CONTACTS 

SUBJECTS
2nd-Opinion Meeting Referral Surgeon at Kaiser Oakland on Criteria f
Patient History 2nd Opinion #2 Submitted to Surgeon in Oakland Print
2nd-Opinion #2 Meeting Referral Surgeon at Kaiser Oakland on Criteri
2nd Opinion #2 Received from Surgeon in Kaiser's Oakland Office

1506 -
1506 -    ..
1507 - Summary/Objective
1508 -
150801 - Follow up ref SDS 34 0000. ref SDS 29 0000.
150802 -
150803 - Excellent 2nd opinion draft received today recommends a curative
150804 - treatment model, ref SDS 0 F49H, supported with mastectomy surgery
150805 - based on visual examination and CT testing that shows no evidence of
150806 - distant metastasis. ref SDS 0 JS4H  A new idea is proposed to test
150807 - biopsy tissue for possibility of changing patient status to open
150808 - additional treatment options. ref SDS 0 F49H  We need assessment of
150809 - experience performing surgery on IBC patients, ref SDS 0 FM5J, and on
150810 - expected benefits of surgery for extending longevity and quality of
150811 - life. ref SDS 0 WU87
150812 -
150813 -     [On 050908 submit comments to Kaiser referral doctor 2nd opinion
150814 -     draft. ref SDS 35 08GF
150816 -      ..
150817 -     [On 050913 during meeting with primary care physician, he provided
150818 -     the final version of Veronica's 2nd opinion, ref SDS 39 6G4I,
150819 -     however, the content of this document was entered in the record on
150820 -     050909. ref SDS 36 1O4I
150821 -
150822 -
150823 -
150824 -
150825 -
150827 -  ..
1509 -
1510 -
1511 - Background
1512 -
1513 -
151301 - Complex Record Not Enough Time to Review Patient History
151302 - Patient History Not Enough Time to Review; Case Too Complicated
151303 -
151304 - Follow up ref SDS 34 V15F, ref SDS 30 0001.
151305 -
151306 - Veronica called and advised that she has just returned from attending
151307 - a professional conference; she submitted a 2nd opinion draft last
151308 - night, as planned during the meeting on 050826, ref SDS 34 967N, but
151309 - the letter bounced back.
151311 -  ..
151312 - Veronica commented that she prefers to avoid changes to the draft
151313 - opinion, due to limited time and because she has made sufficient
151314 - review and examination to make recommendations.  She will distribute
151315 - her opinion within Kaiser tomorrow, and send Mil a copy.
151317 -  ..
151318 - Veronica further indicated during the call that there wasn't enough
151319 - time to review patient history reported on 050812, ref SDS 31 UF4J,
151320 - because the case is too complicated to absorb in the time available
151321 - for preparing a 2nd opinion, following up plans discussed a few weeks
151322 - ago on 050826. ref SDS 34 R44H  Complexity is cited in the opinion,
151323 - ref SDS 0 AE5P, however, even with limited time, the 2nd opinion seems
151324 - thorough and accurate on critical details using familiar tools in
151325 - familiar ways to access test reports filed on Kaiser's computer.  The
151326 - doctor indicated that the physical examination on 050826 aided the 2nd
151327 - opinion, per below. ref SDS 0 JS4H
151328 -
151329 -     [...below mistake on patient history of metastic cancer corrected
151330 -     through doctor partnership model that strengthens accuracy of 2nd
151331 -     opinion through feedback and collaboration. ref SDS 0 2V5F
151333 -  ..
151334 - While we talked, the doctor tried sending the 2nd Opinion report
151335 - again, and we verified the email address.  Sounded like she may have
151336 - omitted a letter or transposed some letters in the email address.
151337 - After a few tries....
151338 -
151339 -
151341 -  ..
151342 - 2nd Opinion Draft Received Looks Terrific
151343 -
151344 - Received ref DRT 1 0001 from Veronica saying...
151345 -
151346 -    1.  I apologize for the delay -- I just came back into town from a
151347 -        meeting.  I noticed that your meeting with [primary care
151348 -        physician] is next week.  Hopefully, this is not too late.
151349 -        Here is a copy. ref DRT 1 0001
151351 -  ..
151352 - If we can finalize by Friday, 050909, which seems doable, then
151353 - distribution via email and internal at Kaiser, should be adequate to
151354 - help guide discussions during the meeting with the primary care
151355 - physician scheduled for 050913.
151357 -  ..
151358 - In our discussion today, Veronica indicated a preference to minimize
151359 - edits to the draft.
151360 -
151361 -
151362 -
151363 -
151364 -
151365 -
1514 -

SUBJECTS
Purpose Meeting Objectives for 2nd Opinion #2 Examination Kaiser Int
Purpose Objectives for 2nd Opinion #2 Not Addressed by Kaiser Intern
Patient History Summarized 2nd Opinion #2 Draft Kaiser Referral Base

2505 -
250601 -  ..
250602 - Purpose and Objectives for Examination Today
250603 - Summary of Patient History Explained During the Meeting
250604 -
250605 - Follow up ref SDS 34 R448.
250607 -         ..
250608 -    2.  Second opinion:  [first draft]
250609 -
250610 -            [On 050909 received final draft. ref SDS 36 1O4I
250612 -         ..
250613 -        Pt is a postmenopausal women with loco-regional recurrence of
250614 -        her left breast cancer.  [Pt] had a great clinical response to
250615 -        chemotherapy.  She is here for a second opinion regarding her
250616 -        surgical options at this point. ref DRT 1 KF5O
250617 -
250618 -            [On 050908 comments submitted to Kaiser referral doctor 2nd
250619 -            opinion draft. ref SDS 35 08GF
250621 -  ..
250622 - The purpose of seeking a 2nd opinion and the issues to be addressed
250623 - were discussed during the meeting on 050826, ref SDS 34 HU9M,
250624 - generally as follows...
250625 -
250626 -    1.  Criteria for determining patient is ready for surgery,
250627 -        primarily related to establishing there has been sufficient
250628 -        recovery from IBC. ref SDS 34 G28J
250630 -         ..
250631 -    2.  Criteria for deciding to have mastectomy on both breasts to
250632 -        reduce chances of relapse and provide tissue for skin grafts,
250633 -        on the left breast, and for patient convenience to avoid
250634 -        prostheses. ref SDS 34 NT9G
250636 -         ..
250637 -    3.  Surgery tasks and issues that may arise performing a mastectomy
250638 -        on patients with IBC that are different from performing the
250639 -        procedure on patients without IBC. ref SDS 34 FM5J
250641 -         ..
250642 -    4.  Criteria for the patient to approve surgery, also, discussed on
250643 -        050727. ref SDS 34 JS4H
250645 -  ..
250646 - Ordinarily the patient's purpose and objectives for a 2nd opinion
250647 - should be addressed directly, as Doctor Benz did at UCSF on 041018.
250648 - ref SDS 13 LX3U  In this case, with limited time the doctor's format
250649 - seems effective.
250651 -  ..
250652 - Doctor's 2nd Opinion draft summarizes patient history...
250653 -
250654 -    5.  Her breast cancer was detected by the patient February, 2002.
250655 -        The mammogram at the time did not show the disease process.  It
250656 -        seems to be that it was very high at the axillary tail which
250657 -        the mammogram has low sensitivity.  Her lumpectomy/SLN/ALND in
250658 -        March, 2002 showed 2 cm ER negative, PR negative, and HER-2
250659 -        negative disease with 4/4 lymph nodes with disease.  She
250660 -        subsequently had AC-taxotere.  Her radiation was done at
250661 -        Mt.Diablo hospital.  I do not have the record.  According to
250662 -        the pt and her husband, they were told that the patient
250663 -        received boost to the lymphatic areas. ref DRT 1 IM6L
250665 -         ..
250666 -    6.  Her recurrence was detected in March, 2004.  Pt presented with
250667 -        inflammatory breast cancer with axillary and supraclavicular
250668 -        lymphadenopathy.  Her chemotherapy regimen have included
250669 -        avastin/taxol/xeloda.  Her chemotherapy was complicated by PE.
250670 -        ref DRT 1 L67L
250672 -  ..
250673 - The initial regimen to treat IBC was Avastin and Taxol, beginning on
250674 - 040420, ref SDS 31 MP6G, and ended on 041104 with discovery of
250675 - pulmonary emboli, as reported in patient history. ref SDS 31 4V5G
250676 - Treatment resumed on 050104 with AC, ref SDS 31 T35J, and was later
250677 - switched to Taxotere and capecitabine (Xeloda) on 050239. ref SDS 31
250678 - 8O8J
250680 -  ..
250681 - Doctor's 2nd Opinion draft continues...
250682 -
250683 -    7.  Currently, she is finished with the chemoregimen and was
250684 -        recommended that she undergoes mastectomy. ref DRT 1 U68H
250686 -  ..
250687 - The doctor's summary of patient history aligns with discussions during
250688 - the meeting on 050826. ref SDS 34 R448
250689 -
250690 -
250691 -
250692 -
250693 -
250694 -
2507 -

SUBJECTS
Metastatic Cancer 2nd Opinion #2 States Patient History on CT Testin

2803 -
280401 -  ..
280402 - Distant Metastasis Not Diagnosed Patient Has Local Regional Disease
280403 - CT Tests and Biopsy Reports Diagnose Metastatic Breast Cancer
280404 - 2nd Opinion Aligns with Patient History Diagnose Metastatic Cancer
280405 - Metastatic Cancer Diagnose Regional Disease Not Distant Metastasis
280406 -
280407 - Follow up ref SDS 34 555G, ref SDS 26 YY7F.
280409 -  ..
280410 - Doctor's 2nd Opinion draft continues...
280411 -
280412 -    8.  CT and bone scan: no evidence of metastatic disease.
280413 -        ref DRT 1 868N
280415 -  ..
280416 - The doctor's expression aligns with CT and other tests that make no
280417 - findings of "distant metastasis," discussed with the doctor on 050826,
280418 - and reported many times throughout the past four (4) years, e.g., on
280419 - 040713, ref SDS 11 NK9H, and supported by patient history listed on
280420 - 050812...
280421 -
280422 -           Initial presentation............ 020321, ref SDS 31 OR56
280423 -           PET test........................ 020603, ref SDS 31 FP9N
280424 -           PET test........................ 030109, ref SDS 31 P94H
280425 -           CT test......................... 030220, ref SDS 31 O64F
280426 -           CT test......................... 041230, ref SDS 31 KU4G
280427 -           CT test......................... 050422, ref SDS 31 L26N
280428 -           CT test......................... 050610, ref SDS 31 M85O
280430 -  ..
280431 - Many test reports in Millie's patient history mention "metastatic
280432 - cancer," for example the test on 041103 makes a reference under
280433 - "History" of...
280434 -
280435 -          H/o metastatic breast CA.
280436 -
280437 - ...as shown in the record on 041104, ref SDS 15 QRUR; another example
280438 - is the report for the test on 041217, received on 041230, ref SDS 21
280439 - PV5I; another is the test on 040710, received on 040811. ref SDS 12
280440 - WV5R Other test reports merely say "breast cancer," e.g., the most
280441 - recent test on 050530, received in the record on 050610. ref SDS 25
280442 - PV5I  This record reflects unevenness in reporting practices
280443 - throughout Millie's case.  Additionally, Millie was diagnosed with
280444 - metastatic cancer in the pathology report on the biopsy from the
280445 - original surgery on 020312, and presented to the patient on 020321.
280446 - ref SDS 3 4U8X
280448 -  ..
280449 - Consideration should be given to aligning the 2nd opinion with patient
280450 - history that consistently describes metastatic cancer with regional
280451 - disease, and shows no evidence of distant metastasis.  The initial
280452 - draft reflects limited time reviewing patient history cited in the 2nd
280453 - opinion, per above, ref SDS 0 D05G, and explaining that complexity of
280454 - the case reduces reliance on case study summarizing critical details,
280455 - per below. ref SDS 0 F49H  On 040416 limited time impacts accuracy
280456 - reviewing patient history. ref SDS 6 GN7J
280457 -
280458 -        [...see below same issue changing "...does not have metastatic
280459 -        disease" to "...does not have distant metastatic..."
280460 -        ref SDS 0 TY7M
280462 -         ..
280463 -        [On 050908 notify Veronica to consider conforming 2nd opinion
280464 -        to describe patient status as related in medical history, per
280465 -        above, ref SDS 0 LK3Q, and citing this record for background.
280466 -        ref SDS 35 LJ3X
280468 -         ..
280469 -        [On 050908 Veronica reports having reviewed issue and advises
280470 -        final version is revised to conform with patient history.
280471 -        ref SDS 35 1W9L
280473 -         ..
280474 -        [On 050909 request final version of 2nd opinion with changes
280475 -        from 1st draft. ref SDS 36 TX4W
280477 -         ..
280478 -        [On 050909 Veronica says final draft changed "no metastatic
280479 -        disease" to no "distant metastatic disease." ref SDS 36 5A9G
280481 -         ..
280482 -        [On 050909 final draft received; still says CT and bone scan
280483 -        tests show no metastatic disease. ref SDS 36 JX7S
280484 -
280485 -
280486 -
280487 -
280488 -
2805 -

SUBJECTS
Criteria Surgery Mastectomy IBC Biopsy Not Necessary for Surgery CA
Examination 2nd Opinion #2 Showed Patient Ready for Surgery Mastecto
Examination 2nd Opinion Reports IBC Inflammation Has Regressed Enoug

4005 -
400601 -  ..
400602 - Criteria for Determining Patient Ready for Mastectomy Surgery
400603 - Examination Shows IBC Regresses No Visible Evidence of Cancer
400604 - 2nd Opinion to Report Patient Meets Criteria for Mastectomy Surgery
400605 -
400606 - Doctor's 2nd Opinion draft continues...
400607 -
400608 -    9.  breast exam:  no palpable supraclavicular or axillary
400609 -        lymphadenopathy; well healed lumpectomy and ALND incisions in
400610 -        the left breast, ref DRT 1 RF9I
400612 -  ..
400613 - This explanation aligns with understandings from the meeting at Kaiser
400614 - in Oakland on 050826, when the doctor made a careful, thorough
400615 - examination. ref SDS 34 AY5N  During the call today, the doctor
400616 - indicated results of the physical examination on 050826, as stated in
400617 - the 2nd opinion, reduced the need to review patient history, per
400618 - above. ref SDS 0 D05G
400620 -  ..
400621 - CA 15-3 has fluctuated significantly tracking closely with symptoms of
400622 - metastatic disease, shown in patient history reported on 050729.
400623 - ref SDS 28 087J  How does this criteria relate to physical examination
400624 - and CT test results cited in the 2nd opinion draft, discussed below.
400625 - ref SDS 0 JS4H
400626 -
400627 -
400628 -
400629 -
400630 -
4007 -

SUBJECTS
Experience Treating IBC Not Critical for Performing Mastectomy Scope
Experience Surgeon Performing Mastectomy on IBC Patient 2nd Opinion

4804 -
480501 -  ..
480502 - Experience Not Critical for Performing Mastectomy on IBC Patient
480503 -
480504 - Follow up ref SDS 34 FM5J, ref SDS 26 QJ3Q.
480505 -
480506 - The 2nd opinion recommends surgery, but does not address factors that
480507 - require consideration for mastectomy surgery on a patient with IBC,
480508 - where inflammation extended beyond the breast, observed at Kaiser in
480509 - Walnut Creek on 050324, ref SDS 23 YY7F, but has since regressed,
480510 - reported on 050727. ref SDS 26 YY7F
480512 -  ..
480513 - During the meeting on 050826 the doctor seemed to indicate the 2nd
480514 - opinion would list of factors that require consideration when
480515 - performing mastectomy surgery on an IBC patient, ref SDS 34 FM5J, as
480516 - related by the surgeon in the Walnut Creek office on 050727.
480517 - ref SDS 26 E863  This issue is not discussed in the draft 2nd opinion
480518 - received today.
480520 -      ..
480521 -     [On 050908 Kaiser referral does not address follow up request on
480522 -     requirements for experience to perform a successful mastectomy
480523 -     surgery on a patient with IBC. ref SDS 35 NG5K
480524 -
480525 -
480526 -
480527 -
480528 -
4806 -

SUBJECTS
Cure Goal Treatment No Evidence Distant Metastasis Patient Stage III
Curative Treatment Model Stage III Not Stage IV Metastatic Cancer Re
Criteria Approve Surgery for Extending Quality of Life Patient Decis

7005 -
700601 -  ..
700602 - Treatment Options May Be Expanded Retest for Status Change
700603 - Cure Goal for Treatment Retest Original Status Presentation
700604 - Test Status Change Possible Huge Improvement Treatment Options
700605 - Stage III Regional Cancer Presents Chance for Curative Treatment
700606 -
700607 - Follow up ref SDS 34 F49H.
700609 -  ..
700610 - Doctor's 2nd Opinion draft continues...
700611 -
700612 -   10.  A/P:  Pt has a very complicated history.  I am going to limit
700613 -        my discussion to surgery mostly.  Pt has very aggressive
700614 -        locoregional recurrence of her left breast cancer.  Anytime
700615 -        when breast cancer recurs within the first five years, it is
700616 -        telling us the aggressive nature of the disease.  I am not
700617 -        completely surprised since her initial tumor was ER, PR, as
700618 -        well as HER-2 negative.  The good news is that is loco-regional
700619 -        recurrence and pt does NOT have metastatic disease.  Thus, our
700620 -        goal is for CURE. ref DRT 1 GY9M  Here are some of my thoughts:
700622 -  ..
700623 - This aligns with reporting on 050826 describing the doctor's plans for
700624 - a curative treatment model. ref SDS 34 T26L  The goal for a cure is
700625 - supported by the recommendation to perform mastectomy surgery in this
700626 - case, per below. ref SDS 0 JS4H
700627 -
700628 -            [On 050908 submit comments to Kaiser referral doctor 2nd
700629 -            opinion draft. ref SDS 35 08GF
700631 -             ..
700632 -            [On 051007 primary care physician recommends mastectomy
700633 -            surgery for the purpose of palliation in the event of
700634 -            future relapse. ref SDS 42 6A4N
700636 -             ..
700637 -            [On 051010 Doctor Grissom explains proposal for very wide
700638 -            mastectomy presents treatment model for cure based on
700639 -            Millie's patient history. ref SDS 43 GW5K
700641 -             ..
700642 -            [On 051007 case study purpose of mastectomy surgery cure,
700643 -            local control, palliation. ref SDS 47 F25H
700645 -             ..
700646 -            [On 061020 primary care physician feels patient profile has
700647 -            too many issues for a 5-year medical case of secondary
700648 -            inflammatory breast cancer (IBC), cellulitus, lymphedema,
700649 -            pulmonary embolism, broken finger. ref SDS 48 MO4K
700651 -  ..
700652 - Limited time for professionals to review patient history, ref SDS 0
700653 - AE5P, reflects erroneous discussion of tests finding no distant
700654 - metastasis. ref SDS 0 AE4S  This aligns with communication challenges
700655 - reported last year on 041209 working with Kaiser, UCSF, and Stanford.
700656 - ref SDS 18 LO5L
700657 -
700658 -        [On 050908 notify Veronica to consider conforming 2nd opinion
700659 -        to describe patient status as related in medical history, per
700660 -        above, ref SDS 0 LK3Q, and citing this record for background.
700661 -        ref SDS 35 LJ3X
700663 -         ..
700664 -        [On 050908 Veronica reports having reviewed issue and advises
700665 -        final version is revised to conform with patient history.
700666 -        ref SDS 35 1W9L
700668 -         ..
700669 -        [On 050909 request final version of 2nd opinion with changes
700670 -        from 1st draft. ref SDS 36 TX4W
700672 -         ..
700673 -        [On 050909 Veronica says final draft changed "no metastatic
700674 -        disease" to no "distant metastatic disease." ref SDS 36 5A9G
700676 -         ..
700677 -        [On 050909 final draft made this change. ref SDS 36 JX7S
700679 -  ..
700680 - Doctor's 2nd Opinion draft continues...
700681 -
700682 -            1)  repeat ER, PR, and HER-2 status in the breast skin
700683 -                biopsy done in 2004.  I do not see that it was
700684 -                repeated.  There is small reported cases when ER, PR,
700685 -                and/or HER-2 status change in the recurrent tumor.
700686 -                Since it makes a huge impact on her further treatment
700687 -                options, this needs to be repeated. ref DRT 1 HG40
700689 -  ..
700690 - During the call this afternoon Veronica mentioned this recommendation
700691 - in the 2nd opinion draft to test neck tissue from the biopsy on
700692 - 040303, ref SDS 4 Y171, for possibility of status change from original
700693 - biopsy reported on 020321. ref SDS 3 6Q6J
700694 -
700695 -            [On 050908 Veronica submits letter saying she reviewed this
700696 -            record, and clarifies her recommendation to test a biopsy
700697 -            in 2004 for change in patient status. ref SDS 35 F49H
700699 -             ..
700700 -            [On 050909 letter to Veronica requests clarification of
700701 -            which among three (3) biopsies in 2004 should be tested for
700702 -            change in status. ref SDS 36 435L
700704 -             ..
700705 -            [On 050909 Doctor Shim clarified that she proposes
700706 -            retesting tissue from the biopsy on 040419. ref SDS 36 P58N
700708 -             ..
700709 -            [On 050909 Doctor Bailey during 2nd opinion meeting concurs
700710 -            with retesting status. ref SDS 37 1G8R
700712 -             ..
700713 -            [On 050912 Doctor Grissom during 2nd opinion meeting
700714 -            concurs with retesting status, and indicates the test
700715 -            requires tissue from a biopsy when the patient suffers from
700716 -            cancer, as found by the biopsy on 040419. ref SDS 38 YD4U
700718 -             ..
700719 -            [On 050913 presented status retest proposal to primary care
700720 -            physician. ref SDS 39 X546
700722 -             ..
700723 -            [On 050923 surgeon at Kaiser concurs retest for status, and
700724 -            notes that biopsy on 040419 may not have enough tissue;
700725 -            discusses using tissue from new biopsies planned for
700726 -            following week to test for IBC recovery. ref SDS 41 U94M
700728 -             ..
700729 -            [On 051022 surgeon reported retest was ordered with no
700730 -            record in surgeon's notes received on 050927, and that
700731 -            results of retesting have not been received; doctor
700732 -            following up to obtain results. ref SDS 46 NE9J
700734 -             ..
700735 -            [On 051027 surgeon has not received results of retesting
700736 -            for status change; will check with pathology department on
700737 -            finding correct biopsy slide to test. ref SDS 47 964L
700739 -  ..
700740 - The prospect of "status change" offering "huge impact on treatment
700741 - options" is illustrated by the 2nd opinion from Doctor Benz at UCSF
700742 - received on 041117 that says in part...
700743 -
700744 -        Given the total lack of hormonal responsiveness, there is no
700745 -        point to the use of endocrine therapy, nor would she be a
700746 -        candidate for Herceptin, given the HER-2/neu negativity.
700747 -        ref SDS 16 OU6W
700749 -  ..
700750 - Later, on 041130 the primary care physician noted that Tumor Board
700751 - review is not required because the patient presents a simple profile
700752 - with obvious treatment options working through a fixed list of
700753 - chemotherapy drugs. ref SDS 17 763L
700755 -  ..
700756 - Testing tissue from the 2004 biopsy may reflect worsening cancer
700757 - occurring at that time, e.g., the meeting on 040517 submitted
700758 - pathology report showing IBC diagnosed.
700759 - Would recent recovery, now
700760 - about 20 months later, present another opportunity to test for change
700761 - to a more favorable status?
700762 -
700763 -          [On 050908 Veronica clarified she proposes testing a biopsy
700764 -          from 2004, but not the FNA biopsy taken in the neck.
700765 -          ref SDS 35 6P9H
700767 -           ..
700768 -          [On 050909 Veronica further explains proposal to test the
700769 -          biopsy from the left breast on 040419 that discovered IBC.
700770 -          ref SDS 36 P58N
700772 -           ..
700773 -          [On 050909 Doctor Bailey supported retesting for status
700774 -          change to increase treatment options. ref SDS 37 1G8R
700776 -           ..
700777 -          [On 050912 Doctor Grissom supported retesting for status
700778 -          change to increase treatment options. ref SDS 38 YD4U
700780 -           ..
700781 -          [On 050913 discussed with primary care physician during
700782 -          meeting to evaluate treatment options. ref SDS 39 X546
700784 -           ..
700785 -          [On 050923 surgeon at Walnut Creek Kaiser hopsital commented
700786 -          that if there is not enough tissue from biopsy on 040419 to
700787 -          retest for status, then status can be retested using new
700788 -          biopsies planned to evaluate scope of mastectomy surgery.
700789 -          ref SDS 41 RX4I
700791 -  ..
700792 - During the meeting on 050826 the doctor mentioned that an advantage of
700793 - mastectomy surgery would be to perform a biopsy to update patient
700794 - status, per below. ref SDS 0 WU9K
700796 -  ..
700797 - The doctor's reference to "small reported cases" of status change may
700798 - fit Millie's patient profile of contracting IBC that is a very rare
700799 - event, and further that over four (4) years there is no evidence of
700800 - distant metastasis.  This latter fact may indicate status change that
700801 - justifies further testing.
700802 -
700803 -
700804 -
7009 -

SUBJECTS
Default Null Subject Account for Blank Record

7103 -
710401 -  ..
710402 - Imaging Bilateral Mammogram Recommended Prior to Next Surgery
710403 -
710405 -  ..
710406 - Doctor's 2nd Opinion draft continues...
710407 -
710408 -            2)  imaging: her last breast imaging was in Feb 2002 before
710409 -                the diagnosis of her initial breast cancer.  It is true
710410 -                that it was non-mamographic finding, I recommend that
710411 -                she gets bilateral mammogram before her next surgery.
710412 -                Her mammographic quality is probably better now that
710413 -                she is older. ref DRT 1 HG4L
710415 -  ..
710416 - What is expected to be determined from mammographic findings that
710417 - cannot be determined from existing regimen of CT and PET scan
710418 - testing?
710419 -
710420 -           [On 050922 bilateral mammogram test performed. ref SDS 40
710421 -           0001
710423 -            ..
710424 -           [On 051019 letter prepared for Millie cites favorable report
710425 -           on mammogram test that found no evidence of cancer.
710426 -           ref SDS 44 DY8R
710428 -            ..
710429 -           [On 051027 biopsy on mastectomy surgery finds ductal
710430 -           carcinoma in situ (DCIS) in nipple tissue that is commonly
710431 -           discovered with mammogram tests, and conflicts with PET scan
710432 -           and mammogram testing which reported no findings of cancer.
710433 -           ref SDS 47 615K
710434 -
710435 -
710436 -
710437 -
710438 -
7105 -

SUBJECTS
Mastectomy Both Breasts Recommend Against Surgery to Remove 2 Breast

7403 -
740401 -  ..
740402 - Scope Surgery Avoid Remove 2 Breasts Reduce Chances Relapse
740403 - Mastectomy Both Breasts Skin Grafts Healthy Tissue Unnecessary
740404 -
740405 - Follow up ref SDS 34 NT9G, ref SDS 26 NT9G.
740407 -  ..
740408 - Doctor's 2nd Opinion draft continues...
740409 -
740410 -                The only reason to offer her right mastectomy will be
740411 -                if there is any sign of disease.  Pt's survival will
740412 -                depend on her left breast cancer and performing right
740413 -                prophylactic mastectomy under this current situation at
740414 -                her age would only increase the complication rate.
740415 -                ref DRT 1 IJ6G
740417 -  ..
740418 - This aligns with understandings from the meeting on 050826.
740419 - ref SDS 34 NT9G
740421 -  ..
740422 - Are there any studies that show complications increase with age when
740423 - performing prophylactic mastectomy?   Has the doctor treated patients
740424 - with Millie's medical profile who have suffered complications with
740425 - prophylactic mastectomy?
740426 -
740427 -
740428 -
740429 -
740430 -
7405 -

SUBJECTS
Criteria Approve Surgery for Extending Quality of Life Patient Decis
Criteria Patient Approve Surgery Mastectomy Pathology Report on Tiss

8104 -
810501 -  ..
810502 - Criteria for Patient to Approve Surgery Reduce Chances of Relapse
810503 - Mastectomy Pathology Report on Tissue Removed Indicates Cancer Status
810504 - Scope of Surgery Standard Mastectomy and Remove Additional Lymph Nodes
810505 - Lymph Nodes Remove from Left Axilla; Supraclavicular Not Considered
810506 -
810507 - Follow up ref SDS 34 JS4H, ref SDS 26 VL4O.
810509 -  ..
810510 - Doctor's 2nd Opinion draft continues...
810511 -
810512 -            3)  surgery: my recommendation is mastectomy with axillary
810513 -                node dissection.  Pt has had great clinical response to
810514 -                systemic treatment.  Since our intent is for cure
810515 -                (since she does not have metastatic disease), I
810516 -                recommend mastectomy.  Since there are only four lymph
810517 -                nodes obtained at her initial surgery and also because
810518 -                she had axillary lymphadenopathy with her recurrence, i
810519 -                recommend another axillary lymph node dissection.  As I
810520 -                mentioned above, I don't see true value in right
810521 -                prophylactic mastectomy. ref DRT 1 HG56
810523 -  ..
810524 - Issue of metastatic disease distinguished from distant metastasis and
810525 - regional metastasis is reviewed above. ref SDS 0 AE4S
810526 -
810527 -        [On 050908 notify Veronica to consider conforming 2nd opinion
810528 -        to describe patient status as related in medical history, per
810529 -        above, ref SDS 0 LK3Q, and citing this record for background.
810530 -        ref SDS 35 LJ3X
810532 -         ..
810533 -        [On 050908 Veronica reports having reviewed issue and advises
810534 -        final version is revised to conform with patient history.
810535 -        ref SDS 35 1W9L
810537 -         ..
810538 -        [On 050909 request final version of 2nd opinion with changes
810539 -        from 1st draft. ref SDS 36 TX4W
810541 -         ..
810542 -        [On 050909 Veronica says in a telephone call that final draft
810543 -        changed "no metastatic disease" to no "distant metastatic
810544 -        disease." ref SDS 36 5A9G
810546 -         ..
810547 -        [On 050909 final draft does not make the change, still says no
810548 -        metastatic disease. ref SDS 36 JX5Q
810550 -         ..
810551 -        [On 051019 prepared letter asking Kaiser to perform Time Out
810552 -        requirements for due diligence and present plans for scope of
810553 -        surgery, including another axillary lymph node dissection, as
810554 -        recommended by Doctor Shim. ref SDS 44 DZ52
810556 -         ..
810557 -        [On 051021 surgeon evidently related to Millie that another
810558 -        axillary lymph node dissection was not performed during surgery
810559 -        in order to reduce risk of further lymphedema. ref SDS 45 QU5I
810561 -  ..
810562 - Recommendation for surgery seems based on criteria of physical
810563 - examination and CT testing showing no distant metastasis, per above.
810564 - ref SDS 0 555G  This recommendation supports the doctor's curative
810565 - treatment model discussed on 050826, and set out in the 2nd opinion.
810566 - ref SDS 0 F49H
810568 -  ..
810569 - Doctor Laio in Kaiser's Head and Neck department of the Walnut Creek
810570 - Office recommended removing swelled lymph nodes in the supraclavicular
810571 - region that were found by a biopsy to be infected with cancer,
810572 - reported on 040309. ref SDS 5 HD5N  How does this relate to the scope
810573 - for the currently contemplated surgery that proposes axillary node
810574 - dissection?
810576 -  ..
810577 - If the patient does not undergo mastectomy surgery on the left breast,
810578 - as recommended here, how is this expected to impact longevity and
810579 - quality of life, posed during the meeting at Kaiser in Oakland on
810580 - 050826, ref SDS 34 GT5K, and citing the earlier comments by the
810581 - surgeon at Kaiser in the Walnut Creek office on 050727? ref SDS 26
810582 - T15N
810583 -
810584 -     [On 050908 Kaiser referral does not address request for risk
810585 -     analysis of surgery for Millie's patient profile. ref SDS 35 YO6I
810587 -  ..
810588 - Previously, on 050826 the doctor cited the advantage of surgery
810589 - providing tissue for another biopsy that may show no further cancer.
810590 - ref SDS 34 XG5J  Consideration should be given to mentioning this
810591 - benefit in the 2nd opinion to support the thesis of a curative
810592 - treatment model being proposed. ref SDS 0 F49H
810594 -  ..
810595 - This biopsy could further clarify current status for staging and
810596 - treatment options, per above. ref SDS 0 AE6P  Actually, "status"
810597 - analysis for treatment options may be different from evaluating
810598 - improvement recovering from cancer.
810599 -
810600 -          [On 050908 Veronica clarified she proposes testing a biopsy
810601 -          from 2004, but not the FNA biopsy taken in the neck.
810602 -          ref SDS 35 6P9H
810604 -           ..
810605 -          [On 050909 Veronica further explains proposal to test the
810606 -          biopsy from the left breast on 040419 that discovered IBC.
810607 -          ref SDS 36 P58N
810609 -           ..
810610 -          [On 050913 discussed with primary care physician during
810611 -          meeting to evaluate treatment options. ref SDS 39 X546
810613 -           ..
810614 -          [On 050923 surgeon at Walnut Creek Kaiser hopsital commented
810615 -          that if there is not enough tissue from biopsy on 040419 to
810616 -          retest for status, then status can be retested using new
810617 -          biopsies planned to evaluate scope of mastectomy surgery.
810618 -          ref SDS 41 RX4I
810619 -
810620 -
810621 -
810622 -
8107 -

SUBJECTS
Default Null Subject Account for Blank Record

8203 -
820401 -  ..
820402 - Radiation Based on Patient History of Maximum Prior Treatment
820403 -
820404 - Doctor's 2nd Opinion draft continues...
820405 -
820406 -            4)  radiation:  I would make sure that she already received
820407 -                maximum radiation at Mt.  Diablo.  If not, boost needs
820408 -                to be given to the supraclavicular, axilla, as well as
820409 -                intrammary nodes. ref DRT 1 HG66
820411 -  ..
820412 - This aligns with the 2nd opinion from Stanford on 041209. ref SDS 18
820413 - O29W
820415 -  ..
820416 - On 041222 radiologist at Mt Diablo Hospital seemed to indicate further
820417 - radiation treatment could be considered following further surgery.
820418 - ref SDS 20 8F6O
820419 -
820420 -     [On 050908 comments submitted to Kaiser referral doctor 2nd
820421 -     opinion draft. ref SDS 35 08GF
820422 -
820423 -
820424 -
820425 -
820426 -
820427 -
820428 -
820429 -
820430 -
8205 -