By Dr. Roberto A. Leon Ferre, Oncologist, Mayo Clinic
Here is a typical (hypothetical) clinical note for a breast cancer patient in a busy oncology clinic such as my own:
A 35-year-old premenopausal female with recently diagnosed breast cancer presents today for recommendations regarding treatment. Her oncologic history is as follows:
- August 15, 2016: patient noticed a palpable right breast mass after breastfeeding.
- September 2, 2016: patient sought medical attention for the breast mass. Diagnostic mammogram revealed a 3.5 cm right breast mass, suspicious for malignancy. Axillary ultrasound revealed two suspicious axillary lymph nodes, concerning for metastatic involvement.
- September 5, 2016: breast MRI revealed a right breast mass measuring 3.8 cm, along with 3 pathological appearing lymph nodes.
- September 6, 2016: Ultrasound-guided biopsy of the right breast reveals an invasive ductal carcinoma, Nothingam grade 3 (of 3), estrogen receptor (ER) positive (ER >75%), progesterone receptor (PR) positive (PR 1-10%), human epidermal growth receptor 2 (HER-2) positive (immunohistochemistry 2+, fluorescence in situ hybridization (FISH) positive for amplification. Biopsy of right axillary lymph node reveals evidence for metastatic adenocarcinoma, consistent with breast primary.
- September 8, 2016: initial visit with Medical Oncology. Neoadjuvant chemotherapy followed by surgery and adjuvant breast radiotherapy is recommended.
- September 15, 2016: patient starts neoadjuvant chemotherapy with paclitaxel, trastuzumab, and pertuzumab.
- January 30, 2017: patient starts dose-dense doxorubicin, cyclophosphamide with neulasta support.
- February 2, 2017: comprehensive hereditary breast cancer panel reveals a germline pathogenic BRCA1 mutation, confirming a hereditary breast cancer predisposition syndrome.
- April 20, 2017: patient undergoes bilateral mastectomy with right axillary sentinel lymph node biopsy. Breast pathology specimen reveals a residual 0.5 cm right breast carcinoma, 43% cellularity, with evidence of treatment effect, and 1 out of 23 lymph nodes with evidence of metastatic disease. Left breast shows only benign parenchyma.
- May 15, 2017: patient initiates adjuvant trastuzumab with plans to continue 12 months of therapy along with tamoxifen.
- July 3, 2017: bilateral salpingo-oophorectomy for prophylactic purposes, given BRCA mutation.
- September 23, 2017: patient develops severe headaches and nausea. MRI brain ordered.
- September 25, 2017: Brain MRI reveals 2 dominant brain metastases.
- September 26, 2017: Neurosurgery consultation. Recommendation is for gamma knife surgery of two major lesions.
- September 30, 2017: patient undergoes gamma knife surgery.
- October 15, 2017: systemic therapy changed to ado-trastuzumab emtansine, with discontinuation of the previous plan of completing 12 months of adjuvant trastuzumab.
- February 20, 2018: evidence of liver metastasis. Ado-trastuzumab emtansine discontinued, and systemic treatment changed to capecitabine/lapatinib. Request for liver biopsy.
- February 25, 2018: liver biopsy reveals metastatic breast cancer, positive for PDL-1.
- March 1, 2018: progressive disease in the liver and bones. Capecitabine/lapatinib stopped. Patient starts experimental pembrolizumab, as part of a clinical trial.
- June 15, 2018: PET/CT scan after 3 months on pembrolizumab reveal a complete radiographic response to therapy.
The above represents a typical clinical note that I will encounter every single day as part of my daily practice. If it is my own patient, no problem, I will likely have lived the story with her, so will be pretty familiar with each step of her disease. However, if I am away, a colleague of mine will have to see her and figure out her whole history.
I find that summarizing the story at the beginning of her record is immensely beneficial – for my colleagues, and also for my future self (hard to remember details of every single patient you see). If I can (progressively) summarize her whole case as a TOP LEVEL sentence at the beginning of her chart as follows, I can include key info on the chart and make everyone’s life easier:
35 yo premenopausal female with a BRCA mutation, diagnosed with node-positive, ER+, HER2+ right breast cancer. Treated with neoadjuvant dual HER2-directed therapy, followed by AC, with residual disease class I. Metastatic disease to the brain noted 4 months after surgery, treated with gamma knife, followed by ado-trastuzumab emtansine. Liver metastasis noted, treatment changed to capecitabine/lapatinib, with subsequent progression, and biopsy revealing PDL-1 positive disease, currently on pembrolizumab leading to a complete response.
The above paragraph pretty much tells any oncologist every bit of info they need to know to make decisions based on the CURRENT situation, in a much more succinct manner. If they have questions, they have the context right below, which outlines all the details. I am experimenting with including such a “summary paragraph” in all of the charts of patients I see.
Previously, our electronic medical record only allowed plain text in clinical notes, so I had to rely on summarizing everything in an independent paragraph. Since I first posted this, our hospital adopted a new electronic record that supports bolding and underlining in clinical notes (amazing it took until 2019 to do this!).
Now that the electronic medical record allows bolding and underlining, I have moved from writing a paragraph like the above to bolding, underlining in the detailed note, and adding a structured paragraph at the beginning of the note. I call this “Oncology history snapshot”.
No highlighting yet, but the ability to underline and bold allows us to add layers of progressive summarization. As such, I now have the full clinical note as noted below, and can then underline important passages (layer 1), then bold the critical pieces of information I need for clinical decision making (layer 2), and then add a very high-level summary at the top of my clinical note. All of these end up being incredibly helpful for colleagues who may be covering my patients while I am away (and may be less familiar with my patients).
Oncology history snapshot: [bolded paragraph above]
Date of diagnosis: Aug 2016 (operable); Sep 2017 (metastatic)
Sites of involvement: brain, liver
Molecular features: ER+, PR+, HER2+, PD-L1+
- early-stage: THP-ddAC (residual disease)
- metastatic: T-DM1, pembro (on trial)
- procedures: gamma knife to brain mets
As an oncologist, I need to have a sense of the duration of my patient’s condition and need to know what treatments they have been exposed to, and some key features of the tumor. I find that this “structured” snapshot is easier to look at and quicker than reading a whole paragraph.
Looking at this, you can quickly determine what is needed for the patient, and if more details are needed, they have the whole story with dates and longer descriptions right below it. We use a lot of abbreviations in the field, so while these may not make a lot of sense to a non-oncologist, any oncologist will know that THP means paclitaxel (also called Taxol), trastuzumab (also called Herceptin), and pertuzumab; that ddAC means dose-dense doxorubicin (aka adriamycin)/cyclophosphamide and that T-DM1 means ado-trastuzumab emtansine.
I welcome any feedback – the purpose here is not to “oversimplify” a patient’s history, but to offer a “snapshot” to other physicians treating the patient, so that decisions can be made quickly and effectively.
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