I’m a board certified veterinary medical oncologist and certified veterinary journalist working on Long Island, delivering high quality, compassionate care to my patients.  Veterinary oncology is my passion!

I’m here to share information about veterinary oncology and dispel myths about cancer care for pets.

I’m also  a professional writer,  avid runner, amateur wine enthusiast, and beach bum, so I’m certain you’ll find my musings about my life outside of the clinic just as interesting as those from within.american society of veterinary journalists logo RGB

I’m part of the problem. Are you?

A recent suicide of another veterinarian once again sparked a burst of concern regarding the mental health of those of us entrenched in this profession. As an isolated event, this news is nothing short of tragic. What is equally as concerning is how this heartbreaking news is an alarmingly repetitive part of our community. In the past few years, we’ve lost far too many outstanding colleagues who felt the only way to relieve their pain was to take their own life.

Statistics describing the emotional status of the “average” veterinarian are shocking. Suicide rates for veterinarians are double that of dentists and physicians and six times higher than the general population. A recent survey indicates as many as one in six veterinarians had considered suicide. Nearly seven percent of male vets and 11% of female vets reported “serious psychological distress” in an online survey.

There’s a disturbing pattern where every few months another veterinarian ends their life – and the magnitude of response on part of those of us in the profession is astounding. We express anger and frustration at pet owners, practice owners, corporations, and the lenders of our student loans. We share information about the rigors we endure on a daily basis with the hope of emphasizing we are just as much a “real doctor” as a human MD.

We are quick to expose the darker side of veterinary medicine, partly in solidarity and partly to educate the public about our concerns. I’ve participated myself, having written several articles on the detrimental impact compassion fatigue has on our profession. There are only so many times we can tolerate being accused of being “in it for the money” or “heartless” before we shatter.

The saddest part to me is despite the commonality in our cause, thus far, we’ve been ineffective in our endeavors. The statistics remain as abysmal today as they were several years ago and fundamentally, veterinarians continue to kill themselves.

When I learned of this most recent suicide, like many of my peers, I felt compelled to express my outrage in written form. But I paused before typing any words. My silence stemmed partly because I knew I’d never be any more eloquent than those who already stated their piece about the tragedy. But a greater portion of my silence arose from a gnawing sensation that exclusively pointing my finger outward was inaccurate. I’d always avoided looking inward and never really asked myself, “To what end do I contribute to the problem?”

To best explain the impetus for my altered point of view, I need to provide a bit of background. After spending nearly eight years in private practice, I recently transitioned to working in academia. It’s been a remarkable change, as my focus has shifted from seeing cases as a primary veterinarian to training students how to become successful veterinarians and teaching house officers (residents) how to become remarkable veterinary oncologists.

While overall the pace is much slower than what I’ve grown accustomed to in private practice, our oncology service is capable of seeing a good number of new consults and rechecks each day and the cases we evaluate tend to be more complex in nature than what I’ve faced previously. I’m also no longer tasked with directly communicating with clients and referring veterinarians. This is the responsibility of the house officers completing their residency. While these individuals possess a solid core of knowledge in oncological principals, the fundamental thing they lack is experience. They are here to learn and grow as specialists, but they aren’t there yet. That’s a huge part of my job – shaping what type of oncologist they will become over time.

Despite all of their spectacular qualities, house officers lack the breadth of experience necessary to be as efficient as a board-certified specialist. They are exceptionally intelligent and motivated, but are fundamentally more methodical in their thought processes than I’d ever be. They are not yet proficient in understanding risk of treatment (or not to treat as it may be.) They will express anxiety about scenarios I’d never consider, simply because my experience over the years has afforded me a sense of self-trust and knowledge that their concerns are unfounded. They need more time to process data and discuss outcomes.

The same is true for our radiology department, where house officers perform all of the assessments of our x-rays, ultrasounds, and CT scans. We face the same struggle with the residents we ask for surgery consultations, who are also trainees lacking the same level of experience as the board-certified service chiefs who back up their plans. Every blood sample or cytology slide we submit will be first analyzed by someone learning to become a specialist. While all house officers at an academic institution are supported by someone like myself – an experienced board certified expert, the frontlines are managed by people who are only just learning how to become the authority.

Beyond my responsibilities to the house officers, I’m also tasked with teaching veterinary students how to be good doctors. I must take the time to belabor pathophysiology and anatomy to ensure they have a strong foundation for clinical work. I have to constantly monitor their progress and remember the fundamental aspect that they lack pattern recognition not because they are not good at what they do, but because they haven’t seen that pattern just yet.

This all equates to an inherent slowness of the process and I must set boundaries as to what our service can reasonably accomplish each day. I have to restrict our schedule to include a specific number of rechecks and new appointments. I need to be cognizant of what I’m asking our staff to accomplish, because even a slight overload could very well surmount available resources. But the caseload far exceeds those restrictive numbers and the waitlist for an appointment with our service is a month long, which is tantamount to eternity for a worried owner with a pet newly diagnosed with cancer.

Here is where I’ve recognized I’m failing to support our profession, and worse, potentially contributing to its failure.

I’m the first to sort out how to squeeze in one more consult. Or to add on a few rechecks. I never want to disappoint pet owners. I’m compelled to help all the newly diagnosed patients. My wants frequently come at the expense of the very people I’m tasked with training. The model I’m setting forth to my trainees is to put owners and their pets first, even to the point of driving yourself down.

I’ve taken my own obligations and passed them along to my apprentices. I expect house officers to see another new consult, even when they’ve been assigned their “maximum” daily load. I ask them to stay late to talk to owners of cases presented on the emergency service whose pets are diagnosed with cancer because I think it’s the right thing to do. I expect students to be one time for 8am rounds, even when they have complicated treatments to accomplish on their hospitalized patients and lack the experience and confidence to ask for help.

While I’m assured my intentions are pure, I’m not accomplishing anything more than setting these fresh-faced doctors, and doctors-to-be, up to fail. I’m telling them this is the “normal” way to approach their profession, yet these are the very attributes I’ve condemned as being the cause of compassion fatigue. Is it fair for me to expect them to share my obligation to fit in the case, talk to the owner, and appease the referring veterinarian? Why am I ok with adding strain to people who already feel stretched thin, years before they’ve even achieved their board certification and have the ability to make such choices for themselves? If I can’t teach them to set boundaries now, when will they learn how to do so in their professional life?

How can I be angered at the status of our profession yet so obviously contribute to the issue at hand? How many others are behaving the same way as I am? How can I rectify sending the mixed message of “take care of yourself and your mental health, but please stay late and see one more case?”

Veterinarians know there’s a problem. We will never control what pet owners say or do and there’s little we can do to control for the debt required to graduate vet school. We will never shut down Dr. Google or eradicate the piles of misinformation surrounding animal health and wellness.

But we can control what we ask of ourselves and our colleagues. And while we may never control the expectations of others, we can teach each other to recognize our limits and be okay with saying no. This is especially those of us tasked with instructing those coming up through the ranks on how to be successful doctors.

It just might be the only way we protect ourselves and the future of our profession.

I’m here to make cancer less scary…

A few weeks ago I was asked to be formally interviewed as a means to introduce me to the surrounding community. NC State takes an active role in promoting recently hired faculty and as the new kid on the block, it made sense it would be my turn to spend some time describing myself and my goals to the community.

As much as I enjoy writing and and publishing posts online for the virtual world to read and examine, if I’m being honest I’d tell you, I detest having my picture taken and I really dislike talking about myself. There’s a huge disparity between publishing written information and posting pictures of my cats and really delving into the more sensitive issues on a “face to face” basis. But I recognized the goal of the assignment was far more important than my personal hang ups and agreed to sit down and talk about veterinary oncology and my choice to leave private practice and work in academia.

The goal here isn’t self-promotion – it’s to promote awareness of veterinary oncology. To let pet owners know there are specialists available who are experts in the diagnosis and treatment of cancer in companion animals. To assure them that the diagnosis of cancer doesn’t equal “there’s nothing we can do.” Pet owners should know the goals of veterinary oncology are not the same as human oncology. While the two disciplines are certainly intertwined, the approach to each case is vastly different. We promote quality of life, not life at all costs.

My wish is everyone facing a diagnosis of cancer in their pets would at least be offered the opportunity to talk to a veterinary oncologist. While a consultation doesn’t equal committing to a treatment plan, you will never be able to make the most informed decision unless you are presented with all the facts.

And the best person to help you make that decision is a veterinary oncologist.

Read all about my new job at NC State College of Veterinary Medicine and veterinary oncology by clicking here

How changing sides made this oncologist a happier person…

I’ve moved to the other side. But the thing is, it’s not so dark where I stand.

 

During my residency in medical oncology, amidst the strain of learning my craft, seeing countless appointments, and studying for board exams, I centered myself by meditating on where I would wind up working when I finished. It would be my first professional job and I envisaged seemingly infinite considerations to ponder – location, benefits, hours, size of facility, caseload, etc. Sitting atop the algorithm for my decision was the question: Did I want to work in private practice or academia?

 

As I approached the terminal days of my residency in 2009, the economy was shifting and the proportion of opportunities for employment were a mere fraction of what is available nowadays. Candidates nowadays have their pick among dozens of opportunities, whereas I applied for the grand sum of three jobs. Two were in private practice, while the third was an academic position at a veterinary school.

 

Each had the requisite pros and cons and I dutifully weighed my options. Would geography be the deciding factor or would it come down to the numbers? Where would I feel the most valued and useful and professionally satisfied? To fully consider those questions I had to take a serious look at what brought me to this decisive point in the first place.

 

Despite wanting to be a veterinarian since I first knew there was such a thing as an “animal doctor”, I took a rather circuitous route to veterinary school and becoming a medical oncologist. I was studious during high school and undergraduate, but my sub-stellar GPA wasn’t going to garner an acceptance, and as I approached graduation, I recognized I concurrently lacked the motivation and maturity necessary for admission at that particular time in my life.
I embarked on a Master’s degree to buy myself some time to cultivate personal needs before committing to such a specific career pathway. To help finance my advanced education, I was offered an instructor position teaching anatomy and physiology to non-Biology majors. A decision made out of a financial necessity morphed into an awakening of a passion for educating others, especially those who lacked the same enthusiasm I possessed about science and the intricacies of the form and function of the human body.

 

A few months into my post-graduate degree, I decided to switch gears and pursue my PhD in biology. My goal was to obtain the appropriate credentials necessary to be employed at a small, liberal arts college, teaching, and maybe think of vet school one day, when I was old. Like, you know, 35 or so…

 

I quickly learned the majority of individuals who pursue PhD degrees in biological sciences rarely do so for the primary want to teach. My ambitions landed as square pegs amongst the round holes of my colleagues, who were vastly more dedicated to basic science research than I was. Without much deliberation, I decided to hasten my timeline and applied for veterinary school sooner than my initial thoughts of “many years into the future”. Fortunately, I was accepted, and approximately 8 years later, found myself repeating the process of deliberating another major life decision related to my professional career. While jumping through the last hoops of my residency I struggled over deciding which job among the three I applied for would be the “perfect” one for me. Though I agonized over miniscule details, my heart and head agreed that teaching was the place for me and the academic job was what I wanted. I never considered the possibility that the choice wouldn’t be mine.

 

I wasn’t offered the job in academia. While not the first time I didn’t get what I wanted out of life, it was the only time I’d targeted a professional goal and failed to obtain it. My disappointment was magnified when my top choice of the two private practice jobs passed me over as well.

 

Four years of undergraduate work, a Master’s degree, two years of a PhD, four years of veterinary school, one year of internship, and three years of residency did not provide me with the promised chance to “be anything I want to be.” Instead, I was left working at the only job I was offered.

 

At no point in my lengthy training did I consider I that I would not wind up happy professionally. I knew I would face day-to-day annoyances and understood there would be expectations beyond my capabilities. I wasn’t expecting rainbows and unicorns, but I never thought I would harbor a persistent and progressive sense of frustration and restlessness in my career.

 

With each passing year of working in private practice, I grew increasingly impatient and discouraged with myself professionally. I changed positions and geographic venues several times over the span of nine years, but never found a place where I felt content with my contribution to my occupation. I was burdened by the relentless nagging concern of, “What if?”

 

What if I had been chosen for the academic job several years ago? What if I was responsible for teaching veterinary students how to be better doctors? What if I had the chance to start engaging in research again? Would that world sustain me greater intellectually? Would I feel more productive or contributory towards my chosen field? Would I even be good at it?
Then there are the more abstract questions: What if I was chosen for the academic position years ago? Would I still have met my husband and be married? Would I have liked living there? Would I always wonder what life in private practice was like?
While contemplating the parallel, but alternative, world my life could have taken was interesting and intellectually stimulating, it didn’t help me understand what the best approach to changing my current situation. I remained stagnant and unfulfilled.

 

About a year ago, an opportunity arose for an academic position for a medical oncologist at North Carolina State University’s teaching hospital. I mentioned it to my husband, more in passing than with any edge of seriousness. When he encouraged me to send in my CV, I listed innumerable reasons why I shouldn’t.

Despite the myriad of reservations I put forth, he provided the one and only one that mattered.  He was the only other person who knew I’d always wondered, “What if?” His persuasion pushed me to apply for the job as I’d already talked myself out doing so.

 

I was stunned when the call came through offering me the position. Once the initial euphoria wore off a little, I immediately questioned if this was the right choice, time, move, or place for me. Self-doubt crept up and reminded me I wasn’t good enough for academia back when I finished my residency, so why would I be a better candidate now?

 

How could I leave my current job and new house? Why would I want to disappoint my friends and family with yet another move and yet another story about how this will be the right job for me. There were many reasons not to take the offer, which were outweighed by the most important reason why I had to do it: it truly was what I always wanted to do. I knew it was time to stop wondering, “What if?”

 

While I have only been here at NC State a few short months, I cannot stress how much this was the right choice for me. I have trouble connecting with that person who so deeply resisted making this change. I am happy professionally and living in a place I’ve already grown to think of as my home.

 

Some say the other side has greener grass, while others say it’s darker. The truth is, you’ll never know until you take the leap of faith over the fence to see what it’s really like.

 

Turns out, the other side was the right side for me.

Top 5 tips for treating and beating lymphoma in dogs!

Lymphoma is a blood-borne cancer of lymphocytes, which are a specific type of white blood cell. It is the most common cancer diagnosed in dogs. There are several forms of lymphoma in dogs, the most common being high-grade lymphoblastic B-cell lymphoma, which closely resembles non-Hodgkin’s lymphoma in people. Lymphoma is one of the most treatable cancers in dogs, and recent developments in targeted therapies, monoclonal antibodies, and bone marrow transplantation could offer the hope of a cure in the future. Whether your dog was recently diagnosed, currently undergoing treatment, or you’re looking for information about disease prevention, you will find the following tips for treating and beating canine lymphoma valuable.

 

1. Pet your pup!

 

While you might expect a dog with cancer to show signs of illness, many dogs with lymphoma behave normally. Feeling enlarged lymph nodes may be the only sign something is wrong, and early detection is helpful for ensuring your dog is a good candidate for treatment. Lymph nodes are most readably felt under your dog’s chin, in front of his or her shoulders, and behind the knees. If you’re not sure about where to feel, here is a helpful video showing the location of lymph nodes in dogs. Don’t be afraid to ask your veterinarian for help. If you feel anything suspicious, contact your veterinarian so your dog can be evaluated as soon as possible.

 

2. Ask your vet for a referral to a board-certified oncologist.

 

If your primary physician was suspicious you had cancer, they would refer you to an oncologist. The same is true for your dog. Meeting with a veterinary oncologist does not mean you are committing to a specific treatment plan. Rather, this is your opportunity to ask questions about what to expect if your pet were to be treated for his disease versus if he were not, and to talk about what tests could be valuable for learning more about your dog’s cancer. Veterinary oncologists have extensive experience in the diagnosis and treatment of canine lymphoma. They will provide the most up-to-date information and have access to advanced treatment options beyond what is available to a general practitioner. For example, there is a newly approved drug for treating lymphoma in dogs that is currently only available to oncologists and could be an excellent option for your pet.

 

3. Purchase pet insurance.

 

While this is not an option to help pay for treatment following a diagnosis, many pet insurance companies will reimburse owners for a portion of the cost of cancer treatment for dogs insured prior to being diagnosed with cancer. Diagnostic tests and cancer treatment costs vary, but typically range from several hundred to several thousand dollars. Owners frequently admit discomfort with the impact that cost has on their decision to pursue treatment. Insurance can relieve some of this burden, allowing them to pursue options they would not have had without coverage. Some pet insurance companies offer “cancer riders” that provide additional reimbursement specifically for cancer care.

 

4. Don’t start treatment with prednisone/steroids before your appointment with your medical oncologist unless absolutely necessary.

 

Prednisone is frequently prescribed to dogs with lymphoma at the time of diagnosis, prior to consultation with a veterinary oncologist. Prednisone is a potent anti-inflammatory drug and can also help kill off a certain proportion of cancerous lymphocytes. While this may seem like a good thing to happen while you’re waiting for your referral appointment, there are two main concerns with this approach. One is prednisone administration prior to pursuing definitive treatment could interfere with tests your veterinary oncologist may recommend. Testing routinely includes labwork to look for cancerous lymphocytes in circulation, as well as imaging tests such as X-rays and abdominal ultrasound exams. If prednisone is started prior to executing these tests, the changes consistent with disease may improve or even completely resolve and your oncologist won’t be able to interpret the data correctly. This means they won’t be able to tell you an accurate stage of your pet’s disease.

 

Secondly, it is speculated that steroids can induce resistance to certain chemotherapy drugs used to treat lymphoma. This means dogs receiving steroids before chemotherapy could have less chance of responding to treatment, and their duration of response could be shorter.

 

Exceptions to this tip include dogs who are sick from lymphoma (e.g. not eating or having trouble breathing) and require more immediate treatment.

 

5. Don’t start your dog on any supplements, vitamins, nutraceuticals, or diet changes until you speak with your veterinarian.

 

It’s human nature to use the Internet to gather information about your pet’s health. A quick search for “canine lymphoma” returns nearly 500,000 hits. An impressive subset of this information is dedicated to the concept of treating dogs with lymphoma with homeopathy or other “natural” substances. Most sites lack evidence-based information proving such data is accurate. The rationale of “it may not help, but it can’t hurt” is false. The absence of a negative side effect does not imply safety—this is what FDA regulation is all about.

 

Some supplements could potentially negatively interfere with chemotherapy. For example, antioxidants may interfere with the mechanism of action of certain chemotherapy drugs as well as the normal physiologic way tumor cells are broken down by the body. There’s also evidence antioxidants may promote cancer growth. This doesn’t mean antioxidants don’t possess potential benefits, it simply reinforces that they must be used rationally and with appropriate research evidence to support their use.

 

While there are no known ways to prevent lymphoma in dogs, we do see this cancer in certain breeds more frequently (Golden Retriever, Labrador Retriever, Boxer, Bull Mastiff, Basset Hound, St. Bernard, Scottish Terrier, Airedale, and Bulldog). Owners of these breeds should talk with their veterinarian about what monitoring steps could be useful. Individuals considering owning one of the at-risk breeds should inquire with their breeder (if possible) about any known cancer patterns in their lines.

On situational awareness and veterinary oncology…

Situational awareness is “the perception of environmental elements and events with respect to time or space, the comprehension of their meaning, and the projection of their status after some variable has changed, such as time, or some other variable, such as a predetermined event.” In other words, were talking about paying deep attention to what’s going on around you.

I have an intense fear of flying. It’s called aviophobia if we’re being technical. I also possess an unnerving obsession with plane crashes. My favorite television show is “Air Disasters”, on the Smithsonian channel. I know it’s weird. But I can’t stop myself from watching.

Each episode of Air Disasters recreates the events surrounding a particular accident, most often using elaborate sets and actors portraying key figures, alongside interviews of the actual people involved in the crashes. The show is in its ninth season, in case you’re wondering if there were enough stories to sustain it over time… A direct description from the shows website:

“Harrowing stories of tragedy and triumph are brought to life through official reports, transcripts and interviews with the pilots, air traffic controllers, and survivors of history’s most terrifying crashes. Widely considered to be the safest form of travel, air transportation is still in its infancy and when midair calamity strikes, the results are often catastrophic. From the cockpit to the cabin, from the control room to the crash scene, we uncover what went wrong, then reveal what’s being done to ensure these atrocities never happen again.”

One of the common themes of each episode is the cause of an air traffic accident is always of a multifactorial nature. Even when the reason for a crash seems obvious; bad weather, pilot error, mechanical failure, etc., that one mistake or problem isn’t the only cause of disaster. And a frequent contributing factor is a lack of situational awareness on the part of the flight crew.

As an example, Flight 173 from JFK to Portland crashed on December 28, 1978. The entire flight was routine and smooth. On approach to Portland, while lowering the landing gear, the flight crew heard and audible “thump” along with an abnormal yaw of the plane. The indicator light showing the landing gear was properly locked in position also failed to illuminate. The crew requested to circle the airport at a low speed and altitude while they sorted out if these was a problem. After circling for over an hour, upon final approach to land, both engines flamed out from lack of fuel, and the plane crashed about 6 miles from the runway.

While the decision to abort the landing was judicious, the accident occurred because the flight crew became so absorbed with diagnosing the problem that they failed to monitor their fuel levels. Lack of situational awareness contributed to the crash.

How does this relate to veterinary oncology?
Remarkably well.

The diagnosis and treatment of cancer in pets requires an intense amount of situational awareness.

I have to listen intently to what an owner describes to me regarding their pet’s clinical signs, previous health history, and also their goals for their pet’s quality of life.

I have to examine prior medical records and sort out important details from extraneous data.

I have to perform a thorough physical exam to ensure the animal is in good enough health to undergo the recommended diagnostic tests and treatments.

I have to decipher lab tests and biopsy reports with precision.

I have to calculate dosages of medications that have the potential to cause severe side effects or even death with a marginal error in their administration.

I have to instruct owners about signs to look for indicated complications related to treatments or their pet’s disease process. The list is endless.

Decreased situational awareness, even if only marginal, in any one of those areas, can lead to mistakes that, at best, could cause a patient to become ill, and at worst, could cause their death.

It’s happened to me before. I’ve made mistakes. Fortunately, not to the extreme of causing significant morbidity.

I’ve forgotten to verify the dates and names on lab work I’m reviewing, deeming it adequate for treatment when, in truth, I lacked the correct information.

I’ve failed to listen to details owners provided about how their pet did after their previous chemotherapy treatment and wound up forgetting to prescribe medication to lessen effects.

I recall intently examining the sequence of images on a CT of a tumor as the dog passed through the scanner, not realizing the pet was actually beginning to wake up from anesthesia before completion.

On the grand scheme of errors, I’m fortunate these are relatively benign instances of me lacking situational awareness. It’s tough to admit to being distracted or losing focus. Like many of my colleagues, I’m a perfectionist. And I’m also hard on myself when it comes to making mistakes.

Those characteristics can be used to my advantage – they make me a better veterinarian and force me to set high standards to the level of medicine I put forth. They can also haunt my success – paralyzing my ability to make timely choices and lead me to over think a case to the point of confusion.

I’ve taken to practicing being fully situationally aware as often as possible. To be honest, it’s a bit exhausting. But given the magnitude of the responsibility of my job, I have an obligation to do so.

I’d expect the same from any professional individual.

Especially a pilot.

How this veterinary oncologist learns more about her specialty when cancer crosses species to her owners.

I’m seated across from one of my favorite owners and her endearing 9-year-old Lhasa Apso, Sparky. I’m reviewing Sparky’s medical record, determining when he’s due for repeat chest x-rays to make sure his there’s no evidence of his cancer resurfacing. Sparky is customarily unimpressed, making no attempt to stifle an uninterested yawn. Mrs. Baker, Sparky’s owner, patiently awaits my decision.

Sparky was diagnosed with a form of skin cancer that was removed about eight months ago. Since recovering from the operation, I see him every month for routine examinations. Though his type of cancer wouldn’t typically spread to distant sites in the body, the probability is not zero, therefore routine monitoring is important.

“It looks like we last checked for spread of his tumor about three months ago. This would be a good time to see if anything has changed. We could perform the x-rays today, or during his check up next month,” I say.

“Let’s do the x-rays now,” Mrs. Baker states emphatically.

I’m grateful for her dedication to Sparky’s care. One of the biggest struggles I have with owners of pets with cancer is relaying the importance of monitoring for recurrence or spread of disease.

As I’m finishing up with writing my notes about the checkup, Mrs. Baker casually adds, “You know, they found another lump and I need to go for more testing.” My pen stutter-steps along the page as I immediately look up, unable to find the words to express my concern.

I knew Mrs. Baker was previously diagnosed with breast cancer over 30 years ago. We had discussed her disease numerous times over the course of Sparky’s visits. She’d told me all about the invasive surgery she underwent and the subsequent six weeks of daily radiation therapy she’d endured.

I heard details of the horrendous long-term side effects she had from her treatments, including persistent lack of sensation along the right side of her chest, a chronic cough, and an intolerance to strenuous activity.

I knew she was as diligent monitoring her own health as she was about her dog’s. She underwent regular mammograms and CT scans and previously always received encouraging news that her cancer was non-existent.

However, over three decades after her initial diagnosis and treatment, she’d developed not only one but two new tumors. One in each breast. Her treatment would be a double mastectomy followed by chemotherapy. Her prognosis was unknown, but the initial biopsies suggested the two tumors were not related to each other and were each likely aggressive.

In some cases, owners of animals with cancer who are diagnosed with cancer themselves are reluctant to pursue treatment for their pets. Their own experiences negatively influence their perception of what their companion would experience.

While there are many similarities between a diagnosis of cancer in animals and people, and the drugs I prescribe are the same used to treat humans with cancer, the dosages are lower and the interval between treatments is extended so as to avoid side effects in pets. This conservative plan of action affords a much lower cure rate for most veterinary cancers. However, we consider this an acceptable consequence because animals with cancer experience an exceptionally low rate of treatment related complications.

More frequently, I encounter owners such as Mrs. Baker, who search for options for their pets on par with what they’ve experienced themselves. I don’t have to go into the details of chemotherapy, or the importance of staging tests or monitoring with cancer survivors. They are already acutely aware of which information is crucial for making optimal decisions about their animal’s care.

While I’m prepared for discussing cancer care in animals, I lack confidence in my capabilities for providing the same support for the human beings attached to those pets facing a similar diagnosis. I’m humbled and honored when owners of pets with cancer open up to me about their own diagnosis. Whether doing so helps them to better understand their pet’s diagnosis, or simply provides them with a sounding board to express their own concerns and fears, I’m appreciative of their disclosure.

I was thrilled to let Mrs. Baker know Sparky’s x-rays turned out to be clear. We spent several additional minutes discussing how happy we were with how well he was doing and joking about his propensity to ingest acorns before she could pry them from his tiny, genetically stunted jaws. We concluded the appointment as we always do, with a quick hug and a few parting sentiments about Sparky’s cuteness, and with me letting her know I looked forward to seeing the both of them next month.

As Mrs. Baker and Sparky exited the hospital, given the recent news regarding her health, I felt just a tiny bit guilty knowing I’d be happier to see her rather than him at their next visit.

When the bottom line is about the bottom line…

Veterinary school taught me veterinary ethics, not business ethics. I’ve never possessed a driving ambition to own my own practice. My professional goal was to earn a living doing what I love rather manage my own hospital. My vision was to be employed in a position where using my expertise in treating cancer in pets was my sole responsibility.

Veterinary medicine is a business like all other professions. Those of us working in the field need to earn a living just as much as the next person. Though we’re driven by a love of animals and a desire to help them live longer and healthier lives, we can’t do it for free. As much as we hate to talk about it, we’re acutely aware of how money plays a role in what we do and how we do it.

Operating a veterinary hospital is expensive, especially for facilities such as the ones where I work, that are open 24 hours a day, 7 days a week. As an oncologist, I expect to maintain an inventory of pricey chemotherapy drugs to use for treating my patients. I want the most experienced technicians to administer chemotherapy. I need expensive equipment such as an ultrasound, a digital x-ray machine, and a CT scanner to accurately stage my patient’s cancer. I’d like to be paid for my time. All of these desires represent overhead for my hospital, and the expenses must be justified by the revenue I’m able to produce.

In reverse, I’m expected to generate a particular amount of income each day in order to “earn my keep.” I have to financially justify my want to continue to be paid, to have the state of the art equipment, and to work with fantastic support staff. When circumstances are favorable, I’m praised for my effort and interest is placed on discerning the “how’s and why’s” of the success so we can expand the benefit further.

When I miss the mark, I’m accountable for explaining my shortages and the emphasis is on the “how’s and why’s” of the deficit and how to reverse the situation. In the toughest of times, this could mean I’ll suffer a decrease in my own compensation or even termination of my services.

There’s a problem with making matters of veterinary care and money so business-like. When success is measured financially, veterinarians are expected to see more and more patients in a day, to increase availability beyond ‘typical’ working hours, and to constantly market themselves to the public and other veterinarians. They therefore work longer days, have fewer days off, and are constantly accessibile via email or social media.

These aren’t necessarily bad characteristics of a doctor. It’s important that I’m accessible to my owners and I want them to be able to trust my judgement in taking care of their pets. I want to see as many cancer cases as possible. It’s the best means I have to educate people against the myths and misconceptions about treating cancer in pets. I want to accomplish these goals with compassion and intelligence, and be thought of as the doctor who makes owners feel as though their pet is the only patient I’m responsible for.

The danger is when throughput is accelerated, doctors hit a point of diminishing returns. In the most extreme cases, patience expires, capabilities are stretched, attention is diverted, and mistakes happen. There comes a point where they may be able to see more cases but they won’t be producing more revenue. Compassion fatigue weighs them down with the greatest of pressure. Concurrently, pet owners will feel rushed and less connected with their veterinarians. They will lose trust and be unwilling to pursue recommendations. This means they’re spending less money in the long run.

I’ve worked in several geographical regions of the US, in hospitals of different sizes, and with varying degrees of staff expertise and capabilities, yet the message has always been the same. The “bottom line” is often the driving factor for any decision made regarding how I’m expected to practice and what I’m expected to produce. I’ve talked with colleagues spread among a wide geographical range who share similar frustrations. The pressure of performing financially as a veterinarian is not unique to any one particular practice type or specialty or location.

I urge those of you considering veterinary medicine as your career to think about how much you will mind manners of money beyond the expected discussions you will have with pet owners. Depending on where you work, your job security might depend more on your ability to generate revenue rather than your knowledge or your bedside manner.

 

 

 

 

Why is my veterinarian NOT recommending chemotherapy?

The results of a study titled Survey of UK-based veterinary surgeons’ opinions on the use of surgery and chemotherapy in the treatment of canine high-grade mast cell tumour, splenic haemangiosarcoma and appendicular osteosarcoma were recently published. The study examined what percent of general veterinarians recommended chemotherapy for the three specific tumor types listed in the title, along with what chemotherapy protocols they recommended, and the reasons why post-operative chemotherapy would not be recommended for cases.

The facts tell us:

Mast cell tumors are the most common skin tumors diagnosed in dogs. The biological behavior of mast cell tumors is variable and best predicted by the grade of the tumor, which is assigned by a pathologist examining the biopsy. Chemotherapy is recommended to lower the risk of regrowth and/or spread of high grade tumors.

Splenic hemangiosarcoma is an aggressive tumor of the cells lining blood vessels. The prognosis with surgery alone (splenectomy) is 2-3 months. Chemotherapy can extend the expected lifespan to approximately 6 months after surgery. Some dogs can live a year or more following completion of such treatment.

Appendicular (limb) osteosarcoma is the most common primary bone cancer in dogs. Tumors are painful, and amputation of the affected limb is recommended to provide immediate relief. Amputation alone doesn’t alter a dog’s expected survival time (4-5 months) because the vast majority of dogs will go on to develop metastases within their lungs or to other bones in that time frame. Chemotherapy is recommended after amputation to increase survival time, typically to about one year, with 10-15% of dogs living 2 years.

Looking back at the study, I found several surprising conclusions.

  • General practitioners were more likely to recommend surgery for mast cell tumors and splenic hemangiosarcoma than for osteosarcoma.

As outlined above, the ideal treatment for all three tumor types is surgery. Yet the study pointed to evidence of veterinarians being less willing to recommend amputation than splenectomy (removal of the spleen) or surgical excision of a skin mast cell tumor. The authors speculate veterinarians might view amputation as excessively disabling. Yet, they point out several studies have examined owners’ opinions of outcome for their pets following amputation surgery and shown favorable responses, whereas similar studies are lacking for splenectomy or mast cell tumor removal.

Most owners are reluctant to pursue amputation for their pets, despite obvious evidence of pain. They frequently counter my opinion their pet is in discomfort, even when the dog is unable to bear weight on the affected leg. They perceive amputation as drastic and incapacitating.

While I understand an owner’s perception being skewed, it’s difficult for me to determine why a veterinarian would feel the same. Especially when knowing surgery would be a means of improving quality of life, rather than debilitating it. Veterinarians must be able to discuss amputation as a feasible and standard option for dogs with osteosarcoma out of responsibility to provide a treatment option that will eliminate pain from their patients.

  • General practitioners were more likely recommend chemotherapy for high grade mast cell tumors than for splenic hemangiosarcoma or osteosarcoma. The most common reason why general practitioners did not recommend chemotherapy for hemangiosarcoma or osteosarcoma was because they questioned the efficacy of treatment for those diseases, yet 51% and 36% of veterinarians did not know a current protocol for each disease, respectively.

Scientific evidence tells us, for all three tumor types, survival time can be extended when chemotherapy is added following surgery. Specific protocols are recommended for each disease based on data from research studies proving the efficacy of such treatment.

I understand the difficulty of keeping current on oncology treatment in pets and I wouldn’t expect a general practitioner to be more successful than I am in doing so. But the data supporting the efficacy of chemotherapy for splenic hemangiosarcoma or appendicular osteosarcoma is actually more established and straightforward to interpret than what’s available for mast cell tumors.

A lack of knowledge isn’t a valid excuse for not offering treatment. Veterinarians are responsible for seeking out options for their patients, and this includes recognizing when it’s time to involve the expertise of a specialist. Owners are appreciative of their veterinarians who are willing to learn from their pets and would likely be happy to know their vet communicated with an oncologist regarding their care.

  • General practitioners most frequently prescribed masitinib (Kinavet®) for dogs with high grade mast cell tumors (40%), with all other potential treatment options (e.g. intravenous vinblastine or oral CCNU) being offered only by 11% or less of respondents.

There are several treatment options for high-grade mast cell tumors in dogs. In terms of efficacy, it’s difficult to say which would be “the best” treatment as there’s no study directly comparing response rates and survival times among the choices. Therefore, I offer owners several options for treatment, and our decisions are made based on objective parameters such as number of required trips to the hospital, concern for side effect, and cost.

Masitinib is an oral form of chemotherapy registered for treating mast cell tumors in Europe, similar to toceranib (Palladia®) which is licensed in the US. Masitinib and toceranib belong to a family of drugs called tyrosine kinase inhibitors, which are small molecular inhibitors. The mechanism of action of small molecule inhibitors is different from ‘traditional’ chemotherapy drugs, which are more directly cytotoxic.

Though not specifically accounted for in the study, I suspect the increased frequency of prescription of Masitinib for mast cell tumors by general practitioners reflects the perceived relative “ease” of administration as compared with injectable vinblastine or even oral CCNU.

There is widespread perception by pet owners and veterinarians that tyrosine kinase drugs are less toxic, less intensive, and less risky than injectable or oral chemotherapy options. While I can’t argue there’s appeal for owners to give their pet’s chemotherapy at home rather than via a trip to the veterinarian’s office, small molecular inhibitors are no less hazardous or costly, and require more intensive monitoring than other forms of chemotherapy in order to be safely administered.

Of course, there are always two sides to a story. In the study, the general practitioner’s answers were based off a questionnaire, with no opportunity to explain their responses, leaving much to question about the conclusions made. The study was done in the United Kingdom, where there are likely differences in access to specialty medicine compared to where I work in the US. I’m also aware of the difficulties faced by general practitioners regarding struggling to explain the benefits of referral to a veterinary oncologist or cancer care in pets. But I can’t avoid considering the results as they are presented.

People assume my job is depressing because I’m the one having conversations with owners about a diagnosis of cancer, however it’s the general practitioners who are the frontline in communication. The results of this study indicate how important their role is in learning the correct information to disseminate, as well as the manner in which it is discussed. And the underlying importance of the veterinary oncologist in ensuring the facts are preserved and the patient’s best interests are kept at the forefront.

For more information on finding a board certified veterinary oncologist for your pet see www.ACVIM.org.

If you want to be a veterinarian, you better like people!

My advice to anyone aspiring to be a veterinarian? Get used to talking to people.

Pursuing a career in veterinary medicine is tough. Just considering the process of applying to veterinary school is daunting. There are numerous standardized tests, the need for superior letters of recommendation, and the stress associated with composing the perfect personal statement of why you’re choosing this particular path. Individuals must have top notch grades, possess a wide breadth of animal-related work experience, and be well-rounded in their extra-curricular activities.

Plenty of worthy applicants are denied admission based due to a lack of available spots. The competition is palpable, and is potentially one of the biggest detriments to the vocation. The aggressive nature of the application process selects for individuals who excel academically. All too often, such individuals lack critical attributes such as comfort with public speaking or interpersonal interactions.

It’s no mystery that veterinary medicine requires a love for animals and science. Whether pursuing small or large animal practice, or a career as a wildlife or zoo vet, or even biological research, individuals are driven by a passion to preserve the health and welfare of animals.

What is often overlooked is the extent to which veterinarians must work with people. Though driven by a passion for helping animals, those working in the profession will be always be surrounded by owners, other veterinarians, technicians, assistants, co-workers, practice managers, owners, etc. who each require time, energy, and attention.

Every pet that steps through my exam room is attached to at least one human being. My interactions with animals comes easy, but those with people come less naturally. Further complicating my particular scenario is that as a veterinary oncologist, I meet people at an extremely emotional time in their lives. I possess no formal training in grief counseling or psychology. My education regarding “bedside manner” comes entirely from personal experience, both as a patient myself and over my years of worming in the field.

I may be walking into my third canine lymphoma consult of the morning, while the people I’m meeting with have never even considered their dog could be diagnosed with cancer. I have to be able to connect with those individuals despite having to repeat facts multiple times within the same work day.

I could be running a half an hour or more behind on appointments, or lack appropriate support staff, or simply not feel well and am still expected to complete my daily roster of appointments with the same amount of kindness and care as I would on a less busy or emotionally tolling day.

The animals I work with never consider my credentials or bedside manner, but I will constantly be judged by their owners on my knowledge, compassion, and ability to make them feel as though their dog or cat is the only pet I am seeing that day. I’m cognizant of how owners acutely remember every word I say and every interaction I have with them and their animal, even when doing so exceeds my reservoir of compassion and my abilities are worn thin.

The best advice I could give would be to learn how to be comfortable speaking to people and in front of groups of people. Learn about how people learn and process information. Discover new ways to listen to people. Observe and record their behavior. Consider ways to keep yourself interactive, even when you don’t feel as though you want to. There will be so many times during your career as a veterinarian you will want to withdraw, but be forced to continue to talk. You won’t always be comfortable doing so, but you need to find sooner rather than later if you’re able to push through your comfort zone.

Attempting these activities is especially important if you’re a particularly shy person. While studying, and memorizing facts will afford you the academic qualifications, what will carry you through this profession as a career will be the way you interact with other people. The more you practice these tasks, the more comfortable you will become with the process.

I’m an imposter?

What are the “things” you use to define yourself? Do you best identify with your familial status (mother, husband, daughter?) Or do you describe yourself by your talents (musician, artist, writer?) What is it that matters most when it comes to saying who you are?

 

I happen to classify myself most consistently with the person I am in my professional life. Despite my varied and intricate physical and emotional components, the sum total of how I label myself is by what I do for a living. I am a veterinary oncologist.

 

These were my thoughts as I attempted to thaw myself out after completing a soggy, icy, and slippery 15-mile group run. I was a few weeks into a new-to-me marathon training program, contemplating what I’d gotten myself into. I was an experienced (though not fast) runner, having completed two previous marathons, three half-marathons, dozens of 5 and 10K races. But I’d never participated in a running club before and I’d never attempted training for such a lengthy distance over the frigid winter months.

 

My muscles were aching, my body was chafed, and I had blisters encircling both insteps. In the midst of my misery, I questioned what kind of person would subject themselves to this torture. My gut answer was only a real runner would commit to such an irrational plan. But deep down, I didn’t consider myself as a real runner at all.

 

Veterinarians are notorious over-achievers in their professional lives. We work extended hours, frequently sacrificing personal time for the sake of the pets we treat. We undervalue our worth, providing discounted services because otherwise we could be accused of ‘being in it for the money”. We are criticized for being greedy and inflexible when we don’t do such things. We struggle to please owners and help animals, despite facing severe financial and emotional restrictions that thwart our best intentions.

 

Many veterinarians possess an “imposter syndrome”. This occurs when highly accomplished individuals lack confidence in their capabilities, downplay deserving their success, and fear their inadequacies will be exposed.

 

Veterinarians consider themselves “lucky” to have achieved their degrees rather than recognize their hard work. They’re worried owners may discover they aren’t as knowledgeable as their accolades suggest. They compulsively try for their patients, even those they cannot save. They worry about not being good enough, even though the truth tells the contrary.

 

Despite defining myself by my career choice, I was guilty of possessing the imposter syndrome in my professional veterinary life. And on that freezing cold morning, I also felt like an imposter as a runner.

 

When people would tell me how remarkable it was that I could run 3 or 6 or 10 miles, I would discredit my abilities and think of those who run further and more frequently. I was constantly considering how far I didn’t run or a how slowly I completed my miles.

 

Given my propensity to temper my accomplishments at work and on the track, I couldn’t help but wonder if I possessed some sort of baseline character flaw. Why was my default set to lessening my achievements? When I really considered it, when push came to shove, each time I’d felt like the biggest of imposters, I always made it through. Could I really be that duplicitous and be as proficient as I’d grown to be?

 

I don’t always have the solution to help my patients. There are times they die, despite my greatest efforts to the contrary. There are times when owners are unhappy with my service, or expect more than I can provide. I constantly worry about being an ineffective doctor. But I help far more owners and pets than not.

 

Likewise, I’ve had many times where I’ve set out to complete a long distance, only to find myself walking after running a few shabby miles. I’ll never win the races I participate in. My mile time has fluctuated greatly over time. Yet I still register for races and train for their distances, and still feel compelled to run as often as I can.

 

On that cold winter morning, I recognized that when I feel like an imposter, I’m allowing the critical voice inside my head to act as my enemy rather than my champion. Whether working in the exam room or running on the road, I would always be the only one appropriately equipped to decipher that voice.

 

It’s just as easy for me interpret something negative, allowing insecurity to propel me towards disappointment professionally or on the pavement, as I could hear something encouraging, and use it to push me towards achievements in either venue. And if my definition of myself rests on what I hear, I must listen carefully and be more objective in my interpretation.

 

And that in the end, all that really matters is that I push through and finish, one step at a time.

 

 

Happy New Year!

Tonight marks the commencement of the Jewish new year. Rosh Hashanah begins on the evening of October 2 and will end on the evening of October 4. Jews will be celebrating the beginning of the year 5777. The Jewish calendar actually contains four separate opportunities to recognize a new year, with Rosh Hashanah literally translating in to “head of the year.” Specifically, Rosh Hashanah is the new year of people, animals, and contracts.

 

Rosh Hashanah is a particularly significant new year as it marks the commencement of the Jewish high holy days. Rosh Hashanah is the Day of Judgement. On this day, it’s believed God opens The Book of Life and decides who will live and who will die over the upcoming year. The deal is sealed in 10 days later on Yom Kippur, which is the Day of Atonement.

 

On Rosh Hashanah, individuals deemed righteous will be destined to survive the upcoming year. Those deemed wicked, well I’m sure you can guess what happens to them. Somewhere in between are the “intermediates” – those people who don’t quite fit into either category.

 

Intermediates are given a chance to repent during the 10 days between Rosh Hashanah and Yom Kippur (and are expected to really give it their all on the actual day Yom Kippur) thereby ensuring a good fate. In other words, if your destiny is on the fence, it’s possible to alter God’s plan during the high holy days.

 

The new year is a time for wonder and excitement and also reflection. This past Jewish year has been the hardest I’ve endured and I possess no nostalgia when thinking of it coming to a close. I don’t mean to seem ungrateful and I recognize and appreciate what I’m privileged with on a daily basis. I simply cannot reminisce on this past year with any sense of fondness. Does this make me less than righteous? Would God therefore consider me wicked? Perhaps, but more likely, I’m biding my time right now as an intermediate.

 

I certainly will use the next 10 days to work towards penitence. Truth is, I’ve been doing it for some time already. This abysmal year has forced me to consciously focus on practicing gratitude and learning how to better incorporate grace and faith in my daily activities. Like some detached admirer, I’ve marveled at my ability to endure situations I’d never imagined I could tolerate. I don’t consider myself particularly strong, I’ve just somehow been able to get through to the other side (so far.) I’m ending this year a different person then how I started it. And I’m ok with that.

 

I’m looking forward to what the next year will bring. I can’t help but feel optimistic a year with three “7s” in it will be filled with a great deal of luck and opportunity. I won’t ever forget what I endured, but I’m accepting how to respect what I’ve learned from it, and am absolutely ready to move forward with a renewed sense of faith and hope.

 

If you’re an intermediate like me, consider what you could do to help seal your fate in the direction you’re hoping it will take. What are you grateful for and what could you do better? Could 5777 be your best year yet?

 

Happy new year!/Shanah Tova!

 

Can’t you just give me the “chemo pill?”

I’ve been a major slacker lately when it comes to writing articles. I blame the fact that a few months back, the staff at PetMD cut back on asking me for contributions, therefore reducing my incentive (read: deadlines) for completing my tasks. My absence doesn’t stem from a lack of thought. I still possess a mind full of tangled deliberations and complicated goals. I’ve simply been depleted of the requirement to put fingertips to keyboard to iterate them intelligently.

One of the topics I’ve churned over and over in my mind is how best to educate owners who inquire about oral chemotherapy options in lieu of injectable treatments because they perceive the former as being less ‘intensive’, and therefore less impacting for their pet.

Countless times, owners ask me if I couldn’t just prescribe the “chemo pill” they heard about from one of several typical sources (insert any one of the following: primary veterinarian, friend, cousin, groomer, teenager worker at the pet food store, etc.) It’s funny, but in all my years of training as a medical oncologist, I never once learned about the “chemo pill”. I’m the first to admit, it would be remarkable if there was a pan-cancer tablet that effectively treated a multitude of tumors. Sadly, this magic bullet doesn’t exist.

After a few awkward seconds and a bit of further probing, I’m usually able to discern owners are asking about one of two oral chemotherapy options: Palladia ®, a tyrosine kinase inhibitor licensed for treating a form of skin cancer called mast cell tumors in dogs, or metronomic chemotherapy, which entails administration of low-dosages of chemotherapy drugs on a continuous basis to inhibit blood vessel growth to malignant cells.

Mainstream use of oral chemotherapy is a relatively recent development in veterinary oncology. For some cancers and the patients attached to those tumors, it can be an excellent treatment alternative. Research with a few specific cancers is available, and data is promising regarding its efficacy. However, evidence based information supporting a superior effect of oral protocols compared to well-studied injectable protocols is lacking for most cancers we treat. In fact, for most tumors, the efficacy of an oral protocols is, at best, theoretical.

Owners are attracted to the option of treating their pet with oral chemotherapy for several reasons. One of the major perceived pros is the incorrect belief that oral chemotherapy is less toxic than injectable treatments. This is a problematic thought process for two reasons: one is it perpetuates the overestimation of frequency and severity of side effects seen with injectable treatment and the two, it underestimates the potential negative effects of the oral drugs. Chemotherapy drugs, regardless of form of administration, carry narrow therapeutic indices, and their ability to induce adverse effects remains a major consequence of their administration.

The typical side effects of injectable chemotherapy include adverse gastrointestinal signs including vomiting, diarrhea, and/or poor appetite, and a temporary lowering of the recipient’s white blood cell counts. These signs are the same potential consequences of oral medications as well.

Another perceived benefit of oral chemotherapy is that treatment is less stressful for pets because it’s done at home, rather than at the hospital as is done for injections. While I cannot argue against the concept that pets, especially cats, are most comfortable in their familiar environments, the majority of animals remain absolutely calm during treatments. The process of administering intravenous chemotherapy is not stressful, and rarely do animals exhibit any distress from the process.  Many owners overestimate the degree to which their pets would be affected by the restraint required for injecting chemotherapy and assume the administration is in some way uncomfortable for them. In reality, this simply isn’t true.

A last area of misconception about oral chemotherapy occurs when owners mistakenly believe animals receiving this form of treatment do not require monitoring. This usually relates to the aforementioned goal of keeping things as low-stress as possible. It also relates to a perception that oral chemotherapy drugs are less costly than injectable ones. Owners are surprised to learn pets receiving oral chemotherapy are monitored closely as they are. For example, I recommend monthly exams and lab work for most patients. Therefore, owners must be aware that choosing an oral treatment plan doesn’t mean their pets are ‘off the hook’ from spending time at the veterinarian’s office. When you consider how little is known about the potential benefits of oral chemotherapy along with their relative newness, it makes sense that an oncologist would want to monitor your pet even more frequently than for a more well-established therapeutic plan. Cost-wise, all this monitoring means most oral chemotherapy plans are on par with injectable protocols.

What concerns me more than owners wanting to use oral chemotherapy are the primary veterinarians who offer such treatments rather than the standard of care injectable protocols because doing so requires no specific equipment or training in its administration. Injectable chemotherapy drugs pose health hazard risks to staff members if not properly drawn up in a biosafety cabinet and without wearing appropriate personal protective equipment and using a closed contained system. The physical act of injecting chemotherapy drugs requires advanced technical skills and experience. These fundamentals may not be present in a general veterinary hospital.

If a veterinarian discusses an oral chemotherapy plan, it should not be done under the guise of it being easier, less toxic, or less invasive. Especially if that veterinarian lacks the necessary training or equipment to successfully administer injectable drugs. A drug that is ‘easier’ to prescribe is not an appropriate substitute for a proven intravenous option for a particular diagnosis.

While I can comprehend why the idea of treating your pet’s cancer with a pill would, on the surface, seem like a simpler and less formidable solution, owner’s must be aware of the potential limitations and drawbacks to such a treatment plan. Consultation with a veterinary oncologist would be the most effective way to understand the available options and potential risks. To locate a veterinary oncologist near you, please visit www.acvim.org

Is a cure for FIP on the horizon?

Feline infectious peritonitis (FIP) is caused by a mutated version of a feline coronavirus that transforms from a benign, minimally pathogenic virus to an aggressive and deadly version. Feline infectious peritonitis (FIP) is a devastating diagnosis for a cat owner as the disease is considered 100% fatal.

FIP is considered an incurable disease and the mainstay of treatment has focused on providing comfort and supportive care to affected patients. Since FIP is a deadly disease, there have been many efforts to develop effective treatments for it, with disappointing results.

However, progress is being made in developing new therapeutic options for FIP in cats. Researchers at Kansas State University devised a new antiviral treatment, which led to full recovery in cats experimentally infected with FIP who were treated at a stage of disease that would otherwise be fatal.

The antiviral treatment works by blocking the replication of the virus, a process required for it to survive within an infected cat. Six out of eight cats treated with the antiviral had resolution of fever, ascites, and low white blood cell counts, and returned to normal health within 20 days or less of treatment.

More on the experimental treatment below, but first, a primer on FIP.

Clinical Signs of FIP

Cats with FIP show non-specific signs of illness, including lethargy, inappetance, and weight loss. They may present with persistent fever and owners can notice abdominal distension or difficulty breathing in cases where fluid build-up within body cavities (effusion) is present.

There are two clinical forms of FIP recognized in cats: the “dry form” (noneffusive) and the “wet form” (effusive). In the dry form of the disease, cats develop mass-like lesions within their abdominal and chest cavities called granulomas. In the wet form of the disease, cats show fluid buildup in these same anatomical regions. There can be overlap between the two forms; cats with the effusive form often can have microgranulomas present and cats with the dry form can develop effusion.

Diagnosing FIP

Diagnosing FIP is difficult, and your veterinarian will likely recommend several tests to determine what is causing your cat’s signs.

Radiographs (x-rays) can help determine if fluid is present within the abdominal or chest cavities. An ultrasound can show enlarged lymph nodes or granulomas within the abdomen and confirm the presence of fluid. Bloodwork may be normal, but one of the most consistent findings is an elevation of a specific protein called globulin.

There is a blood test that measures whether or not a cat has circulating antibodies to the feline coronavirus, but this test is considered of limited utility. Most cats with circulating antibodies never develop FIP. High amounts of antibody make FIP a likely diagnosis, but 10% of cats with FIP will not have circulating antibodies in their bloodstream.

If effusion is present, analysis of this fluid will show a high protein level along with a relatively low cell count. In cats with nervous system involvement (e.g., brain and/or spinal cord), MRI or CT of the brain can show changes including hydrocephalus, which is a build-up of fluid in the brain. Analysis of the pet’s cerebrospinal fluid (CSF) will show high protein and cell counts.

The most reliable test for FIP is detecting the feline coronavirus antigen within white blood cells of the affected patient by special stains.

Treating FIP Experimentally

As I mentioned at the beginning, FIP is considered incurable, with treatment consisting mainly of providing comfort and supportive care. For cats in respiratory distress from fluid buildup around the lungs or within the abdomen, removing the effusion and providing oxygen support can aid in immediate relief.

Though the experimental antiviral treatment at Kansas State University seems promising, there is concern that the coronavirus that causes FIP could acquire further mutations, rendering it resistant to antiviral treatments such as the one developed at Kansas State University. In addition, this form of treatment was only studied in cats with the effusive form of the disease; its efficacy in cats with the dry form is unknown. It is also unknown whether the antiviral will be successful in treating cats naturally infected with FIP as all of the cats in the study were infected experimentally.

Polyprenyl Immunostimulant (PI) is an investigational biologic used to lessen clinical signs associated with herpes virus infections in cats by promoting immune responses to the virus. PI also has been used to treat FIP. In a small study, three cats with the dry form of FIP were treated with PI. Two cats were alive and still receiving treatment two years following diagnosis. The remaining cat was treated for only 4.5 months and lived a total of 14 months. A larger study was done in 58 cats with the dry form of FIP. Five percent of those cats lived longer than one year and 22 percent lived at least 5.5 months.

Though PI might seem like the magic bullet for treating the dry form of FIP, there are a few caveats to consider. In the smaller study, the amount of disease present in all three cats was minimal; two had no clinical signs at their time of diagnosis. In the larger study, cats who were very ill or died within a week of starting treatment with PI were excluded from the survival analysis, likely skewing results.

As some cats with no or minimal signs of disease and localized lesions can spontaneously recover from FIP without treatment, the role of PI in aiding the convalescence in these marginally affected cats is unclear. PI is also completely ineffective in treating cats with the effusive form of FIP.

Though these new treatment options seem promising, further research is necessary to determine how successful they will be for cats affected with FIP.

FIP Prevention

Controversy exists concerning the efficacy of an intranasal vaccine to prevent infection with FIP. The vaccine it is not thought to be effective in preventing disease in cats previously exposed to feline coronavirus, but it may induce some level of protection for a cat that has never been exposed to the virus.

Do we “replace” our pets when they pass?

Many owners look to purchase or adopt a new pet following the loss of a prior companion. I’m frequently consulted as to my opinion the best time to consider bringing another dog or cat into the household. Should they do so prior to the death of their beloved friend, or wait until after they have passed? My answers are a bit feeble, as I’m not the authority for making educated guesses about what works best for the dynamics of their particular family situation.

 

Many owners will send pictures or updates on their new additions- I’m always thrilled to be included, especially when we’re talking fuzzy puppies and squishy kittens. It’s an honor to be a part of meeting new family members and a nice way to close the circle of loss. However, I’m always a bit startled when owners quickly get another pet following the loss of a longtime companion.

 

I know there’s no statue to place on mourning, and I’d never suggest they are truly replacing their lost pet with another animal. But there are many instances where the time between death of one pet and the addition of a new friend is often a few short days or weeks. It has me considering the fragile and fluid nature of the bonds we form as humans.

 

I stand before you guilty as charged – I’ve had the unfortunate experience of losing my first cat at only 4 years of age. I never was a cat person until meeting this my Cosmo, an outgoing and confident 6-week old stray kitten who happened upon a family member’s back porch. Though I’d worked in the veterinary field for some time, and had cats as pets growing up, I never considered them particularly compassionate creatures.

 

Cosmo was more dog-like in nature, and it was his gregarious personality and quirky antics that sold my soul to the crazy cat-lady side of life. Whether it was how he played fetch with his toys, or raced to greet me at the door when I returned, I learned cats could be equally (if not more so) faithful and loving as a dog.

 

When Cosmo passed from feline leukemia, I was devastated by his death, and exceptionally lonely without his ever cheerful presence. I wasn’t looking for another pet, but the absence of his companionship and silly behaviors weighed heavily on my heart. When a stray kitten quite literally fell into my hands a mere 6 weeks after his death, I took him in with barely a second thought.

 

Bailey was a scrawny and fluffy long haired tabby cat who grew into the most handsome feline I’d ever seen. I’m not just bragging or being “that” pet parent – he actually won “Best Looking Cat” at the Feline Follies during vet school. Bailey’s most impressive feature was his sheer size, tipping the scale 23 pounds in adulthood.

 

Bailey was affectionate and outgoing, similar to Cosmo, but different in many ways. He was guaranteed to offer a “Meow” for every time I sneezed and would travel contentedly in my car sans carrier, sleeping quietly in his own car seat.

 

Unfortunately, his great size predisposed him to a myriad of health issues, including cardiac problems. Bailey died suddenly, also at 4 years of age, during the most stressful time of my internship.

 

Once again I was pushed into the shallow depths of sadness and loneliness that comes from the loss of a pet. I hadn’t planned on getting another cat as I was set to move back to upstate New York in 2 months’ time to start my residency in medical oncology.

 

A stranger dropped two pet carriers off at the clinic one evening, packed full of cats of varying ages, genders, and colors. In the midst was a teeny gray tabby kitten who purred when he was held and ate like it was his job. The decision was made to bring all the cats to a local shelter as our hospital was not equipped to handle strays. I took the kitten in under the guise of helping out an animal in need, when actually I was filling the void created by my cat’s death.

 

Nadir was visually essentially short haired version of Bailey, but once past the coat color, there was nothing similar about the two. Nadir was the coolest cat. Ever. Nothing bothered that guy and he had no enemies. Well, maybe the vacuum.

 

Following his tenuous start on life in a cramped carrier, Nadir settled into my apartment as first a “foster” kitten, who stuck around forever. He moved with me from Long Island to Ithaca to Rochester, NY to Rockville, MD. He took it all in stride. As long as there was a full food bowl and a sun patch to sleep in, he didn’t care about geography.

 

Ironically, Nadir also succumbed to a heart problem at the tender age of 9. The difference between this devastating loss and the prior ones was this time was I had adopted another kitten a year after Nadir came into my life. I’d also gotten married and adopted my husband’s cat into our household. When Nadir passed, I wasn’t alone. The crushing sadness was somewhat mitigated by my other pets.

 

I’ve half-jokingly told my husband how sure I was he would replace me within 6 months should I experience an untimely death. He laughs and tells me I’m crazy, but am I really so off base to think loneliness and depression are not the major accelerants for such actions? Does our action to replace animals mirror what would happen in life with our loved ones?

 

The void created by the passing of a pet is obviously different from that created by the loss of a person. Different doesn’t imply an attempt to quantify pain – I’m not here to comment on whether there’s more or less grief under the different circumstances. But there is grief for sure, and the loss can be mitigated with the addition of another pet.

 

It’s human nature to seek to comfort when grieving. And interesting to see the roles pets play in keeping us soothed. Even when their loss is the impetus for our sadness, we are able to find sanctuary in the companionship these future animals so freely and unquestionably provide.

When you can’t make up your mind…

During nearly every consultation, there comes a time where pet owners must make the decision whether to pursue chemotherapy or not. While a small number of people arrive assured that they will treat their pets, more frequently owners arrive with an open mind to the available options, searching for all possible choices before moving forward.

On rare occasions, at the onset of an appointment, an owner will inform me they have no intention of ever pursuing chemotherapy. I’m marginally astonished when faced with such assuredness, given I’m a veterinary oncologist and treating cancer is what I do for a living. With time, I’ve come to appreciate such an owner’s motivation for simply seeking my advice without intention to follow it.

Somewhere in the middle lie owners who initially decline therapy, but later change their minds and elect treatment.

Personal Experience Influences Decision

Most animals with cancer are diagnosed at relatively asymptomatic stages of disease. Owners are typically shocked if I tell them their otherwise happy and healthy dog or cat might only be expected to live a few weeks or months following a diagnosis of an aggressive cancer such as lymphoma or high-grade mast cell disease. Convincing that owner to pursue treatment is a challenge, until the pet’s health declines and the owner feels urgency to move forward out of desperation.

More often, owners digest the information I present to them and reverse their initial decision to not treat after learning the facts about chemotherapy. Their prior misconceptions may stem from personal experience with chemotherapy, or from observations of close friends or family members. Even an owner’s primary veterinarian can discourage meeting with an oncologist by perpetuating myths about cancer care in animals.
Of all the misunderstandings related to chemotherapy preventing owners from pursuing treatment, the biggest hurdle I face is communication with owners who are certain chemotherapy is guaranteed to make their pet sick.

Chemotherapy Side Effects and Quality of Life

The goal of veterinary oncology is to preserve quality of life for as long as possible while minimizing potential deleterious effects. Approximately 25% of all animals receiving chemotherapy will experience self-limiting side effects from chemotherapy. This generally entails mild gastrointestinal upset and/or lethargy that occurs during the first several days following treatment, and they only last for a day or so.

Adverse signs can usually be controlled using over the counter or prescription medications. Roughly 5% of chemotherapy patients will have severe side effects that require hospitalization. With appropriate management, the risk of these side effects causing the death is less than 1%.

If a patient experiences serious side effects, the prescribing oncologist will reduce future doses of chemotherapy to avoid similar complications in the future. Additionally, to help reduce the risk of complications in sick pets, every precaution is made to ensure they are strong enough to undergo treatment prior to instituting therapy.

The quality of life for animals receiving chemotherapy is excellent. Multiple studies indicate that the majority of owners are happy with their choice to pursue treatment for their companions and their outcomes and would elect to pursue treatment again if necessary.

Placing Your Trust in Medicine

For those owners who initially decline treatment, but then move ahead, experience tells me they would feel no different from those owners committed from the onset of diagnosis.

If you’re facing a diagnosis of cancer in your pet, you do not need to be absolutely positive you want to pursue treatment prior to speaking with an oncologist about your options. If you’re concerned chemotherapy will be “torture” for your animal, I can assure you this is untrue. No veterinary oncologist endures the rigors associated with their training and credentialing with the goal of imparting pain and suffering on their patients.

Veterinary oncologists are here to make your pet feel better from their disease and to know the appropriate and least impacting treatment for their situation. We’re not here to convince you to treat with chemotherapy. We’re here to provide the facts and allow you to consider what is most appropriate for your companion.

Even if it takes a little time for you to reach your decision, your oncologist will be there for you and your pet during your time of need.