The Breast Disease Clinic  
Frequently Asked Questions
Frequently Asked Questions

By Donald A. Hopkins, MD


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.

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.

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.

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.

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.

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.

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.

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.

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.