CONTACTS 
0201 - Stanford Medical Center                                                                                                                                            O-00000837 0609
020104 - Stanford Referral Center and Liason Services                                                                                                                     O-00000837 0609
0202 - Stanford Medical Center                                                                                                                                            O-00000837 0604
020201 - Ms. Carol Walovich, RN; Manager
020203 - Stanford Referral Center and Liason Services                                                                                                                     O-00000837 0604

SUBJECTS
2nd Opinion #3 Stanford Medical Center Letter Requests List Chemothe

0603 -
0603 -    ..
0604 - Summary/Objective
0605 -
060501 - Follow up ref SDS 37 0000. ref SDS 35 0000.
060502 -
060503 - Submitted request to Stanford Medical Center for 2nd opinion.
060504 -
060505 -
060506 -
060507 -
060509 -  ..
0606 -
0607 -
0608 - Background
0609 -
060901 - Planning for support opinion was developed on 060721, ref SDS 35 IS6F,
060902 - based on background reviewed at that time. ref SDS 35 YK6N
060904 -  ..
060905 - 2nd opinion was requested from UCSF on 060725. ref SDS 37 ST9O
060907 -  ..
060908 - Patient history communicating with Stanford Medical Center on
060909 - arranging 2nd opinions has email addresses, reported on 041002,
060910 - ref SDS 3 YR5I, and later in letters to particular staff at Stanford
060911 - on 041008, ref SDS 6 0001, including Carol Walovich, ref DIP 1 0001,
060912 - and followed up on with the Medical Center requesting medical records,
060913 - telecon on 041011. ref SDS 7 U186
060915 -  ..
060916 - Today, Millie submitted ref DIT 1 0001 to Michelle at Stanford Medical
060917 - Center who assisted in getting 2nd opinions previously on 041008,
060918 - ref SDS 6 0001, and with a copy to Carol Walovich, who gave assistance
060919 - a few days earlier on 041006. ref SDS 4 0001
060921 -  ..
060922 - Millie says in her letter...
060923 -
060924 -    1.  Doctor Guardino examined me at Stanford Medical Center on
060925 -        October 19, 2004, and prepared a 2nd opinion that helped me
060926 -        recover.  My letter to Stanford Medical Center on November 8,
060927 -        2005 thanked the Doctor for helpful advice. ref DIT 1 0001
060929 -         ..
060930 -    2.  Now, disease has progressed, and I need a new treatment plan.
060931 -        Doctor Guardino indicated that Stanford Medical Center would be
060932 -        willing to follow up with further advice.  Please let me know
060933 -        the cost for this service to review the record and submit
060934 -        comments on questions presented (see below) along with
060935 -        additional guidance as deemed helpful. ref DIT 1 JR6L
060937 -         ..
060938 -    3.  I need a 2nd opinion on options for treating secondary IBC that
060939 -        has relapsed for the 3rd time after 9 months NED, following
060940 -        left breast mastectomy surgery on October 21, 2005. ref DIT 1
060941 -        TR7I
060943 -         ..
060944 -    4.  I am currently being treated at Kaiser in Walnut Creek, CA, for
060945 -        left breast cancer, originally diagnosed in February, 2002, and
060946 -        treated with lumpectomy surgery on March 12, 2002.  Two cycles
060947 -        of AC chemotherapy were not effective.  Treatment was switched
060948 -        to Taxotere for 2 cycles, which yielded improvement.  Radiation
060949 -        during July and August 2002, and then 4 more cycles of Taxotere
060950 -        completed initial treatment. ref DIT 1 6S7N
060952 -         ..
060953 -    5.  IBC symptoms first appeared in PET scan test on December 18,
060954 -        2002.  Red rash was reported on January 9, 2003.  Symptoms
060955 -        gradually increased; however, there was no treatment during
060956 -        2003. ref DIT 1 IS8L
060958 -         ..
060959 -    6.  In 2004, I was treated for IBC with Avastin and Taxol from May
060960 -        until November, when pulmonary emboli ended treatment.  IBC
060961 -        subsided on the Avastin trial, but relapsed severely, until
060962 -        treatment was changed beginning on April 15, 2005 to Taxotere
060963 -        and capecitabine.  There was strong recovery; inflammation
060964 -        fully subsided, image testing reported no swelled nodes, and CA
060965 -        15-3 dropped from 107 down to 39, then bounced back to 45.
060966 -        ref DIT 1 6T9G
060968 -         ..
060969 -    7.  On October 21, 2005 I had a left breast "simple" mastectomy, as
060970 -        discussed in Doctor Guardino's opinion letter received December
060971 -        9, 2004.  Biopsy reported finding no evidence of IBC disease in
060972 -        the removed tissue.  DCIS was reported in the biopsy.
060973 -        ref DIT 1 CT9O
060975 -         ..
060976 -    8.  Lymphedema occurred in January 2006.  I am controlling this
060977 -        with home treatment. ref DIT 1 QT4K
060979 -         ..
060980 -    9.  This year two (2) PET scan tests, and one (1) contrast CT study
060981 -        report no express findings of metastatic disease.  CA 15-3
060982 -        initially dropped to 28, following surgery, but has steadily
060983 -        climbed since January, and is now at 71. ref DIT 1 GU4O
060985 -         ..
060986 -   10.  Disease at this time appears local by test criteria.  PET scan
060987 -        test on April 14, 2006 found FDG SUV 2.6 right axilla and FDG
060988 -        SUV of 4.5 left supraclavicular.  CT contrast study on May 5,
060989 -        2006 did not find lymphadenophy of any kind. ref DIT 1 NU5K
060991 -         ..
060992 -   11.  Examination on April 28th, 2006 showed the left breast was
060993 -        still clear of disease.  Slight rash was evident during
060994 -        examination on June 23rd, and by July 11th this formed an
060995 -        approximate 1" circular area concentrated left of the sternum
060996 -        at the right end of the mastectomy incision. ref DIT 1 OU6G
060997 -        There is a meandering line of low intensity inflammation
060998 -        extending about 2" - 3" from the circular area and about .5"
060999 -        above the incision line, and another about .5" below the
061000 -        surgical incision line. (see examination notes for meeting on
061001 -        July 11th), ref SDS 33 8Z8G
061003 -         ..
061004 -   12.  In a meeting on July 11, 2006, the primary care physician
061005 -        recommended a strategy of resuming prior treatment with cycles
061006 -        of Taxotere - 102 MG, and capecitabine (Xeloda) - 500 MG
061007 -        tablets taking 1.5 pills twice a day for 2 weeks, then 1 week
061008 -        off. At that time, other treatments were considered.
061009 -        ref DIT 1 FW3I
061011 -         ..
061012 -   13.  Last Friday, on July 21 I had my first treatment for relapse,
061013 -        which was the 9th cycle of Taxotere and capecitabine (Xeloda),
061014 -        following the 8th cycle on September 16, 2005. ref DIT 1 YW3O
061016 -         ..
061017 -   14.  Questions for 2nd opinion....
061019 -             ..
061020 -        1.  What is the full range of drugs for treatment of IBC,
061021 -            including combinations? ref DIT 1 NX4J
061023 -             ..
061024 -            For example, in a meeting on November 30, 2004 the primary
061025 -            care physician submitted a list of drugs.  The list was not
061026 -            legible, but seemed to have 4 or 5 entries.  Kaiser
061027 -            publishes a pamphlet that lists about 10 drugs, and some
061028 -            combinations.  The doctor has stated there is a "declining
061029 -            pool" of treatment options.  This conflicts with the record
061030 -            of a seemingly expanding list of drugs, and so presents a
061031 -            question of professional opinion as to what drugs are
061032 -            available? ref DIT 1 LX5F
061034 -             ..
061035 -        2.  What criteria determines the order prescribing drugs and
061036 -            the dosage of treatments, and timing switching to another
061037 -            treatment? ref DIT 1 LN5O
061039 -             ..
061040 -            For example, on April 28, 2006 the primary care physician
061041 -            (PCP) proposed treating relapse with Navelbine. ref DIT 1
061042 -            YO6H .......... ref SDS 32 9H5I
061044 -             ..
061045 -            Upon discussion, on July 11th, the decision was changed and
061046 -            treatment started with Taxotere and capecitabine,
061047 -            originally recommended by Doctor Benz in a 2nd opinion
061048 -            received from UCSF Medical Center on November 17, 2004.
061049 -            However, Doctor Benz, also, recommended trying Gemzar and
061050 -            capecitabine.  Additionally, research shows IBC has been
061051 -            treated with Navelbine and capecitabine, and that patients
061052 -            who relapse and resume with drugs that were previously
061053 -            successful may suffer disease progression from mutated
061054 -            cancer cells. ref DIT 1 PO6N
061056 -             ..
061057 -            Does IBC relapse represent microscopic mutated cells that
061058 -            avoided treatment with Taxotere and capecitabine in 2005,
061059 -            and therefore follow on treatment should be with different
061060 -            drugs, for example, Gemzar and Taxotere, or Navelbine and
061061 -            capecitabine, or something else?  How can this be assessed
061062 -            in time to avoid a critical mass of cancer from forming
061063 -            that resists treatment? ref DIT 1 YP7N
061065 -             ..
061066 -            What criteria drives changing treatments?  Does rising or
061067 -            stable CA 15-3 signal the need to try another treatment?
061068 -            ref DIT 1 LP8K
061070 -             ..
061071 -        3.  Surgery - Kaiser elected to "postpone" breast
061072 -            reconstruction surgery on October 21, 2005, and instead
061073 -            used a conservative solution, recommended in Kaiser's
061074 -            letter dated September 28, 2005, and received from Kaiser
061075 -            on October 7, 2005. ref DIT 1 3Q8O .... ref SDS 30 KO58
061077 -             ..
061078 -            Since the prior surgery was partially successful, can
061079 -            "postponed" surgery now be performed to remove a wider area
061080 -            of infected tissue, and perform breast reconstruction, as
061081 -            previously considered, toward reducing the need for
061082 -            continuous chemotherapy treatments? ref DIT 1 HQ9L .....
061083 -            ref SDS 29 QS65
061085 -             ..
061086 -        4.  Radiation - Kaiser's Tumor Board recommended additional
061087 -            radiation treatment to the left neck after surgery, in a
061088 -            report received from Kaiser on May 17, 2004. ref DIT 1 EQ4J
061089 -            .... ref SDS 1 F77M
061091 -             ..
061092 -            When would such treatment be performed?  Can breast
061093 -            reconstruction surgery expand Kaiser's original plan for
061094 -            radiation therapy? ref DIT 1 WQ5F
061096 -             ..
061097 -        5.  Biopsy left breast mastectomy tissue - how can this show no
061098 -            evidence of disease, reported on October 27, 2005, when
061099 -            this tissue contained the greatest concentration of IBC,
061100 -            and now, 9 months later, adjacent tissue with no visible
061101 -            signs of IBC suddenly is an active site of disease?  How
061102 -            thorough and dependable are biopsies?  Does IBC present
061103 -            unique challenges for biopsy procedures? ref DIT 1 5N4O
061105 -         ..
061106 -   15.  Patient history from inception in February 2002 through
061107 -        preparations for surgery in October 2005, is listed in the
061108 -        record on August 12, 2005. ref DIT 1 PQXV ..... ref SDS 23 UF4J
061110 -         ..
061111 -   16.  Patient history beginning with mastectomy surgery on October
061112 -        21, 2005 to the present is listed in the record on July 22,
061113 -        2006. ref DIT 1 JR6M ...... ref SDS 36 XQ7H
061115 -         ..
061116 -   17.  Patient history for CA 15-3 cancer marker is listed in the
061117 -        record on July 11, 2006. ref DIT 1 TS3I ..... ref SDS 33 087J
061119 -         ..
061120 -   18.  Image test analyst reports are all also listed and accessible
061121 -        for review. ref DIT 1 NS3O .... ref SDS 33 FE8F
061123 -         ..
061124 -   19.  Biopsy slides and test films are available as needed.
061125 -        ref DIT 1 0T4J
061127 -         ..
061128 -   20.  I am asking for review by Doctor Guardino, based on her helpful
061129 -        2nd opinion in 2004.  If her schedule is full, another doctor
061130 -        should be able to address the issues presented.  I am sending a
061131 -        copy to Carol Walovich, because she is listed in the record as
061132 -        supporting administration for the prior 2nd opinion.
061133 -        ref DIT 1 8T4M
061135 -         ..
061136 -   21.  Thanks very much for consideration. ref DIT 1 FT5J
061137 -
061138 -
061140 -  ..
0612 -
0613 -
0614 - 1343
0615 -
061501 - Received ref DRT 1 0001 from Dorothy at Stanford Medical Center
061502 - responding to Millie's letter, ref DIT 1 0001, submitted earlier
061503 - today, per above. ref SDS 0 ST9O
061505 -  ..
061506 - Dorothy says...
061507 -
061508 -    1.  The Cancer Referral Service at Stanford is pleased to provide
061509 -        information to physicians and consumers who wish to access
061510 -        medical services at either Stanford Hospital & Clinics or
061511 -        Lucile Salter Packard Children's Hospital.
061513 -         ..
061514 -    2.  Thank you for your inquiry. If you will contact our toll free
061515 -        number 1 877 668-7535 Monday - Friday between the hours of
061516 -        8:00am and 5:00pm we will put you in contact with a new patient
061517 -        coordinator.  She will then assist you in setting an
061518 -        appointment with the appropriate physician and answer any
061519 -        questions you might have.
061520 -
061522 -  ..
0616 -
0617 -
0618 - 1350
0619 -
061901 - Called Dorothy at Stanford................ 877 668-7535
061902 -
061903 - Dorothy will forward Millie's letter, ref DIT 1 0001, to Rachelle, who
061904 - works with Doctor Guardino for initial review.
061906 -  ..
061907 - Rachelle will coordinate with the doctor, and call later today or
061908 - tomorrow and advise whether Doctor Guardino is able and willing to
061909 - support 2nd opinion review in this case.
061910 -
061911 -    Actually, Carol's letter and the call to Denise indicates that
061912 -    Rochelle has Millie's letter. ref SDS 0 Z23H
061913 -
061914 -
061916 -  ..
0620 -
0621 -
0622 - 1417
0623 -
062301 - Received ref DRT 2 0002 from Carol also responding to Millie's letter,
062302 - ref DIT 1 0001, submitted per above. ref SDS 0 ST9O
062304 -  ..
062305 - Carol says...
062306 -
062307 -    1.  Thank you for your email. (As an aside, Michelle Malig no
062308 -        longer works here.) The out of pocket cost of a second opinion
062309 -        for the consultation alone is roughly $650.00.  This would
062310 -        require you to come to Stanford since it is much safer in
062311 -        establishing a plan of care to have you present for the
062312 -        consult.  I have cc'd your email to Rochelle Wallach who can
062313 -        coordinate your schedule with Dr.  Guardino's.  In case you
062314 -        would like to call her directly, her phone number is (650)
062315 -        725-7330.
062317 -         ..
062318 -    2.  Thanks again for your interest in Stanford Hospital and
062319 -        Clinics.
062320 -
062321 -
062323 -  ..
0624 -
0625 -
0626 - 1440
0627 -
062701 - Called Rochelle and talked to Denise............. 650 725 7330
062702 -
062703 - Not sure if this the Denise who assisted Doctor Guardino, along with
062704 - Todd, when the doctor visited with Millie at Stanford on 041019.
062705 - ref SDS 10 QR3N
062707 -  ..
062708 - Denise said that Rochelle is talking to another patient.  She found
062709 - Millie's identification in Stanford's records.
062711 -  ..
062712 - She will ask Rochelle to call back later today.
062713 -
062714 -     [On 060731 Rochelle called and left a message. ref SDS 38 T04O
062715 -
062716 -
062717 -
062718 -
062719 -
062720 -
062721 -
0628 -