CONTACTS 
0201 - Medical Offices Nima Grissom                                                                                                                                       O-00000849 0601
020101 - Ms. Mary NLN; Secretary                                                                                                                                          O-00000849 0601
020103 - Administration Department                                                                                                                                        O-00000849 0601

SUBJECTS
2nd Opinion #2 Surgical Oncologist 2nd Referral by UCSF on Criteria
2nd Opinion Draft Received from Doctor Recommending Course of Treatm

0904 -
0904 -    ..
0905 - Summary/Objective
0906 -
090601 - Follow up ref SDS 30 0000. ref SDS 24 0000.
090602 -
090603 -
090604 -
090605 -
090606 -
090607 -
090609 -  ..
0907 -
0908 -
0909 - Progress
0910 -
0911 -
091101 - 2nd Opinion Draft Recommending Course of Treatment for IBC Relapse
091102 -
091103 - Follow up ref SDS 30 AI8N, ref SDS 24 P68V.
091104 -
091105 - Received via email the doctor's first draft, per planning on 050912 to
091106 - implement doctor/patient partnership for timely, accurate, and
091107 - comprehensive understanding of patient history for crafting effective
091108 - recommendations. ref SDS 30 YR8H
091110 -  ..
091111 - Limited time for professionals to review patient history, cited by
091112 - Doctor Shim in a 2nd opinion received on 050907, ref SDS 27 AE5P,
091113 - reflects communication challenges reported last year on 041209 working
091114 - with Kaiser, UCSF, and Stanford. ref SDS 7 LO5L
091115 -
091116 -           [...below, timely communication with Doctor Grissom refined
091117 -           accuracy and clarified scope to strengthen second opinion
091118 -           analysis. ref SDS 0 XX4R
091120 -  ..
091121 - Doctor's 1st draft says...
091122 -
091123 -    1.  Office meeting with the patient and her friend, took
091124 -        place on 9/12/05.
091126 -         ..
091127 -    2.  The meeting consisted of record review, examination of the
091128 -        patient and a discussion of surgical options and treatment
091129 -        planning.  The patient is interested in surgical options for
091130 -        treatment of locoregional recurrence of her breast cancer.
091132 -         ..
091133 -    3.  Millie is a 69 year old woman who initially was treated for
091134 -        carcinoma of the left breast at Kaiser Hospital.  She was
091135 -        diagnosed in February 2002 and underwent a left lumpectomy and
091136 -        axillary dissection.  The sentinel node was positive with
091137 -        perinodal invasion and three out of three axillary nodes were
091138 -        positive.  The tumor measured 2 cm.  It was poorly
091139 -        differentiated, ER/PR and HER2NEU negative.  Margins were
091140 -        involved.  The patient subsequently underwent re-excision with
091141 -        negative margins.
091143 -         ..
091144 -    4.  The patient was started on Adriamycin/Cytoxan for two cycles,
091145 -        but was changed to Taxotere after elevation of CA15-3.
091146 -        Following completion of chemotherapy, Millie underwent full
091147 -        breast radiation at Mt.  Diablo hospital.
091149 -         ..
091150 -    5.  In January 2003, the patient developed a red rash involving the
091151 -        left breast and axillary swelling.  This was treated
091152 -        intermittently with antibiotics without resolution.  In
091153 -        February 2004, the patient developed supraclavicular adenopathy
091154 -        which prompted needle biopsy.  This showed metastatic
091155 -        carcinoma.  The patient began Avastin and taxol.
091157 -         ..
091158 -    6.  A punch biopsy of the left breast skin was taken in May 2005.
091159 -        This revealed dermal lymphatic invasion consistent with
091160 -        inflammatory carcinoma.  Avastin and taxol were stopped after 7
091161 -        cycles due to pulmonary emboli.  The patient had four more
091162 -        cycles of A/C starting in January 2005.  Her disease progressed
091163 -        with this treatment.  After a second opinion by Dr.  Benz at
091164 -        UCSF the patient started taxotere and xeloda in April 2005.
091165 -        She has had resolution of her cervical and axillary adenopathy
091166 -        and improvement in her breast erythema with this latest
091167 -        treatment.  Her CA15-3 has also fallen.
091169 -         ..
091170 -    7.  On examination today, the right breast appears normal to
091171 -        inspection and palpation.  There is no axillary or
091172 -        supraclavicular adenopathy on the right.
091174 -         ..
091175 -    8.  The left breast has moderate post-treatment retraction.  There
091176 -        is diffuse skin thickening and mild erythema of the inferior
091177 -        portion of the breast.  The prior skin biopsy site at 6:00 has
091178 -        healed.  There is no adenopathy.  The breast is mobile on the
091179 -        chest wall.
091181 -         ..
091182 -    9.  Millie has the unusual situation of skin recurrence post
091183 -        lumpectomy and radiation.  This is considered inflammatory
091184 -        cancer in view of dermal lymphatic invasion.  The patient has
091185 -        evidence of locoregional disease by biopsy of her
091186 -        supraclavicular node, but no findings of systemic spread of her
091187 -        cancer.
091189 -         ..
091190 -   10.  It is unclear by physical examination whether the current skin
091191 -        changes of the left breast are due to postradiation changes or
091192 -        residual cancer.
091194 -         ..
091195 -   11.  My recommendations to this patient are that she could either
091196 -        continue her current chemotherapy which appears to be
091197 -        controlling her disease without surgery, or consider mastectomy
091198 -        to assist in controlling her local disease.  She understands
091199 -        that her risk for systemic spread of her cancer is high and
091200 -        might not be affected by her local treatment.
091202 -         ..
091203 -   12.  If she does decide to pursue mastectomy, I would certainly
091204 -        recommend restaging with a PET scan.  She should also have skin
091205 -        biopsies to determine whether she has had a complete response
091206 -        of her local disease.  The skin biopsies would be better
091207 -        performed as thin full thickness surgical biopsies with suture
091208 -        closure rather than punch biopsies in view of the difficulty
091209 -        with healing of the last punch biopsy.
091210 -
091211 -            [...see below letter to the doctor requests clarification
091212 -            of basis for deciding to pursue mastectomy. ref SDS 0 4R9F
091214 -             ..
091215 -            [On 050920 final draft of Doctor Grissom's 2nd opinion
091216 -            explains options for surgery, but does not discuss benefits
091217 -            and risks that drive a decision to approve surgery in this
091218 -            case. ref SDS 31 Q650
091220 -         ..
091221 -   13.  If these tests are negative, and the patient wants to proceed
091222 -        with mastectomy, I would recommend a very wide excision of the
091223 -        breast and skin incorporating all the previously irradiated
091224 -        skin.  A microvascular flap such as a Diep flap or possibly a
091225 -        TRAM could be used for closure.  Even with wide excision, local
091226 -        skin recurrence could recur.  With a large tissue flap, the
091227 -        patient could possibly have localized radiation again if really
091228 -        needed.  It is unlikely that skin grafts would provide adequate
091229 -        coverage of previously irradiated tissue.  Millie understands
091230 -        that this is a major operation requiring many hours of
091231 -        operating time and anesthesia.
091233 -         ..
091234 -   14.  This patient has difficult decisions to make and is free to
091235 -        contact me in the future if she has any further questions
091236 -        regarding her care.
091237 -
091239 -         ..
091240 -        Nima Grissom MD
091241 -
091242 -
091244 -  ..
0913 -
0914 -
0915 - 2251
0916 -
091601 - Submitted comments
091602 -
091603 -    1.  Subject: 2nd Opinion Doctor Grissom Comments
091604 -        Date: Wed, 14 Sep 2005 23:39:18 -0700
091609 -         ..
091610 -    2.  Mary,
091612 -         ..
091613 -    3.  Please forward to the doctor...
091615 -         ..
091616 -    4.  Doctor Grissom,
091618 -         ..
091619 -    5.  Thanks for timely attention to Millie's case in your 2nd
091620 -        opinion draft received today.
091622 -         ..
091623 -    6.  Millie met with the Primary Care Physician in Oncology at
091624 -        Kaiser, Doctor Johnson, yesterday morning.  Nominally, oncology
091625 -        should take the lead, as you mentioned in our discussions on
091626 -        Monday, by reviewing 2nd opinions and patient history to
091627 -        present recommendations for the patient to consider in making a
091628 -        timely decision on invasive procedures.  For some reason PCP
091629 -        eschews written analysis, and instead urged Mil to ignore
091630 -        experts by consenting on the spot to mastectomy surgery.
091631 -        Without going into detail, we have a delicate situation which
091632 -        at a minimum needs written opinions laying out risks and
091633 -        benefits of alternate treatment scenarios, as shown in your
091634 -        draft today.
091636 -         ..
091637 -    7.  Good news - while the doctor was insistent on scheduling
091638 -        surgery immediately, and called the surgeon during our meeting
091639 -        leaving a voice mail with pointed instruction, he also
091640 -        scheduled a PET scan, and scheduled Mil to get another chemo
091641 -        treatment beginning this Friday to maintain her good condition.
091642 -        Giving the Doctor his due, he was adamant about expediting
091643 -        surgery as a means of "local control" -- he mentioned this
091644 -        several times during the meeting.  Certainly this is a critical
091645 -        objective.
091647 -         ..
091648 -    8.  The challenge is weighing risks of losing control due to
091649 -        surgery vs enhancing control with surgery under Mil's patient
091650 -        profile.  You touch on this in your draft, ref SDS 0 K86R, but
091651 -        possibly more of the details can be spelled out expressly in
091652 -        the final draft.
091653 -
091654 -            [On 050920 final draft of Doctor Grissom's 2nd opinion
091655 -            explains options for surgery, but does not discuss benefits
091656 -            and risks that drive a decision to approve surgery in this
091657 -            case. ref SDS 31 Q650
091659 -         ..
091660 -    9.  We will see the surgeon hopefully next week, and will ask her
091661 -        to take the sliver skin biopsies you recommend.  That, along
091662 -        with the PET test may yield more evidence for deciding which
091663 -        way to go.
091665 -         ..
091666 -   10.  Couple of points on your current draft....
091668 -         ..
091669 -   11.  Calling for a "very wide mastectomy" does this need to be
091670 -        related or otherwise distinguished from a "radical mastectomy?"
091672 -         ..
091673 -   12.  What guidelines determine the boundaries of "very wide
091674 -        mastectomy."  Does the surgeon rely on memory of seeing the
091675 -        rash back in March?  This seems inherently risky, since the
091676 -        surgeon has only seen Millie 3 times in 8 months.  There were
091677 -        no photographs, diagrams or other renderings prepared to
091678 -        memorialize the maximum spread of disease on those occasions.
091679 -        Is the idea then to be extra conservative, and if memory
091680 -        recalls area "x", then remove x + .5" or some such approach.
091681 -        You emphasized in our meeting on Monday that there are no cut
091682 -        and dried answers, no studies, etc., but if this operation goes
091683 -        forward someone will have figure this out, and it helps to
091684 -        discuss it.  That's why Millie was heartened when you offered
091685 -        to consult with Doctor Riley-Paul, since at this time it looks
091686 -        like the machinery is moving in that direction.
091687 -
091688 -            [On 050920 Doctor Grissom proposes series of thin surgical
091689 -            biopsies to helps locate boundaries of surgery. ref SDS 31
091690 -            XL8U
091692 -         ..
091693 -   13.  Some housekeeping -- on patient history in the para beginning
091694 -        Millie is a 69 year... please consider ending the para by
091695 -        indicating the initial surgeries were completed by the end of
091696 -        March 2002; re-excission was actually performed on 020327.
091697 -
091699 -         ..
091700 -   14.  Treatment with AC began on 020423, and this was switched to
091701 -        Taxotere on 020610.  She had 2 treatments of Taxotere, then
091702 -        radiation in July and August, then 4 more treatments of
091703 -        Taxotere were given ending on 021204.
091705 -         ..
091706 -   15.  Note the punch biopsy was performed on 040419 rather than in
091707 -        May.
091709 -         ..
091710 -   16.  Doctor Benz examined Mil on 041018.  His 2nd opinion was
091711 -        received on 041117, and proposed that Taxotere and capecitabine
091712 -        might be a follow on treatment if disease progressed on the
091713 -        Avastin trial.  Doctor Guardino examined Mil at Stanford, and
091714 -        her 2nd opinion received on 041209 recommended more AC.  When
091715 -        PE was diagnosed on 041104, Kaiser (eventually) followed
091716 -        Guardino's recommendation to treat with AC beginning on 050104.
091717 -        When this was not effective, then Kaiser switched on 050329 and
091718 -        implemented the Benz plan received 5 months earlier.
091720 -         ..
091721 -   17.  The only other point I mention, and this may be redundant,
091722 -        because the hour is late, is that the Kaiser team has a big
091723 -        sense of potential benefits from surgery, but there has been no
091724 -        discussion with the patient of risks.  Suppose the PET scan
091725 -        test shows no distant metastasis, but the sliver skin biopsies
091726 -        are positive, does this weigh toward surgery.  I feel this
091727 -        should be spelled out somewhat, but leave it to your
091728 -        discretion.
091730 -         ..
091731 -   18.  Again, we loved meeting you on Monday, and appreciated very
091732 -        much your insightful analysis.
091734 -         ..
091735 -   19.  Please send the 2nd opinion to...
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0918 -