CONTACTS 

SUBJECTS
Biopsy Wound Healing Significantly Again After Getting Treatment Sur
Meeting Surgeon Evaluate Masectomy Left Breast Requested by Primary

0704 -
0704 -    ..
0705 - Summary/Objective
0706 -
070601 - Follow up ref SDS 29 0000. ref SDS 25 0000.
070602 -
070603 - The examination evaluated prospects for masectomy on referral from the
070604 - primary care physician in the Oncology Department, and follows up a
070605 - prior visit on January 7.  Chemotherapy treatments since January 7
070606 - have partially healed the wound from the biopsy taken on 040419.
070607 - ref SDS 0 WI6K  There is otherwise observable advance of disease.
070608 - Inflammation spread above the breast since January 7. ref SDS 0 YY7F
070609 - There was discussion about "pockets of resistance" to chemotherapy,
070610 - cited by Oncology. ref SDS 0 GK9M  Criteria for sufficient recovery
070611 - from IBC to permit surgery needs more work; possibly UCSF and Stanford
070612 - can follow up opinions from visits in October 2004. ref SDS 0 OV5H
070613 - Research on the Internet yielded an email address where inquiries
070614 - might, also, be made, ref SDS 0 QJ5H, and, also, suggest a role for
070615 - surger with metastatic cancer limited to regional involvement of lymph
070616 - nodes, as in this case. ref SDS 0 TN76  However, with disease now
070617 - spreading, there is no evident boundary for surgery, and there is not
070618 - sufficient healthy tissue on the breast to close a surgical wound.
070619 - ref SDS 0 WH5L  Options were considered to work around a "treatment
070620 - loop." Oncology calls for surgery to complement chemotherapy, and
070621 - Surgery wants a site cleared of disease with chemotherapy. ref SDS 0
070622 - WH5L  The surgeon indicated limited experience treating IBC patients.
070623 - ref SDS 0 QJ3Q  The surgeon will schedule additional review and
070624 - recommended getting more opinions, including collaboration and due
070625 - diligence through the Tumor Board. ref SDS 0 O85O
070626 -
070627 -     [On 050727 follow up examination by surgeon shows IBC has suddenly
070628 -     and miraculously healed completely after 5 treatments with
070629 -     Taxotere and capecitabine, ref SDS 37 YY7F, considerations for
070630 -     surgery relate to scope of masectomy, ref SDS 37 JV5F, and unique
070631 -     factors for IBC patients, ref SDS 37 QJ3Q, and to advisability for
070632 -     extending quality of life. ref SDS 37 VL4O
070633 -
070634 -
070635 -
070636 -
070638 -  ..
0707 -
0708 -
0709 - Progress
0710 -
071001 - Biopsy Wound Healing Significantly Again After Getting Treatment
071002 -
071003 - Follow up ref SDS 24 IS5N.
071004 -
071005 - The surgeon examined Millie's left breast in accordance with request
071006 - by the Oncologist on 050311, ref SDS 28 XQ41, and following up
071007 - examination of the biopsy wound on 050107. ref SDS 24 IS5N
071008 - Previously, the surgeon met with the patient on 040429 to present
071009 - results of a biopsy showing cancer, ref SDS 9 0001, performed earlier
071010 - by the surgeon on 040419 to evaluate inflammation (redness) observed
071011 - on the left breast. ref SDS 7 789F
071013 -         ..
071014 -    1.  The surgeon was pleased and surprised to observe the wound from
071015 -        the punch biopsy taken on 040419, ref SDS 7 XU52, finally shows
071016 -        some healing after three (3) treatments with Adriamycin Cytoxan
071017 -        (AC) (the 3rd on 050225, ref SDS 26 0001), compared to the
071018 -        examination on 050107, when the wound was "messy," ref SDS 24
071019 -        778O, and further reversing worsening conditions reported on
071020 -        041230. ref SDS 22 6T5G and previously on 041210 when the
071021 -        primary care physician indicated that surgery may be required
071022 -        to treat IBC in the left breast. ref SDS 19 ZV5J
071023 -
071024 -            [On 050727 follow up examination by surgeon shows biopsy
071025 -            wound fully healed after 4 treatments with Taxotere and
071026 -            capecitabine. ref SDS 37 WI6K
071027 -
071028 -
071029 -
071030 -
071031 -
071032 -
0711 -

SUBJECTS
IBC Worsens Spreading Beyond Breast Toward Neck New Cancer Sores Dil

1703 -
170401 -  ..
170402 - IBC Worsens Spreading Beyond Breast Toward Neck New Cancer Sores
170403 - Pockets of Resistance to Chemotherapy Require Treatment with Surgery
170404 -
170405 - Follow up ref SDS 24 6W6O.
170406 -
170407 -    2.  The surgeon noted expanding inflammation (red rash) compared to
170408 -        the examination of the left breast on 050107. ref SDS 24 UM6I
170409 -        Skin texture seems thicker and markedly more firm than the
170410 -        right breast.  Disease now reaches above the breast toward the
170411 -        neck, worse than on 050107, ref SDS 24 UM6I, and several new
170412 -        cancer sores, observed initially on 050311 by the primary care
170413 -        physician, ref SDS 28 UA8N, indicate worsening inflammatory
170414 -        breast cancer (IBC).  There was no discussion of rising CA 15-3
170415 -        now above 80, reported on 050311. ref SDS 28 087J  There were
170416 -        no diagrams prepared nor pictures taken to preserve an accurate
170417 -        memory on the spread of disease in order to guide the scope of
170418 -        surgery, which the doctor noted is critical to successful
170419 -        mastectomy for IBC conditions, during the meeting on 050107.
170420 -        ref SDS 24 UM6I
170422 -         ..
170423 -        Diagrams and pictures proposed to determine boundaries of
170424 -        future surgery, discussed below. ref SDS 0 0347
170425 -
170426 -            [On 050520 dramatic improvement after 2 cycles of treatment
170427 -            with Taxotere and Xeloda. ref SDS 32 025H
170429 -             ..
170430 -            [On 050727 surgeon examination finds left breast fully
170431 -            healed and ready for surgery after treatment with Taxotere
170432 -            and capecitabine. ref SDS 37 YY7F
170434 -         ..
170435 -        Millie asked about primary care physician concerns in the
170436 -        meeting on 050311 that the left breast may have "pockets" of
170437 -        resistance to treatment by chemotherapy, and therefore requires
170438 -        a surgical solution. ref SDS 28 PA4N
170439 -
170440 -
170442 -  ..
170443 - Surgery for Masectomy Waiting for Chemotherapy to Heal IBC
170444 - Treatment Loop Chemo Needs Surgery and Surgery Waiting for Chemo
170445 - Complex Surgery Need Recovery IBC for Incision into Healthy Skin
170446 - Dilemma Chemo Needs Surgery Surgery Waiting for Chemo Treatment Loop
170447 -
170448 -
170449 -        The surgeon explained again today that, until IBC is cleared
170450 -        from the breast with chemotherapy, masectomy surgery cannot be
170451 -        performed to prevent cancer from relapsing as occurred on
170452 -        041230, because spread of IBC toward the neck, per above,
170453 -        ref SDS 0 YY7F, presents a complex problem of finding a
170454 -        physical location on the body for making an incision to remove
170455 -        infected tissue, and further there is not enough healthy skin
170456 -        on the breast to the close the wound from surgery.  The surgeon
170457 -        cited prior analysis on 050107, ref SDS 24 UM6I, which in turn
170458 -        relied on examination and review of the case previously on
170459 -        040429. ref SDS 9 SD7F
170460 -
170461 -            [...see below surgeon has performed mastectomy surgery on a
170462 -            patient with IBC possibly once 5 years ago. ref SDS 0 QJ44
170464 -             ..
170465 -            [...see below research does not yield guidance on criteria
170466 -            for when a patient is ready for surgery and how to set
170467 -            physical boundaries of the procedure. ref SDS 0 QJ5H
170469 -             ..
170470 -            [On 050401 Millie and Pam met with Doctor Choi who
170471 -            recommended against surgery at this time; there was no
170472 -            evident discussion on criteria that establish level of
170473 -            recovery where surgery can be performed. ref SDS 31 PPSU
170475 -         ..
170476 -        Millie noted that analysis today presents a complex dilemma to
170477 -        break out of an evident "treatment loop."  Surgery is waiting
170478 -        for chemotherapy to achieve completely healthy tissue, and
170479 -        Oncology says surgery is needed to overcome "pockets of
170480 -        resistance" to chemotherapy, described in the Oncology
170481 -        department on 050311. ref SDS 28 PA4N
170482 -
170483 -            [On 050727 follow up examination by surgeon shows IBC has
170484 -            suddenly and miraculously healed completely after 5
170485 -            treatments with Taxotere and capecitabine, ref SDS 37 YY7F,
170486 -            considerations for surgery relate to scope of masectomy,
170487 -            ref SDS 37 JV5F, and unique factors for IBC patients,
170488 -            ref SDS 37 QJ3Q, and to advisability for extending quality
170489 -            of life. ref SDS 37 VL4O
170491 -             ..
170492 -            [On 061020 primary care physician feels patient profile has
170493 -            too many issues for a 5-year medical case of secondary
170494 -            inflammatory breast cancer (IBC), cellulitus, lymphedema,
170495 -            pulmonary embolism, broken finger. ref SDS 45 MO4K
170496 -
170497 -
170498 -
170499 -
170500 -
1706 -

SUBJECTS
Criteria Surgery Masectomy IBC Spreading Above Breast Will Biopsy De

2203 -
220401 -         ..
220402 -    3.  Criteria for Surgery to Perform Masectomy on IBC Patient
220403 -
220404 -        On 050311 the primary care physician in Oncology seemed to
220405 -        expect the Surgery Department to present criteria for deciding
220406 -        when to perform surgery in the event that chemotherapy fails.
220407 -        ref SDS 28 PB4N
220409 -         ..
220410 -        Background on considerations to perform surgery for a masectomy
220411 -        is summarized on 041210. ref SDS 19 ZV5J
220412 -
220413 -            [...below, surgeon will collaborate with primary care
220414 -            physician to present criteria pending review to determine
220415 -            when patient is ready for surgery and whether this is a
220416 -            good risk for the patient to take. ref SDS 0 QQ4N
220418 -             ..
220419 -            [...see below for research on the Internet. ref SDS 0 QJ5H
220421 -         ..
220422 -        What criteria will inform Surgery that the patient is ready for
220423 -        a masectomy, i.e., what conditions establish "successful"
220424 -        chemotherapy for sufficient recovery in a case of IBC?
220425 -
220426 -                [On 050401 Doctor Choi did not discuss criteria for
220427 -                when surgery can be performed on a patient recovering
220428 -                from IBC. ref SDS 31 RS5L
220430 -                 ..
220431 -                [On 050610 window of opportunity for surgery to perform
220432 -                masectomy after switching treatments to Taxotere and
220433 -                capecitabine (Xeloda), and dramatic recovery from IBC
220434 -                after 3 treatments; doctor calls for follow up
220435 -                examination to schedule masectomy surgery, ref SDS 34
220436 -                XQ41; did not discuss criteria for surgery, ref SDS 34
220437 -                2J72, listed on 050324. ref SDS 0 O16N
220439 -             ..
220440 -        a.  Will another biopsy be taken to establish IBC has been
220441 -            fully or sufficiently treated to permit successful surgery,
220442 -            based on experience using biopsy on 040419 to discover IBC
220443 -            after other measures had failed? ref SDS 7 789F
220444 -
220445 -                [On 050727 patient wants to avoid another slow healing
220446 -                biopsy experience; surgeon indicated another biopsy is
220447 -                not needed for determining patient is ready for
220448 -                mastectomy surgery. ref SDS 37 SZ6M
220450 -                 ..
220451 -                [On 050826 referral surgeon in Kaiser's Oakland office
220452 -                indicated a needle punch biopsy as performed on 040419
220453 -                to discover IBC is not helpful determining IBC has
220454 -                recovered sufficiently for a successful mastectomy.
220455 -                ref SDS 38 T14L
220457 -                 ..
220458 -                [On 050920 Doctor Grissom 2nd opinion proposes thin
220459 -                full thickness surgical biopsies with suture closure
220460 -                (rather than punch biopsy) to test for recovery from
220461 -                IBC and help determine scope of surgery. ref SDS 39
220462 -                XL7P
220464 -                 ..
220465 -                [On 050923 the surgeon at Kaiser in Walnut Creek agrees
220466 -                to perform biopsies to determine complete response to
220467 -                treatment for local disease. ref SDS 40 SZ6M
220469 -                 ..
220470 -                [On 051012 4 biopsies were taken during minor surgery
220471 -                at Kaiser in Walnut Creek. ref SDS 42 DG6J
220473 -                 ..
220474 -                [On 051006 Gloria called with the Kaiser Coagulation
220475 -                Clinic in Martinez, and related Millie should stop
220476 -                taking Coumadin to prepare for minor biopsy surgery on
220477 -                051012. ref SDS 41 YV6I
220479 -                 ..
220480 -                [On 051012 biopsies on left breast taken at Kaiser to
220481 -                further evaluate recovery from IBC. ref SDS 42 DG6J
220483 -                 ..
220484 -                [On 051018 Millie notified of favorable results from skin
220485 -                biopsies, no evidence of cancer. ref SDS 43 QN3I
220487 -             ..
220488 -        b.  Will the surgeon look at CA 15-3, now very elevated above
220489 -            100, but if this drops to normal, how long before surgery
220490 -            can be performed - a week, a month...?  On 040812 the
220491 -            primary care physician discussed needing several reports
220492 -            for a month or more consistently below the "normal" value
220493 -            of 39. ref SDS 12 CT9J
220494 -
220495 -                [On 050708 CA 15-3 dropped below 39 to 37 for the first
220496 -                time in 4 years. ref SDS 35 2N5J
220498 -                 ..
220499 -                [On 050727 surgeon found CA 15-3 had increased to 46.
220500 -                ref SDS 37 YK6K
220502 -             ..
220503 -        c.  If coloration clears from the breast, and normal to near
220504 -            normal texture is achieved compared with the healthy right
220505 -            breast, will this signal surgery can be safely performed?
220506 -
220507 -                [On 050727 follow up examination by surgeon shows IBC
220508 -                has suddenly and miraculously healed completely after 5
220509 -                treatments with Taxotere and capecitabine, ref SDS 37
220510 -                YY7F, considerations for surgery relate to scope of
220511 -                masectomy, ref SDS 37 JV5F, and unique factors for IBC
220512 -                patients, ref SDS 37 QJ3Q, and to advisability for
220513 -                extending quality of life. ref SDS 37 VL4O
220515 -             ..
220516 -        d.  How will effects of coloration and texture change caused by
220517 -            radiation treatments, noted by primary care physician on
220518 -            040402, ref SDS 6 8T5O, and cited previously in CT test
220519 -            report on 030710, ref SDS 4 GJ69, be distinguished from IBC
220520 -            symptoms in order to permit surgery to proceed?
220522 -             ..
220523 -        e.  In that case, how will the boundary of surgery for removing
220524 -            the breast be established?  Will surgery extend above the
220525 -            breast to remove areas observed today with inflammation and
220526 -            coloration extending toward the neck? ref SDS 0 YY7F
220527 -            Should the doctor prepare diagrams and take photographs to
220528 -            record maximum spread of disease for guiding surgical
220529 -            removal of infected tissue? also cited above. ref SDS 0
220530 -            YY7F
220532 -             ..
220533 -        f.  How will boundaries of surgery to clear IBC be
220534 -            distinguished from boundaries of red rash observed 041202
220535 -            following reaction to antibiotcs? ref SDS 16 415Y
220536 -
220537 -                [On 050727 follow up examination by surgeon addressed
220538 -                considerations for scope of surgery. ref SDS 37 JV5F
220540 -                 ..
220541 -                [On 051012 biopsies taken to help establish limits of
220542 -                mastectomy surgery. ref SDS 42 UM8O
220544 -                 ..
220545 -                [On 061020 photographs discussed to determine
220546 -                measurable disease required for treatment at UCSF in
220547 -                clinical study of new cancer drugs. ref SDS 45 JQ3J
220549 -                 ..
220550 -                [On 070130 photographs planned to determine measureable
220551 -                disease treating Millie with drug trial in clinical
220552 -                study at UCSF. ref SDS 46 M661
220554 -             ..
220555 -        g.  Does IBC present issues that benefit from experience by the
220556 -            surgeon in assessing scope and accomplishing particular
220557 -            surgical details that are different and so not commonly
220558 -            considered in performing masectomy surgery on patients who
220559 -            do not have IBC, as discussed further below? ref SDS 0 F14N
220561 -             ..
220562 -            Does it help for a surgeon who has not performed masectomy
220563 -            on an IBC patient to consult with a surgeon who has done
220564 -            say 5 - 10 such cases, i.e., in relation to issues d and
220565 -            e. ref SDS 0 JS6N
220566 -
220567 -                [On 050727 follow up examination by surgeon addressed
220568 -                investigating unique factors for IBC patients.
220569 -                ref SDS 37 QJ3Q
220570 -
220571 -
220572 -
220573 -
2206 -

SUBJECTS
Criteria Approve Surgery for Extending Quality of Life Where Researc

2703 -
270401 -         ..
270402 -    4.  Criteria to Approve Surgery for Extending Quality of Life
270403 -
270404 -        The study on 041210 considered factors for surgery. ref SDS 19
270405 -        657F  Objective to extend longevity and quality of life has
270406 -        been previously considered in a study reported on 041230.
270407 -        ref SDS 22 P19O
270409 -             ..
270410 -        a.  What factors in patient history have proven conducive to
270411 -            treating IBC with surgery in light of research on 040517
270412 -            indicating mastectomy can increase chances for cancer to
270413 -            recur, when cancer spreads beyond the breast? ref SDS 10
270414 -            YM3M  How does this relate to the patient profile in this
270415 -            case, shown below, ref SDS 0 M54Q, and to recommendations
270416 -            against surgery by Doctor Benz at UCSF in an opinion
270417 -            received on 041117, ref SDS 13 OU5V, and further where
270418 -            primary care physician proposes surgery on 050311 to treat
270419 -            "areas of resistance to chemotherapy" in left breast,
270420 -            ref SDS 28 XQ41, and further where Doctor Guardino at
270421 -            Stanford cites possibility of surgery, if regression of
270422 -            inflammation occurs? ref SDS 17 SN97  Does Kaiser have data
270423 -            on patients with conditions similar to Millie; is there
270424 -            published guidance on benefits of masectomy surgery for
270425 -            Millie's patient profile as follows...
270426 -
270427 -                    [On 050610 primary care physician discusses surgery
270428 -                    after regression of inflammation occurs in the left
270429 -                    breast. ref SDS 34 XQ41
270430 -
270431 -            1.  Age 69 generally good health, weight normal, 40 years
270432 -                exercise regular and vigorous (until about a year ago,
270433 -                when chemo treatments proscribed exercise), non-smoker,
270434 -                social drinker.
270436 -                 ..
270437 -            2.  CT testing for 4 years shows no evidence of distant
270438 -                metastasis.
270439 -
270440 -                    [On 050610 history of CT tests, including recent
270441 -                    report on 050530. ref SDS 34 NL4N
270443 -                 ..
270444 -            3.  Metastatic disease involving regional lymph nodes
270445 -                by criteria...
270446 -
270447 -                a.  Out of capsule under left arm, and other cancer
270448 -                    factors reported on 020321. ref SDS 1 6Q6J
270449 -
270450 -                    Case history of recurring cancer swelling under
270451 -                    left arm, reported on 040517. ref SDS 10 OW3I
270453 -                     ..
270454 -                b.  Cancerous lymph nodes discovered on left side of
270455 -                    neck reported on 040318. ref SDS 5 8R6M
270457 -                     ..
270458 -                c.  Research today seems to suggest IBC is not always
270459 -                    inoperable, and that some patients present with
270460 -                    metastatic cancer with regional disease involving
270461 -                    lymph nodes, per below. ref SDS 0 TN76
270462 -
270463 -                        [On 051121 primary care physician finds patient
270464 -                        has no evidence of disease (NED) based on
270465 -                        estensive testing with biopsy, PET, CA 1503;
270466 -                        prognosis is for future relapse due to
270467 -                        diagnosis of metastatic cancer, and therefore
270468 -                        mastectomy surgery on 051021 was palliation for
270469 -                        furture relapse. ref SDS 44 LH7M
270471 -                 ..
270472 -            4.  IBC was not original diagnosis; patient was first
270473 -                treated with surgery to remove a tumor on 020212; after
270474 -                treatment with AC then switching to Taxotere, then
270475 -                radiation, and more Taxotere, treatment was ended in
270476 -                December 2002, reported on 031206, ref SDS 2 SM6M; on
270477 -                030109 symptoms of IBC were reported. ref SDS 3 KW5F
270478 -                On 040614 patient was diagnosed with IBC, ref SDS 11
270479 -                6T5G, after starting treatment on the Avastin trial on
270480 -                040420. ref SDS 8 9Z5J
270482 -             ..
270483 -        b.  What benefits are expected for longevity and quality of
270484 -            life from a surgical solution to perform a masectomy, as
270485 -            the core objective of treatment, shown in the study on
270486 -            041230? ref SDS 22 XV7M
270488 -             ..
270489 -        c.  What risks flow from masectomy surgery with Millie's
270490 -            patient profile, ref SDS 0 YW6M, that give pause to
270491 -            approving surgery in this case, cited by Doctor Benz at
270492 -            UCSF in a 2nd opinion received on 041117? ref SDS 13 OU5P
270493 -
270494 -
270495 -
270496 -
270497 -
270498 -
270499 -
270500 -
270501 -
2706 -

SUBJECTS
Experience Performing Surgery Limited Maybe 1 about 5 Years Ago on I
Surgery Scope 2 Breasts Remove Evaluate Criteria for Masectomy Left

3604 -
360501 -         ..
360502 -        Experience Performing Surgery on IBC Patients Rare Disease
360503 -        Skin Grafts to Avoid Restoring Surgery with Infected Tissue
360504 -
360505 -        Millie asked about resolving the dilemma of a "treatment loop"
360506 -        discussed today, per above, ref SDS 0 WH5L, by removing both
360507 -        breasts and using skin from the healthy right breast to close
360508 -        the wound from a masectomy on the left breast.  Another
360509 -        possibility would be to graft skin from another part of the
360510 -        body, say the leg, to close the wound.  Might this procedure
360511 -        reduce risk in closing a masectomy wound with tissue infected
360512 -        by IBC, discussed by the surgeon today, per above, ref SDS 0
360513 -        WH5L, and also addressing the primary care physician's
360514 -        objectives on 050311 to treat "pockets of resistance" to
360515 -        chemotherapy with surgery? ref SDS 28 PA4N
360517 -         ..
360518 -        For example, research on 040517 indicated that on rare
360519 -        occasions skin grafts are needed to heal wounds from masectomy
360520 -        surgery. ref SDS 10 VW5F  Perhaps this is such an occasion.
360522 -         ..
360523 -        The surgeon indicated today not having performed this type of
360524 -        surgery.
360525 -
360526 -            [On 050329 primary care physician advised that examination
360527 -            today was performed by the most experienced surgeon at the
360528 -            Kaiser Walnut Creek hospital and clinic. ref SDS 30 YV95
360530 -         ..
360531 -        Millie asked how many surgeries have been performed on patients
360532 -        with IBC, and what has been the track record, e.g., 8 out of 10
360533 -        successful in the past year; 2 out of 10 successful in the past
360534 -        5 years?  What experience is available for criteria to guide a
360535 -        decision on when the patient has recovered sufficiently from
360536 -        IBC to enable surgery, per above, ref SDS 0 O16N, under the
360537 -        doctor's reasoning during the meeting on 040429, ref SDS 9
360538 -        SD7F, and what are the chances for success?  Any lessons
360539 -        learned from past surgery on IBC patients, per criteria listed
360540 -        above? ref SDS 0 YW6O
360542 -         ..
360543 -        The surgeon indicated having performed a surgery once in the
360544 -        past 5 years that may have been similar to Millie's condition
360545 -        of IBC.  This aligns with research on 040517 that found IBC is
360546 -        a rare disease affecting about 1% of cancer patients.
360547 -        ref SDS 10 TO7L
360548 -
360549 -            [On 050329 primary care physician disclosed that the
360550 -            examination today was performed by a lead surgeon with as
360551 -            much or more experience than other surgeons at the Kaiser
360552 -            Walnut Creek hospital. ref SDS 30 XQ41
360554 -             ..
360555 -            [On 050727 the surgeon confirmed limited experience
360556 -            treating IBC patients because IBC occurs in less than 1% of
360557 -            breast cancer patients; indicated that Kaiser in Walnut
360558 -            Creek, CA sees maybe 1 IBC patient a year. ref SDS 37 YK78
360559 -
360560 -
360561 -
360562 -
360563 -
3606 -

SUBJECTS
Masectomy Evaluate Surgery for IBC 2nd Opinion Tumor Board Review No
Mastectomy Evaluate Surgery for IBC 2nd Opinion Tumor Board Review t
Tumor Board Review Work Plan Treatment Work Up Patient Requests to S
Tumor Board Team Care Communication Collaboration Due Diligence Chal
Stanford Offers Additional Consultation as Needed 2nd Opinion

5907 -
590801 -         ..
590802 -        Masectomy Evaluate Surgery for IBC 2nd Opinion Recommended
590803 -        Tumor Board Review to Set Criteria on Surgery to Treat IBC
590804 -        2nd Opinion Recommended to Evaluate Surgery for IBC Masectomy
590805 -
590806 -        To address limited experience treating IBC patients, per above,
590807 -        ref SDS 0 QJ3Q, the surgeon suggested getting other opinions on
590808 -        criteria for surgery to treat IBC with "pockets of resistance"
590809 -        to chemotherapy, and drawing on advice from the tumor board in
590810 -        this case to resolve the dilemma of a treatment loop shown by
590811 -        the record today, per above. ref SDS 0 WH5L
590813 -         ..
590814 -        Millie agreed.
590816 -         ..
590817 -        Doctor Benz at UCSF Cancer Center proposed in a letter received
590818 -        on 041117 to provide additional consultation on future trial
590819 -        protocols, ref SDS 13 OV3T, that supplements 2nd opinion based
590820 -        on an examination performed on 041018.  Similarly, Doctor
590821 -        Guardino in the Cancer Center at Stanford Medical Center
590822 -        offered additional consultation at the end of the 2nd opinion
590823 -        received on 041209. ref SDS 17 HS6L
590825 -         ..
590826 -        The surgeon will schedule a meeting with another doctor at
590827 -        Kaiser to examine the left breast for a determination of
590828 -        criteria on when surgery will have a good chance of succeeding.
590829 -
590830 -            [On 050401 Millie and Pam met with Doctor Choi who
590831 -            recommended against surgery at this time; there was no
590832 -            evident discussion on criteria that establish level of
590833 -            recovery where surgery can be performed. ref SDS 31 PPSU
590835 -         ..
590836 -        The surgeon will visit with the primary care physician to
590837 -        collaborate and coordinate review by the Tumor Board that draws
590838 -        on Kaiser's expertise for criteria on when to perform surgery.
590839 -        This hearing will supplement the hearing on 040416 that
590840 -        discussed surgery, reported in the meeting between the doctor
590841 -        and the patient on 040517. ref SDS 10 F77M
590842 -
590843 -            [On 050727 due diligence, collaboration, communication and
590844 -            Team Care are planned for evaluating surgical solution to
590845 -            Millie's patient profile, ref SDS 37 PF7O; for some reason
590846 -            analysis of the case through the Tumor Board process has
590847 -            not made progress at Kaiser. ref SDS 37 R36H
590849 -         ..
590850 -        The surgeon will submit a written report on the meeting today
590851 -        that clarifies understandings on the work plan to address
590852 -        pending issues.
590853 -
590854 -            [On 050329 the primary care physician had not seen a report
590855 -            from the surgeon on the meeting today, and cited a hectic
590856 -            schedule. ref SDS 30 XQ41
590857 -
590858 -
590859 -
590860 -
590861 -
590862 -
5909 -

SUBJECTS
Metastatic Cancer Regional and Distant Metastasis Very Different Reg
Research Criteria on Surgery for Masectomy to Reduce Chance of Relap

7104 -
710501 -  ..
710502 - Research Criteria on Surgery for Masectomy to Reduce Chance of Relapse
710503 -
710504 - Research on the Internet addresses requirements for criteria to assess
710505 - when surgery can be performed on a patient with IBC, per above,
710506 - ref SDS 0 OV5H, and further supports the surgeon's comments today on
710507 - treating IBC with chemotherapy before surgery. ref SDS 0 WH5L  This
710508 - research complements work on 040517 developing background on IBC.
710509 - ref SDS 10 6M9H and further. ref SDS 10 L17O
710511 -         ..
710512 -        [On 050712 further research for natural remedies to supplement
710513 -        medical treatments. ref SDS 36 4P62
710515 -         ..
710516 -        [On 050712 research types of breast surgery for masectomy.
710517 -        ref SDS 36 J46O
710519 -  ..
710520 - Nearly every authority indicates that surgery is not an appropriate
710521 - treatment for IBC.  There is an exception, but no criteria is shown
710522 - for when surgery can be performed, and the scope of removal when
710523 - disease has spread, per above. ref SDS 0 WH5L
710525 -  ..
710526 - One authority says in part...
710527 -
710528 -        Journal of Clinical Oncology, Vol 23, No 16 (June 1), 2005:
710529 -        pp. 3860-3862; 2005 American Society of Clinical Oncology
710530 -        DOI: 10.1200/JCO.2005.05.294
710531 -
710532 -                http://www.jco.org/cgi/content/full/23/16/3860
710534 -         ..
710535 -        CORRESPONDENCE
710537 -         ..
710538 -        In Reply
710540 -         ..
710541 -        George Somlo
710543 -         ..
710544 -        Division of Medical Oncology and Therapeutics Research, City
710545 -        of Hope Comprehensive Cancer Center, Duarte, CA
710546 -
710548 -         ..
710549 -        Metastatic Cancer Regional Lymph Nodes May be Operable
710550 -        Regional Metastasis May be Operable Not Distant Metastasis
710551 -        Surgery Criteria Metastatic Sites within Regional Lymph Nodes
710552 -        IBC Not Always Inoperable Indicates Surgery is Not Common
710553 -
710554 -
710555 - Solmo continues...
710556 -
710557 -        Next, I would like to address comments regarding treatment and
710558 -        outcome. Inflammatory breast carcinoma is not always
710559 -        inoperable, although we agree that a surgeon's willingness and
710560 -        ability to perform an operation does not mean that such
710561 -        approach should be encouraged. While up-front surgery is not
710562 -        the current recommendation in the management of inflammatory
710563 -        breast cancer, lack of familiarity with neoadjuvant strategies
710564 -        and inflammatory carcinomatous presentation, especially in our
710565 -        earlier cases, did lead to the occasional primary surgical
710566 -        intervention followed by adjuvant chemotherapy.
710568 -         ..
710569 -        Our patient population was somewhat heterogeneic both from the
710570 -        biologic and treatment point of view, but we did not include
710571 -        any patient with metastatic sites beyond regional lymph nodes.
710573 -  ..
710574 - This presentation indicating IBC is not always inoperable, suggests
710575 - that surgery is an exception for treatment of IBC, and so supports
710576 - authorities who discourage surgery for treatment in Millie's case,
710577 - e.g., primary care physician in Oncology Department at Kaiser on
710578 - 040812, ref SDS 12 SE61, supported by Doctor Benz at UCSF in a 2nd
710579 - opinion received on 041117. ref SDS 13 OU5P  Doctor Guardino at
710580 - Stanford indicated only that surgery might be useful for Millie, in a
710581 - 2nd opinion received on 041209. ref SDS 17 SN97
710583 -             ..
710584 -            [On 050712 research indicates surgery can be a treatment
710585 -            option for stage III cancer, and is generally not attempted
710586 -            for stage IV cancer patients, who instead receive
710587 -            palliative treatment. ref SDS 36 B65G
710589 -             ..
710590 -            [On 051121 primary care physician finds patient has no
710591 -            evidence of disease (NED) based on estensive testing with
710592 -            biopsy, PET, CA 1503; prognosis is for future relapse due
710593 -            to diagnosis of metastatic cancer, and therefore mastectomy
710594 -            surgery on 051021 was palliation for furture relapse.
710595 -            ref SDS 44 LH7M
710597 -  ..
710598 - Millie's condition may fit the criteria of not having "metastatic
710599 - sites beyond regional lymph nodes," ref SDS 0 O84N, based on the
710600 - meeting with the primary care physician at Kaiser on 040812.
710601 - ref SDS 12 LQ5M  Earlier on 020321 the doctor submitted excerpts from
710602 - the AJCC Cancer Staging Handbook, which mentions Regional Lymph Nodes,
710603 - ref SDS 1 6Q6N, as distinct from a local site for tumor, ref SDS 1
710604 - ON5I, and further distinct from distant metastatis. ref SDS 1 6R5X
710606 -  ..
710607 - We still need guidance on when IBC has recovered sufficiently for
710608 - surgery, and how far the surgery should extend toward the neck.
710610 -  ..
710611 - There is an email address...
710612 -
710613 -                   gsomlo@coh.org
710614 -
710615 - ...for the author.  May be able to get criteria for when to perform
710616 - surgery.
710617 -
710618 -
710620 -  ..
710621 - Another site....
710622 -
710623 -       Inflammatory Breast Cancer
710624 -       Help Website - Surgery
710625 -
710626 -              http://www.ibchelp.org/mrm.html
710627 -
710628 - ...discusses surgery, but not criteria for when surgery can be
710629 - performed.
710630 -
710631 -
710632 -
710633 -
710634 -
710635 -
710636 -
710637 -
710638 -
710639 -
7107 -