Example Notes (de-identified) - for illustration purposes only

The notes below may not be applicable to you depending on your specific situation.

Example 1

SITUATION
Infiltrating ductal carcinoma breaks through duct membrane and invades breast tissue.
Your closest margin is 0.5 cm, others are 2.0 cm.

CHOICES
No chemotherapy
Stay on Arimidex, maintain weight, exercise
Come to UCSF once every 4-6 months for monitoring, have mammograms done here
Chemotherapy
- 4 cycles of Adriamycin + Cytoxan (AC): 1 dose every 3 weeks, each dose takes about 90 min
OR
- 4 cycles of Taxotere + Cytoxan (TC)
We can try to get authorization for you to receive Neulasta on day 2 at home. Depends on insurance and cost (oftentimes insurance requires that Neulasta be given at an infusion center).

Tests
No further tests anticipated. If you do decide to go on AC, we need to do an echocardiogram or a MUGA scan on your heart to determine how well it squeezes.

OBJECTIVES
Gather enough information to make an informed decision about whether to undergo chemotherapy.

PEOPLE
Oncologists in your area for Neulasta shots:  Dr. X and Dr. Y
The practice assistant will contact you to schedule chemotherapy if you decide to do it at UCSF

EVALUATION
Chemotherapy vs. no chemotherapy
Ten-year risk estimate – based on cases similar to yours from various databases
24.5% risk of recurrence without any treatment besides surgery and radiation
12.5% risk of recurrence if taking aromatase inhibitor
9.4% risk of recurrence if taking chemotherapy plus aromatase inhibitor

So an overall 3.1% reduction in 10-year risk from chemotherapy

Adriamycin + Cytoxan (AC) chemotherapy effects:
Side effects from adriamycin: hair loss, nausea, vomiting, fatigue
Small (1%) chance of damaging the heart by affecting strength of muscle responsible for contractions

Taxotere + Cytoxan (TC) chemotherapy effects:
Possible side effects: hair loss, body aches, fever, neutropenia (low blood counts) =  risk of infections.
Neulasta causes bone pain.

DECISIONS
Are you comfortable with idea that you have 12.5% risk of recurrence in next 10 years without doing chemotherapy?  Is it worth it to do chemotherapy for a 3% benefit in recurrence?  That is the key issue.
I would recommend chemotherapy, since you are young  and healthy.
We usually start chemotherapy within 6-8 weeks of surgery but would definitely want to start within 3-4 months after surgery

 

Example 2

SITUATION
Your cartilage is worn down on the top and bottom of the hip socket on your right hip.
- This is causing bone to rub on bone.
Your pain is consistent with your X-rays and explains why your movements are so stiff.

CHOICES
Surgery is not your only option but it is the only way to make the biggest difference.
Preliminary treatment for hip pain is modifying your activity and Tylenol or Advil.
If your hip pain is interfering too much with your daily life, then your best option is a total hip replacement surgery.
- A total hip replacement surgery would remove the ball and socket and replace it with a new metal stem ball and clean out the socket and replace it with a new socket.
If you want to continue to wait, you can, and we can see you again in a few months.

OBJECTIVES
Main goal is to get you back to normal.

PEOPLE
Nurse X is Dr. Johnson's nurse and she will give you all of the information you need about what to expect.
Scheduler Y is Dr. Johnson's scheduler and she will come in next to help you pick a date for your surgery.
Some shoulder surgeons prefer to have the hip surgery done first because then you can bear weight on the hip without using your shoulder too much. But you can also make an argument for doing the shoulder surgery before the hip surgery.
- My recommendation is that you go with what is bothering you the most right now.

EVALUATION
Hip Replacement Surgery
The surgery would be scheduled for 2-3 months from now, most likely in May or June.
There are classes you can attend with your sister or daughter before surgery that can help you learn about the surgery and what to expect.
The surgery will happen at UCSF and will take about an hour.
You will be under spinal anesthesia, so you will be asleep but breathing on your own.
We will have you up and walking in the same day and you will stay in the hospital for 2 days.
It would be best if you could go to your sister or daughter's house after the surgery so they can help you and you aren't alone or in a nursing facility.
You will use a walker for a week or two.
You will need physical therapy in the hospital and at home.
Overall recovery is about 3 months to feel like yourself again.
The surgery will get rid of your hip pain, restore movement, and improve your quality of life.
- 90% of hip replacements are still in 30 years later.
- About 10% of hip replacements need to be revised again.

DECISIONS

Nurse X and Scheduler Y will help you with the next steps.