Subject: RE: plan
From: "Yung,W K Alfred" <[email-masked]>
To: "'Jon Glass'" <[email-masked]>
Cc: "Hallie Biden" <[email-masked]>, "Beau Biden" <[email-masked]>, <[email-masked]>, "Howard Krein" <[email-masked]>
Date: Fri, 16 Jan 2015 16:12:14 +0000

Jon,
It is very important that Beau and Hallie receive one single message re Beau’s treatment plan. I think it will be best that this message comes from me. So, to avoid confusion please refer those questions to me. I usually, as in the past, talk to you ahead of time my plan.

I talked to Hallie this morning. I asked the consultant group that we gathered before to review the scans and the treatment options. I also review the scans with Dr. Sawaya, our neurosurgeon who did the original surgery. I asked him the question of the possibility of removing the nodule in the anterior temporal lobe. His feeling is: yes, the nodule is very accessible, can be removed. But it is not causing any problem at this time, it is not responsible for his speech and arm weakness, it has no mass effect to suggest it is a growing tumor. One can wait for another scan to see if the necrosis will recede by itself before we entertain the decision of removing it by surgery. There is an advantage of removing it, it will give us the pathology, to know if there is any tumor cells.
The consensus at this point is to finish CCNU cycle #5, get another MRI, revisit the question of surgery if necessary, switch over to Pembrolizumab + Avastin. I am also thinking of taper off Avastin after we see no swelling come from Pembrolizumab.

As to when to start CCNU, I like to reduce the dose to 90 mg/m2, this is to reduce the hit on the bone marrow and 90mg/m2 is an effective dose. WBC 2.3 is very good, higher than 2 weeks ago. That is where Beau usually level off. I like to see the ANC. But I think he is ready to have the CCNU, we have start early next week.
I hope this clarify the plan.

Al

W.K. Alfred Yung, M.D.
Chairman, Department of Neuro-Oncology
Margaret and Ben Love Chair in Clinical Cancer Care
UT M. D. Anderson Cancer Center, Unit 431
1515 Holcombe Blvd
Houston, TX 77030
Tele:  713-794-1285
Fax:  713-563-0151
[email-masked]

From: Jon Glass [mailto:[email-masked]]
Sent: Friday, January 16, 2015 8:49 AM
To: Hallie Biden; Yung,W K Alfred
Subject: Re: plan

​​The next avastin will be at the same dose.  I discussed the potential for restarting CCNU, which is contingent on the blood count results.  The white blood cell count was 2.3, which is still too low to start.  If and when it is resumed, it would be at a lower dose.  I will be faxing the complete blood count results to Dr. Yung and review the final treatment plan.

Jon Glass, MD

________________________________
From: Hallie Biden <[email-masked]<mailto:[email-masked]>>
Sent: Friday, January 16, 2015 9:41 AM
To: Jon Glass; Yung,W K Alfred; jim smith
Subject: plan

Hi Jon and Al,
I was not with Beau this morning when Jon spoke with him. Can you please update me on the plan? He mentioned that next round of avastin will be lower, why is that? How was his bloodwork?
thanks

--
Hallie Olivere Biden

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