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Meeting Agenda Surgeon Evaluate Mastectomy Left Breast Follow Up Requ
Surgeon Notes on Meeting with Patient 050923 Received

0504 -
0504 -    ..
0505 - Summary/Objective
0506 -
050601 - Follow up ref SDS 60 0000. ref SDS 39 0000.
050602 -
050603 - Surgeon's notes closely align with the record of meeting on 050923,
050604 - and emphasize plans for testing to explore feasibility of mastectomy
050605 - surgery.  The doctor mentions that the patient asked a number of
050606 - questions to assess feasibility of surgery, but none are actually
050607 - listed nor resolved in the notes; review today summarizes these
050608 - questions for convenient response. ref SDS 0 AK3P  A major question is
050609 - deciding the scope of surgery, and this seems to require feedback from
050610 - consultants. ref SDS 0 EU67
050611 -
050612 -        [On 050928 submitted surgeon's notes to consultants for
050613 -        comments. ref SDS 61 1J5J
050615 -         ..
050616 -        [On 050928 plastic surgeon submitting written report on meeting
050617 -        explaining plans for Millie's surgery. ref SDS 62 EH8F
050619 -         ..
050620 -        [On 051019 prepared letter asking Kaiser to take Time Out for
050621 -        performing due diligence requirements presenting risks and
050622 -        benefits, ref SDS 67 DY5P, on the scope of mastectomy surgery
050623 -        in this case. ref SDS 67 DZ56
050625 -         ..
050626 -        [On 051021 surgeon reported performing a very wide mastectomy
050627 -        and that a standard closure was accomplished. ref SDS 68 8K6N
050628 -
050629 -
050630 -
050632 -  ..
0507 -
0508 -
0509 - Progress
0510 -
051001 - Received ref DRT 1 0001 from the surgeon transmitting notes from the
051002 - meeting on 050923, ref SDS 60 WI6K, and as requested at the end of the
051003 - meeting at that time. ref SDS 60 PF6H
051004 -
051005 -    1.  Visit Note:, ref DRT 1 WE9F
051007 -         ..
051008 -        Pt returns with her ex husband to discuss her treatment
051009 -        options.  They have seen Drs Bailey and Grissom (outside
051010 -        Kaiser) as well as Dr Shim at KP OAK. they have many questions.
051012 -  ..
051013 - This comment aligns with the record on 050923 showing the doctor had
051014 - received 2nd opinions, and these were presented by the patient during
051015 - the meeting for discussion. ref SDS 60 Z46K
051017 -  ..
051018 - These notes illustrate typical work records of busy professionals that
051019 - limits usefulness for collaboration, as discussed on 050923.
051020 - ref SDS 60 4G5F
051022 -  ..
051023 - Ordinarily patient questions should be set out in the record, with
051024 - further comment on resolution of issues.  Kaiser's Healthwise Handbook
051025 - calls for response to patient questions on surgery, reviewed on
051026 - 050923. ref SDS 60 UL8K
051028 -  ..
051029 - In this case, Millie asked the following questions...
051031 -             ..
051032 -        a.  Millie requested comments on 2nd opinion findings and
051033 -            recommendations. ref SDS 60 4E8G
051035 -             ..
051036 -        b.  Millie asked the surgeon for results of meeting with the
051037 -            primary care physician? ref SDS 60 LP6H
051039 -             ..
051040 -        c.  Does patient history of IBC occurring on relapse present
051041 -            risks to traditional treatment of IBC with chemotherapy,
051042 -            surgery, chemotherapy, and radiation, reported on 040517,
051043 -            ref SDS 10 XG7K; because the patient was previously
051044 -            radiated in July and August, 2002, then in order to give
051045 -            more radiation, called out by the Kaiser Tumor Board on
051046 -            040416, ref SDS 7 2U5V; the breast and surrounding tissue
051047 -            must be replaced with plastic surgery; and additionally,
051048 -            since control of IBC wavered during March 2005, when
051049 -            treatment was interrupted for three (3) months and
051050 -            infection spread beyond the breast, does this introduce
051051 -            risk determining the scope of surgery that can be resolved
051052 -            with very wide mastectomy, which can only be closed with
051053 -            plastic surgery?  Are there other considerations that
051054 -            require analysis to fully resolve this issue? ref SDS 60
051055 -            4G4F
051057 -             ..
051058 -        d.  The patient requested a joint meeting with the mastectomy
051059 -            surgeon and the plastic surgeon to obtain close order
051060 -            collaboration for evaluation of prospects and risks.
051061 -            ref SDS 60 4G5F
051063 -             ..
051064 -        e.  The surgeon today described prior experience doing "very
051065 -            wide mastectomy" operations, and in collaboration with a
051066 -            plastic surgeon to perform contemporaneous reconstructive
051067 -            surgery in a complicated 10 hour surgery, as explained in
051068 -            2nd opinions by Doctors Grissom and Bailey. ref SDS 60 F13L
051069 -            Kaiser's Healthwise Handbook calls for review of experience
051070 -            performing specific surgery procedures? ref SDS 60 CO5J
051072 -             ..
051073 -        f.  If breast tissue is replaced with DIEP flap or TRAM
051074 -            technique, does this reduce chance of recurrence, perhaps
051075 -            through radiation treatment?  Does surgery itself reduce
051076 -            chance of relapse by removing tissue proven to be
051077 -            susceptible to cancer? ref SDS 60 4H48
051079 -             ..
051080 -            If PET scan is favorable, but one or more thin skin
051081 -            biopsies are positive for cancer, does this eliminate the
051082 -            surgical option, or should the perimeter of the very wide
051083 -            mastectomy be extended based on further skin biopsies?
051084 -            ref SDS 60 4J5L
051085 -
051087 -  ..
051088 - Surgeon's notes continue...
051089 -
051090 -    2.  Physical Exam:
051092 -         ..
051093 -    3.  L breast still soft and no obvious skin involvement clincially.
051094 -        No palpable masses or nodes. ref DRT 1 00FR
051096 -  ..
051097 - This aligns with the record on 050923. ref SDS 60 YY7F
051098 -
051100 -  ..
051101 - Surgeon's notes continue...
051102 -
051103 -    4.  Mammogram results pending.
051105 -         ..
051106 -    5.  I/P D/W pt and her ex husband at length recommendations by the
051107 -        other surgeons.  They appear to understand that mastectomy is
051108 -        for local control only and will have NO influence on her
051109 -        distant disease or survival. ref DRT 1 WE4J
051111 -  ..
051112 - This seems in general alignment with surgeon's comments on 050923
051113 - citing discussions with the primary care physician, ref SDS 60 7K6K,
051114 - and analysis of risks for replapse regardless of mastectomy to improve
051115 - local control. ref SDS 60 VL4O
051116 -
051117 -     [On 051007 primary care physician presents purpose of standard
051118 -     mastectomy is for palliation in the event of future relapse.
051119 -     ref SDS 65 6A4N
051121 -      ..
051122 -     [On 051007 patient history shows background on surgery for local
051123 -     control. ref SDS 65 MW5O
051125 -  ..
051126 - Patient history indicates primary care physician seeks to enhance
051127 - local control through surgery with the understanding that testing so
051128 - far shows no distant metastasis, reported most recently on 050913.
051129 - ref SDS 54 5T4J
051131 -  ..
051132 - During the meeting on 050923, the surgeon cited the biopsy of lumps in
051133 - the neck that found cancer, reported on 040309, ref SDS 5 0001, and
051134 - concluded there is distant metastatic disease. ref SDS 60 O15H  Review
051135 - on 040517 found that regional cancer in lymph nodes and axilla on the
051136 - same side as inflammatory breast skin are all symptoms of IBC.
051137 - ref SDS 10 N23J
051139 -  ..
051140 - Testing the past four (4) years with PET and CT scans listed in the
051141 - record on 050610 has shown no evidence of distant metastatic disease.
051142 - This history will be expanded with PET scan testing on 051005.
051143 -
051144 -          [On 051007 history of imaging tests show no distant
051145 -          metastasis. ref SDS 65 AG6G
051147 -  ..
051148 - Assuming no findings of distant metastasis, then does local control to
051149 - prevent cancer from spreading by any means, e.g., surgery, radiation,
051150 - systemic treatment, etc., reduce the chances, or otherwise prolong the
051151 - time and severity of relapse, though not eliminating such chance.  If
051152 - so, this seems to influence survival favorably??
051153 -
051154 -          [On 051007 PET test report shows no distant metastasis and
051155 -          all prior cancer findings favorably resolved, indicating
051156 -          positive local control. ref SDS 65 L66M
051158 -  ..
051159 - On 050907 Doctor Shim in a 2nd opinion on referral from the surgeon at
051160 - Kaiser in Walnut Creek recommended that patient history presents
051161 - opportunity for cure. ref SDS 49 F49H  Doctor Grissom in a 2nd opinion
051162 - received on 050920 proposed removing breast skin in a wide mastectomy
051163 - that was previously infected with IBC in order to reduce chance of
051164 - relapse toward a cure.
051165 -
051167 -  ..
051168 - Surgeon's notes continue...
051169 -
051170 -    6.  The risks of local recurrence were again discussed. ref DRT 1
051171 -        3U5G
051173 -  ..
051174 - This part of surgeon notes can be strengthened by citing risks and
051175 - some of the discussion.  Simply saying risks were discussed does not
051176 - guide planning to address risks.
051178 -  ..
051179 - What risks does Kaiser see, and what remedies are proposed, with what
051180 - expectations, as called out by Kaiser's Healthwise Handbook, reviewed
051181 - on 050923? ref SDS 60 CO5J
051182 -
051184 -  ..
051185 - Surgeon's notes continue...
051186 -
051187 -    7.  The suggestion, made by one of the consultants, of multiple
051188 -        skin biopsies to evaluate the chest skin for residual
051189 -        involvement is reasonable and feasible.  We discussed the
051190 -        procedure at length.  She would like to procede with this.  If
051191 -        there is no tumor found then a standard mastectomy could be
051192 -        performed. ref DRT 1 0V5J
051194 -  ..
051195 - This generally aligns with the record on 050923. ref SDS 60 SZ6M
051196 -
051197 -     [On 050929 biopsies surgery scheduled for 051012 1600. ref SDS 64
051198 -     0001
051199 -
051200 -     [On 051012 4 biopsies were taken during minor surgery at Kaiser in
051201 -     Walnut Creek. ref SDS 66 DG6J
051203 -      ..
051204 -     [On 051021 surgeon performed surgery and explained that a very
051205 -     wide mastectomy was accomplished with standard closure and without
051206 -     complications. ref SDS 68 MM6M
051208 -  ..
051209 - Textual construction here proposing a "standard mastectomy," if
051210 - testing finds no tumor activity was presented by the surgeon during
051211 - the meeting on 050923; and there was not enough time for discussion,
051212 - because the doctor was called away to another matter. ref SDS 60 4G4L
051213 - In any event, this is a professional issue.
051215 -  ..
051216 - Proposing a "standard mastectomy" requires feedback from consultants,
051217 - and reflects a question to Doctor Bailey on 050918, which has not yet
051218 - been addressed. ref SDS 56 E38J  Doctor Grissom already seems to be
051219 - saying in her opinion that favorable test results are grounds for
051220 - "very wide mastectomy," reviewed on 050920, ref SDS 57 XL8U, so
051221 - hopefully, she can explain why the comment in this part of Kaiser's
051222 - notes requires further support.
051223 -
051224 -     [On 050928 submitted surgeon's notes to consultants for comments.
051225 -     ref SDS 61 1J5J
051227 -      ..
051228 -     [On 051021 surgeon performed surgery and explained that a very
051229 -     wide mastectomy was accomplished with standard closure and without
051230 -     complications. ref SDS 68 MM6M
051232 -  ..
051233 - Doctor Bailey raises the risk of death if the patient's coumadin
051234 - treatment is delayed due to prolonged healing of surgical wound,
051235 - reviewed on 050922. ref SDS 58 6Z5Q  This seems directed toward a very
051236 - wide mastectomy, rather than a standard mastectomy.  Additionally, on
051237 - 050729 the primary care physician addressed the coumadin issue for a
051238 - standard mastectomy. ref SDS 41 WE9H
051239 -
051241 -  ..
051242 - Surgeon's notes continue...
051243 -
051244 -    8.  The suggestion of an extensive free flap reconstruction was
051245 -        also made by on of the consultants, in the hopes of allowing a
051246 -        more extensive local resection and healing.  I explained that
051247 -        this would be up to the Plastic surgeons to decide if she would
051248 -        be a candidate for such an extensive procedure.  I will refer
051249 -        her for consultation. ref DRT 1 00AP
051251 -  ..
051252 - This aligns with the record on 050923 indicating the surgeon commented
051253 - that Kaiser's Plastic Surgeon's may object to surgical procedures
051254 - proposed by Grissom and Bailey. ref SDS 60 F144  Getting concerns of
051255 - plastic surgeons and others on viability of a surgical solution, and
051256 - developing work arounds is critical to deciding on this course of
051257 - action proposed by the primary care physician.
051259 -  ..
051260 - This part of the notes does not mention the proposal for a "very wide
051261 - mastectomy" presented by 2nd opinions, and discussed at length on
051262 - 050923, ref SDS 60 E863, though this may be implied with reference to
051263 - "extensive free flap reconstruction" described in the notes.
051264 -
051265 -     [On 051019 prepared letter asking Kaiser to take Time Out for
051266 -     performing due diligence requirements presenting risks and
051267 -     benefits, ref SDS 67 DY5P, on the scope of mastectomy surgery in
051268 -     this case. ref SDS 67 DZ56
051270 -      ..
051271 -     [On 051021 surgeon reported performing a very wide mastectomy and
051272 -     that a standard closure was accomplished. ref SDS 68 8K6N
051274 -  ..
051275 - Besides comment from the plastic surgeon, the general surgeon seemed
051276 - to say during the meeting on 050923 that the proposal for a very wide
051277 - mastectomy using contemporaneous collaboration with the plastic
051278 - surgeon for closure was a viable scheme, ref SDS 60 E863, and that the
051279 - surgeon was experienced performing this type of surgery. ref SDS 60
051280 - F13L
051281 -
051283 -  ..
051284 - Surgeon's notes continue...
051285 -
051286 -    9.  The patient seems to be inclined at this time to procede with a
051287 -        L mastectomy if it is deemed feasible.  A PET scan is scheduled
051288 -        for 10/5 to look for more distant disease. ref DRT 1 00CM
051290 -  ..
051291 - This aligns with the record on 050923 showing that Millie wants
051292 - mastectomy surgery, if determined to be feasible, based on risks and
051293 - benefits for reducing the chance of relapse that extends quality of
051294 - life. ref SDS 60 G49M
051295 -
051296 -     [On 051019 prepared letter asking Kaiser to take Time Out for
051297 -     performing due diligence requirements presenting risks and
051298 -     benefits, ref SDS 67 DY5P, on the scope of mastectomy surgery in
051299 -     this case. ref SDS 67 DZ56
051301 -      ..
051302 -     [On 051021 surgeon reported performing a very wide
051303 -     mastectomy and that a standard closure was accomplished.
051304 -     ref SDS 68 8K6N
051306 -  ..
051307 - There does not seem to be mention of ordering retesting of the biopsy
051308 - taken by the surgeon on 040419 and discussed on 050923 for evaluating
051309 - change in status. ref SDS 60 RX4I
051310 -
051311 -     [On 051007 primary care physician planned to order retest of
051312 -     biopsy for status change. ref SDS 65 KE5L
051314 -      ..
051315 -     [On 051022 surgeon reported that retest was ordered despite no
051316 -     record in surgeon's notes received on 050927, and that results of
051317 -     retesting have not been received; doctor following up to obtain
051318 -     results. ref SDS 69 NE9J
051320 -      ..
051321 -     [On 051027 surgeon has not received results of retesting for
051322 -     status change; will check with pathology department on finding
051323 -     correct biopsy slide to test. ref SDS 70 964L
051324 -
051325 -
051326 -
051327 -
051328 -
051329 -
051330 -
0514 -