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1...I would also recommend a work-up for a hypercoagulable state.
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 Received from 3rd Referral Explains Treatment Options
0903 -
0903 - ..
0904 - Summary/Objective
0905 -
090501 - Follow up ref SDS 14 0000. ref SDS 12 0000.
090502 -
090503 - Doctor Bailey submitted a 2nd opinion which has been sent to Millie's
090504 - doctor's in Kaiser's Walnut Creek office to prepare for a meeting with
090505 - Millie tomorrow. ref SDS 0 HP3H This is an excellent opinion in scope
090506 - and detail based on patient history. ref SDS 0 9R8N Doctor Bailey is
090507 - cautious about mastectomy surgery, ref SDS 0 XD6U; she explains risks
090508 - and proposes significant work up to prepare for a complex surgery, if
090509 - Millie decides to have a mastectomy. ref SDS 0 XD7U Millie sent a
090510 - letter thanking Doctor Bailey for getting this done in time for the
090511 - meeting tomorrow at Kaiser. ref SDS 0 6G64 Millie clarified a fact
090512 - pattern in the Doctor's opinion on timing and discovery of IBC,
090513 - ref SDS 0 QO5Y, and further updates the doctor on implementation of
090514 - her recommendations. ref SDS 0 QP6R This evening, Doctor Bailey's
090515 - opinion was sent to Doctor Shim in Kaiser's Oakland office, as
090516 - prevsiously requested by Doctor Shim, ref SDS 0 TL3I, and so that the
090517 - doctor can offer support for Millie's meeting tomorrow with the
090518 - surgeon in Kaiser's Walnut Creek office. ref SDS 0 YG4Q
090519 -
090520 - [On 051010 letter to Doctor Bailey requests additional guidance on
090521 - change in purpose of surgery from local control to palliation.
090522 - ref SDS 23 X93F
090524 - ..
090525 - [On 051011 Doctor Bailey comments that risks of mastectomy are
090526 - compounded for secondary IBC patients, because, where there is no
090527 - evident tumor to remove within the breast, benefits of palliation
090528 - are reduced by removing breast mass with blood vessels needed to
090529 - treat relapse of cancer. ref SDS 24 G65S
090530 -
090531 -
090532 -
090533 -
090534 -
090536 - ..
0906 -
0907 -
0908 - Progress
0909 -
090901 - Received ref DRT 2 0001 dated this morning at 0214 from Doctor Bailey
090902 - saying...
090903 -
090904 - Attached is the consultation that was sent to Drs. Johnson and
090905 - Riley-Paull. I hope the discussions on Sept. 23 go well.
090907 - ..
090908 - This responds to the correspondence, ref DIP 5 0001, submitted
090909 - yesterday, 050921, ref SDS 14 UE6S, and following up the Doctor's
090910 - letter, ref DRP 6 0001, received yesterday reporting that the opinion
090911 - was mailed to Kaiser the day before on 050920. ref SDS 14 R26L
090913 - ..
090914 - The file on the 2nd opinion, however, was not attached, likely due to
090915 - the late hour, just a tired overlight.
090917 - ..
090918 - Doctor Bailey does not address follow up on contacting Doctor Parks at
090919 - UCSF for Millie to participate in a new trial, cited in a post script
090920 - to the letter to Doctor Bailey, ref DIP 5 00W2, which was submitted
090921 - yesterday. ref SDS 14 UE4U
090922 -
090923 -
090924 -
090925 -
090927 - ..
0910 -
0911 -
0912 - 0723
0913 -
091301 - Submitted ref DIT 1 0001 to the doctor with a copy to the office
091302 - manager, Roberta, but hopefully Gena who is sitting in while Roberta
091303 - is on vacation. The letter to the doctor says...
091304 -
091305 - 1. A little glitch; the file on Mil's 2nd opinion was not attached
091306 - to your letter this morning.
091308 - ..
091309 - 2. Please resubmit.
091310 -
091311 -
091312 -
091314 - ..
0914 -
0915 -
0916 - 0831
0917 -
091701 - Received ref DRT 1 0001 Doctor Bailey's 2nd opinion dated 050920
091702 - which the doctor reported earlier this morning was mailed to Kaiser in
091703 - Walnut Creek, per above, ref SDS 0 WM4F, which enables the surgeon to
091704 - be prepared for meeting with Millie has tomorrow. Doctor Bailey's 2nd
091705 - opinion received today follows up examination and consultation on
091706 - 050909, ref SDS 8 RE4M, and finalizes preliminary analysis in the 1st
091707 - draft received on 050918. ref SDS 11 LW3O As noted previously, this is
091708 - a well organized, thorough and well reasoned opinion, given limited
091709 - time for preparation to support the meeting tomorrow with Kaiser, as
091710 - requested on 050918. ref SDS 11 SS8X Many tasks to prepare for
091711 - surgery, and also to advance Millie's care beyond consideration for
091712 - surgery are identified that have not been previously presented in the
091713 - record.
091715 - ..
091716 - 1. Second Opinion Consultation on Millie ***** 9/9/2005
091717 -
091718 - [...see below, Millie thanks Doctor Bailey for excellent
091719 - opinion, and corrects glitch in patient history. ref SDS 0
091720 - 6G64
091721 -
091722 - [...see below submitted copy to Doctor Shim at Kaiser in
091723 - Oakland. ref SDS 0 TL3I
091725 - ..
091726 - [On 050923 surgeon at Kaiser in Walnut Creek office received
091727 - Doctor Grissom's 2nd opinion; discussed during meeting with
091728 - patient. ref SDS 18 7J67
091730 - ..
091731 - This 69 year old female was first diagnosed with breast cancer
091732 - in March of 2002, with a left breast mass in the 12 o'clock
091733 - position of her left breast, and a 3 cm lymph node in her left
091734 - axilla. A core biopsy of the axillary lymph node showed a
091735 - high-grade infiltrating ductal carcinoma. A partial mastectomy
091736 - was performed with sentinel node biopsy. A 2 cm high-grade
091737 - invasive ductal carcinoma was removed along with lymph nodes.
091738 - Three of three lymph nodes were found to contain metastatic
091739 - cancer, with tumor infiltrating through the node capsule into
091740 - the peri-nodal fat. The estrogen receptor, progesterone
091741 - receptor, and the her2neu oncogene were all negative. She
091742 - underwent a re-excision to clear the margins of resection, but
091743 - no other lymph nodes were removed at that time. Subsequently,
091744 - she received adjuvant chemotherapy with Adriamycin and Cytoxan
091745 - on 4/23/02, radiation therapy to her left breast, and
091746 - supraclavicular lymph nodes. As the tumor marker was still
091747 - rising, a PET scan performed on 5/29/02 showed disease in her
091748 - left axilla. Her chemotherapy was changed to Taxotere, and her
091749 - CA 15-3 values dropped with the chemotherapy treatments.
091750 - ref DRT 1 0001
091752 - ..
091753 - 2. By December of 2002, she had thickened skin on her left breast,
091754 - and left axillary discomfort. A PET scan on December 18, 2002,
091755 - showed increased uptake of the left supraclavicular, and
091756 - axillary nodes and left upper chest. In January, 2003, a red
091757 - rash was noted on the skin of her left breast. Her CA15-3 was
091758 - rising. She was initially treated with antibiotics.
091759 - ref DRT 1 HZ75
091761 - ..
091762 - This final draft corrects problem reported on 050918, and adds
091763 - reference to PET test findings cited in comments. ref SDS 11 XJ3W
091765 - ..
091766 - Doctor Bailey 2nd opinion continues...
091767 -
091768 - By late 2003, the majority of the skin of her left breast was
091769 - involved with this rash, the patient identified palpable left
091770 - cervical lymph nodes and requested examination. An FNA of a
091771 - palpable left cervical posterior triangle lymph node on March
091772 - 18, 2004 showed metastatic cancer, ref DRT 1 9P8F,
091773 -
091774 - [...see below Millie thanks Doctor Bailey for excellent
091775 - work, and mentions glitch in patient history that does not
091776 - affect recommendations. ref SDS 0 L57L
091778 - ..
091779 - [On 050923 Doctor Bailey reports misunderstanding came from
091780 - remembering a record or comment that is not readily
091781 - available to cite; and notes that Millie tried to get the
091782 - matter evaluated, but it took a long time for a biopsy to
091783 - be performed. ref SDS 17 4N5J
091785 - ..
091786 - [On 051010 letter to Doctor Bailey requests additional
091787 - guidance on change in purpose of surgery from local control
091788 - to palliation. ref SDS 23 X93F
091790 - ..
091791 - Not clear the basis for saying the majority of the left breast was
091792 - involved with a rash in later 2003. The first draft received on
091793 - 050918 said this, and comment back to Doctor Bailey clarified patient
091794 - history. ref SDS 11 4R43 Further review today found the 2nd opinion
091795 - prepared by Doctor Benz at UCSF, and received on 041117, says in
091796 - part...
091798 - ..
091799 - The patient noticed, within two months of going off
091800 - adjuvant chemotherapy, that she was developing a rash on
091801 - her left breast. There were attempts to treat this with
091802 - antibiotics, and the rash waxed and waned. There was
091803 - another attempt to treat this with steroid pills. Again,
091804 - the rash waxed and waned. By late 2003, she had almost 90%
091805 - of her left breast involved in this rash, and in early
091806 - 2004, began to notice lumps in the posterior portion of her
091807 - left neck. ref SDS 3 OS6W
091808 -
091809 - ...which closely aligns with the Bailey text, and so nominally
091810 - suggests appropriate reliance on the prior work.
091812 - ..
091813 - Review on 041117 found that the gist of the Benz text is okay for the
091814 - purpose of the report, but details are incorrect, including the last
091815 - sentence, because the doctor was unable to access patient history
091816 - online, and so was forced to rely on personal memory and hurried
091817 - scribbled notes from conversation during the examination that in turn
091818 - drew on vague, and hurried memories of a cancer patient during a brief
091819 - meeting on 041018. ref SDS 3 4Q6M Review further shows that the last
091820 - sentence in this part of the Benz report seems substantially similar
091821 - to the 2nd opinion received today, and so may account for persistant
091822 - error. During the meeting on 050909 Doctor Bailey asked for guidance
091823 - on opening the Benz report, identified as available from prior
091824 - correspondence scheduling the meeting, and this was provided along
091825 - with setting up access to actual patient history on 050812 on which a
091826 - 2nd opinion was requested. ref SDS 8 1G89 Possibly, Bailey's 2nd
091827 - opinion relies on the prior Benz report, but does not mention this
091828 - source. Cannot find any other basis for persistant error.
091830 - ..
091831 - Persistant error due to meaning drift is a common communication malady
091832 - described as the "telephone game" in NWO. ref OF 11 XF5H The
091833 - expanding burden of cognitive overhead to assume rather than rely on
091834 - the record reflects a major challenge for the new world order of
091835 - information density.
091837 - ..
091838 - [On 050923 Doctor Bailey reports error in patient history
091839 - came from remembering a record or comment incorrectly that
091840 - can no longer be found, and so cannot be cited for
091841 - verification; and notes that Millie tried to get evaluation
091842 - during the year 2003 of episodically expanding inflammation
091843 - in the left breast but it took a long time for the medical
091844 - system to perform a biopsy that eventually discovered IBC
091845 - in April of 2004. ref SDS 17 4N5J
091847 - ..
091848 - Doctor Bailey 2nd opinion continues...
091849 -
091850 - ...and on April 19, 2004, a punch biopsy of the left breast
091851 - skin in the area of the rash revealed cancer in dermal
091852 - lymphatics. A CT scan performed on April 9, 2004, showed a
091853 - liver cyst, and a small calcified lung nodule. Chemotherapy
091854 - was delayed to treat the rash on the breast with antibiotics.
091855 - However, the rash persisted.
091857 - ..
091858 - Chemotherapy was then begun with Taxol and Avastin, with
091859 - improvement in the findings, but the patient developed a
091860 - pulmonary embolus, and on November 4, 2004, a CT scan showed
091861 - pulmonary emboli. She was withdrawn from the Avastin trial,
091862 - and Coumadin was begun. ref DRT 1 DV9G
091864 - ..
091865 - She was restarted on chemotherapy with Adriamycin and Cytoxan
091866 - in January of 2005, but the rash on the skin of her left breast
091867 - worsened. On March 25, 2005, a CT scan showed enlarged right
091868 - axillary lymph nodes, the largest measuring 18x20 mm.
091869 - ref DRT 1 3W9N
091871 - ..
091872 - Her chemotherapy was switched to Taxotere and Capecitabine on
091873 - March 25, 2005, with the first treatment on 4/15/05. Since
091874 - then she has had significant improvement in the thickening and
091875 - redness of the skin of her left breast. Her CT scan on May 5,
091876 - 2005, shows significant reduction in the size of the right
091877 - axillary lymph nodes. ref DRT 1 3W9N
091879 - ..
091880 - This final draft corrects some of the problem reported on 050918, but
091881 - for some reason continues to report incorrectly that treatment was
091882 - changed on 050325, rather than 040329. ref SDS 11 7A46
091884 - ..
091885 - Doctor Bailey 2nd opinion continues...
091886 -
091887 - She has had no evidence of distant metastatic disease. She has
091888 - been recommended by her Kaiser doctors to have a mastectomy,
091889 - and she presents here for a second opinion. ref DRT 1 LX4N
091891 - ..
091892 - This final draft corrects problem reported on 050918. ref SDS 11 7A46
091894 - ..
091895 - Doctor Bailey 2nd opinion continues...
091896 -
091897 - 3. Past medical history
091898 -
091899 - Surgery: tubal ligation in the 1970's, left partial mastectomy
091900 - and sentinel node biopsy, re-excision of left breast carcinoma,
091901 - bladder repair for incontinence in the 1980's, ORIF left ankle,
091902 - bilateral breast implants 20 years ago which were removed one
091903 - year later. ref DRT 1 HZ42
091905 - ..
091906 - 4. Medical history: osteoarthritis (degenerative joint disease),
091907 - ref DRT 1 SY5M
091909 - ..
091910 - 5. Medications: Coumadin, Centrum, Vitamin B6, glucosamine
091911 - chondroitin, Taxotere (last 8/19/2005), ref DRT 1 HZ48
091913 - ..
091914 - 6. Allergies: none known to medications, ref DRT 1 PI6O
091916 - ..
091917 - 7. Family history: no family history of breast cancer. Maternal
091918 - grandfather died of lung cancer, mother died at 40 from
091919 - arteriothrombosis, aunt died of liver cancer at age 80 (patient
091920 - is not sure if this is a primary cancer or metastatic), son had
091921 - a pulmonary embolus at age 49, daughter has ulcerative colitis,
091922 - Maternal grandmother and maternal aunt had diabetes mellitus.
091923 - ref DRT 1 HZ54
091925 - ..
091926 - 8. Menarche at approximately age 14, menopause in her 50's.
091927 - G3P3Ab0, first child born when she was 18, and she breast fed
091928 - all three of her children, ref DRT 1 HZ59
091930 - ..
091931 - 9. Cigarettes: None currently. She previously smoked less than 1
091932 - pack per day from mid teens to approximately 20 years old.
091933 - ref DRT 1 HZ63
091935 - ..
091936 - 10. Hormone history: birth control pills for a short time in her
091937 - 20's, no fertility medications, no DES exposure, was on
091938 - Premarin for about 15 years after menopause, and discontinued
091939 - the Premarin in 2002 after her breast cancer diagnosis,
091940 - ref DRT 1 HZ65
091941 -
091943 - ..
091944 - 11. Physical examination:
091945 -
091946 - She is wearing a wig. She has no palpable cervical or
091947 - supraclavicular adenopathy, and her thyroid exam is normal.
091948 - Face is symmetric. Her lungs are clear with no rales, rhonchi,
091949 - or wheezes. Her respiratory rate was 18/minute. Her cardiac
091950 - exam showed no murmur or gallop, and her blood pressure was
091951 - 148.78, with heart rate 72 and regular. ref DRT 1 H143
091953 - ..
091954 - Her right breast was normal to visual inspection and palpation,
091955 - and there were no palpable axillary lymph nodes. ref DRT 1 TN6J
091957 - ..
091958 - Her left breast showed some thickened skin which was slightly
091959 - erythematous, in the medial and inferior breast, measuring 12
091960 - cm by 9 cm. She had healed incisions at the 6 o'clock areolar
091961 - edge, the upper outer quadrant, and axilla. There was no
091962 - palpable axillary adenopathy. ref DRT 1 FO6N
091964 - ..
091965 - On 050913 patient experienced impression observing slight red
091966 - inflammation, coloration, and flushness; yet, within minutes doctor
091967 - made examination and found coloration was cleared. ref SDS 9 025H
091969 - ..
091970 - Doctor Bailey 2nd opinion continues...
091971 -
091972 - Her abdominal examination was unremarkable, with normal bowels
091973 - sounds, no masses or tenderness, or hepatosplenomegaly. Her
091974 - extremities showed normal range of motion and no edema, and her
091975 - neurologic exam was grossly normal. ref DRT 1 VO7K
091976 -
091978 - ..
091979 - 12. Discussion:
091981 - ..
091982 - This patient has a difficult situation with spread of her
091983 - initial breast cancer through the breast dermal lymphatics and
091984 - regional lymph nodes. With her current chemotherapy, there has
091985 - been significant improvement. However, she continues to have
091986 - a large area of skin thickening and erythema of her medial and
091987 - inferior left breast. No adenopathy is currently palpable, and
091988 - no breast mass has been palpated since her initial diagnosis.
091989 - She has had no mammogram or other breast imaging for 2 years.
091990 - ref DRT 1 H148
091992 - ..
091993 - For some reason the correction presented on 050918 was not adopted.
091994 - ref SDS 11 PRYV
091995 -
091996 - [On 051010 letter to Doctor Bailey requests additional guidance on
091997 - change in purpose of surgery from local control to palliation.
091998 - ref SDS 23 X93F
092000 - ..
092001 - Doctor Bailey 2nd opinion continues...
092002 -
092003 - 13. A mastectomy at this time, without evidence of involvement of
092004 - the breast tissue with cancer, is not recommended. At this
092005 - time, the disease has been a regional involvement of lymphatic
092006 - spread involving the dermal lymphatics of the skin of the left
092007 - breast, left and right axillary lymph nodes, and
092008 - supraclavicular and cervical lymph nodes. She has shown that
092009 - when off chemotherapy, her disease has quickly recurred, and
092010 - the prolonged recovery from any planned surgery, which would
092011 - need to be extensive, could put her in jeopardy for recurrence
092012 - of her disease which is now under control. Continuing her
092013 - chemotherapy would be her best option to keep her disease under
092014 - control. ref DRT 1 H154
092016 - ..
092017 - This aligns with patient's report to primary care physician on 050913
092018 - relating understandings from consultation with Doctor Bailey on
092019 - 050909. ref SDS 9 VO44
092020 -
092021 - [On 051010 letter to Doctor Bailey requests additional guidance on
092022 - change in purpose of surgery from local control to palliation.
092023 - ref SDS 23 X93F
092025 - ..
092026 - Doctor Bailey 2nd opinion continues...
092027 -
092028 - 14. I would first recommend a work-up of breast, as well as a
092029 - restaging for metastatic disease. I would recommend a
092030 - bilateral mammogram as well as a breast MRI, and a PET scan.
092031 - If she has metastatic disease, further chemotherapy would be
092032 - indicated. ref DRT 1 H16H
092034 - ..
092035 - This aligns with patient's report to primary care physician on 050913
092036 - relating understandings from consultation with Doctor Bailey on
092037 - 050909. ref SDS 9 VO50
092038 -
092039 - [On 050922 bilateral mammogram performed at Kaiser in
092040 - Walnut Creek office. ref SDS 16 EA5H
092042 - ..
092043 - [On 051005 Millie got a combined PET and CT test at Kaiser
092044 - in Walnut Creek. ref SDS 20 0001
092046 - ..
092047 - [On 051019 letter prepared for Millie cites favorable
092048 - report on mammogram test that found no evidence of cancer.
092049 - ref SDS 26 DY8R
092051 - ..
092052 - [On 051027 biopsy on mastectomy surgery finds ductal
092053 - carcinoma in situ (DCIS) in nipple tissue that is commonly
092054 - discovered with mammogram tests, and conflicts with PET
092055 - scan and mammogram testing which reported no findings of
092056 - cancer. ref SDS 28 615K
092057 -
092059 - ..
092060 - Doctor Bailey 2nd opinion continues...
092061 -
092062 - 15. If she has disease within her left breast, a mastectomy might
092063 - then be considered. However, a mastectomy, if performed, would
092064 - necessitate a very large area of skin to be removed, in order
092065 - to remove any involved skin. Anything less than this would
092066 - chance cutting through an area of skin involvement with cancer,
092067 - and result in non-healing of her wound. ref DRT 1 H173
092069 - ..
092070 - This aligns with the 1st draft reviewed on 050918, ref SDS 11 XK5P,
092071 - that clarifies understandings from the meeting with Doctor Bailey on
092072 - 050909, ref SDS 8 MA6H, and does not explain procedures for
092073 - determining the precise area of breast and skin to remove for a very
092074 - wide mastectomy, which was requested from the doctor on 050918.
092075 - ref SDS 11 VQ6M
092076 -
092077 - [On 051010 letter to Doctor Bailey requests additional
092078 - guidance on change in purpose of surgery from local control
092079 - to palliation. ref SDS 23 X93F
092081 - ..
092082 - [On 051027 surgeon describes mastectomy that appears to
092083 - have cut through skin previously infected with IBC.
092084 - ref SDS 28 QR7L
092086 - ..
092087 - On 050920 Doctor Grissom proposes series of thin surgical biopsies,
092088 - ref SDS 13 GT3M, to help locate boundaries of a very wide mastectomy
092089 - surgery. ref SDS 13 XL8U
092091 - ..
092092 - Doctor Bailey 2nd opinion continues...
092093 -
092094 - 16. The area of skin which would need to be removed would make it
092095 - difficult to close this wound by primary closure. A skin graft
092096 - would not be recommended in light of the previous radiation
092097 - therapy and the recent chest wall involvement. A major
092098 - reconstructive effort with autogenous tissue would need to be
092099 - planned as immediate reconstruction along with the mastectomy
092100 - if this were performed. Planning preoperatively with a plastic
092101 - surgeon would be critical. ref DRT 1 RS5O
092102 -
092103 - [On 051010 letter to Doctor Bailey requests additional
092104 - guidance on change in purpose of surgery from local control
092105 - to palliation. ref SDS 23 X93F
092107 - ..
092108 - Doctor Bailey 2nd opinion continues...
092109 -
092110 - Additionally, consultation with a vascular surgeon regarding
092111 - any preoperative recommendations would be important.
092112 - ref DRT 1 UT6N
092114 - ..
092115 - There would be major risks to this surgery, both in terms of
092116 - the delay to further chemotherapy, but also in light of her
092117 - history of pulmonary emboli. She would need to be off of her
092118 - coumadin for several days before and after any surgery, and
092119 - considering the lengthy nature of any mastectomy and
092120 - reconstruction that might be done, would be at increased risk
092121 - for further emboli and possibly death. ref DRT 1 5V3H
092122 -
092123 - [On 051007 primary care physician proposed mastectomy for
092124 - palliation strategy in the event of relapse caused by
092125 - microscopic cancer cells not detected by testing,
092126 - ref SDS 22 I482, illustrated by the recent PET scan test on
092127 - 051005 that shows no locoregional nor distant metastatic
092128 - disease. ref SDS 22 L66M
092130 - ..
092131 - [On 051010 letter to Doctor Bailey requests additional
092132 - guidance on change in purpose of surgery from local control
092133 - to palliation. ref SDS 23 X93F
092135 - ..
092136 - [On 051011 Doctor Bailey comments that risks of mastectomy
092137 - are compounded for secondary IBC patients, because, where
092138 - there is no evident tumor to remove within the breast,
092139 - benefits of palliation are reduced by removing breast mass
092140 - with blood vessels needed to treat relapse of cancer.
092141 - ref SDS 24 G65S
092143 - ..
092144 - On 050729 the primary care physician indicated Coumadin would need to
092145 - be paused for 10 days prior to surgery, and further related plans to
092146 - substitute another treatment to accomplish objectives of Coumadin
092147 - during the surgery and recovery period of a mastectomy surgery.
092148 - ref SDS 5 RZ4I
092149 -
092150 - [On 050928 plastic surgeon during meeting at Kaiser cites
092151 - risks of bleeding during mastectomy surgery, that would be
092152 - increased with contemporaneous reconstructive surgery.
092153 - ref SDS 19 UM4I
092155 - ..
092156 - [On 051006 nurse in Coagulation Clinic at the Kaiser
092157 - Martinez hospital recommends reducing period for pausing
092158 - Coumadin for minor, outpatient biopsy surgery, and in order
092159 - to reduce the risk of adverse impact on pulmonary emoboli.
092160 - ref SDS 21 YV7Q
092162 - ..
092163 - [On 051021 Millie has mastectomy surgery; nurse draws blood
092164 - to evaluate pulmonary emboli risk related to treatment with
092165 - Coumadin. ref SDS 27 QW4I
092166 -
092167 -
0922 -
SUBJECTS
Hypercoagulable State Work Up Risk Assesment Genetic Acquired Dispos
1803 -
180401 - ..
180402 - Hypercoagulable State Work Up Risk Assesment for Surgery
180403 -
180404 - Doctor Bailey 2nd opinion continues...
180405 -
180406 - 17. I would also recommend a work-up for a hypercoagulable state.
180407 - Besides this patient's own pulmonary emboli, her mother died of
180408 - an arterial thrombosis, and her son has had a pulmonary
180409 - embolus. ref DRT 1 H193
180411 - ..
180412 - Millie's last clinical symptoms for pulmonary emboli were reported on
180413 - 050729, and attributed to loss of fitness from debilitating side
180414 - effects of chemotherapy treatments. ref SDS 5 RZ4I CT testing which
180415 - identified pulmonary emboli on 041104, ref SDS 2 4Y9G, has since that
180416 - time consistently shown no evidence of pulmonary emboli, beginning on
180417 - 041230, ref SDS 4 RZ4I, and continuing as noted in the record on
180418 - 050729. ref SDS 5 WE9H
180419 -
180420 - [On 060714 oldest son hospitalized again with pulmonary
180421 - emboli. ref SDS 30 8S6I
180423 - ..
180424 - [On 060722 oldest son reports doctor performed test and
180425 - found genetic disposition for blood clots that requires
180426 - continuing treatment. ref SDS 31 3D9T
180428 - ..
180429 - [On 060722 scope for work up on pulmonary emboli patients
180430 - reported in professional article. ref SDS 31 7V7I
180432 - ..
180433 - [On 060722 research 10% pulmonary emboli patients have
180434 - recurrence, and 45% of those who suffer recurrence die,
180435 - indicating high risk that supports continuing treatments to
180436 - avoid recurrence. ref SDS 31 BI5J
180438 - ..
180439 - [On 061002 Millie diagnosed with recurrence pulmonary
180440 - emboli; requires treatment again with Lovenox to relieve
180441 - blood clots, then continuing treatment with Coumadin to
180442 - prevent recurrence. ref SDS 32 JK7J
180444 - ..
180445 - Research shows a paper...
180446 -
180447 - Medicine Net.com...
180448 -
180449 - Definition of Hypercoagulable state
180450 -
180451 - Hypercoagulable state: A hypercoagulable state is the medical
180452 - term for a condition in which there is an abnormally increased
180453 - tendency toward blood clotting (coagulation).
180454 -
180455 - http://www.medterms.com/script/main/art.asp?articlekey=9240
180457 - ..
180458 - Another paper...
180460 - ..
180461 - Evaluation of the Hypercoagulable State
180462 -
180463 - Whom to screen, how to test and treat
180464 -
180465 - Amy P. Barger, MD; Randy Hurley, MD
180466 -
180467 - http://www.postgradmed.com/issues/2000/09_00/barger.htm
180469 - ..
180470 - VOL 108 / NO 4 / SEPTEMBER 15, 2000 / POSTGRADUATE
180471 - MEDICINE
180473 - ..
180474 - Paper says in part...
180475 -
180476 - Hypercoagulable conditions are inherited and acquired disorders
180477 - that predispose to venous thromboembolism [blood clots].
180478 - Laboratory testing can identify a predisposing genetic cause in
180479 - up to 50% of patients with venous thromboembolism (1-4). (see
180480 - Table 1, ref SDS 0 V85K)
180482 - ..
180483 - Ongoing discovery of new inherited and acquired prothrombotic
180484 - abnormalities complicates diagnosis. Paradoxically, technology
180485 - to diagnose a multitude of hypercoagulable conditions has
180486 - outpaced practical application to treatment. Short-term
180487 - treatment of venous thromboembolism [blood clots] varies
180488 - little. Moreover, convincing evidence regarding the intensity
180489 - or duration of anticoagulation is still lacking, since much of
180490 - the information on underlying biologic defects is new and
180491 - evolving.
180492 -
180494 - ..
180495 - Classification of Hypercoagulable Conditions Primary Secondary
180496 -
180497 - Hypercoagulable conditions can be classified as either primary
180498 - (inherited) or secondary (acquired).
180499 -
180501 - ..
180502 - Table 1. Classification of Hypercoagulable Conditions
180503 -
180504 - Primary (inherited)
180505 -
180506 - Antithrombin deficiency
180507 - Protein C deficiency
180508 - Protein S deficiency
180509 - Factor V Leiden (resulting in APC resistance)
180510 - Prothrombin 20210 mutation
180511 - Hyperhomocystinemia
180512 - Elevated factor VIII levels
180513 - Dysfibrinogenemia
180514 - Factor XII deficiency
180515 - Disorders of plasmin generation
180517 - ..
180518 - Secondary (acquired)
180519 -
180520 - Cancer
180521 - Pregnancy
180522 - Immobility
180523 - Trauma
180524 - Postoperative state
180525 - Use of oral contraceptives, estrogen, tamoxifen (Nolvadex)
180526 - Antiphospholipid syndrome
180527 - Hyperhomocystinemia
180528 - Other disease states
180529 -
180530 - Malignancy
180531 - Nephrotic syndrome
180532 - Myeloproliferative disorders
180533 - Congestive heart failure
180534 - Heparin-induced thrombocytopenia with thrombosis
180535 - Paroxysmal nocturnal hemoglobinuria
180536 - Beh‡et's disease
180538 - ..
180539 - Family history of blood clot problems was reported to Kaiser during
180540 - the meeting on 040812, when risks of pulmonary emboli were considered
180541 - based on news reports of problems on the Avastin drug trial.
180542 - ref SDS 1 MG4M
180543 -
180544 - [On 051007 Kaiser Surgery Department review cites extreme
180545 - high risk of surgery for patient with history of pulmonary
180546 - emboli. ref SDS 22 635M
180548 - ..
180549 - [On 051007 patient removed from treatment for blood clots
180550 - based on ending treatment with chemotherapy drug Avastin a
180551 - year earlier, and in order to remove concerns about blood
180552 - clots that make surgery high risk. ref SDS 22 EQ7K
180554 - ..
180555 - [On 051027 surgeon recommends oncology department review
180556 - work-up on Millie's hypercoagulable state. ref SDS 28 6G6I
180558 - ..
180559 - [On 051121 primary care physician ends treatment with
180560 - Coumadin because blood clots reported on 041103 occurred
180561 - while being treated with Avastin chemotherapy drugs, which
180562 - have side effects of pulmonary emboli. ref SDS 29 RZ4I
180564 - ..
180565 - [On 060714 oldest son hospitalized again with pulmonary
180566 - emboli. ref SDS 30 8S6I
180568 - ..
180569 - [On 060722 oldest son reports doctors performed tests and
180570 - found genetic cause of blood clots that will require
180571 - continuing treatment. ref SDS 31 3D9T
180573 - ..
180574 - [On 060722 research 10% pulmonary emboli patients have
180575 - recurrence, and 45% of those who suffer recurrence die,
180576 - indicating high risk that supports continuing treatments to
180577 - avoid recurrence. ref SDS 31 BI5J
180579 - ..
180580 - [On 061002 Millie diagnosed with recurrence pulmonary
180581 - emboli; requires treatment again with Lovenox to relieve
180582 - blood clots, then continuing treatment with Coumadin to
180583 - prevent recurrence. ref SDS 32 JK7J
180585 - ..
180586 - 18. Finally, a repeat of the ER, PR, and her2neu on the skin biopsy
180587 - could be considered. It is unusual for the ER and PR to become
180588 - positive when previously negative, but this would be useful
180589 - information. In addition, the her2neu oncogene, if now
180590 - positive, would change therapy recommendations. ref DRT 1 H198
180591 -
180592 - [On 050923 surgeon ordered retest for status change.
180593 - ref SDS 18 RX4I
180595 - ..
180596 - This aligns with patient's report to primary care physician on 050913
180597 - relating understandings from consultation with Doctor Bailey on
180598 - 050909. ref SDS 9 X561
180599 -
180600 -
180601 -
180602 -
180604 - ..
1807 -
1808 -
1809 - 1419
1810 -
181001 - Received ref DRT 3 0001 from Millie thanking Doctor Bailey for a well
181002 - prepared opinion received earlier this morning, per above. ref SDS 0
181003 - HP3H
181005 - ..
181006 - Millie says...
181007 -
181008 - 1. Thank you very much for assisting me and my doctors at Kaiser
181009 - figure out next steps, and especially for sending your opinion
181010 - in time for my meeting tomorrow at Kaiser. Your commitment to
181011 - high standards of professional practice shines through in your
181012 - report, and helps me consider difficult choices with confidence
181013 - that issues have been fully vetted. ref DRT 3 0001
181014 -
181015 - [On 050923 Doctor Bailey responds. ref SDS 17 4N5J
181017 - ..
181018 - 2. I've been looking forward to telling you how much I appreciated
181019 - your examination a few weeks ago, because you seemed very
181020 - thorough and brought up a number of points that have not been
181021 - discussed by the other doctors. I know it's hard to read up on
181022 - a long, complex medical history, and prepare an opinion on
181023 - short notice, so getting everything done in time for my meeting
181024 - is wonderful. ref DRT 3 NI5N
181026 - ..
181027 - 3. Just a note that really doesn't impact your recommendations.
181028 - ref DRT 3 KI6L
181030 - ..
181031 - 4. You mention in the 2nd opinion that by late 2003 the majority
181032 - of the skin of my left breast was involved with a red rash. I
181033 - don't recall that happening. ref DRT 3 UI6O
181035 - ..
181036 - This reflects error in Bailey's patient history, possibly obtained
181037 - from the same error in an earlier opinion submitted by Doctor Benz
181038 - last October. ref SDS 0 EE7V
181039 -
181040 - [On 050923 Doctor Bailey reports error in patient
181041 - history came from remembering a record or comment
181042 - incorrectly that can no longer be found, and so cannot
181043 - be cited for verification; and notes that Millie tried
181044 - to get evaluation during the year 2003 of episodically
181045 - expanding inflammation in the left breast but it took a
181046 - long time for the medical system to perform a biopsy
181047 - that eventually discovered IBC in April of 2004.
181048 - ref SDS 17 4N5J
181050 - ..
181051 - Millie's letter to Doctor Bailey continues...
181052 -
181053 - 5. After the doctor saw the rash in January of 2003, the next time
181054 - I noticed the rash was late May or early June, so I asked for
181055 - an exam. By the time the doctor could see me a week or so
181056 - later, he said the two breasts looked alike, so nothing was
181057 - done, and the rash in fact subsided, as it had earlier in
181058 - January. The rash may have flared up on other occasions, but
181059 - we did not know it was important, and so were not examining for
181060 - it. Rod noticed the rash in mid-March 2004 when I got out of
181061 - the shower, so when we met with the doctor at that time, then
181062 - at the end of a long meeting getting me set up to start chemo
181063 - again due to the problem in the neck, I asked the doctor to
181064 - check my breast. The doctor saw the problem, and left the room
181065 - to consult with Rosalie, the protocol nurse. He came back and
181066 - said the protocol for the trial requires clearing up the rash,
181067 - which he called cellulitus. ref DRT 3 9O7J
181069 - ..
181070 - 6. The rest of your description is accurate, in that starting
181071 - treatment was delayed, but the rash persisted, so diagnosis was
181072 - changed to reaction from radiation, and I was cleared for
181073 - treatment. This is when the rash got worse -- in early April
181074 - of 2004. It may have covered the majority of the left breast,
181075 - I'm not sure on that, but it looked bad, so after the doctor
181076 - installed a port for my chemo above the right breast, Rod asked
181077 - her to check my left breast, and that was when the biopsy was
181078 - taken. ref DRT 3 HO8O
181080 - ..
181081 - 7. I don't mean this as a criticism of your opinion, because I
181082 - think your analysis is crucial for me to decide what to do, and
181083 - the sequence of when IBC actually flared up doesn't impact what
181084 - you propose, as far as I can see. I also realize that you have
181085 - to summarize a lot of details. I just don't feel comfortable
181086 - with an official document out there saying a majority of my
181087 - breast was all red in late 2003 and I did nothing about it for
181088 - months. ref DRT 3 RO9N
181090 - ..
181091 - 8. I've tried my best to be a good patient, and my note here is to
181092 - emphasize how much I admire your work and appreciate your good
181093 - counsel based on a common set of facts. ref DRT 3 KO4M
181094 -
181095 - [On 050923 Doctor Bailey reports error in patient history
181096 - came from remembering a record or comment incorrectly that
181097 - can no longer be found, and so cannot be cited for
181098 - verification; and notes that Millie tried to get evaluation
181099 - during the year 2003 of episodically expanding inflammation
181100 - in the left breast but it took a long time for the medical
181101 - system to perform a biopsy that eventually discovered IBC
181102 - in April of 2004. ref SDS 17 4N5J
181104 - ..
181105 - 9. I had a chemo treatment last Fri, and finally today, I seem to
181106 - be back in the swim of things. I also had the mammogram test
181107 - this morning, which you suggested. So, it sounds like Kaiser
181108 - may be listening to you. Boy did the "fur fly" when we met
181109 - with the doctor last week and handed in a summary of 2nd
181110 - opinions saying that surgery needs more thought. I really
181111 - don't like emotional meetings, so I was ready to consent to
181112 - anything. Now it seems we may be on the right track with
181113 - everybody working together, not arguing. ref DRT 3 2P5H
181115 - ..
181116 - This reports implementation of Bailey's recommendations for
181117 - chemotherapy, per above, ref SDS 0 XD6U, and for further testing, per
181118 - above. ref SDS 0 XD7U
181120 - ..
181121 - Millie's letter to Doctor Bailey continues...
181122 -
181123 - 10. Hopefully, the tests will be favorable in the next few weeks,
181124 - and we can figure things out. Am I correct that you would only
181125 - contemplate surgery if the left breast is positive for cancer.
181126 - That sounds counterintuitive, but if there is no cancer can I
181127 - take a break from these treatments or try something else that
181128 - does not make me feel so bad? ref DRT 3 LP6G
181130 - ..
181131 - 11. Thanks again for an excellent opinion. ref DRT 3 RP6N
181132 -
181133 -
181134 -
181135 -
181136 -
181137 -
1812 -
SUBJECTS
2nd Opinion Doctor Bailey Request Comment from Doctor Shim Internal
2703 -
2704 - 2223
270501 - ..
270502 - Submit Doctor Bailey 2nd Opinion for Comment from Doctor Shim
270503 -
270504 - Submitted ref DIT 2 0001 to Doctor Veronica Shim in Kaiser's Oakland
270505 - Office with a link to Doctor Bailey's opinion, per above, ref SDS 0
270506 - HP3H, and as requested by Veronica in a letter on 050909. ref SDS 7
270507 - N44Q
270509 - ..
270510 - 1. Per the request in your letter on Sep 9, ref SDS 7 N44Q, here
270511 - is Lisa Bailey's 2nd opinion, ref DIT 2 0001, received today.
270512 - ref SDS 0 HP3H
270514 - ..
270515 - 2. There is an error in patient history, ref SDS 0 EE7V, but this
270516 - does not impact recommendations. ref DIT 2 KA6J
270518 - ..
270519 - 3. Additionally, a few days ago on 050920, ref DIT 2 TA6O,
270520 - received a 2nd opinion from Doctor Nima Grissom. ref SDS 13
270521 - PQ5S
270523 - ..
270524 - 4. Your comments are appreciated. Mil is meeting with the surgeon
270525 - tomorrow afternoon at 5p to discuss next steps. ref DIT 2 WX7H
270526 - This meeting was scheduled by the Primary Care Physician during
270527 - a meeting on 050913 following discussion of your opinion and
270528 - preliminary findings from Doctor Grissom and Doctor Bailey.
270529 - ref SDS 9 T46F
270531 - ..
270532 - 5. Meeting on 050913 was difficult for Millie due emotional
270533 - aspects when the doctor was troubled by the patient obtaining
270534 - review of proposed invasive procedure. The doctor urged
270535 - proceeding with surgery without delay for review and planning.
270536 - ref DIT 2 WX8G
270538 - ..
270539 - 6. Ultimately the following actions were taken following the
270540 - meeting on 050913...
270541 -
270542 - a. Millie was scheduled for an 8th cycle of chemo with
270543 - Taxotere and capecitabine, per Bailey recommendation, and
270544 - this was performed on 050916. ref SDS 10 407N She starts
270545 - the 2nd week of capecitabine (Xeloda) treatments with pills
270546 - tomorrow. ref DIT 2 6C9F
270548 - ..
270549 - b. PET scan test was ordered, per recommendation of Bailey and
270550 - Grissom, and is now scheduled for 051005. ref DIT 2 MC9N
270552 - ..
270553 - c. Retesting for checking status, recommended in your report
270554 - was discussed, but not scheduled. This may occur in the
270555 - meeting with the surgeon tomorrow. ref DIT 2 IC4G
270557 - ..
270558 - d. Mammogram test recommended in your opinion was ordered
270559 - after the meeting, and subsequently performed today at
270560 - Kaiser in Walnut Creek. ref DIT 2 VC4K
270562 - ..
270563 - e. Breast MRI suggested by Doctor Bailey has not been ordered.
270564 - Do you have a view on the need for this??? ref DIT 2 8D4O
270566 - ..
270567 - 7. As things currently stand, Primary Care Physician recommends
270568 - mastectomy surgery, ref DIT 2 E45F, per meetings on 050729,
270569 - ref SDS 5 BZ56, and again on 050913. ref SDS 9 T46F You have
270570 - supported this proposal, reported to the Primary Care Physician
270571 - during the meeting on 050913, ref SDS 9 X56N, and citing your
270572 - opinion reviewed on 050907. ref SDS 6 JS4H Doctor Bailey and
270573 - Doctor Grissom say a mastectomy could be effective under
270574 - certain conditions (see Grissom on 050920, ref SDS 13 XL8P; and
270575 - see Bailey on 050922, ref SDS 0 XD8P), and further note this
270576 - would be a complicated procedure with attendant risks. Doctor
270577 - Grissom proposes thin skin biopsies to verify status of IBC,
270578 - and to help define the area of a "very wide mastectomy". (see
270579 - again the record on 050920, ref SDS 13 XL7P)
270581 - ..
270582 - Wound be helpful for Veronica to comment on Doctor Grissom's proposal
270583 - for a microvascular flap such as a DIEP or possibly a TRAM for closure
270584 - of the surgical wound, reported on 050920. ref SDS 13 XL8U
270585 -
270586 - [On 050923 surgeon at Kaiser in Walnut Creek concurs thin
270587 - skin biopsies would be helpful. ref SDS 18 NT9G
270589 - ..
270590 - [On 051012 thin skin biopsies performed to assess
270591 - boundaries for mastectomy surgery. ref SDS 25 DG6J
270593 - ..
270594 - Letter to Veronica continues...
270595 -
270596 - 8. Seems like tomorrow the surgeon could take, or order, these
270597 - biopsies, and she can order the retesting of the biopsy on
270598 - 040419, ref DIT 2 E366, which you proposed in your letter on
270599 - 050909 to check on whether Millie's status has changed for
270600 - possibly expanding treatment options. ref SDS 7 P58N
270602 - ..
270603 - 9. If you have time to comment, perhaps you could suggest an
270604 - agenda for the meeting tomorrow. My sense is we need to get
270605 - the tests done, then see what they show. ref DIT 2 0G4F
270607 - ..
270608 - 10. You have been very helpful, and your support is greatly
270609 - appreciated. ref DIT 2 5G4K
270610 -
270611 -
270612 -
270613 -
270614 -
270615 -
270616 -
270617 -
270618 -
270619 -
270620 -
270621 -
270622 -
270623 -
270624 -
270625 -
270626 -
2707 -
Distribution. . . . See "CONTACTS"