THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net

S U M M A R Y


DIARY: November 15, 2007 09:15 AM Thursday; Rod Welch

Millie at UCSF 1st treatment 11th cycle cetuximab for 3rd relapse IBC.

1...Summary/Objective
2...Schedule Meetings and Treatments
3...Labs Blood Test
4...Coagulation Control INR 2.2 Normal Stable PT 25.5 High
5...ANC 1840 Below 1800 Criteria for Blood Counts to Approve Treatment
6...CA 15-3 36 Rises Above Target Aligns Kaiser Rise Signals Relapse


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CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 7 0000, ref SDS 6 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040508 -
040510 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Schedule Meetings and Treatments
040902 -
040904 -  ..
040905 - This morning, Millie asked Nola about scheduling treatments for the
040906 - next few months.  Nola checked the computer and submitted an updated
040907 - schedule that also shows meetings with the doctor for examinations...
040909 -     ..
040910 -    Date  Time  Staff      Sta Type Dept  Loc  Dur Number Cycl/Trmnt
040911 -    -----------------------------------------------------------------
040912 -    071115 0830  Catherine    PEN  P1H  CCINF  INF  60            11  01
040913 -    071121 0830  Catherine    PEN  P1H  CCINF  INF  60            11  02
040914 -    071129 0830  Catherine    PEN  P1H  CCINF  INF  60            11  03
040915 -    071206 0830  Catherine    PEN  P1H  CCINF  INF  60            11  04
040916 -    071213 0800  Brigid       PEN  CHF  BCC    Z4F  30  13542775  12  01
040917 -                 Jackie
040918 -    071213 0900  Catherine    PEN  P1H  CCINF  INF  60            12  01
040919 -    071220 0830  Catherine    PEN  P1H  CCINF  INF  60            12  02
040920 -    071227 0830  Catherine    PEN  P1H  CCINF  INF  60            12  03
040921 -    080103 0830  Catherine    PEN  P1H  CCINF  INF  60            12  04
040922 -    080110 0830  Rugo         PEN  CHF  BCC    Z4F  30  13542784  13  01
040923 -                 Brigid
040924 -                 Jackie
040925 -    080110 0900  Catherine    PEN  P1H  CCINF  INF  60            13  01
040926 -    080117 0830  Catherine    PEN  P1H  CCINF  INF  60            13  02
040927 -    080124 0830  Catherine    PEN  P1H  CCINF  INF  60            13  03
040928 -    080131 0830  Catherine    PEN  P1H  CCINF  INF  60            13  04
040929 -    080207 0830  Rugo         PEN  CHF  BCC    Z4F  30            14  01
040930 -                 Brigid
040931 -                 Jackie
040932 -    080207 0900  Catherine    PEN  P1H  CCINF  INF  60            14  01
040934 -  ..
040935 - The schedule received from UCSF shows a meeting with Doctor Rugo on
040936 - 080110 0830, and the next meeting is listed for 080131 0830.  This
040937 - schedule seems to be incorrect, because meetings with the medical team
040938 - are every 4 weeks, and 4 weeks after 080110 will be 080207 not on
040939 - 080131.
040940 -
040941 -
040942 -
040944 -  ..
040945 - Labs Blood Test
040946 -
040947 - Follow up ref SDS 5 OB5H.
040948 -
040949 - During treatment, Catherine submitted results of the test.
040950 -
040965 -     ..
040966 -    Log#:                   071115 08:15
040967 -    <----------------------- U C S F -----------------------> <-------------  Kaiser -------------->
040968 -    Type                 Results   Units        Normal        ACRO   Type            Units        Normal
040970 -     ..
040971 -    CBC with DIFF & PLT CT                                     CBCD
040972 -     ..
040973 -    WBC COUNT               4.5    x10E9/L     3.4  -   10     WBC   WBC x10-3        K/uL     3.4  -  10.0
040974 -    RBC COUNT               4.51   x10E12/L      4  -   5.2    RBC   RBC x10-6        M/uL    3.60  -  5.70
040975 -    HEMOGLOBIN             14.1    g/dL         12  -   15.5   HGB   Hemoglobin       g/dL    11.5  -  15.0
040976 -    HEMATOCRIT             41.5    PERCENT      36  -   46     HCT   Hematocrit       %       34.0  -  46.0
040977 -    MCV                    92      fL           80  -   100    MCV   MCV              fL      80.0  -  100.0
040978 -    MCH                    31.3    pg           26  -   34     MCH
040979 -    MCHC                   33.9    g/dL         31  -   36     MCHC
040980 -    PLATELETS             214      x10E9/L     140  -  450     PLT   Plt x10-3        K/uL     140  -  400
040981 -    ..
040982 -       (posted 070531, rex SDS 82 NQ6K)
040983 -    CA 15-3      H*        43      U/mL             <  31    CA15-3  CA 15-3                        <  39
040984 -
040985 -         Note new reference range and change in methodology.  Performed
040986 -         using the Roche Elecsys 2010 ECLIA method.  Performed at UCSF
040987 -         China Basin Lab, 185 Berry, San Francisco, CA  94107.
040988 -    ..
040989 -     (NEUTS x 1000 = ANC for Kaiser)
040990 -    NEUTS                   1.96   x10E9/L     1.8  -  6.8     N-A   ANC                      1500
040991 -    Neutrophils    Not Reported                                      Neutrophils       %        50  -  70
040993 -     ..
040994 -    LYMPHS                  1.87   x10E9/L     0.9  -  2.9     L-A   Lymphocytes       %        20  -  50
040995 -    MONOS                   0.35   x10E9/L     0.1  -  0.6     M-A   Monocyte          %         0  -  11
040996 -    EOS                     0.20   x10E9/L       0  -  0.4     E-A   Esoinophils       %         1  -  5
040997 -    BASOS                   0.08   x10E9/L       0  -  0.1     B-A   Basophil          %         0  -  2
040998 -                                                                                                 0  -  5
040999 -     ..
041000 -    <----------------------- U C S F -----------------------> <-------------  Kaiser -------------->
041001 -    Type                 Results   Units        Normal        ACRO   Type            Units        Normal
041002 -    .
041003 -    PT              H*     29.3    S          12.5  - 16.0     PT    PT, patient       sec     8.9  -  11.1
041004 -    INL NRM Ratio           2.7                0.9  -  1.2     INR   PT INR            sec     2.0  -  3.0
041005 -
041006 -         Performed at Mt Zion Clinic Lab, 1600 Divisadero, San
041007 -         Francisco, CA 94115
041009 -     ..
041010 -    PARTIAL
041011 -     THROMBOPLASTIN  Not Reported  S          22.4  - 33.3     PTT
041013 -     ..
041014 -    ELECTROLYTE PANEL                                          LYTE
041015 -    SODIUM          L*    131      mmol/L      134  -  143     NA    Sodium            mEq/L   137  -  145
041016 -    POTASSIUM               3.8    mmol/L      3.4  -  4.9     K     Potassium         mEq/L   3.5  -  5.3
041017 -    CHLORIDE               98      mmol/L       98  -  107     CL
041018 -    CARBON DIOX TOTAL L*   22      mmol/L       23  -  32      CO2
041019 -    ANION GAP              11                    3  -  14      ANGA
041021 -     ..
041022 -    UREA NITROGEN          12      mg/dL         8  -  23      BUN   BUN               mg/dL     7  -  17
041023 -    CALCIUM                 9.0    mg/dL       8.7  -  10.1    CA    Calcium           mg/dL   8.4  -  10.2
041024 -    MAGNESIUM       no report      mg/dL       1.8  -  2.3     MG    Magnesium         mg/dL   1.6  -  2.3
041026 -     ..
041027 -    CREATININE              0.8    mg/dL       0.6  -  1.2     CR    Creatinine        mg/dL   0.6  -  1.2
041028 -    GLUCOSE               128      mg/dL        70  -  199     GLU   Glucose           mg/dL     ?  -   ?
041029 -    AST            H*      42      U/L          16  -  41      AST   AST (SGOT)        U/L      14  -  36
041030 -    ALT                    21      U/L          11  -  54      ALT   ALT (SGPT)        U/L      11  -  66
041031 -    BILIRUBIN TOTAL         0.7    mg/dL       0.3  -  1.3     BILT  Bili Total        mg/dL   0.2  -  1.3
041032 -    ALKALINE PHOSPHATASE   62      U/L          29  -  111     ALKP  Alkaline Ph       U/L      38  -  126
041033 -    PROTEIN TOTAL           6.7    g/dL        5.8  -  8.0     TP    Protein, Total    g/dL    6.3  -  8.2
041034 -    ALBUMIN                 4.1    g/dL        3.4  -  4.7     ALB   Albumin           g/dL    3.4  -  4.8
041035 -
041036 -
041037 -
041038 -
0411 -

SUBJECTS
INR 2.2 Coagulation Control Coumadin Treatment Pulmonary Embolism PT

1403 -
140401 -  ..
140402 - Coagulation Control INR 2.2 Normal Stable PT 25.5 High
140403 -
140404 - Follow up
140405 -
140406 - The test today shows PT 25.5 and INR 2.2, per above. ref SDS 0 PU7Y
140407 -
140408 -
140409 -
140410 -
1405 -

SUBJECTS
Absolute Neutrophils Count ANC 1840 Above 1800 Safe Level UCSF Requi

2303 -
230401 -  ..
230402 - ANC 1840 Below 1800 Criteria for Blood Counts to Approve Treatment
230403 -
230404 - Follow up
230405 -
230406 -
230407 -
230408 -
2305 -

SUBJECTS
CA 15-3 37 Blood Tests 070524 Cancer Marker Reverses Begins Rising P

3303 -
330401 -  ..
330402 - CA 15-3 36 Rises Above Target Aligns Kaiser Rise Signals Relapse
330403 -
330404 - Follow up
330405 -
330406 -
330407 -
330408 -
330409 -
3305 -








































Counts to Approve Treatment 230403 - 230404 - Follow up ref SDS 73 P560, ref SDS 71 P560. 230405 - 230406 - Background on differences representing ANC in Kaiser and UCSF blood 230407 - testing is reported on 070301. ref SDS 47 U37I 230409 - .. 230410 - Background on testing prior to treatment to verify immune system is 230411 - strong enough for safe treatment is reported on 070426. ref SDS 71 230412 - 4J4O 230414 - .. 230415 - ANC is shown as "NUETS" in the UCSF system, which reported 1.84 for 230416 - the blood test today, per above. ref SDS 0 QY6H This is equivalent to 230417 - 1840 in Kaiser's scheme. Catherine noted NEUTS 1.84 is above UCSF 230418 - criteria of 1800 and so signals safe treatment based on strength of 230419 - the immune system. Other authorities list 1.50 (ANC 1500) as a common 230420 - level for safe treatments, including cetuximab. This is a significant 230421 - increase from the previous test showing 1.54 on 070503. 230423 - .. 230424 - ANC suddenly falls... 230425 - 230426 - 6972................................ 060814, ref SDS 19 P560 230427 - 6390................................ 060908, ref SDS 20 P560 230428 - 5200................................ 060929, ref SDS 21 P560 230429 - 3869................................ 061020, ref SDS 47 P560 230430 - 2880................................ 061110, ref SDS 29 P560 230431 - 2888................................ 061201, ref SDS 30 P560 230432 - 1760................................ 070201, ref SDS 36 P560 230433 - 1230................................ 070301, ref SDS 47 P560 230434 - 1510................................ 070308, ref SDS 46 P560 230435 - 1810................................ 070329, ref SDS 61 P560 230436 - 1870................................ 070419, ref SDS 68 P560 230437 - 1470................................ 070426, ref SDS 71 P560 230438 - 1540................................ 070503, ref SDS 73 P560 230439 - 1840................................ 070524, ref SDS 0 P560 230440 - 230441 - 230442 - 2305 - SUBJECTS CA 15-3 37 Blood Tests 070524 Cancer Marker Reverses Begins Rising P 3303 - 330401 - .. 330402 - CA 15-3 36 Rises Above Target Aligns Kaiser Rise Signals Relapse 330403 - 330404 - Follow up ref SDS 78 2N5J, ref SDS 71 2N5J. 330406 - .. 330407 - UCSF testing today with the Roche Elecsys 2010 ECLIA calibration 330408 - method yielded CA 15-3 37, ref SDS 0 A16M, increasing 30% compared to 330409 - CA 15-3 29 reported by UCSF a few weeks ago on 070426. ref SDS 70 087J 330410 - Rising cancer marker aligns with concerns raised by Kaiser's test on 330411 - 070511, showing CA 15-3 56 using a different methodology, and reported 330412 - by Kaiser on 070516. ref SDS 77 RH9H 330413 - 330414 - [...in another record today, UCSF medical team reviewed CA 15-3 330415 - diagnostic issues. ref SDS 80 087J 330417 - .. 330418 - At that time, on 070516 Kaiser was asked to verify test data and 330419 - coordinate findings with UCSF on rising CA 15-3 in relation to patient 330420 - history showing CA 15-3 declined substantially during the prior 330421 - period. ref SDS 77 ZJ9N The next day, Kaiser reported using a 330422 - different calibration method from UCSF, which accounts for the large 330423 - disparity in test results, ref SDS 79 NT3O, but does not address the 330424 - change in direction from falling to rising cancer marker diagnostics, 330425 - ref SDS 79 H38K, and noted in Millie's letter to Kaiser the next day 330426 - on 070517. ref SDS 79 IV9S 330428 - .. 330429 - There is no record that Kaiser verified test data or coordinated to 330430 - support UCSF referral work. 330431 - 330432 - [On 070610 Kaiser reported the right channels of communication 330433 - are now open with UCSF. ref SDS 83 OG7F 330435 - .. 330436 - On 070517 UCSF responded to notice from Millie of rising CA 15-3 56 on 330437 - 070516, ref SDS 77 J55T, and proposed avoiding cross checks to verify 330438 - accuracy of laboratory work. ref SDS 79 466H UCSF indicated Kaiser's 330439 - findings do not raise concerns about progression of Millie's cancer 330440 - and treatment. ref SDS 79 6E4G 330441 - 330442 - [On 070531 UCSF not concerned results of blood test today show 330443 - CA 15-3 37 rising 30% from the prior report on 070426, because 330444 - CT scans show no metastatic cancer, and IBC inflammation 330445 - appears to be subsiding. ref SDS 82 NQ6K 330447 - .. 330448 - Nurses Notes on treatment in the Infusion Clinic on 070517 show UCSF 330449 - considered testing CA 15-3 again, ref SDS 79 JU5F, in response to 330450 - notice in Millie's letter on 070516 transmitting Kaiser's report on CA 330451 - 15-3 56. ref SDS 77 J55T 330453 - .. 330454 - Testing today aligns with considerations on 070517 that CA 15-3 cancer 330455 - marker has stopped falling, and begun to rise again, signalling 330456 - possible relapse under the current treatment. Rising CA 15-3 reported 330457 - by Kaiser and UCSF seems conflicting with CT testing, most recently on 330458 - 070520. Review during the examination today shows no findings of 330459 - metastatic disease that might cause CA 15-3 to rise. Examination 330460 - today shows IBC rash at all sites continues to subside. Implication 330461 - is that cancer is expanding broadly at a microscopic level that 330462 - registers in the CA 15-3 cancer marker test, but is too small for 330463 - identification with CT image testing and visual observation IBC rash 330464 - on the patient's skin. 330465 - 330466 - 330467 - 330468 - 330469 - 330470 - 3305 - 041041 - 041042 - 041043 - 041044 - 041045 - 041046 - 041047 - 041048 - ME="L2200">NAME="L041042">-