
200683 - ..
200684 - Citing side effects from Avastin/Taxol trial reflects discussion
200685 - during meeting on 041019. ref SDS 37 4G9H
200687 - ..
200688 - Doctor Guardino does not discuss correlations with side effects of
200689 - Avastin/Taxol chemotherapy trial cited on 040402, ref SDS 23 Z95O, and
200690 - reviewed recently on 040812 considering patients family history of
200691 - blood clot problems. ref SDS 32 RZ4I
200693 - ..
200694 - Stanford's 2nd opinion recommends continuing on Avastin/Taxol trial,
200695 - per below. ref SDS 0 XS4I
200696 -
200697 -
200698 -
200699 -
200700 -
200701 -
2008 -
SUBJECTS
Examination Patient Good Health for Recovering from Cancer Stanford
2203 -
220401 - ..
220402 - Examination Patient Good Health for Recovering from Cancer
220403 -
220404 -
220405 - 12. PHYSICAL EXAMINATION: VITAL SIGNS:
220407 - ..
220408 - Vital signs are stable. KPS performance status 90. ref DRT 1
220409 - 04XZ
220410 -
220411 - 1. GENERAL:
220412 -
220413 - Alert well-nourished, well-hyderated female who appears her
220414 - stated age in no apparent distress. ref DRT 1 04XZ
220416 - ..
220417 - 2. HEENT:
220418 -
220419 - Pupils are equally round and reactive to light, extraocular
220420 - muscles are intact, mucous membranes moist, and oral
220421 - cavity/oropharynx clear. ref DRT 1 04ZZ
220423 - ..
220424 - 3. NECK:
220425 -
220426 - Supple without thyromegaly. ref DRT 1 526N
220428 - ..
220429 - 4. LYMPH NODES:
220430 -
220431 - No palpable aurcular, submandibular, cervical,
220432 - supraclavicular, infraclavicular, axillary or iguinal
220433 - lymphadenopathy appreciated. ref DRT 1 0802
220435 - ..
220436 - 5. CARDIOVASCULAR EXAM:
220437 -
220438 - Regular rate, regular rhythm, normal S1, normal S2, no
220439 - murmurs, rubs, or gallops. ref DRT 1 0421
220441 - ..
220442 - 6. LUNGS:
220443 -
220444 - Clear to auscultation bilaterally without wheezes, rales,
220445 - or rhonchi. ref DRT 1 5341
220447 - ..
220448 - 7. BREASTS:
220449 -
220450 - 1. The breasts are asymmetric with a noted 12 o'clock
220451 - volume loss in the left breast. There is a 3 cm well
220452 - healed excision scar overlying the volume loss. There
220453 - is noted retraction of the breast tissue on the left.
220454 - ref DRT 1 5345
220456 - ..
220457 - 2. There is a 16 cm x 10 cm poorly demarcated region of
220458 - the erythema overlying the left breast with minimal
220459 - warmth as compared to the contralateral breast.
220460 - ref DRT 1 05T3
220462 - ..
220463 - 3. The left breast is firmer and consistently with some
220464 - swelling and subtle peau d'orange changes along the
220465 - lateral aspect. ref DRT 1 5354
220467 - ..
220468 - 4. There is a poorly healing punched out biopsy site on
220469 - the left breast. ref DRT 1 5359
220471 - ..
220472 - This aligns with the report from UCSF describing findings from
220473 - examination on 041018 of an "incompletely healed" wound, and received
220474 - in the record on 041117. ref SDS 40 OU5T
220475 -
220476 - [On 050727 after 5 treatments with Taxoters and capecitabine
220477 - (Xeloda), recommended by Doctor Benz, surgeon at Kaiser found left
220478 - breast substantially healed by visualization, and in condition for
220479 - surgery. ref SDS 55 YY7F
220481 - ..
220482 - Stanford 2nd opinion examination continues...
220483 -
220484 - 5. There is a well healed scar in the left axilla.
220485 - ref DRT 1 05V3
220487 - ..
220488 - 6. The right breast is without masses or contour defects
220489 - and the nipple is everted. ref DRT 1 5366
220491 - ..
220492 - 8. BACK:
220493 -
220494 - No spinal, paravertebral, or flank tenderness palpated.
220495 - ref DRT 1 5365
220497 - ..
220498 - 9. ABDOMEN:
220499 -
220500 - Soft nontender, nondistended, no orangonmeagaly.
220501 - ref DRT 1 05X2
220503 - ..
220504 - 10. EXTREMITIES:
220505 -
220506 - No clubbing, cyanosis, or edema. ref DRT 1 5378
220508 - ..
220509 - 11. NEUROLOGIC EXAM:
220510 -
220511 - Cranial nerves II-XII intact, no focal findings.
220512 - ref DRT 1 0486
220513 -
220514 -
220515 -
220516 -
220517 -
2206 -
SUBJECTS
Diagnosis Patient High Risk for Relapse with Metastastic Cancer Stan
2503 -
250401 - ..
250402 - Diagnosis Patient High Risk for Relapse with Metastastic Cancer
250403 -
250404 -
250405 - 13. ASSESSMENT AND PLAN:
250406 -
250407 - 1. A 68-year-old female with history of stage IIB (T2 N1)
250408 - carcinoima of the left breast managed with surgery,
250409 - chemothearpy, and radiation therapy, now with metastatic
250410 - disease and inflammatory left breast carcinoma treated with
250411 - paclitaxel and bevacizumab with noted clinical improvement.
250412 - ref DRT 1 E665
250414 - ..
250415 - 2. After reviewing the plethora of information provided by the
250416 - patient and her multiple imaging studies, recommendations
250417 - as to the patient's continued therapy were discussed.
250418 - ref DRT 1 E672
250420 - ..
250421 - Review of Stanford's patient history shows good accuracy with few
250422 - mistakes given limited time for 2nd opinion referrals, and as shown
250423 - above. ref SDS 0 OW4T
250425 - ..
250426 - Stanford's Assesment and Plan continue...
250427 -
250428 - 3. It was noted that her initial presentation included
250429 - high-risk disease. The patient was told of the approximate
250430 - 66% chance of relapse for her initial presentation, without
250431 - including some of the more high-risk features extracapsular
250432 - extension of her sentinal node biopsy. ref DRT 1 H39N
250434 - ..
250435 - High risk of relapse requires close attention to early discovery and
250436 - immediate treatment to avoid cancer cascading out of control, shown by
250437 - research on 040517, ref SDS 28 L17O, and further discussed with
250438 - primary care physician on 030606. ref SDS 14 NE4G
250440 - ..
250441 - There is nothing in the record on 041019 showing 66% risk of relapse;
250442 - this could have been mentioned without the patient remembering,
250443 - despite clarity of such representation. Patient remembers the doctor
250444 - indicating there is no "cure" that avoids further treatment, due to
250445 - out of capsule finding from orginal surgery. ref SDS 37 TX9P
250447 - ..
250448 - Metastatic cancer finding based on what evidence and against which
250449 - published guidance, per study listed above? ref SDS 0 WZ3L
250451 - ..
250452 - Stanford's analysis aligns with the opinion from UCSF reported on
250453 - 041117 that says metastatic cancer cannot be cured. ref SDS 40 OU5P
250454 - Previously, the primary care physician at Kaiser made a similar
250455 - representation on 030606. ref SDS 14 NE4G An article last year
250456 - received on 031010 explains that 50% of breast cancer patients relapse
250457 - within five (5) years. ref SDS 16 IM6N
250459 - ..
250460 - Are factors of "high risk disease cited here, and discussed on 041019
250461 - those listed in Stanford's report under para...
250462 -
250463 - BREAST CANCER RISK FACTORS
250464 -
250465 - ...reviewed above? ref SDS 0 O151
250467 - ..
250468 - The primary care physician and oncologist offered similar analysis on
250469 - 030606 when the patient asked about rising CA 15-3. ref SDS 14 NE4G
250471 - ..
250472 - Stanford's Assesment and Plan continue...
250473 -
250474 - 4. It was unfortunate that the features of tumor, for instance
250475 - estrogen receptor (negative), progesterone receptor
250476 - (negative), and HER2/neu (negative) has prevented the use
250477 - of additional adjunct hormonal or monoclonal antibody
250478 - therapy. ref DRT 1 Z34J
250479 -
250480 -
250481 -
2505 -
SUBJECTS
Stanford 2nd Opinion Recommends Continue Current Treatment with Tria
2703 -
270401 - ..
270402 - Stanford Recommendations...
270404 - ..
270405 - Stanford Recommends Continuing Current Treatment
270406 -
270407 - 1. The patient has been doing well with some clinical
270408 - improvement in the lymphadenopathy and subjectively the
270409 - erthema and swelling of her breast. She has reportedly
270410 - completed her seventh cycle of experimental treatment, and
270411 - would likely benefit from continuing her present therapy.
270412 - ref DRT 1 E682
270414 - ..
270415 - Stanford's recommendation to continue on Avastin/Taxol trial seems to
270416 - conflict with findings of persistant and severe side effects of
270417 - fatigue, cough, shortness of breath, per above, ref SDS 0 O18U, and
270418 - further aligns with UCSF 2nd opinion received on 041117 that similarly
270419 - recommended continuing on Avastin trial without consideration of side
270420 - effects. ref SDS 40 OT5Q
270422 - ..
270423 - [On 041104 patient was removed from Taxol Avastin trial
270424 - due to report in CT test showing pulmonary emboli
270425 - (blood clot), which had not been seen in prior tests,
270426 - and which did not appear on any subsequent tests.
270427 - Patient began immediate treatment with cumodin.
270428 - ref SDS 39 N43I
270429 -
270430 -
270431 -
270432 -
270433 -
270434 -
2705 -
SUBJECTS
Back and Bone Pain Symptoms Rising Metastatic Disease Change Treatme
3003 -
300401 - ..
300402 - Change Treatment Immediately When New Symptoms Occur
300403 -
300404 - 2. The patient was, however, warned to be particularly
300405 - vigilant as to the development of symptoms consistent with
300406 - metastatic disease, such as back or bone pain, progression
300407 - of the erythema of the left breast, or additional
300408 - lymphadenopathy.
300410 - ..
300411 - It was recommended that she advise her oncologist to amend
300412 - her treatment without delay should such symptoms occur.
300413 - ref DRT 1 E85L
300415 - ..
300416 - This aligns with understandings from the meeting on 041019 calling for
300417 - continuous treatment to recover from IBC. ref SDS 37 5W6H
300418 -
300419 - [On 041230 primary care physician meets with patient
300420 - and discovers worsening IBC relapse after no treatment
300421 - since 041104. ref SDS 47 CW53
300423 - ..
300424 - [On 050104 patient begins treatment with Adriamycin
300425 - Cytoxan chemotherapy after various delays following
300426 - termination of treatment on 041104, and increasing
300427 - symptoms of IBC. ref SDS 48 0001
300429 - ..
300430 - [On 050329 inflammation spreads toward neck; cancer
300431 - blisters appear on breast, CA 15-3 rises to over 100;
300432 - treatment plan changed from AC to combination of
300433 - Taxotere and capecitatine (Xeloda) recommended in 2nd
300434 - opinion by Doctor Benz at UCSF. ref SDS 52 AW5G
300436 - ..
300437 - [On 051007 patient improves; testing shows no distant
300438 - and no local disease; doctor recommends mastectomy for
300439 - palliation. ref SDS 66 MW6O
300441 - ..
300442 - [On 051027 examination of surgical wound from
300443 - mastectomy on 051021 shows normal healing; doctor says
300444 - patient now disease-free; local control and no distant
300445 - metastasis indicates complete response to treatment
300446 - based on biopsy and image testing; current treatment is
300447 - CA 15-3 and imaging tests to monitor for relapse.
300448 - ref SDS 69 0001
300449 -
300450 -
300451 -
300452 -
300453 -
300454 -
3005 -
SUBJECTS
Adriamycin Cytoxan Stanford Recommends Trying Again Stanford 2nd Opi
3403 -
340401 - ..
340402 - Adriamycin Cytoxan Stanford Recommends Trying Again
340403 - Stanford Recommends Trying Adriamycin Cytoxan Again
340404 -
340405 - 3. We would recommend an anthracycline-containing regimen,
340406 - namely CMF or CAF at that point. As the patient received
340407 - only 2 of 4 doses of the AC chemotherapy, there is
340408 - additional room to tolerate such therapy. ref DRT 1 V86J
340410 - ..
340411 - Stanford's recommendation refers to stopping treatments with
340412 - Adriamycin Cytoxan chemotherapy, ordered on 020603, ref SDS 5 WO4O,
340413 - and commenced on 020610, ref SDS 6 MR5I, which is also listed in
340414 - Stanford's patient history. ref SDS 0 OX5Y
340415 -
340416 - [On 041230 primary care physician meets with patient and
340417 - discovers worsening IBC conditions after no treatment
340418 - since 041104, ref SDS 47 CW53; Kaiser elects to resume
340419 - treatment based on Stanford recommendations using
340420 - Adriamycin/Cytoxan chemotherapy. ref SDS 47 IM5H
340422 - ..
340423 - [On 050329 primary care physician changes treatment from
340424 - AC to Taxotere and capecitabine (Xeloda. ref SDS 52 T58M
340425 -
340426 -
340427 -
340428 -
340429 -
340430 -
3405 -
SUBJECTS
Radiation Treatment Consult with Radiologist Stanford 2nd Opinion
3703 -
370401 - ..
370402 - Radiation Treatment Consult with Radiologist
370403 -
370404 - 4. As well, there may be room for additional radiation therapy
370405 - in this patient. Such decisions should be made in
370406 - consultation with the radiation oncologist with treatment
370407 - data from her precious radiation. ref DRT 1 E697
370408 -
370409 - [On 041222 radiologist at Mt Diablo Hospital seemed to
370410 - indicate further radiation treatment could be considered
370411 - following further surgery. ref SDS 45 8F6O
370413 - ..
370414 - [On 050823 Doctor Richards mentions need for radiologist
370415 - to evaluate prior treatments to determine if the patient
370416 - can get more radiation. ref SDS 59 GK9H
370418 - ..
370419 - [On 050907 surgeon in Kaiser's Oakland office discusses
370420 - reviewing the record to determine if the patient has
370421 - room for further raditation treatment. ref SDS 61 AF4W
370422 -
370423 -
370424 -
370425 -
370426 -
370427 -
3705 -
SUBJECTS
Surgery Possibility After Regression of IBC Stanford 2nd Opinion Tre
4203 -
420401 - ..
420402 - Surgery Possibility After Regression of IBC
420403 -
420404 - 5. At this point, surgery would not be favored as her disease
420405 - is far from controlled. It may be possible, at some
420406 - juncture, to consider a surgical approach if and when the
420407 - regression of the inflammatory component occurs.
420408 - ref DRT 1 R43J
420410 - ..
420411 - This aligns with understandings from the meeting on 041019 at
420412 - Stanford. ref SDS 37 TX96 Doctor Benz 2nd opinion received on 041117
420413 - has indicated that surgery is not an effective treatment for Millie's
420414 - patient profile.. ref SDS 40 OU5P
420415 -
420416 - [On 041210 primary care physician in Oconolgy at Kaiser
420417 - proposes surgery to treat IBC; case study reviews
420418 - history considering surgery for Millie. ref SDS 44 ZV5J
420420 - ..
420421 - [On 041230 surgery incorporated into treatment plans
420422 - based on sufficient progress treating IBC. ref SDS 46
420423 - CW6J
420425 - ..
420426 - [On 050107 surgeon feels the degree of IBC relapse from
420427 - lack of treatment beginning on 041104 prevents surgery
420428 - until further recovery from IBC. ref SDS 49 IS5N
420430 - ..
420431 - [On 050324 surgeon at Kaiser finds expanding IBC with AC
420432 - treatments, ref SDS 51 YY7F, discusses criteria for
420433 - surgery that supports Doctor Guardino's 2nd opinion.
420434 - ref SDS 51 WH5L
420436 - ..
420437 - [On 050324 research yielded a professional comment that
420438 - IBC is not always inoperable, ref SDS 51 TN76, which
420439 - seems to present a bias against surgery that may align
420440 - with Doctor Benz at UCSF, who discouraged surgery in a
420441 - 2nd opinion received on 041117. ref SDS 40 OU5P
420443 - ..
420444 - [On 050324 research indicates metastatic cancer
420445 - involving regional lymph nodes, diagnosed on 040318,
420446 - ref SDS 22 8R6M, may be operable to reduce chances of
420447 - relapse, which is different from "distant metastasis,"
420448 - that surgery cannot cure, but may play a palliative
420449 - role, ref SDS 51 O84N, further explained from research
420450 - on 050712. ref SDS 54 B65G
420452 - ..
420453 - [On 050329 primary care physician changes treatment from
420454 - AC to Taxotere and capecitabine (Xeloda. ref SDS 52 T58M
420456 - ..
420457 - [On 050610 after 3 cycles of treament, patient recovers
420458 - substantially; primary care physician discusses surgery
420459 - because inflammation subsides in the left breast, as
420460 - called out by Doctor Guardino. ref SDS 53 XQ41
420462 - ..
420463 - [On 050712 research indicates surgery can be a treatment
420464 - option for stage III cancer, and is generally not
420465 - attempted for stage IV cancer patients, Millie's level,
420466 - who instead receive palliative treatment. ref SDS 54
420467 - B65G
420469 - ..
420470 - [On 050727 surgeon at Kaiser finds IBC symptoms subside,
420471 - ref SDS 55 YY7F; begin due diligence to evaluate
420472 - surgical solution, ref SDS 55 O85O; develop criteria for
420473 - patient to consider approval of masectomy. ref SDS 55
420474 - VL4O
420476 - ..
420477 - [On 050729 primary care physician in Oncology at Kaiser
420478 - asks about schedule for surgery; discuss mid-September
420479 - time frame for performing a masectomy. ref SDS 56 XQ41
420481 - ..
420482 - [On 050811 planning for follow up 2nd opinion on issue
420483 - of surgery after recovery from IBC. ref SDS 57 0001
420485 - ..
420486 - [On 050920 Doctor Grissom proposes very wide mastectomy
420487 - surgery with immediate reconstruction, and for the
420488 - purpose of reducing the risk of relapse by removing
420489 - tissue which may contain microscopic cancer cells not
420490 - detected by tests. ref SDS 64 Q63L
420492 - ..
420493 - [On 050923 meeting with surgeon on 2nd opinion proposal
420494 - for very wide mastectomy with immediate reconstruction,
420495 - ref SDS 65 NT9G; surgeon proposes standard mastectomy if
420496 - PET and biopsy tests favorable, ref SDS 65 4G4L;
420497 - explains risks of standard mastectomy for Millie's
420498 - patient profile. ref SDS 65 KF6I
420500 - ..
420501 - [On 051007 primary care physician proposes purpose of
420502 - standard mastectomy is palliation in the event of future
420503 - relapse due to microscopic cancer cells. ref SDS 66 6A4N
420505 - ..
420506 - [On 051021 Millie has surgery described as very wide
420507 - mastectomy with standard closure; no initial
420508 - complications; pre-op biopsies indicated site was clear
420509 - of disease. ref SDS 68 EG5L
420511 - ..
420512 - [On 051027 examination of surgical wound from mastectomy
420513 - on 051021 shows normal healing; doctor says patient now
420514 - disease-free; local control and no distant metastasis
420515 - indicates complete response to treatment based on biopsy
420516 - and image testing; current treatment is CA 15-3 and
420517 - imaging tests to monitor for relapse. ref SDS 69 0001
420519 - ..
420520 - [On 051108 letter to Doctor Guardino commending work on
420521 - 2nd opinion, reporting results of implementation, and
420522 - noting opportunity for Peggy to get high quality
420523 - treatment from the doctor. ref SDS 70 KS5N
420524 -
420525 -
420526 -
420527 -
420528 -
4206 -
SUBJECTS
Testing Frequent Diagnostic Imaging CT PET Xray Stanford 2nd Opinion
4403 -
440401 - ..
440402 - Testing Frequent Diagnostic Imaging CT PET Xray
440403 -
440404 - 6. Again, we recommend frequent interval diagnostic imaging.
440405 - ref DRT 1 P44F
440406 -
440407 -
440408 -
4405 -
SUBJECTS
Stanford Offers Additional Consultation as Needed 2nd Opinion
4603 -
460401 - ..
460402 - Stanford Offers Additional Consultation as Needed
460403 -
460404 - 7. I will be happy to provide additional consultation as
460405 - necessary. ref DRT 1 JX4J
460407 - ..
460408 - This aligns with a similar offer by Doctor Benz at UCSF in a letter
460409 - received on 041117. ref SDS 40 OV3T
460410 -
460411 - [On 050324 surgeon at Kaiser recommended getting
460412 - additional opinions on performing surgery for a
460413 - masectomy to treat pockets of resistance to
460414 - chemotherapy causing worsening IBC. ref SDS 51 FN6I
460415 -
460416 -
460417 -
460418 -
460419 -
460420 -
460421 -
460422 -
460423 -
460424 -
460425 -
4605 -