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1...Consideration might be given to replacing the above with something
2...Local control -- this might a good place in the opinion to directly
CONTACTS
0201 - Medical Offices Lisa Bailey O-00000850 0605
020101 - Ms. Roberta Bennett O-00000850 0605
020103 - Administration Department O-00000850 0605
SUBJECTS
2nd Opinion #2 Draft Received from 3rd Referral Explains Treatment O
0903 -
0903 - ..
0904 - Summary/Objective
0905 -
090501 - Follow up ref SDS 38 0000. ref SDS 35 0000.
090502 -
090503 - The doctor does an excellent job in the first draft explaining risks
090504 - of mastectomy, and the scope of surgical removal required to be
090505 - effective, if attempted, for Millie's patient profile. This opinion
090506 - uses a very professional format with detailed patient history,
090507 - ref SDS 0 XI6H, detailed account of examination, ref SDS 0 SJR3, and
090508 - then discussion of options, noting initially that the patient has a
090509 - difficult situation. ref SDS 0 XJ63 Submitted an email with
090510 - corrections to chronology, and provided support to clarify explanation
090511 - of critical details. ref SDS 0 4Q94
090513 - ..
090514 - [On 050921 Doctor Bailey reported the final draft of the
090515 - 2nd opinion was distributed to Kaiser on 050920.
090516 - ref SDS 40 L88M
090518 - ..
090519 - [On 050922 received Doctor Bailey's 2nd opinion.
090520 - ref SDS 41 HP3H
090521 -
090522 -
090523 -
090524 -
090526 - ..
0906 -
0907 -
0908 - Progress
0909 -
090901 - Received ref DRT 1 0001 from Doctor Bailey with a draft 2nd opinion,
090902 - and responding to the letter on Friday, 050916, ref SDS 38 0U5Q,
090903 - requesting timely submission to support the meeting with Kaiser
090904 - surgery department on 050923.
090906 - ..
090907 - [On 050922 received final opinion dated 050920. ref SDS 41
090908 - HP3H
090910 - ..
090911 - Generally, this is an excellent 2nd opinion in scope and analysis that
090912 - presents serious issues for consideration in making a determination on
090913 - surgery.
090915 - ..
090916 - There are a few date errors, which we can correct, and it might help
090917 - to address PCP focus on "local control" (see below, ref SDS 0 4V42)
090919 - ..
090920 - Doctor Bailey says...
090921 -
090922 - 1. This 69 year old female was first diagnosed with breast cancer
090923 - in March of 2003, with a left breast mass in the 12 o'clock
090924 - position of her left breast, and a 3 cm lymph node in her left
090925 - axilla. ref DRT 1 UE7M
090927 - ..
090928 - This work was performed in March 2002, rather than 2003, per patient
090929 - history listed on 050812. ref SDS 21 TW6H
090931 - ..
090932 - Doctor Bailey 2nd opinion draft continues...
090933 -
090934 - A core biopsy of the axillary lymph node showed a high-grade
090935 - infiltrating ductal carcinoma. A partial mastectomy was
090936 - performed with sentinel node biopsy. A 2 cm high-grade
090937 - invasive ductal carcinoma was removed along with lymph nodes.
090938 - Three of three lymph nodes were found to contain metastatic
090939 - cancer, with tumor infiltrating through the node capsule into
090940 - the peri-nodal fat. The estrogen receptor, progesterone
090941 - receptor, and the her2neu oncogene were all negative. She
090942 - underwent a re-excision to clear the margins of resection, but
090943 - no other lymph nodes were removed at that time. Subsequently,
090944 - she received adjuvant chemotherapy with Adriamycin and Cytoxan,
090945 - radiation therapy to her left breast, and supraclavicular lymph
090946 - nodes. ref DRT 1 WM8H
090948 - ..
090949 - Consideration might be given to saying chemo treatments began on
090950 - 020423, per patient history on 050812. ref SDS 21 7E8M
090952 - ..
090953 - Doctor Bailey 2nd opinion draft continues...
090954 -
090955 - As the tumor marker was still elevated, she was the treated
090956 - with Taxotere. A PET scan performed in June of 2003 showed
090957 - disease in her left axilla, and her CA15-3 was elevated, though
090958 - this value dropped with the chemotherapy treatments.
090959 - ref DRT 1 ON9J
090961 - ..
090962 - Consideration might be given to replacing the above with something
090963 - like...
090964 -
090965 - The tumor marker CA 15-3 continued rising during two (2)
090966 - treatments with AC, reaching 117. A PET scan was performed
090967 - on May 29, 2002 and showed disease in her left axilla. As
090968 - a result, on June 3, 2002 treatment was changed to
090969 - Taxotere. The patient responded well to Taxotere; CA 15-3
090970 - dropped to near normal.
090971 -
090972 - ...as shown in patient history on 050812. ref SDS 21 FP9N
090974 - ..
090975 - Doctor Bailey 2nd opinion draft continues...
090976 -
090977 - 2. By December of 2003, she had thickened skin on her left breast,
090978 - and left axillary discomfort. A PET scan on December 18, 2002,
090979 - showed increased uptake of the left supraclavicular, and
090980 - axillary nodes. ref DRT 1 UE9L
090982 - ..
090983 - Change "December of 2003" to "December of 2002."
090985 - ..
090986 - Consider... PET scan test report also cited "increased uptake on the
090987 - left upper chest," see patient history citing meeting on 030109,
090988 - ref SDS 21 P66P, and which further seems to correlate with "thickened
090989 - skin on left breast" recognized at the time, and diagnosed as reaction
090990 - to radiation.
090991 -
090992 - [On 050922 corrections entered in final draft.
090993 - ref SDS 41 WW6K
090994 -
090996 - ..
090997 - Doctor Bailey 2nd opinion draft continues...
090998 -
090999 - In January, 2003, a red rash was noted on the skin of her left
091000 - breast. Her CA15-3 was rising. She was initially treated with
091001 - antibiotics. ref DRT 1 RR4K
091003 - ..
091004 - This expression aligns with patient history.
091006 - ..
091007 - Doctor Bailey 2nd opinion draft continues...
091008 -
091009 - By late 2003, the majority of the skin of her left breast was
091010 - involved with this rash, and she developed palpable left
091011 - cervical lymph nodes. An FNA of a palpable left cervical
091012 - posterior triangle lymph node on March 18, 2004 showed
091013 - metastatic cancer... ref DRT 1 CT5F
091014 -
091015 - [On 050922 final draft contains same erroneous report on
091016 - evolution of IBC discovery, ref SDS 41 6E8K, possibly due
091017 - to reliance on the Benz report. ref SDS 41 WO4O
091019 - ..
091020 - Consideration should be given to revising the above construction as
091021 - follows...
091022 -
091023 - In early June of 2003 the patient observed a severe rash on
091024 - the left breast, and requested examination in advance of a
091025 - scheduled appointment for July. Examination by the doctor
091026 - on June 6, 2003 indicated the rash had subsided, so there
091027 - was no diagnosis nor treatment. In February of 2004, the
091028 - patient identified palpable left cervical lymph nodes, and
091029 - requested examination. On February 11, 2004 the doctor
091030 - prescribed antibiotics. A follow up examination on
091031 - February 27th showed no improvement in swelled lymph nodes.
091032 - A biopsy was performed on March 3, 2004. On March 9, the
091033 - report on the biopsy of left side lymph nodes was positive
091034 - for cancer. The patient met with the primary care
091035 - physician in Oncology on March 18, 2004 to schedule
091036 - systemic treatment of metastatic cancer with Avanstin and
091037 - Taxol through participation in a drug trial. At that time,
091038 - on March 18, the doctor observed the red rash had returned
091039 - to the left breast. Starting chemotherapy was delayed for
091040 - treating the rash on the left breast with antibiotics to
091041 - clear cellulitus in order to qualify the patient for
091042 - participating in the Avastin trial. On April 2, 2004
091043 - examination showed the rash persisted. Diagnosis was
091044 - changed to reaction to radiation and the patient was
091045 - cleared to start chemotherapy treatment on the Avastin
091046 - trial.
091048 - ..
091049 - [On 050922 final draft submitted to Kaiser contains same
091050 - erroneous report on evolution of IBC discovery.
091051 - ref SDS 41 EE7V
091053 - ..
091054 - [On 050922 Millie submitted a correction. ref SDS 41 QO5Y
091056 - ..
091057 - For above, see patient history listed on 050812. ref SDS 21 E49H
091058 -
091059 - Neck lymph nodes, relapse and red rash. ref SDS 21
091060 - YC4O
091061 -
091062 - Starting chemo on Avastin. ref SDS 21 YY93
091064 - ..
091065 - Doctor Bailey 2nd opinion draft continues...
091066 -
091067 - ...and on April 19, 2004, a punch biopsy of the left breast
091068 - skin in the area of the rash revealed cancer in dermal
091069 - lymphatics. A CT scan performed on April 9, 2004, showed a
091070 - liver cyst, and a small calcified lung nodule. Chemotherapy
091071 - was begun with Taxol and Avastin, with improvement in the
091072 - findings, but the patient developed a pulmonary embolus, and on
091073 - November 4, 2004, a CT scan showed pulmonary emboli. She was
091074 - withdrawn from the Avastin trial, and Coumadin was begun. She
091075 - was restarted on chemotherapy with Adriamycin and Cytoxan in
091076 - January of 2005, but the rash on the skin of her left breast
091077 - worsened. On March 25, 2005, a CT scan showed enlarged right
091078 - axillary lymph nodes, the largest measuring 18x20 mm. Her
091079 - chemotherapy was switched to Taxotere and capecitabine in
091080 - March, 2005. ref DRT 1 RM5L
091082 - ..
091083 - Consideration might be given to changing the last sentence along the
091084 - lines...
091086 - ..
091087 - Her chemotherapy was switched to Taxotere and capecitabine
091088 - on March 29, 2005, with the first treatment beginning on
091089 - April 15, 2005.
091091 - ..
091092 - See patient history on above dates. ref SDS 21 8O8J
091093 -
091094 - [On 050922 final version for some reason says chemo was
091095 - switched on 050925 rather than 050929, rest of correction
091096 - was made. ref SDS 41 6X4K
091098 - ..
091099 - Doctor Bailey 2nd opinion draft continues...
091100 -
091101 - Since then she has had significant improvement in the
091102 - thickening and redness of the skin of her left breast. Her CT
091103 - scan on May 5, 2005, shows significant reduction in the size of
091104 - the right axillary lymph nodes. She has had no evidence of
091105 - distant metastatic disease. She has been recommended by her
091106 - Kaiser doctors to have a mastectomy, and she presents her for a
091107 - second opinion. ref DRT 1 RR6O
091109 - ..
091110 - Possibly the last sentence should read...
091111 -
091112 - ...she presents here for a second opinion"
091113 -
091114 - ...changing "her" to "here," but not sure.
091115 -
091116 - [On 050922 final draft makes correction.
091117 - ref SDS 41 PT7J
091118 -
091120 - ..
091121 - Doctor Bailey 2nd opinion draft continues...
091122 -
091123 - Physical Examination:, ref DRT 1 UF5X,
091125 - ..
091126 - No comments.
091127 -
091129 - ..
091130 - Doctor Bailey 2nd opinion draft continues...
091131 -
091132 - Discussion:, ref DRT 1 WV9I
091134 - ..
091135 - 3. This patient has a difficult situation with spread of her
091136 - initial breast cancer through the breast dermal lymphatics and
091137 - regional lymph nodes. With her current chemotherapy, there has
091138 - * been significant t improvement. However, she continues to have
091139 - a large area of skin thickening and erythema of her medial and
091140 - inferior left breast. No adenopathy is currently palpable, and
091141 - no breast mass has been palpated since her initial diagnosis.
091142 - She has had no mammogram or other breast imaging for 2 years.
091144 - ..
091145 - Just a typo to remove extraneous "t" at...
091146 -
091147 - "...been significant t improvement...
091148 -
091149 - [On 050922 final draft did not make correction. ref SDS 41
091150 - XD54
091151 -
091153 - ..
091154 - Doctor Bailey 2nd opinion draft continues...
091155 -
091156 - 4. A mastectomy at this time, without evidence of involvement of
091157 - the breast tissue with cancer, is not recommended. At this
091158 - time, the disease has been a regional involvement of lymphatic
091159 - spread. She has shown that when off chemotherapy, her disease
091160 - has quickly recurred, and the prolonged recovery from any
091161 - planned surgery, which would need to be extensive, could put
091162 - her in jeopardy for recurrence of her disease which is now
091163 - under control. Continuing her chemotherapy would be her best
091164 - option to keep her disease under control. ref DRT 1 UF8Z
091166 - ..
091167 - This seems to be saying that if a PET scan and/or thin skin biopsies
091168 - proposed by Grissom on 050914, ref SDS 37 K86Y, show positive for
091169 - cancer in the left breast, this could be grounds for mastectomy
091170 - surgery??
091171 -
091172 - Does this mean that if IBC is found active in the left
091173 - breast, then surgery might be tried? Or, does it mean that
091174 - if, and only if, some other form of cancer is found in the
091175 - left breast, then mastectomy should be considered?
091177 - ..
091178 - What if tests show no cancer in the breast, and no distant
091179 - metastasis, which is the hoped for result? Are we still no
091180 - go surgery, which seems likely under Baily's anlaysis of
091181 - risks; but, what about continuing chemo? Can systemic
091182 - treatment be stretched out, or dosage reduced in order to
091183 - reduce side effects relative to quality of life, and until
091184 - positive evidence of progression? That was the policy
091185 - followed in 2003, albeit in possible conflict with evidence
091186 - of progression. If we have no evidence of cancer, what do
091187 - we do?
091188 -
091189 - [On 050927 surgeon at Kaiser cites discussion on 050923
091190 - proposing that test findings of no disease supports
091191 - performing standard mastectomy. ref SDS 42 WX5F
091193 - ..
091194 - [On 051007 report on PET scan test performed on 051005
091195 - shows no locoregional nor distant metastatic disease.
091196 - ref SDS 43 L66M
091198 - ..
091199 - [On 051021 very wide mastectomy surgery performed; no
091200 - initial complications, surgeon hopeful effort will be
091201 - effective. ref SDS 44 EG5L
091203 - ..
091204 - [On 051021 report on biopsies taken 051012 show
091205 - negative for inflammatory carcinoma in left breast.
091206 - ref SDS 44 LH6O
091208 - ..
091209 - Doctor Bailey may feel this is another issue for another
091210 - opinion at a later time; and the big objective now is for
091211 - clarity on surgery questions.
091213 - ..
091214 - Just musings, but...
091216 - ..
091217 - Mil went off chemo OA 021206, ref SDS 21 XX8G, The PET scan on 021218
091218 - together with exam on 030109 showing red rash on left breast could
091219 - suggest she had symptoms of IBC througout 2003, given rising CA 15-3
091220 - and rising discomfort on left axilla. So, while she was off treatment
091221 - during 2003, she may have had rising disease at all times.
091223 - ..
091224 - If, on the other hand, new testing ordered in the current period shows
091225 - no distant metastasis and no local involvment, then this could be the
091226 - first time when there is no evidence of disease. As well, the patient
091227 - was off treatment from 041021 until 050104, ref SDS 21 T35J, and IBC
091228 - increased rapidly, but testing and examinations at that time showed
091229 - she was not free from disease. Possibly, this record suggests that
091230 - there is no patient history for relapse after testing negative for
091231 - disease. On the other hand, this analysis may be spltting hairs that
091232 - conflicts with prudence and good practice.
091234 - ..
091235 - Local control -- this might a good place in the opinion to directly
091236 - address PCP goals for surgery to achieve local control. The entire
091237 - opinion seems to say that, if testing shows no distant metastasis,
091238 - then local control might be achieved with mastectomy surgery; however,
091239 - equally, and perhaps more likely, local control will be lost, and
091240 - disease will cascade out of control due to cirsumstances presented by
091241 - patient profile. Local control can be lost due to existing disease
091242 - that is not resolved by surgery, no matter how well performed, and can
091243 - also be lost by critical details of surgery not performed or are
091244 - performed incorrectly through inexperience or inadvertance in a very
091245 - complex operation. These multiple risks augur for caution.
091247 - ..
091248 - Doctor Bailey 2nd opinion draft continues...
091249 -
091250 - 5. I would first recommend a work-up of breast, as well as a
091251 - restaging for metastatic disease. I would recommend a
091252 - bilateral mammogram as well as a breast MRI, and a PET scan.
091253 - If she has metastatic disease, further chemotherapy would be
091254 - indicated. ref DRT 1 UF9Z
091256 - ..
091257 - Should there also be a "work-up" for contemplated surgery?
091259 - ..
091260 - A flow diagram of tasks, and CPM schedule, along with listing of the
091261 - surgical team and pre-op meetings to brief everyone on risks and work
091262 - arounds planned for problems that might arise -- all seem helpful in a
091263 - complex case.
091264 -
091266 - ..
091267 - Doctor Bailey 2nd opinion draft continues...
091268 -
091269 - 6. If she has disease within her left breast, a mastectomy might
091270 - then be considered. However, a mastectomy, if performed, would
091271 - necessitate a very large area of skin to be removed, in order
091272 - to remove any involved skin. Anything less than this would
091273 - chance cutting through an area of skin involvement with cancer,
091274 - and result in non-healing of her wound. The area of skin which
091275 - would need to be removed would make it difficult to close this
091276 - wound by primary closure. A skin graft would not be
091277 - recommended in light of the previous radiation therapy and the
091278 - recent chest wall involvement. A major reconstructive effort
091279 - with autogenous tissue would need to be planned as immediate
091280 - reconstruction along with the mastectomy if this were
091281 - performed. There would be major risks to this surgery, both in
091282 - terms of the delay to further chemotherapy, but also in light
091283 - of her history of pulmonary emboli. She would need to be off
091284 - of her coumadin for several days before and after any surgery,
091285 - and considering the lengthy nature of any mastectomy and
091286 - reconstruction that might be done, would be at increased risk
091287 - for further emboli and possibly death. ref DRT 1 UF4W
091289 - ..
091290 - Wound from a punch biopsy on 040419 did not heal for over a year,
091291 - noted by surgeon at Kaiser in Walnut Creek on 050324, ref SDS 12 WI6K,
091292 - and supporting Doctor Bailey's concern about prolonged healing of a
091293 - major surgical procedure.
091295 - ..
091296 - Layout of surgical area -- can further comment explain how this would
091297 - be done? For example, since the surgeon has only seen the patient
091298 - three (3) times in nine (9) months, would she consult with the
091299 - patient, and the oncologist on the spread of disease for setting the
091300 - boundaries of surgery? The speculative character of this exercise
091301 - supports caution. Would the surgeon ask the oncologist for a diagram
091302 - showing the maximum spread of disease, and then layout on the patient
091303 - the dimensions of removal + plus some margin for error? How does
091304 - this relate to the common term "radical mastectomy"?
091305 -
091306 - [On 050920 Doctor Grissom proposes very wide mastectomy
091307 - surgery layed out based on series of thin surgical biopsies
091308 - to helps locate boundaries of surgery. ref SDS 39 XL8U
091310 - ..
091311 - [On 050922 Doctor Bailey does not offer guidance on
091312 - determining the area of breast and skin to remove for a
091313 - very wide mastectomy. ref SDS 41 JZ4K
091315 - ..
091316 - [On 051021 very wide mastectomy surgery performed and layed
091317 - out based on test biopsies proposed by Doctor Grissom.
091318 - ref SDS 44 8K6N
091320 - ..
091321 - Doctor Bailey 2nd opinion draft continues...
091322 -
091323 - 7. I would also recommend a work-up for a hypercoagulable state.
091324 - Besides this patient's own pulmonary emboli, her mother died of
091325 - an arterial thrombosis, and her son has had a pulmonary
091326 - embolus.
091328 - ..
091329 - 8. Finally, a repeat of the ER, PR, and her2neu on the skin biopsy
091330 - could be considered. It is unusual for the ER and PR to become
091331 - positive when previously negative, but this would be useful
091332 - information. In addition, the her2neu oncogene, if now
091333 - positive, would change therapy recommendations.
091334 -
091335 -
091337 - ..
0914 -
0915 -
0916 - 1741
0917 -
091701 - Submitted comments to the doctor via email with link to this record.
091702 -
091703 - 1. Subject: Comments Buck 2nd Opinion Draft
091704 - Date: Sun, 18 Sep 2005 19:34:29 -0700
091711 - ..
091712 - 3. Excellent opinion, and thanks for timely attention. You raise
091713 - critical issues for Millie and Kaiser to consider. I read some
091714 - of your analysis to Mil; naturally, she has mixed feelings
091715 - about continuing chemo indefinitely, but she is very grateful
091716 - for your input. She commented after we left your office on
091717 - thoroughness of your examination and review of patient history.
091719 - ..
091720 - 4. Below, are links to comments in the context of your 1st draft
091721 - received today...
091723 - ..
091724 - Notes:
091725 -
091726 - (1) your text is presented with numbered paragraphs;
091727 - comments are below numbered para, then there is a
091728 - demarcation saying "Doctor Bailey's draft continues..."
091729 - and you will see your next text in numbered para. Not
091730 - all of your text is shown, only where comments are made.
091732 - ..
091733 - (2) if the format and intent of comments seems unclear,
091734 - please call to discuss.
091736 - ..
091737 - 5. There are a few date issues in your initial case history which
091738 - need adjustment in the final draft; I also took a crack at
091739 - constructing some alternate narrative in a couple of places to
091740 - fit chronology, and for your consideration. ref SDS 0 FH5I
091742 - ..
091743 - 6. Your recommendations layout critical issues as needed.
091745 - ..
091746 - 7. If you feel it is appropriate, please consider expanding
091747 - slightly on implications of alternate test result scenarios, as
091748 - shown in the record today. ref SDS 0 XK3U
091750 - ..
091751 - 8. "Local Control" might be addressed expressly, even though the
091752 - entire opinion speaks to that issue. Since PCP often grounds a
091753 - call for surgery on achieving "local control," it would help to
091754 - treat this phrase in writing. Here are some musings for
091755 - consideration. ref SDS 0 4V42
091757 - ..
091758 - 9. Finally, a good way to further illustrate risks of surgery in
091759 - this case is to explain mechanics for determining and laying
091760 - out the boundaries of surgery. You make clear this is a core
091761 - risk, but if they go ahead anyway, typically what steps would
091762 - have to be done, per comments on your draft. ref SDS 0 YP48
091764 - ..
091765 - 10. Again, I cannot express enough appreciation for the quality of
091766 - your work product on a 2nd opinion to help Millie. I was
091767 - disappointed when UCSF made referrals after we asked for follow
091768 - up opinion from Doctor Benz. You and Doctor Grissom have fully
091769 - vindicated referral. I look forward to thanking the UCSF folks
091770 - for telling us about you.
091772 - ..
091773 - 11. My sense is that your opinion should be addressed to the
091774 - Primary Care Physician (PCP) in oncology, with a copy to the
091775 - surgeon, per addresses shown below in my earlier letter on
091776 - 050916. ref SDS 38 0U7T Please send the computer file via
091777 - email, and a signed copy in the mail addressed to Millie...
091783 - ..
091784 - 12. I may have mentioned that Veronica Shim in Kaiser's Oakland
091785 - office asked to see a copy of your opinion, so with your
091786 - permission, I plan to email her a copy and ask for feedback in
091787 - advance of the meeting on 050923 (Friday) with the surgeon in
091788 - Walnut Creek.
091790 - ..
091791 - 13. Hopefully, we can get our "ducks in a row" in time to be
091792 - prepared for an effective meeting. I suggested in the recent
091793 - meeting on 050913 that the Oncologist join the meeting with the
091794 - surgeon, and he declined. Did not press, because the meeting
091795 - was emotional. We'll keep working to get review of your
091796 - opinion.
091797 -
091798 - [On 050921 Doctor Bailey reported the final draft of the
091799 - 2nd opinion was distributed to Kaiser on 050920.
091800 - ref SDS 40 L88M
091802 - ..
091803 - [On 050922 received Doctor Bailey's 2nd opinion.
091804 - ref SDS 41 HP3H
091805 -
091806 -
091807 -
091808 -
091809 -
091810 -
091811 -
0919 -
Distribution. . . . See "CONTACTS"