CONTACTS 

SUBJECTS
Biopsy Wound Healed Completely After 5 Treatments Taxotere Capecitab
Meeting Surgeon Evaluate Masectomy Left Breast Follow Up Requested b

0704 -
0704 -    ..
0705 - Summary/Objective
0706 -
070601 - Follow up ref SDS 28 0000. ref SDS 27 0000.
070602 -
070603 - Examination showed significant progress treating IBC in the left
070604 - breast. ref SDS 0 YY7F  Millie was cleared for surgery to have a
070605 - mastectomy based on criteria previously developed to assess recovery
070606 - from IBC. ref SDS 0 OV5H  Limited experience treating patients with
070607 - IBC, ref SDS 0 QJ3Q, will be resolved by performing due diligence to
070608 - collaborate over the next few weeks, and leverage expertise on scope
070609 - and details performing mastectomy on patients with IBC, which is a
070610 - very rare disease. ref SDS 0 O85O  The surgeon did an excellent job
070611 - reviewing criteria for patient to consider surgery based on variables
070612 - of metastatic cancer with involvement of regional lymph nodes, but no
070613 - evident distant metastasis. ref SDS 0 VL4O
070614 -
070615 -     [On 050729 Doctor Shim called and talked to Millie on referral
070616 -     from the surgeon and recommended surgery on only the left breast,
070617 -     rather than remove both breasts. ref SDS 38 V15F
070619 -      ..
070620 -     [On 050729 primary care physician in Oncology discusses surgeon's
070621 -     examination today. ref SDS 39 025H
070623 -      ..
070624 -     [On 050826 examination by a surgeon in Kaiser's Oakland office
070625 -     found substantially similar conditions, i.e., that the patient has
070626 -     recovered sufficiently from IBC to be ready for surgery.
070627 -     ref SDS 46 AY5N
070629 -      ..
070630 -     [On 050923 criteria revised and additional testing ordered to
070631 -     evaluate when patient diagnosed with IBC on relapse is ready for
070632 -     mastectomy surgery. ref SDS 51 OV5H
070633 -
070634 -
070635 -
070637 -  ..
0707 -
0708 -
0709 - Progress
0710 -
071001 - Wound from Punch Biopsy Taken on 040419 Now Fully Healed
071002 -
071003 - Follow up ref SDS 28 WI6K, ref SDS 22 IS5N.
071004 -
071005 - The surgeon examined Millie's left breast in accordance with request
071006 - by the primary care physician in Oncology on 050610, ref SDS 35 XQ41,
071007 - and following up examinations on 050107, when the surgeon found there
071008 - were no evident "boundaries" for peforming surgery to remove infected
071009 - tissue. ref SDS 22 UM6I   Similar findings on 050324, ref SDS 28 WI6K,
071010 - were later discussed with the primary care physician on 050329,
071011 - ref SDS 29 XQ41, and examined again by Doctor Choi on 050401.
071012 - ref SDS 30 EY9J
071014 -         ..
071015 -    1.  The surgeon noticed the wound now seems fully healed from the
071016 -        punch biopsy taken on 040419, ref SDS 6 XU52, continuing
071017 -        improvement reported on 050324, and following five (5)
071018 -        treatments with Taxotere and capecitabine (Xeloda), reported on
071019 -        050708. ref SDS 36 0001
071020 -
071021 -            [On 050729 primary care physician noted the surgeon's
071022 -            examination today. ref SDS 39 6T5G
071023 -
071024 -
071025 -
071026 -
071027 -
071028 -
0711 -

SUBJECTS
IBC Symptoms Left Breast Resolved Inflammation Red Thickened Skin Ca

1803 -
180401 -  ..
180402 - Regional Symptoms Cancer Left Breast Subside
180403 - IBC Symptoms Resolved Inflammation Red Thickened Skin Cancer Sores
180404 -
180405 - Follow up ref SDS 28 YY7F.
180406 -
180407 -    2.  The surgeon commented that problems setting surgical boundaries
180408 -        that prevented mastectomy on 050107, ref SDS 22 UM6I, have now
180409 -        been eliminated after five (5) cycles with Taxotere and
180410 -        capecitabine (Xeloda), reported on 050708, ref SDS 36 0001, and
180411 -        begun on 050415, ref SDS 31 407N, folloiwng the doctor's order
180412 -        to switch treatments on 050329, ref SDS 29 FP57, that
180413 -        implements recommendations on 041117 by Doctor Benz at UCSF.
180414 -        ref SDS 10 OU6S  Examination today shows inflammation (redness)
180415 -        in the left breast is now completely eliminated by
180416 -        visualization compared to the right breast, and further
180417 -        compared to prior examinations on...
180419 -                   ..
180420 -                  050401......................... ref SDS 30 EY9J
180421 -                  050324......................... ref SDS 28 YY7F
180422 -                  050107......................... ref SDS 22 IS5N
180423 -                  041209......................... ref SDS 15 O23T
180424 -                  041117......................... ref SDS 10 OU5T
180425 -                  040429......................... ref SDS 7 SD7F
180426 -                  040419......................... ref SDS 6 XU4S
180428 -             ..
180429 -            [On 050729 primary care physician noted the surgeon's
180430 -            examination today. ref SDS 39 025H
180432 -             ..
180433 -            [On 050923 examination shows recovery from IBC has been
180434 -            maintained with three (3) more chemotherapy treatment
180435 -            cycles. ref SDS 51 7J6G
180437 -         ..
180438 -        Contortion of the nipple appears fully resolved.
180440 -         ..
180441 -        Skin texture of left breast, including the biopsy wound, cited
180442 -        above, ref SDS 0 WI6K, is nearly the same as the right breast,
180443 -        and closer to normal than found by examination on 050324.
180444 -        ref SDS 28 YY7F  Remaining stiffness of the skin on the left
180445 -        breast may be reaction to radiation treatments in July and
180446 -        August 2002, based on prior analysis by the primary care
180447 -        physician on 030710 citing analysis in CT test report.
180448 -        ref SDS 3 WQ5K
180450 -         ..
180451 -        Examination today shows marked improvement from conditions
180452 -        observed by Doctor Benz at UCSF on 041018, following treatment
180453 -        on the Avastin trial, and described in a report received on
180454 -        041117, ref SDS 10 OU5T, and further containing similar
180455 -        findings from examination by Doctor Guardino at Stanford on
180456 -        041019, and described in a report received on 041209.
180457 -        ref SDS 15 O23T
180459 -         ..
180460 -        This examination combined with CA 15-3 falling substantially,
180461 -        (see below, ref SDS 0 YK6K), and CT test report on 050610
180462 -        indicates that regional symptoms of cancer at axillary and
180463 -        supraclavicular sites have subsided, and now seem controlled,
180464 -        as presented by the primary care physician in Oncology on
180465 -        050610. ref SDS 35 XQ41  This seems close to the condition
180466 -        described by Doctor Guardino at Stanford for considering
180467 -        surgery, in a 2nd opinion received on 041209. ref SDS 15 SN97
180468 -
180469 -            [On 050729 primary care physician in Oncology relied on
180470 -            surgeon's examination today. ref SDS 39 025H
180472 -             ..
180473 -            [On 050826 examination by a surgeon in Kaiser's Oakland
180474 -            office found substantially similar conditions, i.e., that
180475 -            the patient has recovered sufficiently from IBC to be ready
180476 -            for surgery. ref SDS 46 AY5N
180477 -
180478 -
180479 -
180480 -
180482 -  ..
180483 - Dilemma Resolved Chemo Heals IBC Sufficient for Surgery
180484 - Surgery for Masectomy Ready to Go After Chemotherapy Heals IBC
180485 - Treatment Loop Resolved Surgery Ready to Go After Chemo Heals IBC
180486 -
180487 - Follow up ref SDS 28 WH5L.
180489 -  ..
180490 - Background on considerations for surgery are summarized on 041210,
180491 - ref SDS 17 ZV5J, and case study to prevent disease from cascading out
180492 - of control to extend quality of life is reported on 041230.
180493 - ref SDS 20 XV7M
180495 -  ..
180496 - Findings today resolve the "treatment loop" (i.e., dilemma) caused by
180497 - "pockets of resistance" to chemotherapy cited during the meeting in
180498 - the Oncology Department on 050311, ref SDS 26 PA4N, and later
180499 - presented to the surgeon during the meeting on 050324, ref SDS 28
180500 - QI5N, and, further, was accomplished by changing the chemotherapy drug
180501 - prescription on 050329. ref SDS 29 E87M
180502 -
180503 -
180504 -
180505 -
180506 -
1806 -

SUBJECTS
Criteria Surgery Masectomy IBC Biopsy Not Necessary for Surgery CA 1

2303 -
230401 -         ..
230402 -    3.  Criteria for Surgery to Perform Masectomy on IBC Patient
230403 -        Surgery Patient Ready Based on Criteria to Assess IBC Recovery
230404 -
230405 -        Follow up ref SDS 28 OV5H, ref SDS 26 XQ41.
230406 -
230407 -        Background on considerations to perform surgery for a
230408 -        mastectomy is summarized on 041210. ref SDS 17 ZV5J  Today, the
230409 -        surgeon indicated mastectomy can now be performed based
230410 -        criteria from the meeting on 050324, ref SDS 28 OV5H, and as
230411 -        requested by the primary care physician on 050311. ref SDS 26
230412 -        PB4N
230414 -         ..
230415 -        On 050329 the primary care physician planned to discuss with
230416 -        the surgeon criteria for mastectomy surgery in Millie's case.
230417 -        ref SDS 29 T89H  The surgeon advised today that she has
230418 -        received several telephone messages from the primary care
230419 -        physician, and has returned calls and left messages, but so far
230420 -        there has not been enough time for discussions.
230421 -
230422 -               [...see below for challenge of collaboration in team
230423 -               care practice. ref SDS 0 R36H
230425 -                ..
230426 -               [On 050913 patient requests joint meeting between
230427 -               oncology and surgery departments to aid collaboration
230428 -               that has been difficult to accomplish previously; this
230429 -               was rejected because team care practice and
230430 -               collaboration are not practical due to conflicting
230431 -               schedules. ref SDS 48 6W4L
230433 -                ..
230434 -               [On 050916 primary care physician reported during a
230435 -               brief meeting with the patient in the Chemotherapy
230436 -               Clinic that he had met and discussed Millie's case with
230437 -               the surgeon.  Results of the meeting were not presented.
230438 -               ref SDS 49 PF3G
230440 -                ..
230441 -               [On 050923 the surgeon reported on meeting with the
230442 -               primary care physician in the hallway for a brief
230443 -               discussion. ref SDS 51 LP6H
230445 -                ..
230446 -               [On 050923 criteria revised and additional testing
230447 -               ordered to evaluate when patient diagnosed with IBC on
230448 -               relapse is ready for mastectomy surgery. ref SDS 51 OV5H
230450 -         ..
230451 -        The surgeon explained having a personal website at Kaiser's
230452 -        location on the Internet that presents background, credentials,
230453 -        and guidelines in the Healthwise Handbook...
230454 -
230455 -                  http://www.permanente.net/doctor/rileypaull
230457 -             ..
230458 -        a.  Biopsy criteria listed on 050324.
230459 -            ref SDS 28 OV8L
230461 -             ..
230462 -            Millie said she wants to avoid a biopsy test, because it
230463 -            took so long (about 15 months) to cure the wound from the
230464 -            last biopsy, cited by the surgeon on 050107. ref SDS 22
230465 -            IS5N
230467 -             ..
230468 -            The surgeon commented that a biopsy could be performed to
230469 -            verify that IBC has been cured, similar to the procedure
230470 -            that originally discovered IBC on 040419, ref SDS 28 OV8L,
230471 -            but feels biopsy is not an essential criteria for deciding
230472 -            to have surgery in this case.
230473 -
230474 -                [On 050826 referral surgeon in Kaiser's Oakland office
230475 -                indicated a needle biopsy as performed on 040419 to
230476 -                discover IBC is not helpful determining IBC has
230477 -                recovered sufficiently for a successful mastectomy.
230478 -                ref SDS 46 T14L
230480 -                 ..
230481 -                [On 050920 Doctor Grissom 2nd opinion proposes thin
230482 -                full thickness surgical biopsies with suture closure
230483 -                (rather than punch biopsy) to test for IBC and help
230484 -                determine scope of surgery. ref SDS 50 XL7P
230486 -                 ..
230487 -                [On 050923 the surgeon at Kaiser in Walnut Creek agrees
230488 -                to perform biopsies to determine complete response to
230489 -                treatment for local disease. ref SDS 51 SZ6M
230491 -                 ..
230492 -                [On 051012 4 biopsies were taken during minor surgery
230493 -                at Kaiser in Walnut Creek. ref SDS 52 DG6J
230495 -             ..
230496 -        b.  CA 15-3 criteria consistently below normal listed on
230497 -            050324. ref SDS 28 K13M
230499 -             ..
230500 -            The surgeon checked the computer and found CA 15-3 elevated
230501 -            to 46 following the prior test of 37 on 050708. ref SDS 36
230502 -            2N5J  There was discussion that getting CA 15-3 within the
230503 -            "normal" range below 39 for a month or so is encouraging,
230504 -            as previously noted by primary care physician on 040812,
230505 -            ref SDS 9 CT9J, but should not necessarily control the
230506 -            timing of surgery.
230507 -
230508 -                [On 050729 primary care physician extends chemotherapy
230509 -                treatment for 2 more cycles and maintains strength,
230510 -                rather than reduce the dose to reduce side effects,
230511 -                aiming for due diligence to avoid another relapse that
230512 -                might delay surgery, or otherwise prolong and compound
230513 -                disease. ref SDS 39 VP4N
230515 -                 ..
230516 -                [On 050819 CA 15-3 dropped to 39 after 6th cycle of
230517 -                Taxotere and capecitabine (Xeloda), and for blood test
230518 -                drawn on 050812, which was reported during chemotherapy
230519 -                treatment. ref SDS 44 VK8K
230521 -             ..
230522 -        c.  Coloration and texture criteria restored to normal listed
230523 -            on 050324. ref SDS 28 034H
230525 -             ..
230526 -            The surgeon indicated that clinical examination today
230527 -            finding regression of inflammation, including healing of
230528 -            the biopsy wound, and improved skin texture, ref SDS 0
230529 -            YY7F, might establish that IBC is sufficiently "cured" or
230530 -            otherwise subsided for surgery to have a chance of success,
230531 -            discussed with Doctor Choi on 050401. ref SDS 30 EY9J
230532 -            Collaboration may shed more light on this issued, as noted
230533 -            below. ref SDS 0 O85O
230535 -             ..
230536 -        d.  Regional symptoms at axillary and supraclavicular sites
230537 -            have closely tracked rise and fall of local cancer symptoms
230538 -            in the left breast, and have now subsided and seem
230539 -            controlled, as a result of treating IBC with Taxotere and
230540 -            capecitabine (Xeloda), reported on 050610. ref SDS 35 XQ41
230541 -            Compare study of patient history on lump under left arm in
230542 -            the record on 040517, ref SDS 8 OW3I, with study of
230543 -            inflammation and skin thickening on left breast, also,
230544 -            listed on 040517. ref SDS 8 2F4G
230546 -             ..
230547 -            Activity on the right axillary reported on 050329, and
230548 -            almost resolved on 050610 may present as "distant," rather
230549 -            than "regional" symptoms. ref SDS 35 B58M
230551 -             ..
230552 -        e.  Boundary and scope of wider than normal mastectomy surgery
230553 -            based on planning criteria listed on 050324. ref SDS 28
230554 -            0347
230556 -             ..
230557 -            The surgeon emphasized and demonstrated by pointing to the
230558 -            patient's breast that visual observation today indicates
230559 -            there is now ample healthy tissue to close the wound above
230560 -            and below the local area of breast tissue to be removed.
230562 -             ..
230563 -            Millie asked how the boundary will be established for
230564 -            making a surgical incision to remove the breast, and what
230565 -            criteria or purpose will guide this determination?
230567 -             ..
230568 -            The surgeon commented that boundaries for surgery can be
230569 -            estimated to reduce the risk of relapse based on memory of
230570 -            how far IBC spread toward the neck, observed during
230571 -            examination on 050107.  At that time, no boundary could be
230572 -            established, because IBC "fingered out" in patches toward
230573 -            the neck. ref SDS 22 UM6I  Today, the doctor feels surgical
230574 -            boundaries can be set because there is no visible evidence
230575 -            of IBC.  The surgeon placed her index finger on the right
230576 -            hand slightly above the nipple to indicate the top boundary
230577 -            for a normal mastectomy; she then spread her middle finger
230578 -            up about an inch or so to indicate her plan to perform
230579 -            mastectomy surgery with a wider than normal boundary in
230580 -            this case to remove skin previously infected with IBC, as
230581 -            observed on 050324. ref SDS 28 YY7F  Disparity between
230582 -            conditions on 050107 and 050324 were not discussed during
230583 -            the meeting because nobody could remember that far back in
230584 -            time.
230585 -
230586 -               [On 050920 Doctor Grissom 2nd opinion proposes series of
230587 -               thin skin biopsies to investigate recovery from IBC and
230588 -               set boundaries for very wide standard mastectomy to
230589 -               reduce risk of relapse. ref SDS 50 XL8U
230591 -                ..
230592 -               [On 050923 the surgeon explained plans for a standard
230593 -               mastectomy if PET scan tests, and test biopsies show no
230594 -               evidence of disease. ref SDS 51 4G4L
230596 -                ..
230597 -               [On 051021 surgeon performed surgery and explained that
230598 -               a very wide mastectomy was accomplished with standard
230599 -               closure and without complications. ref SDS 53 MM6M
230600 -
230601 -
230602 -
230603 -
230604 -
230605 -
2307 -

SUBJECTS
Surgery Scope 2 Breasts Remove Evaluate Criteria for Masectomy Left
Breasts Surgery Both Right Left One Operation Reduce Chances of Rela

2604 -
260501 -             ..
260502 -            Mastectomy Both Breasts Skin Grafts Healthy Tissue
260503 -            Scope Surgery Remove 2 Breasts Reduce Chances Relapse
260504 -
260505 -            Millie asked again about having both breasts removed,
260506 -            rather than bother with prostheses, reconstructive surgery,
260507 -            etc., and to further reduce chances of relapse assuming
260508 -            that so far the breast area has proven most susceptible to
260509 -            cancer, as discussed previously with the surgeon on 050324
260510 -            in connection with considering a skin graft. ref SDS 28
260511 -            QJ3Q
260513 -             ..
260514 -            The doctor commented that since there now appears to be
260515 -            ample healthy skin within boundaries that permit closure of
260516 -            a standard mastectomy, per above, ref SDS 0 JV5F, skin
260517 -            graft procedures need no longer be considered, eliminating
260518 -            concerns about limited experience discussed on 050324.
260519 -            ref SDS 28 F14N  How the skin area would be determined
260520 -            where IBC inflammation has previously occurred, but is no
260521 -            longer visible due to interim healing, was not clear from
260522 -            the demonstration during the meeting.  This is likely a
260523 -            common problem in cases of IBC, and so undoubtedly has been
260524 -            addressed successfully, and further can be applied through
260525 -            collaboration, per below. ref SDS 0 O85O
260526 -
260527 -                [On 050908 Kaiser referral does not address
260528 -                requirements for experience to perform a successful
260529 -                mastectomy surgery on a patient with IBC. ref SDS 47
260530 -                NG5K
260531 -
260533 -             ..
260534 -            The surgeon indicated that removing both breasts when only
260535 -            one is currently infected is a fairly common practice,
260536 -            though not always recommended, and so should be discussed
260537 -            with the primary care physician in the Oncology Department.
260538 -
260539 -                [On 050729 Doctor Shim in Kaiser's Oakland office
260540 -                called Millie on referral from the surgeon, and
260541 -                recommended mastectomy on only the left breast, rather
260542 -                than remove both breasts. ref SDS 38 V15F
260544 -                 ..
260545 -                [On 050826 following examination, and before reviewing
260546 -                patient history, the surgeon in Oakland proposed not
260547 -                removing both breasts. ref SDS 46 T24G
260548 -
260549 -
260550 -
260551 -
2606 -

SUBJECTS
Experience Performing Surgery Limited Maybe 1 about 5 Years Ago on I

3403 -
340401 -             ..
340402 -        f.  Experience Rare Doing Surgery on Patients IBC Rare Disease
340403 -
340404 -            Follow up ref SDS 28 QJ3Q.
340405 -
340406 -            Experience performing mastectomy surgery for IBC patients
340407 -            criteria listed on 050324. ref SDS 28 YW6O
340409 -             ..
340410 -            The surgeon confirmed understandings from the meeting on
340411 -            050324 having limited experience treating patients with
340412 -            IBC, ref SDS 28 QJ44, noting this is a rare form of cancer
340413 -            that occurs in less than 1% of breast cancer patients,
340414 -            reported previously from research on 040517. ref SDS 8 TO7L
340415 -
340416 -                [On 050908 Kaiser referral does not address follow up
340417 -                request on requirements for experience to perform a
340418 -                successful mastectomy surgery on a patient with IBC.
340419 -                ref SDS 47 NG5K
340421 -             ..
340422 -            The surgeon said that they see maybe 1 patient a year with
340423 -            IBC, and confirmed that the last time the surgeon performed
340424 -            a mastectomy on a patient with IBC-like complications was
340425 -            about 5 years ago.  Results of that experience were not
340426 -            presented today.
340427 -
340428 -
340429 -
340430 -
340431 -
340432 -
340433 -
3405 -

SUBJECTS
Mastectomy Evaluate Surgery for IBC 2nd Opinion Tumor Board Review N

7003 -
700401 -         ..
700402 -        Due Diligence Communicate Collaboration Leverage Experience
700403 -        Masectomy Evaluate Surgery for IBC 2nd Opinion Recommended
700404 -        Tumor Board Review to Set Criteria on Surgery to Treat IBC
700405 -        2nd Opinion Recommended to Evaluate Surgery for IBC Masectomy
700406 -
700407 -        Follow up ref SDS 28 O85O.
700409 -         ..
700410 -        The surgeon feels that limited experience can be leveraged by
700411 -        performing due diligence through consulting practitioners for
700412 -        second opinions who specialize in working with IBC patients.
700413 -        The surgeon will investigate by "asking around" within Kaiser
700414 -        on criteria discussed today for surgery on IBC patients.
700415 -        ref SDS 0 OV5H
700416 -
700417 -            [On 050908 Kaiser referral does not address requirements
700418 -            for experience to perform a successful mastectomy surgery
700419 -            on a patient with IBC. ref SDS 47 NG5K
700421 -         ..
700422 -        The next 4 - 6 weeks can be used to solidify evaluation of
700423 -        stable recovery from IBC, based on CA 15-3 and other factors,
700424 -        noted above. ref SDS 0 YK6K  During this time, due diligence
700425 -        can run concurrently with the surgeon and primary care
700426 -        physician collaborating on issues performing surgery for
700427 -        Millie's patient profile.  The surgeon will submit written
700428 -        analysis of findings and recommendations to the primary care
700429 -        physician in the Oncology Department.
700430 -
700431 -            [On 050729 primary care physician discusses due diligence,
700432 -            ref SDS 39 BZ56, ordering additional treatments to avoid
700433 -            another relapse. ref SDS 39 VP4N
700435 -             ..
700436 -            [On 050913 primary care physician objected that performing
700437 -            2nd opinions on the Time Out checklist for due diligence
700438 -            evaluating mastectomy surgery delayed surgery. ref SDS 48
700439 -            5T4J
700441 -         ..
700442 -        Sources identified so far for consultation and collaboration
700443 -        on surgical solution...
700444 -
700445 -            1.  Primary care physician....... 050311, ref SDS 26 PA4N
700446 -            2.  Tumor Board.................. 041130, ref SDS 11 J66G
700447 -            3.  Doctor Benz at UCSF.......... 041117, ref SDS 10 OV3T
700448 -            4.  Doctor Guardino at Stanford.. 041209, ref SDS 15 HS6L
700449 -            5.  Kaiser IBC experience........ 050727, ref SDS 0 O85O
700450 -            6.  George Somlo wrote paper..... 050324, ref SDS 28 TN69
700452 -                  ..
700453 -                 [On 050729 Doctor Shim called and talked to Millie on
700454 -                 referral from the surgeon and recommended surgery on
700455 -                 only the left breast, rather than remove both breasts;
700456 -                 there was no evident review of criteria. ref SDS 38
700457 -                 V15F
700459 -                  ..
700460 -                 [On 050805 Millie received a letter from Doctor Shim's
700461 -                 assistant requesting that Millie meet with the doctor;
700462 -                 scheduled meeting for 050826 0930. ref SDS 40 V15F
700464 -                  ..
700465 -                 [On 050811 begin planning for 2nd opinion. ref SDS 41
700466 -                 0001
700468 -                  ..
700469 -                 [On 050812 case study on chronology patient history
700470 -                 prepared to support 2nd opinion. ref SDS 42 0001
700472 -                  ..
700473 -                 [On 050819 letter to UCSF requesting 2nd opinion to
700474 -                 backup Kaiser's analysis. ref SDS 43 0001
700476 -                  ..
700477 -                 [On 050908 Kaiser referral does not address
700478 -                 requirements for experience to perform a successful
700479 -                 mastectomy surgery on a patient with IBC. ref SDS 47
700480 -                 NG5K
700482 -         ..
700483 -        There was no discussion today on performing due diligence (see
700484 -        NWO, ref OF 13 PQ4M) to draw on experience from a Tumor Board
700485 -        hearing, planned during the meeting on 050324. ref SDS 28 O85O
700486 -        Previously, communication and collaboration with Kaiser's Team
700487 -        Care practice has proven difficult to accomplish, reported on
700488 -        050311, ref SDS 26 U83K, and again on 050329; a hectic schedule
700489 -        necessarily limits time for review to understand and follow up
700490 -        critical details. ref SDS 29 X76G  The surgeon's report today
700491 -        that discussions have been delayed with the primary care
700492 -        physician on criteria for surgery, per above, ref SDS 0 OV5H,
700493 -        illustrates that collaboration presents a significant challenge
700494 -        in team care practice.  On 041130 the primary care physician
700495 -        discussed Tumor Board hearing to support change in treatment
700496 -        planning. ref SDS 11 YR8F  This record indicates that investing
700497 -        time to study, analyse, and learn presents a burden of
700498 -        cognitive overhead, that seems, in the moment, to delay working
700499 -        intelligently in order to make action effective, and therefore
700500 -        remains a big challenge, explained in NWO. ref OF 13 LH6K
700502 -             ..
700503 -            [On 050517 case study cognitive overhead shows culture
700504 -            resists due diligence to collaborate, communicate,
700505 -            investigate, study, analyse, and verify accuracy that
700506 -            leverages experience for taking effective action, because
700507 -            people do not have time to think. ref SDS 32 PY4U
700509 -             ..
700510 -            [On 050913 primary care physician objected that performing
700511 -            2nd opinions on the Time out checklist for due diligence
700512 -            evaluating mastectomy surgery delayed surgery. ref SDS 48
700513 -            5T4J
700515 -             ..
700516 -            [On 050913 patient requests joint meeting between oncology
700517 -            and surgery departments to aid collaboration that has been
700518 -            difficult to accomplish previously; this was rejected
700519 -            because team care practice and collaboration are not
700520 -            practical due to conflicting schedules. ref SDS 48 6W4L
700522 -             ..
700523 -            [On 050916 primary care physician reported during a brief
700524 -            meeting with the patient in the Chemotherapy Clinic that he
700525 -            had met and discussed Millie's case with the surgeon.
700526 -            Results of the meeting were not presented. ref SDS 49 PF3G
700528 -             ..
700529 -            [On 050923 the surgeon reported on meeting with the primary
700530 -            care physician in the hallway for a brief discussion.
700531 -            ref SDS 51 LP6H
700532 -
700533 -
700534 -
700535 -
700536 -
700537 -
700538 -
700539 -
7006 -

SUBJECTS
Criteria Approve Surgery for Extending Quality of Life Where Researc

7703 -
770401 -         ..
770402 -    4.  Criteria to Approve Surgery for Extending Quality of Life
770403 -        Patient Decision to Have Surgery Consult with the Oncologist
770404 -        Regional Lymph Nodes Metastatic Cancer Surgery Close Call
770405 -        Surgery Close Call Regional Lymph Nodes Metastatic Cancer
770406 -
770407 -        Follow up ref SDS 28 VL4O.
770408 -
770409 -        The surgeon noted that in addition to determining criteria for
770410 -        patient condition that permits surgery, discussed above,
770411 -        ref SDS 0 OV5H, the strategic decision on whether to have a
770412 -        mastectomy rests with the patient in consultation with Oncology,
770413 -        and guided by another set of criteria.
770415 -             ..
770416 -            [On 050729 primary care physician asks for the date surgery
770417 -            has been scheduled. ref SDS 39 BZ56
770419 -             ..
770420 -            [On 050811 planning begins for 2nd opinion. ref SDS 41 0001
770422 -             ..
770423 -            [On 050823 UCSF makes referral to surgical oncologists for
770424 -            considering decision to have a mastectomy. ref SDS 45 QF81
770426 -         ..
770427 -        The surgeon advised that mastectomy surgery has become a fairly
770428 -        routine procedure; most women recover without complications.
770429 -        This aligns with recent research on 050712. ref SDS 37 J46O
770430 -        Since Millie was diagnosed with metastatic cancer on 040318,
770431 -        ref SDS 5 8R6M, this presents higher risks that require careful
770432 -        consideration.  The surgeon indicated that issues on extending
770433 -        quality of life considered in the record on 050324 offer good
770434 -        criteria for making this important decision. ref SDS 28 VL4O
770435 -
770436 -            [On 050908 Kaiser referral does not address request for
770437 -            risk analysis of surgery for Millie's patient profile.
770438 -            ref SDS 47 YO6I
770440 -         ..
770441 -        Research on 050324 yielded a professional comment that IBC is
770442 -        not always inoperable, ref SDS 28 TN76, which seems to present
770443 -        a bias against surgery that may align with Doctor Benz at UCSF,
770444 -        who discouraged surgery in a 2nd opinion received on 041117.
770445 -        ref SDS 10 OU5P  Earlier research on 040517 indicated
770446 -        mastectomy surgery in some cases can worsen conditions for IBC
770447 -        patients. ref SDS 8 S74N  On the other hand, Doctor Guardino at
770448 -        Stanford stated in a 2nd opinion received on 041209 that
770449 -        surgery might be an option after inflammation regresses, though
770450 -        without indicating criteria for evaluating when sufficient
770451 -        regression has occurred. ref SDS 15 SN97
770453 -         ..
770454 -        In this case, the patient experienced continuing and slight
770455 -        inflammation and skin thickening centered on alighment of
770456 -        radiation treatments in 2002.  How does the practitioner
770457 -        distinguish this condition to determine that IBC has fully
770458 -        regressed?
770460 -         ..
770461 -        The surgeon today elaborated by further observing that removal
770462 -        of a breast, where regional cancer has occurred beyond the
770463 -        breast, reaching into the lymph nodes under the arm, found
770464 -        during the original surgery on 020212, and later in the neck on
770465 -        040309, ref SDS 4 0001, suggests microscopic cancerous cells
770466 -        still exist in the breast skin and even beyond the breast that
770467 -        are not detectable by CT testing.  Removing the breast may have
770468 -        no impact on relapse from cells at very low levels.  Research
770469 -        on 050324 also indicates surgery is performed on patients with
770470 -        metastatic cancer that involves regional lymph nodes,
770471 -        ref SDS 28 O84N, which applies in this case, rather than
770472 -        distant metastasis, which does not apply in this case based on
770473 -        CT testing, but no PET testing.  The patient might be lucky
770474 -        with chemotherapy destroying all of cancerous cells, shown by
770475 -        favorable CT tests, and falling CA 15-3 cancer marker to below
770476 -        the high end of normal (39) over an extended period, cited by
770477 -        the primary care physician in Oncology on 040812. ref SDS 9
770478 -        CT9J  The report today that CA 15-3 has risen above 39 again is
770479 -        not dispositive, but may indicate cancer activity somewhere.
770480 -        ref SDS 0 YK6K
770481 -
770482 -            [On 051121 primary care physician finds patient has no
770483 -            evidence of disease (NED) based on estensive testing with
770484 -            biopsy, PET, CA 1503; prognosis is for future relapse due
770485 -            to diagnosis of metastatic cancer, and therefore mastectomy
770486 -            surgery on 051021 was palliation for furture relapse.
770487 -            ref SDS 54 LH7M
770489 -             ..
770490 -            [On 060711 patient diagnosed with IBC relapse in left
770491 -            breast. ref SDS 55 025H
770493 -         ..
770494 -        PET scan testing has previously identified cancer activity not
770495 -        identified by CT tests, reported on 020603.  At that time,
770496 -        Oncology indicated this test did not establish distant
770497 -        metastasis, ref SDS 1 0001, but rather showed regional lymph
770498 -        node activity that is treatable.  PET test on 021218 at the end
770499 -        of phase II chemotherapy was reviewed on 030109, ref SDS 2
770500 -        LK5L, and showed mild diffuse increased soft tissue activities
770501 -        in the left axilla, upper chest wall, and supraclavicular
770502 -        regions, ref SDS 2 L66M, attributed to post-radiation symptoms.
770503 -        ref SDS 2 GJ69  On 040517 review of the biopsy report on left
770504 -        breast found IBC, ref SDS 8 6T5G, and research indicated that
770505 -        regional metastasis in left axilla, upper chest wall, and
770506 -        supraclavicular cited in the PET scan test on 021218 are
770507 -        symptoms of IBC. ref SDS 8 LS3L
770509 -         ..
770510 -        Therefore, if the left breast is driving regional metastasis,
770511 -        then removing the breast could lengthen quality of life by
770512 -        reducing opportunity for cancer to strike, described on 050311
770513 -        by the primary care physician as "pockets of resistance" to
770514 -        chemotherapy, ref SDS 26 PA4N, which has otherwise been
770515 -        effective so far beating back cancer in local-regional sites
770516 -        e.g., under the arm and in the neck.  The record in this case
770517 -        preventing spread of disease to distant sites in organs that
770518 -        impact quality of life, noted by the primary care physician in
770519 -        Oncology on 040812, ref SDS 9 LQ5M, may weigh toward surgery to
770520 -        remove a source of cancer in the breast that has a bigger
770521 -        chance of spreading disease if left in tact.
770523 -         ..
770524 -        How then to assess chances of doing more harm than good?
770525 -
770526 -            [On 050908 Kaiser referral does not address request for
770527 -            risk analysis of surgery for Millie's patient profile.
770528 -            ref SDS 47 YO6I
770529 -
770530 -
770531 -
770532 -
770533 -
770534 -
770535 -
770536 -
770537 -
770538 -
7706 -