MOST FREQUENTLY ASKED QUESTIONS FROM BREAST CANCER PATIENTS
By Donald A. Hopkins, MD
ANSWERS TO FREQUENTLY ASKED QUESTIONS ABOUT BREAST CANCER
1.
WILL CHEMOTHERAPY OR OTHER MEDICAL TREATMENT OF THE CANCER BE
NECESSARY? To better answer this question, in all cases of invasive
breast cancer I arrange a consultation with a medical oncologist, a
specialist in medical treatment of cancer. Once this specialist has
complete information about an individual case, which must include
information from all tissue taken at surgery and studied in the
pathology laboratory, he can make an informed recommendation. As a
surgeon, I am not qualified by training or experience to give detailed
information regarding the best medical management of breast cancer.
However, in general:
A. If the primary breast tumor is very
large at time of diagnosis and/or involves the skin- medical treatment
will almost certainly be required. Sometimes this is done before
surgery to "shrink" the tumor mass to make it easier for the surgeon to
remove it. There are some clinical studies that involve placing
patients with small tumors on chemotherapy before surgery, but it will
be several years before the results of these studies are known.
B.
If the tumor is small the determination for possible additional medical
treatment after surgery will depend upon several factors, including,
most importantly, the status of the lymph nodes removed at surgery.
Even in small tumors there are sometimes indications for medical
treatment.
C. This medical oncologist is experienced and
knowledgeable regarding the current conventional recommendations for
medical treatment based upon the stage of the tumor. The oncologist may
suggest one of several clinical studies (called protocols). Protocols
are very structured studies that use various combinations of
medications in hopes of improving survival from breast cancer by
comparing results of the study, when complete, with results of current
conventional treatment methods known to be beneficial. The experienced
oncologist also takes into consideration the lifestyle and desires of
the patient. The medical oncologist is not trained or experienced in
the various techniques and expected results of breast surgery for
local-regional control of the tumor and therefore should not be
expected to give detailed advice regarding the appropriate surgical
procedure in an individual case.
2. WILL IRRADIATION TREATMENT BE NECESSARY? Irradiation
treatment, under the supervision of a specialist called a Radiation
Oncologist is recommended under certain circumstances. This type of
treatment is for local-regional control of disease (like surgery) in
contrast to chemotherapy or hormonal therapy that is given systemically
to reach disease in all parts of the body. Irradiation is generally
recommended for treatment of the remaining breast tissue if a patient
has had a partial mastectomy (lumpectomy) for invasive breast cancer.
Irradiation
therapy is also sometimes recommended if there is reason to believe
that there may be tumor remaining in the tissues of the chest wall or
axilla (armpit) after surgical attempts to remove the cancer. It is
sometimes useful to control symptoms from isolated deposits of cancer
that show up away from the breast.
Specific questions regarding
irradiation for breast cancer and its possible complications are best
addressed by the radiation oncologist. A pre-operative consultation
with this specialist is suggested for patients who wish to consider a
partial mastectomy or "lumpectomy" as the initial treatment for their
breast cancer.
3. CAN I HAVE BREAST RECONSTRUCTION? Breast
reconstruction after mastectomy is a common procedure available to
breast cancer patients. There are several different types of procedures
for this, some involving an implant (perfectly safe!) and other more
complicated procedures involving transfer of tissue from other parts of
the body. A Plastic Surgeon is the consultant for breast reconstruction
and other cosmetic procedures. It is somewhat unusual for plastic
surgeons to involve themselves directly in the diagnosis or treatment
of breast cancer.
a. CAN RECONSTRUCTION BE DONE IMMEDIATELY? Technically,
Yes. However remember that until the tissue removed at surgery is
studied in the pathology laboratory, it is not known what will be
required as possible additional treatment for the cancer. Convalescence
from immediate reconstruction may somewhat delay any recommended
chemotherapy treatment. Many patients prefer to wait for reconstruction
until they know what lies ahead. Reconstruction is usually available in
the future if the patient desires it. Also, reconstruction can make
additional treatment with irradiation to the chest wall somewhat
difficult, if such treatment is needed. I do not encourage immediate
reconstruction except for non-invasive breast cancer or occasionally
for very small invasive tumors with no clinical suggestion that
additional treatment will be needed. It should be noted that
complications from reconstruction are much more common in smokers.
4. DID HORMONES CAUSE MY CANCER? There
is no good scientific evidence showing that replacement hormones make
non-cancerous tissue turn to cancer. Studies do show that there may (or
may not!) be a slightly higher incidence of cancer in women who have
taken hormones for long periods, but if there is any increased risk, it
is far outweighed by beneficial effects of the hormones in preventing
osteoporosis and cardiovascular problems. There are also some recent
studies that suggest that the hormones may slow the onset of
Altzeimer's disease.
a. THEN WHY CAN'T I TAKE MY HORMONES AFTER I HAVE HAD BREAST CANCER? This
is a very complex question. A test called the hormone receptor test is
done on invasive breast cancers. This often shows that a particular
cancer can grow better in an estrogen rich hormone environment- not
that hormones caused the tumor, or that the tumor "feeds on estrogen."
When this test is positive the patient should not take estrogen, at
least for several years. Unfortunately, in this country (as opposed to
England) there is an unfounded perception that taking estrogen is
somehow bad in all breast cancer cases. This feeling is so universal in
our country that most physicians will not risk the legal consequences
of prescribing estrogen for women who have had breast cancer. The test
for hormone receptors is valuable because, if positive, it allows for
consideration for treatment with medications such as tamoxifen which
block this estrogen effect on the tumor.
In certain uncommon
situations where the lack of estrogens so adversely affects a woman's
quality of life, I will allow the patient to take estrogen replacement
if her family physician or gynecologist concurs. In such cases it is
important that the patient understand that we simply do not know if she
will be placing herself in significant risk for exacerbation of her
breast cancer.
5. SINCE I HAVE BREAST CANCER, ARE MY DAUGHTER'S AT INCREASED RISK? If
your current age is near 50 years, or older, you most likely have a
non-familial breast cancer. (Over 90% of breast cancer is probably not
related to family history or genetics). If you are nearer to 40 years
of age, or younger, this may mean that there are familial or genetic
factors that pass on to your daughters. If there are several documented
cases of breast cancer in your family, many of them at younger ages,
then it is likely that there is some familial or genetic risk factor.
However, to be prudent, in all cases it is wise to advise your adult
daughters to do their monthly breast self exam, to have a physician
check them at least once a year, and to begin annual mammograms at the
appropriate time.
6. SHOULD I GET A SECOND OPINION? I strongly encourage second opinions regarding surgery for breast cancer from any qualified breast surgeon. It is very important to me that my patient and her immediate family have confidence my advice. Remember, as a surgeon, my recom- mendations are directed toward the most effective method(s) of gaining control of the disease in the breast and surrounding tissues. Opinions about surgical procedures from physicians not trained or experienced in local-regional control of cancer, (for example a medical oncologist or internist), can be misleading. Perhaps this is because non-surgeons have had little experience dealing with persistence or recurrence of breast cancer in the breast or tissues of the chest wall after inadequate surgery. They often tend to recommend "conservative" surgical procedures in cases where it is not, in my opinion, appropriate or the patient does not desire it. Local-regional recurrence of breast cancer is devastating from a medical care point of view and is a major psychological and quality of life issue. I consider local- regional recurrence in the early (stage I -II) breast cancer patient a surgical failure.
7. SHOULD I GO TO A "CANCER CENTER" FOR ADVICE AND TREATMENT? This
is a personal choice item in most cases. The well-established cancer
centers such as M.D. Anderson, Sloan-Kettering, Fox Chase, and others
are sources of much of our knowledge about cancer treatment. They all
evaluate various treatment methods by placing patients in clinical
studies called protocols, and keeping data to see if a particular
protocol is an improvement over current conventional treatment methods.
Occasionally an improved method of treatment is firmly worked out and
it almost immediately becomes the standard of care throughout the
country. However, the bulk of the care at cancer centers is along the
lines of conventional therapy as advised by myself and other breast
surgeons throughout the country.
Treatment in such centers is
very beneficial in those cases that have not responded to conventional
methods of treatment. There are several ongoing studies trying
different methods in these unfortunate cases. Consultation with cancer
centers is always useful in very rare and unusual types of cancer (this
does not include breast cancer) with which practicing physicians out in
the community might have limited experience.
There are
some well-designed studies under the supervision of experienced and
qualified investigators at other referral centers such as large medical
centrers, clinics, and medical schools. Unfortunately, some studies at
such places are poorly designed or poorly supervised, often single
institution studies. Many of the latter, instead of being properly
carried out under appropriate supervision and peer review, simply carry
forward a particular investigator's bias toward treatment of breast
cancer. The very worst scenario is when a 'protocol' is promoted as
less radical treatment than standard conventional treatment, simply as
a marketing tool. Naturally all women would like to have this terrible
disease treated with as little alteration and disruption of their
lifestyle and body contour as possible. This makes them liable to
become willing subjects of some of these less aggressive but
scientifically unproven treatment programs.
Meet The Doctor
Dr.
Donald A. Hopkins was born and raised in Mississippi. His early years
were spent in rural south-central Mississippi. He moved to Jackson when
he was in the 9th grade and remained there until he had graduated from
medical school.
He has experienced a broad spectrum of medical
practice. At age 23 he was one of the youngest graduates ever from the
University Of Mississippi School of Medicine. With plans to practice in
a rural area he interned in a highly regarded General Practice program
in Fort Worth, Texas. After one year of internship, as a member of the
U.S. Naval Reserve, he was sent to Field Medical Service School at Camp
Pendleton, California. From there he went to the Republic of South
Vietman and in August 1965 was assigned as Battalion Surgeon, 1st
Battalion, 9th Marines. In July 1966 he was wounded while trying to
extricate dead and wounded Marines from a mine field. Military
decorations included the Purple Heart, Bronze Star with combat "V",
South Vietnamese Service Medal, and the National Defense Medal. The
remainder of his military service was as General Medical Officer at the
U.S. Naval Auxillary Air Station, Meridian, Mississippi.
In
1967 he went into practice at the Dabney-Hopkins Clinic in Crystal
Springs, Mississippi. This was a busy rural practice consisting of
general medicine, surgery, obstetrics and pediatrics.
In 1970,
Dr. Hopkins entered the General Surgical residencey at The University
Medical Center in Jackson Mississippi under the world reknown surgeon,
James D. Hardy. During the four years of residency Hopkins maintained
his practice on a part time basis at the Dabney-Hopkins Clinic. He also
worked weekends at various emergency departments throughout the state.
In
1974 Dr. Hopkins moved to the Mississippi Gulf Coast and joined the
Byrne-Stewart Clinic. After one year he established his own clinic, The
Gulfport Surgical Clinic, for general, vascular, and thoracic surgery.
He later established the Gulfport Cardiovascular Laboratory for
non-invasive peripheral vascular studies and cardiac pacemaker
monitoring. As a community general surgeon Dr. Hopkins performed the
first permanent cardiac pacemaker insertions, the first parathyroid
surgery, the first adrenalectomy and the first fiberoptic bronchoscopy
done in the community. He was instrumental in setting up the Cancer
Committee at Memorial Hospital under the guidelines of the American
College of Surgeons. He also was active in early efforts to provide a
chaplain service and a hospice organization for Memorial hospital.
In
1987 Dr. Hopkins established The Breast Disease Clinic as part of his
general surgical practice. Two years later, in July 1989, he began to
devote his practice entirely to diseases of the breast.
Dr.
Hopkins lives in Gulfport with his family. He is a serious student of
Southern history and has published two books related to the Civil War,
and is currently working on a third. He enjoys collecting Civil War
artifacts and also enjoys hunting and fishing.
Dr.
Hopkins is a Board Certified General Surgeon and Fellow of the American
College of Surgeons. He is a charter member of the American Society of
Breast Surgeons.
This private independent practice devoted
exclusively to breast disease is one of the few such clinics in the
country and perhaps the only one in Mississipi. Most practices devoted
to breast disease are associated with large centers or teaching
facilities.
