CONTACTS 

SUBJECTS
2nd Opinion Retainer $300 Notify Medical Consultant Scope of Work Su

1503 -
1503 -    ..
1504 - Summary/Objective
1505 -
150501 - Follow up ref SDS 42 0000. ref SDS 41 0000.
150502 -
150503 -
150504 -
150506 -  ..
1506 -
1507 -
1508 - Progress
1509 -
150901 - Background on Millie meeting Doctor Stritter is reported on 081018 in
150902 - connection with a seminar presentation at the Wellness Community
150903 - cancer support group. ref SDS 27 PQ6X  At that time, the doctor asked
150904 - for copies of Millie's correspondence with the medical team on
150905 - response to sunitinib targeted drug for cancer at UCSF that supports
150906 - Doctor Stritter's research on advanced cancer treatments. ref SDS 27
150907 - 1Y4G
150909 -  ..
150910 - Doctor Stritter was helpful on 081114 finding a referral for resolving
150911 - payment issues with Kaiser for treatment on referral to UCSF.
150912 - ref SDS 30 638G
150914 -  ..
150915 - Background on 081219 Millie was confused, worried, and emotional about
150916 - plans to maintain strong recovery from cancer and reduce side effects
150917 - by adjusting treatments to tolerable levels next week on 081226,
150918 - presented during the meeting at UCSF on 081218, ref SDS 37 QW48, as
150919 - set out in the letter confirming understandings to the medical team.
150920 - ref SDS 38 GF4V
150922 -  ..
150923 - Millie has been suffering rising side effects of cancer treatments for
150924 - several weeks reported on 081218, ref SDS 36 6E7G, so the doctor
150925 - changed the treatment by eliminating Methotrexate on 081218,
150926 - ref SDS 38 GF9X, responding to Millie's report the day before on
150927 - 081217. ref SDS 35 YJ6R
150929 -  ..
150930 - Millie submitted a copy to Doctor Stritter of the letter on 081218 to
150931 - the medical team reporting results of the examination at UCSF on
150932 - 081218. ref SDS 38 4P7F
150934 -  ..
150935 - Millie sent a copy to Doctor Stritter of another letter to the primary
150936 - care physician at Kaiser on 081219, requesting assistance managing the
150937 - work plan at UCSF for Millie's treatment with sunitinib, ref SDS 40
150938 - KY8Q, noting that case management is difficult due to limited time and
150939 - emotional feelings that prevent thorough analysis during meetings with
150940 - doctors. ref SDS 40 SU8X
150942 -  ..
150943 - On 081220, Millie sent a letter to Doctor Stritter, ref SDS 41 I69Q,
150944 - transmitting the report meeting with the medical team at UCSF on
150945 - 081218, and also sending a copy of Millie's letter to the primary care
150946 - physician to discuss during a meeting at Kaiser in the late morning on
150947 - 081219 complex decision on adjusting treatments for IBC, and further
150948 - explaining objectives for getting a second opinion on Millie's
150949 - treatment with sunitinib staying at full strength and reducing or
150950 - ending treatment with cyclophosphamide to reduce side effects.
150952 -  ..
150953 - On 081223 Millie received a response from Doctor Stritter submitting
150954 - terms for 2nd opinion support. ref SDS 42 AO3Y
150955 -
150958 -
150960 -  ..
150961 - Patient history...
150962 -
150963 -        1.  Summary
150964 -
150965 -            Millie is being treated at UCSF on referral from Kaiser for
150966 -            her 5th relapse of secondary IBC.  She was diagnosed with
150967 -            breast cancer on 020321, as triple negative, based on
150968 -            biopsy performed 020304. ref SDS 2 MA5K  IBC symptoms were
150969 -            reported in PET scan test on 021218, reviewed at Kaiser on
150970 -            030109. ref SDS 7 L66M  Symptoms were diagnosed and treated
150971 -            as Cellulitis. ref SDS 7 KW5F  This error persisted through
150972 -            2003.  During that period, Millie received no treatment.
150973 -            Secondary IBC was diagonsed with biopsy on 040419, shown in
150974 -            pathology report received from Kaiser on 040517.
150975 -            ref SDS 11 7D6F
150977 -             ..
150978 -            Millie is fortunate that in 7 years of treatment she has
150979 -            not been diagnosed with distant metastasis other than
150980 -            axillary and supraclavicular nodes, which are symptoms of
150981 -            IBC. (see patient history of image tests listed on 081112,
150982 -            ref SDS 28 GM3N  In effect, she only has IBC.
150984 -             ..
150985 -            Pulmonary embolism was diagnosed with CT test on 041103,
150986 -            reported at Kaiser the next day on 041104.  Millie was
150987 -            removed from treatment on clinical study with bevacizumab
150988 -            and Taxol. ref SDS 12 RZ4I  Kaiser delayed treatment of IBC
150989 -            for 3 months while searching for another clinical trial to
150990 -            treat Millie.  Millie was treated again with another 4
150991 -            cycles of AC beginning on 050104. ref SDS 14 407N
150993 -             ..
150994 -            Treatment is limited by triple negative status.
150996 -             ..
150997 -        2.  Labs Blood tests...
150998 -
150999 -            Millie has extensive blood testing, currently every 3 weeks
151000 -            at UCSF, but weekly for the past 2 years.
151002 -             ..
151003 -            Occassionally, there are backup labs at Kaiser.  The most
151004 -            recent blood test was a Kaiser on 081226. ref SDS 44 S65I
151005 -            All of these tests are connected with "Follow up" links to
151006 -            track history.
151007 -
151008 -               [On 090108 labs at UCSF start 3rd cycle sunitinib
151009 -               protocol. ref SDS 46 075H
151011 -                ..
151012 -               [On 090116 labs at Kaiser show WBC 5.2 rising for first
151013 -               time, ref SDS 48 OT8J, but cancer marker CA 15-3 303
151014 -               indicates Millie suffering 6th relapse of IBC.
151015 -               ref SDS 48 PQTQ
151016 -
151018 -             ..
151019 -        3.  Image tests show no evidence distant metastasis in 7 years,
151020 -            listed on 081112... ref SDS 28 GM3N
151021 -
151022 -                Millie had a CT test on 081230; results received on
151023 -                090107 show no significant change. ref SDS 45 GM3N
151024 -
151026 -             ..
151027 -        4.  Treatment history...
151029 -             ..
151030 -            Left breast sentinel node procedure
151031 -            and left axilary disection and
151032 -            left breast lumpectomy........... 020312, ref SDS 1 Q78M
151034 -             ..
151035 -            AC 2 cycles...................... 020423, ref SDS 3 0001
151036 -            Taxotere 2....................... 200610, ref SDS 4 LO9N
151037 -            Radiation........................ 020924, ref SDS 5 0J7H
151038 -            Taxotere 2 (total 4)............. 021204, ref SDS 6 F5Z5
151039 -            Bevacizumab Taxol 7.............. 040420, ref SDS 10 9Z5J
151040 -            AC 4 (total 6)................... 050104, ref SDS 14 407N
151041 -            Capacitabine and Taxotere 8...... 050329, ref SDS 15 T58M
151042 -              completed...................... 050916, ref SDS 16 407N
151044 -             ..
151045 -            Mastectomy left breast........... 051021, ref SDS 17 EG5L
151047 -             ..
151048 -            Relapse cancer...
151049 -            Capacitabine and Taxotere 7
151050 -            (total 15)....................... 060721, ref SDS 19 407N
151051 -            Cetuximab (total 90)............. 070201, ref SDS 20 G68I
151052 -            Carboplatin and cetuximab 21..... 080313, ref SDS 24 4E9N
151053 -            Sunitinib (daily)................ 081114, ref SDS 29 506F
151054 -            Cyclophosphamide Methotrexate.... 081128, ref SDS 31 PA8Y
151055 -            Sunitinib Cyclophosphamide
151056 -            paused........................... 081219, ref SDS 39 716I
151057 -            Methotrexate ended............... 081219, ref SDS 39 716I
151059 -             ..
151060 -            Sunitinib Cyclophosphamide
151061 -            resumed.......................... 081226, ref SDS 43 505G
151062 -            Sunitinib only
151063 -            Cyclophosmphamide paused
151064 -            1 week........................... 090109, ref SDS 47 UF3Q
151066 -             ..
151067 -            Sunitinib treatment ended due
151068 -            to rising symptoms of 6th
151069 -            relapse IBC...................... 090122, ref SDS 49 K96F
151070 -
151072 -  ..
151073 - Issues 2nd Opinion Can Address
151074 -
151075 - We would like to develop collaboration for Doctor Stritter to fill the
151076 - gap between frontline practitioners with limited time seeing many
151077 - patients, and researchers who do more writing, and so can optimize
151078 - deliberation for maintaining Millie's quality of life...
151080 -             ..
151081 -        1.  Treatment options 8th year stage IV IBC...
151082 -
151083 -            After 5 relapses, Millie's cancer has mutated to resist
151084 -            most single-agent chemotherapy drugs, noted by primary care
151085 -            physician on 080829, cited in the letter to the medical
151086 -            team at that time. ref SDS 25 RP9R  This issue was
151087 -            presented with 2nd opinion research on 060721. ref SDS 18
151088 -            RQ5N
151090 -             ..
151091 -            Recent biopsy on 081107 checked for triple negative status
151092 -            change.  On 081202 Kaiser reported no change in triple
151093 -            negative status, ref SDS 33 PV4I, and further presented
151094 -            pathology showing HER2 neu FISH test = 1.1, ref SDS 34
151095 -            FG5G, well below criteria for positive 2.0, and below
151096 -            change in criteria to 1.6 reported under consideration on
151097 -            071007. ref SDS 21 S68T
151099 -             ..
151100 -            What does Doctor Stritter's research show might be follow
151101 -            on treatments for Millie after progression occurs with
151102 -            sunitinib?
151103 -
151104 -               [On 090122 message from USCF Doctor Rugo ends treatment
151105 -               on sunitinib clinical study when Millie suffers
151106 -               progression of disease. ref SDS 49 K96F
151108 -             ..
151109 -            On 081016 Doctor Rugo indicated UCSF might have another
151110 -            clinical study starting in 4 months which could treat
151111 -            Millie after sunitinib.  This would be about February.
151112 -            ref SDS 26 J35X  Since sunitnib has shown good results,
151113 -            we have a little breathing room.  The record on 081016
151114 -            shows that discussions with the medical team are
151115 -            rushed, so there is no evidence at this time of options
151116 -            and planning.
151117 -
151118 -               [On 090130 Millie sent copy to Doctor Stritter of letter
151119 -               to medical team reporting Doctor Rugo prescribed on
151120 -               090129 using hyperthermia with Doxil to treat Millie's
151121 -               6th relapse of IBC. ref SDS 51 AY9Q
151123 -             ..
151124 -            Doctor Stritter can identify specific treatment options and
151125 -            propose an order of use with respect to most promising
151126 -            results, and possibly provide contact information and/or
151127 -            facilitate 2nd opinion consultations to investigate
151128 -            treatment options.
151130 -             ..
151131 -            Can drugs be customized from biopsy of patient cancer
151132 -            cells, and testing in the laboratory to discover effective
151133 -            treatment?  For example, Kaiser discovered Millie had IBC
151134 -            when Millie requested a biopsy during a surgery for another
151135 -            matter on 040419. ref SDS 9 789F  Pathology reported
151136 -            findings of IBC received on 040517. ref SDS 11 RH5V  Could
151137 -            that tissue be tested for response to varioud treatments in
151138 -            the laboratory, rather than use the patient as a testing
151139 -            laboratory?  Would it at least provide clues about which
151140 -            treatments might be more effective?
151142 -                ..
151143 -               [On 090129 research found off-shore sources to test
151144 -               patient blood to discover cancer treatments that are
151145 -               effective for a particular patient. ref SDS 50 YL7G
151146 -
151148 -             ..
151149 -        2.  Exercise optimize synergy with treatments...
151150 -
151151 -            Exercise was cited in Doctor Stritter's seminar on
151152 -            081018 at the Wellness Community cancer support group.
151153 -            The doctor reported research indicating exercise helps
151154 -            recover and resist cancer. ref SDS 27 IT68
151156 -             ..
151157 -            Millie's patient history of vigorous exercise listed on
151158 -            081226, ref SDS 43 X64F, may be a factor that has resisted
151159 -            stage IV cancer spreading in 7 years, and tracks well with
151160 -            avoiding progression of disease on the cetuximab and
151161 -            Carboplatin protocol for nearly two years.  This was about
151162 -            14 months longer than any other patient in the study.
151163 -            Since cetuximab is a "targeted" drug, Millie was able to
151164 -            maintain vigorous exercise.  Even after adding Carboplatin,
151165 -            exercise continued in the same manner.
151167 -             ..
151168 -            As shown on 081226, exercise has dropped to nearly zero due
151169 -            to side effects of daily chemotherapy with cyclophosphamide
151170 -            and Methotrexate. ref SDS 43 X64F  Methotrexate treatment
151171 -            was ended on 081218; Millie has not been able to continue
151172 -            exercising.  Less exercise conflicts with Doctor Stritter's
151173 -            research presented on 081018, which Millie's doctor noted
151174 -            earlier at Kaiser on 030606 citing exercise strengthens the
151175 -            immune system, which complements medical treatment for
151176 -            recovering from cancer. ref SDS 8 JP7G
151178 -             ..
151179 -            What can Doctor Stritter propose to optimize these
151180 -            dynamics?  For example, Millie was able to maintain
151181 -            vigorous exercise during the first 14 days of
151182 -            sunitinib, which is a "targeted" treatment.  She
151183 -            achieved significant recovery during this period with
151184 -            sunitinib alone, reported at UCSF on 081126, cited in
151185 -            Millie's letter to the medical team on 081202.
151186 -            ref SDS 32 YJ3G
151187 -
151188 -                [On 090109 Millie's letter confirmed work plan; during
151189 -                meeting at UCSF on 090108 Doctor Rugo changed treatment
151190 -                protocol continuing sunitinib at full strength, and
151191 -                pausing cyclophosphamide until blood counts recover,
151192 -                and then reduced cyclophosphamide from 7 to 5 days per
151193 -                week. ref SDS 47 UF3T
151194 -
151196 -             ..
151197 -        3.  Deliberation through written analysis.
151198 -
151199 -            Millie reported in a letter to the primary care physician
151200 -            at Kaiser on 081219, ref SDS 40 SU8R that meetings with
151201 -            doctors are emotional and rushed. ref SDS 40 SU8X  Doctor
151202 -            Stritter can invest time for deliberation in written
151203 -            analysis, illistrated by Doctor Benz's report for the UCSF
151204 -            2nd opinion received on 041117. ref SDS 13 ZO6L
151206 -             ..
151207 -            Telephone calls and meetings are useful for exploring near
151208 -            term ideas and clues about solutions.  Written opinions
151209 -            that cite the record are powerful diagnostic and planning
151210 -            tools, but frontline doctors do not have time to perform,
151211 -            illistrated by Brigid's response to Millie's letter on
151212 -            080109, ref SDS 22 4P9K, saying the next day on 080110 that
151213 -            UCSF has never performed an annual review of patient status
151214 -            because doctors do not have enough time for written
151215 -            analysis. ref SDS 23 BF66
151216 -
151217 -
151219 -  ..
1513 -
1514 -
1515 - 1347
1516 -
151601 - Called Doctor Stritter's office and left message returning her several
151602 - calls last week, and that payment of $300 has been submitted.
151603 -
151604 -
151606 -  ..
1517 -
1518 -
1519 - 1653
1520 -
152001 - Millie submitted ref DIT 1 0001 letter to Doctor Stritter submitting
152002 - payment for consultation, and linked to this record on scope of
152003 - work...
152004 -
152005 -    1.  Thanks for being so kind and thorough following up discussions
152006 -        on assisting with my case. ref DIT 1 0001
152008 -         ..
152009 -    2.  This confirms Rod's call this afternoon leaving a message
152010 -        advising that I am submitting under separate cover check #277
152011 -        dated today Jan 6, 2009 in accordance with your letter on
152012 -        December 23rd. ref SDS 42 AO3Y, ref DIT 1 W95L
152014 -         ..
152015 -    3.  Since my case has extended over 7 years, we have had 5 or 6 2nd
152016 -        opinions [see case study 080110, ref SDS 23 F47O].  They all
152017 -        proved to be very effective guiding my care at Kaiser, and more
152018 -        recently at UCSF.  I am sure your specialty practice can be
152019 -        helpful as well. ref DIT 1 W963
152021 -         ..
152022 -    4.  Please review 3 issues to apply your services, listed in the
152023 -        record of patient history today. ref SDS 0 PQ6Q, ref DIT 1 W969
152025 -         ..
152026 -    5.  After initial review, please call Rod to agree on what
152027 -        specifically will be done, and any additional cost that might
152028 -        be required.  I feel we are in some respects breaking new
152029 -        ground, and look forward to an effective doctor/patient
152030 -        partnership. ref DIT 1 W976
152032 -         ..
152033 -    6.  Note the record today also lists patient history of tests and
152034 -        treatments. ref SDS 0 IP6H, ref DIT 1 W983
152036 -         ..
152037 -    7.  You will be working with Rod who is familiar with patient
152038 -        history and can guide your consulting on my case.  The record
152039 -        is very complex, so it is easy to get lost in details.  Please
152040 -        call to request clarification, as needed. ref DIT 1 W989
152042 -         ..
152043 -    8.  Thanks again for interest in my case. ref DIT 1 KG9F
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