The instinct for a patient with a new breast cancer diagnosis is often one of fight or flight. The urgency to act quickly, to rid oneself of it immediately, is common. So is the tendency to rely on the knowledge of friends, relatives, neighbors, co-workers, even scant acquaintances, to determine a course of action.
The most important aspect of breast cancer, to any patient, is its complicated, unique nature, according to Dr. Tom Thompson, MD and general surgeon with Surgical Associates of East Tennessee in Morristown (affiliated with Morristown-Hamblen Healthcare System/Covenant Health).
“There are a lot of misconceptions,” Thompson said. “Between the American Cancer Society and Susan G. Komen (and other organizations), it gets a lot of attention. But a lot of times, when you just read about somebody else’s experience or a report in USA Today or a five-minute segment on CNN – you can’t extrapolate that to yourself, when nine months later, you get a diagnosis.”
The initial conversation with Dr. Tom, as his patients like to call him, can last anywhere from 30 to 90 minutes, depending on their age and health background.
“Patients do better when they understand not only what we’re doing, but why — we look at their general biology, the mammogram, the status of lymph nodes, along with body size and medications.
“We get there without a panic,” he said.
The treatment used to kill cancer cells that may be in the breast or the rest of the body, and sometimes given prior to surgery to help make the procedure easier, has been used by the practice for eight to 10 years. The therapy is now gaining traction nationwide.
“We’re basing our adjuvant therapy more on biology than on size of the tumor, age of patient or status of lymph nodes, which was a more traditional approach,” Thompson said. “We are able to pick out the more aggressive tumors, if anatomically not visible, and make that decision pre-operatively.”
The first step for Thompson is to put in a port and check the patient’s sentinel nodes, the first few lymph nodes into which a tumor drains.
“It’s complex in a good way, because we are making so much ground,” he said. “There’s not another surgical treatment that is so varied. With some forms of breast cancer, there may be no surgery. Or treatment can range from hormone blockers to someone with partial mastectomy. Now the national data is supporting our intuitive.”
The traditional method of treating a large tumor within the breast was first, surgery — either a partial or full lumpectomy or removal of nodes — then consultations with an oncologist, installation of a port, lab work and follow-ups, followed by four to six weeks of chemotherapy.
“Now we are starting the chemo within a week of presentation,” Thompson said. With traditional treatment, when would we determine chemotherapy was effective? At the five year checkup? Now, I’ve got a tumor, gone down 50 to 70 percent, and the patient can see the results, we can see the results.”
On average, 10 percent of patients with large or aggressive tumors will not respond to the adjuvant treatment.
“So instead of giving them a full course, we can change the approach. We are fleshing out those patients at the front end, with no delay,” he said.
Adjuvant treatment, done prior to surgery, will enable some patients to respond better to overall treatment.
“People who die, actually die from systemic spread,” Thompson said. “Chemo goes after that. Why would we not address that first? For example, if I have an elderly patient, feeble, just a tiny woman with a ping pong ball-size tumor, we’ll put her on an agent and the thing will have shrunk by 50 percent when we check it. Then we have surgery when it’s smaller.”
Several years ago, Thompson began using an instrument for his surgeries on breasts that was initially designed for neck surgery. The retractor can be used on a small incision, approximately one inch, and makes the tiny wound a circle that leaves a scar that is very difficult to see.
“We can do that under the breast, under the nipple, under the arm; it’s very rare for a scar to be on the visible part of the breast,” he said.
Thompson jokes with those patients who may say they aren’t concerned if the wound is visible during their three-month follow-up visits and those thereafter.
I tell them, ‘It matters to me, I don’t want to see a big, ugly scar every time you come back!’ he said.
Photos are taken after surgery and during the follow-up visits: at the one, two and three-year marks. When medical students are doing their residency at the practice, Thompson has them try to guess which side of a patient’s chest was operated on.
“They can’t see it,” Thompson said. He has pioneered a procedure that inserts a port under a patient’s arm; he has performed a little more than a dozen to date — “Hiding the portentries is a significant advance,” he said.
The Right Information
Those patients who do not receive initial information from a medical professional that is concise and comprehensive may undergo unnecessary radical surgeries, like mastectomies, Thompson said.
“The fact is, the indications for mastectomy — in the traditional sense — the majority of women do not have one of those indications. The tragedy is they can find someone who will do it. At the forefront is survival – there are equal treatments that do not involve losing a breast (or both). Our bilateral mastectomy rates are low, better than a lot of the nationwide centers,” he said.
“Folks are emotional when they walk in, they want both breasts off and immediate reconstruction. Those procedures may not turn out as well as folks had hoped. The majority of people don’t need that,”
“The assumption people make about a full mastectomy it’s that there will be a zero reoccurrence of the cancer; in fact, there is a five percent local reoccurring rate, it is not zero. A partial mastectomy, with appropriate radiation, is about six percent. In fact, in certain age groups, we have at times seen an improved rate, in specific circumstances,” he said.
More than 60 new breast cancers have been presented to the practice in 2019, according to Thompson, with more than 100 surgeries performed. The practice is the busiest of its kind in the Covenant system. Patients travel from southeast Kentucky, southwest Virginia, western North Carolina, east Tennessee and as far west in the state as Cookeville. Two patients made dramatic commutes: one from Liverpool, England; the other from Miami, Florida.
“Every single case is a collaboration,” he said. “The goal is optimized survival with an acceptable cosmetic result. We spend time with patients, and that’s time that you don’t necessary get paid for. It takes what it takes.”
His moniker may be general surgeon, but Thompson has become a breast specialist, due to demand.
“You find that in a lot of practices. If you stay up on this stuff, you get possessed by it. The typical myriad of cases in general practice, that just doesn’t work anymore,” he said.
“I would never tell a first-time patient anything just to make them feel better,” Thompson said.
“They need to understand that during the process, they will be surrounded by the ‘foremost experts,’ and I what I mean by that is people they will see at the grocery store and hair salon, their friends and neighbors. But this is a highly varied illness, with regard to each patient and their medical background. They don’t have to be an actual foremost expert to make their own decision. They will become an expert because of what we recommend and when we recommend it. The treatment options are for maximum survival, depending on which one is best in a particular case.”
According to Thompson, when a breast cancer is diagnosed, whether through mammography or physically detectable, has been biologically present for one to two years.
“So we can take one to two weeks to determine what is best and make those decisions to minimize the long-term effect. We start with the biology of cancer, which is a replication process, not growth process. We talk about rabbits (he has plenty of them in his back yard, he said). Our treatment is designed to get rid of the source of replication and treat the replication.”
Thompson keeps a large white board in his office that he uses to illustrate procedures and treatments. He brings in former patients to talk with new patients.
“It helps to see someone who is three years down the road and they’re doing fine,” he said.
The survival rate of breast cancer patients is high — “There are a lot of breast cancer survivors in this town. We are very fortunate,” he said. “Tragic, advanced cases are more rare than people think. Mammogram-detected cancer is exceptionally treatable. It’s disruptive for a period of time; even at that, more times than not, it is not as disruptive as what patients have anticipated.”
Between the chemo, surgery, radiation and follow-up, many are able continue with their lives. We’ve had stockbrokers, physicians, janitors and bankers that work right on through this,” he said.
Dr. Tom has a reputation of being well-liked by his patients.
“I would like to think it’s because they have a sense that I take their case very seriously. We are detail-oriented at the practice. My mentor, John Bell (John L. Bell MD, director of the Cancer Institute at UT Medical Center in Knoxville, Tennessee), would say, ‘Details, details, details!’ I feel like I’m channeling my inner John Bell. It is all about taking time and genuinely being invested in their outcome.
It’s just a different deal. There are simpler discussions (regarding other conditions) that have bad outcomes. There are conditions where the discussions are not 30 to 90 minutes long. Or the options are less; there may be just one option for treatment.”
The long hours (he is also the Hamblen County medical examiner) are an investment Thompson is happy to make in his hometown.
“I’m where God wants me to be, doing what God wants me to do. That’s a good feeling when you l down at night. I’m just grateful,” he said.