I’m an assistant professor of medical oncology at North Carolina State University and Certified Veterinary Journalist.
I’m here to share information about veterinary oncology and dispel myths about cancer care for pets!
While I love all animals, I’m known for being partial to cats. This wasn’t always the case – in fact, prior to having a cat, I really never understood their appeal. I questioned the redeeming value of owning something so aloof and independent. Dogs, with their unconditional love and constant want to please, were my preferred pet of choice.
Everything changed when my brother’s in laws asked me to take in an unusually social kitten that lived under the deck in their yard along with his feral mama and equally unfriendly littermates. I was a graduate student, devoid of any real responsibilities, on a meandering path towards becoming a veterinarian, and therefore the logical choice out of all the family members to adopt the kitten. I named him Cosmo, after the irrevocably laughable and notoriously clumsy character on the TV sitcom Seinfeld. Despite his tiny stature, Cosmo had tremendous personality, behaving more dog-like than I’d ever expect from a feline. I learned how to love cats because of, and sometimes in spite of, him.
Cosmo was a part of my life for only four years. He passed from complications related to infection with the feline leukemia virus. I was devastated and lonely without him. I’d grown accustomed to finding the tiny toy mice he would leave as a gift in my shoes, or his fervent greetings when I arrived home after class. I missed his kneading paws and throaty purr as we both drifted off to sleep. I tried living without a cat, but my home felt bizarrely empty. I was a veterinary student at the time, with the typical fortune of being surrounded by an abundance of animals needing homes, and it wasn’t long before I found another kitten to raise. Fast forward several years, numerous geographical locations, and one marriage later, and the number of cats I owned rose to five. Yes, five cats in one house. That was, until about two weeks ago.
Sepsis, or Sepsie as I called her, came to me during the first year of my medical oncology residency. She was my “first second cat”. The one that taught me bringing another pet into your household causes you to multiply your love rather than divide it. We were introduced during her brief stay in the SPCA wards of the teaching hospital. She was estimated to be about five months old and had a rocky start to her life, having been taken from a hoarder’s household. She was there as part of the student spay/neuter program and scheduled for surgery the day after I met her.
I visited the SPCA wards frequently, as a means to diffuse some of the stress of my training. Petting and snuggling up with stray cats and kittens was my form of meditation. I’d been considering adopting another cat for some time but wasn’t quite ready to open my home to another pet, already harboring guilt about not devoting enough time to my current animals; a fat young tabby and geriatric dachshund.
Of the many cats I came across in the ward, I couldn’t tell you a specific reason why Sepsie was the right one for me. Perhaps it was how she purred incessantly, even immediately after her spay surgery. Or it was her petite features, or that she was such a pretty cat, or simply fate that brought her to me at the perfect time. I just knew she needed to be a part of my family, and vice versa.
Sepsie was a mellow kitten, who preferred to snuggling and purring to practicing pouncing and clawing. She patiently endured my long work and study hours, eagerly waiting for me to return from the hospital or put down my research articles and spend time with her. She accepted my future husband when we started dating during my third year of training, willingly using his lap for a bed and sharing her love among the two of us equally. She did not, and would never, accept his cat, having become accustomed to her less crowded lifestyle outside of the hoarder’s home.
Sepsie moved with me six times. Some were short stints where we spent a few weeks in a temporary arrangement, while other were long-term residencies. She was there during the highlights of my life, including becoming board certified as a veterinary oncologist, starting my first “real” job, my engagement and wedding, and my move to North Carolina to take a faculty appointment at the veterinary school. Equally as important, she was with me during the darkest times including the loss of both of her original animal companions and several life choices and health issues that resulted in outcomes far less positive than I’d originally hoped for.
Perhaps it was our vagabond ways or her perpetual youthful behavior that confused me as to the length of time I had her. In the early years, whenever asked how old she was, I stumbled and had to count upwards from the year I adopted her. Later on, I’d always says she was about 9 or 10 years old, even when I knew she’d been with me much longer.
One morning this past February, while readying myself for work, I found Sepsie curled up asleep on the corner of my bed. This was abnormal as she’d usually be bouncing around the house, enthusiastically asking for food. I went over and pet her and she woke up and purred and I figured, perhaps she’s just getting older and needs a little more time to get going in the morning. I left for work and didn’t give her behavior much thought. When I returned, late that evening, she was not waiting for me at the door. This, along with the unusual lethargy earlier that morning, caused concern for something more serious. I frantically searched the house and found her, closed eyed and scrunched up in the corner of my closet. When I attempted to pick her up and bring her out, she growled.
I’ve always said cats are not creative in pronouncing signs of illness. Typically, regardless of the underlying cause, they will stop eating, hide in areas they would normally not be found, and potentially show other signs such as weight loss, vomiting, or diarrhea. Knowing this, I did a brief exam and when I palpated her belly, I felt a mass effect towards the mid-portion of her abdomen. I wasn’t sure if it was truly a mass, or potentially something stuck in her digestive tract. She was definitely the kind of cat to eat things she shouldn’t and I’d remembered that earlier in the week I’d lost a hair tie.
My husband and I debated the pros and cons of bringing her back to his hospital to further investigate the cause of her signs. Despite the late hour and both of us having a full schedule at work the following day and me being 33 weeks pregnant, we knew the only option was to try to get some answers as quickly as possible.
We considered hypothetical algorithms on the drive to the hospital:
If it looked like a foreign body, would my husband do surgery that evening or the following day?
If it looked like a tumor, we would consider aspirates and submitting slides to the clinical pathologists at my teaching hospital?
If it was something terrible would we do everything or nothing?
How would we know what the right choice would be?
We continued the “if/then” conversation over the miles, and I tried focusing on how we could figure out what was wrong and what I thought would be the “right” thing to do.
When we arrived at the hospital, we performed lab work and radiographs and a brief ultrasound. Results showed no clear evidence of an intestinal obstruction, a possible mass in her intestines or enlarged lymph nodes, an abnormal appearance to her liver, elevated liver values, and anemia. The signs pointed towards a diagnosis of cancer, but we couldn’t know for sure. It was late and we were forced to leave with little answers but kept a plan to have aspirates done the following day.
Unfortunately, as can frequently happen, the aspirates returned inconclusive as to a cause of her signs. Our options were to take her to surgery for biopsies or to not put her through additional tests and keep her as comfortable as possible. During the 48 hours we considered our choices, Sepsie’s behavior returned to complete normalcy.
Many times, as a veterinary oncologist, I’d listened to pet owners debate the same options we’d considered in some form or another. Whether they were facing a known cancer diagnosis, or a suspected one, I’d witnessed their struggle between wanting to know and do more for their pet and ensuring their best interests are met. I’d always felt I connected with their intentions but it wasn’t until I was placed in the exact same scenario myself that I truly could understand how difficult it was.
Sepsie was a cat who did not travel well and would be excessively stressed if asked to undergo multiple medical procedures and treatments. She despised any physical manipulation that wasn’t done on her own terms. She was older and whatever was causing her signs was likely serious and only potentially manageable but would not be curable. The other cats had clearly noted the changes and had begun chasing her around and cornering her in areas where she could not escape.
Given these limitations, we ultimately chose to do nothing further, and to enjoy the time we had left. Our goal was to limit her to as few bad days as possible.
In the ensuing weeks, while my husband and I hovered over Sepsie, searching for signs of pain or illness, she continued enjoy life as she usually did. Potentially feeding off of our anxiety, she grew clingier and more food motivated than ever before. We would joke about how annoying she was, behaving more like a dog than a cat when it came to begging for treats or stealing food off our plates. She’d dig scraps out of the sink and eagerly awaited her special treat of canned food every morning.
We repeated an ultrasound and lab work after about a month to monitor her progression. Miraculously, the mass effect had resolved, but her liver still appeared abnormal and her liver enzymes had worsened, as did her anemia and she now had a low platelet count. She still seemed happy and we stuck to our decision to not pursue any aggressive measures. The only sign she showed was persistent weight loss, which prompted us starting her on an oral steroid as a palliative measure. This seemed to do the trick, not only further increasing her appetite, but also seemed to have stopped her weight loss.
For the duration of her illness, we achieved our goal, as Sepsie truly had no bad days. Until she had a terrible night. I was up with our newborn, when I heard her start vomiting. I considered leaving cleaning up after her until the morning, but figured since I was up already, I may as well just do it at that time. I was surprised to find a large amount of foul-smelling liquid that left the slightest pink tinge on the paper towels I used to wipe it up. Just as I returned to bed, Sepsie began vocalizing in the strange way cats do when they are extremely sick. I found her hiding in the corner of our bathroom, too weak to stand. She passed large amounts of diarrhea and began showing abnormal neurological signs. This all came on without warning, as just hours earlier she was begging for food while I ate my dinner.
Once again, my husband and I measured our options. Of course, we wanted to know why she had this sudden change in status and if there was anything we could do to help her. But overall, we faced the same considerations we’d had four months prior. We knew the right choice for her was to end her suffering, and to be grateful she had the amount of good time she did. We made the difficult decision to euthanize her just a few hours after she became sick.
Sepsie, I will miss you greeting me when I come home and your uncanny ability to know whether I’d entered through the front or back door. I keep looking to chase you off the kitchen countertops or away from my plate of food. I will miss your constant purring and watching you snuggle up with my husband at the end of a long day. I hope you’re sleeping deeply on a balcony in heaven, where you chase bugs, eat people food, and never have to have your nails trimmed. I hope you’ve found Nadir and Schnitzie and that the three of you are happy together again.
Thanks for being the best girl you could be to me. I’ll think of you always.
My goal for this website is to provide pet owners with factual information regarding the diagnosis and treatment of cancer in pets and to delve into the complicated emotional aspects surrounding cancer care in animals. While this will always be my main focus, I wanted to revisit the basics of veterinary specialty care and help owners understand the role of a board-certified veterinary oncologist in their pet’s care. Most people appreciate what a veterinarian does, regardless of whether or not they own animals. The differences between the role of a general veterinarian and a veterinary specialist are less clear.
HOW TO BECOME A VETERINARIAN
In the US, most people earn their veterinary degree following completion of a Bachelor’s degree. Their major can be in any field, but there are specific pre-requisites for veterinary schools including biology, chemistry, biochemistry, physics, mathematics, and writing courses among many others. These are minimum requirements, and applicants frequently have advanced degrees including Master’s or Doctorate level accolades following their name. Admission is competitive, and candidates possess intensely successful academic and co-curricular records.
Veterinary school is four years duration. During that time, student learn the fundamentals of anatomy, physiology, as well as pathophysiology of disease as it relates to form and function of several major specials of animals. Upon graduation, and a passing score on a national licensing exam, newly minted veterinarians can enter into a variety of different working eenvironments.
Graduates most frequently enter small animal general practice. This equates to the veterinarian you’re probably most familiar with when you think of the profession. General veterinarians regularly treat common (and uncommon) medical and surgical conditions of dogs and cats. On a typical day, they consult with owners on general wellness and preventative care, behavior issues, and disorders affecting numerous body systems. They interpret x-rays, perform dental cleanings, prescribe medications, and discuss nutrition. The breadth of their knowledge is vast, and the expectations from owners are high. General veterinarians are comparable to primary care physicians; however, this is an oversimplification of the role they play in animal health. In truth, they are part internist, surgeon, radiologist, dentist, nutritionist, and psychologist (among others.)
WHAT IS A VETERINARY SPECIALIST?
While general veterinarians excel at many angles of veterinary medicine, there are times where more in-depth, specified care is necessary to achieve a diagnosis and/or impart a treatment plan. That is where veterinary specialists play a role in the care of complicated medical and surgical case. It’s akin to the treatment you would expect for yourself should your primary doctor refer you for more specialized care.
Veterinary specialists are veterinarians who have undertaken further training beyond their initial degree. For veterinary oncologists, this means they’ve completed at least one year in an internship in general medicine and surgery and emergency care, followed by a minimum of three years in a residency program focused solely on managing complex cancer cases. Many have also completed 1-2 additional years of specialty internship training in oncology and clinical trial design. During a typical busy internship and residency program, a candidate typically sees between 25-35 cases per week, affording them exposure to a huge variety of complex and routine cancer cases. This is far greater than then number they would see during a career working as a general practitioner. This intensive exposure provides them with accelerated experience diagnosing and treating complex cancer cases and provides a solid foundation for their future career.
To achieve board-certification there are several additional achievements candidates must accomplish beyond enduring their residency program. There are two rigorous examinations: one following the second year of residency training that focuses on general physiology and pathophysiology, and one following the third year that comprehensively tests all aspects of veterinary oncology, including principles of medical, radiation, and surgical cancer care. An additional component of this exam includes a working knowledge of several years’ worth of research studies published in the same fields. In addition to passing scores on both exams, before obtaining board-certification, prospective oncologists must publish at least one original research project in a peer reviewed medical journal.
HOW DO I KNOW IF I NEED A VETERINARY ONCOLOGIST?
Most veterinary oncologists operate on a referral basis, and some may require referral from a primary care veterinarian before agreeing to see a pet. Others will take self-referred cases; a common scenario for owners who may not be presented with the option of specialty care, but discover the opportunity on their own. In most cases, there’s a working partnership between the specialist and general veterinarian and there is a triad of care between the pet owner, the primary veterinarian, and the specialist. However, there are instances where poor communication on one or both side leads to a breakdown in care.
From a specialist’s perspective, the most common negative outcome from the primary care side occurs when veterinarians do not offer referral out of presumption of an owner’s financial capabilities or because of an inaccurate knowledge of treatment options and prognosis. Conversely, the most common complaint I’ve had from referring veterinarians is a lack of disclosure and follow-up following referral, a particularly frustrating scenario for veterinarians who have been part of a pet’s care for many years.
Some pet owners fear seeking a veterinary oncologist is akin to signing on to a treatment plan, and an expensive one at that. While it’s true some aspects of specialty care can be costly, scheduling an appointment is a simple step towards discovering what options are available. Your veterinary oncologist will work with you to devise a treatment plan that works with your goals for your pet, and ensure it works within your budget. They often work in conjunction with your primary care veterinarian to provide the optimal level of care for your pet.
WHERE CAN I FIND A VETERINARY ONCOLOGIST?
If your pet is diagnosed with cancer, and your able to consider referral to a veterinary specialist, I urge you to discuss this option with your primary care veterinarian. You can also find a board certified veterinary oncologist near you by searching www.acvim.org. Veterinary specialty care.
Learning that your pet has cancer is devastating. Deciding on which, if any, treatment path to take is confusing and it is normal to feel anxious as you are making decisions for your pet. Owners frequently struggle with feeling a lack of control and search for options to enhance their pet’s prognosis during their treatment plan. While most of these choices are not harmful, sometimes an owner’s best intentions can unknowingly offset their pet’s progress. The following are suggestions of what to consider avoiding during cancer treatment to optimize your pet’s care.
Avoid starting your pet on any supplements or medications before talking to your primary veterinarian and/or veterinary oncologist.
You might be tempted to start your pet on supplements, vitamins, or other medications as part of a regimen to aid in their body’s defenses against cancer and to support them through their treatments. Most supplements do not undergo regulation regarding content. These products, which may be touted as “natural,” could negatively interact with your pet’s prescribed medications, reducing the benefit of chemotherapy and harming your pet’s system.
Owners are often surprised to learn that some of the chemotherapy drugs we administer come from plants and are therefore also classified as natural substances. The effects of interactions between different natural substances, such as with conventional medicine and alternative medicine/supplements, are unpredictable at best. Veterinarians who cannot guarantee that mixing the two would not lead to treatment failure or harm will honestly explain their concerns and advise you on how to proceed.
See Dietary Supplements and Cancer Treatment: A Risky Mixture to learn more about potential negative interactions between supplements and chemotherapy.
Don’t overfeed your pet.
Some pets with cancer, especially cats, will show signs of a poor appetite during treatment. This occurs because of the disease process itself and in response to the prescribed treatments. In those cases, veterinarians frequently lift the typical dietary restrictions placed on companion animals and permit owners to offer a wider variety of foods, including typically prohibited menu items such as fast food or other kinds of “people” food. But for pets whose normal appetites are not being affected by treatment, overfeeding them and/or routinely offering food items the pet would not normally ingest can cause gastrointestinal upset, which may mimic adverse signs from treatment, leading to confusion about how best to proceed. In addition, pets can easily become overweight even with minimal overfeeding, which can exacerbate previous orthopedic disease and lead to concurrent health problems, including cardiorespiratory disease and pain, resulting in a reduction in the pet’s quality of life.
While it’s understandable to want to keep your pet happy during this difficult time, it’s better to shower your pet with attention and toys and activity and not to overdo it with calorie-rich “comfort” foods.
Don’t be a loner.
You may encounter individuals who question your decision to treat your pet’s cancer, arguing that you’re being selfish or traumatizing your animals. Personally, I’ve been told countless times that treating pets with cancer is the equivalent of “torturing” them. Such harsh judgment can be isolating, making you second-guess your choices and intentions. Please find reassurance in knowing that there are thousands of owners who choose to treat their pets, just as you are, and these individuals can be your best resources for information and as sounding boards for you to express your concerns, questions, and frustrations.
Many owners of pets that have undergone cancer treatment are happy to provide insight and advice to owners considering their options. This may be in person or via the Internet. For example, Tripawds is an online community of owners of pets with three (or fewer!) limbs that is an excellent resource for owners considering limb amputation for bone tumors.
Skip the dog park (but only at the specific times outlined by your veterinary oncologist).
Pets receiving chemotherapy can experience temporary drops in their white blood cell counts at specified times following their treatment. During these periods where the immune system is being compromised, animals are more susceptible to infection. While the overall risk of illness is low, there will likely be times you should avoid situations where your pet might encounter new pathogens. This may mean occasionally missing a trip to the dog park or groomer, or keeping your typically outdoor cat indoors for a short period of time. In addition, reducing stress levels to a minimum during periods where your pet may have lowered immune defenses is of utmost importance. This means limiting house guests (two or four-legged) if your pet is the kind to become anxious in such situations, avoiding boarding your pet if you decide to travel (get a pet sitter to stay at your home instead), or taking your pet with you rather than leaving them alone if they have a tendency toward separation anxiety.
While such physical challenges may seem to cause significant negative impacts in your pet’s quality of life, the important consideration is that this change is truly temporary and will only be for a few days following certain medical treatments your pet receives.
Don’t be afraid to ask your vet questions.
You will likely have dozens of questions about your pet’s condition and treatment plan and it’s important to have those questions or concerns addressed as quickly and efficiently as possible. You probably won’t think of all of them right away, so writing them down as they occur to you is important.
While the internet is a valuable resource, internet writers do not know your pet personally. Your veterinarian and/or veterinary oncologist will be the most appropriate resource for your concerns. You should never feel that any question is insignificant, and if you are feeling that you or your pet’s needs are not being met, voice your concerns. This empowers you to make the best decisions about your pet’s care and to feel confident in the plan.
Some questions to consider:
- What is the exact type of cancer my pet has and where in his/her body is it found?
- What signs should I look for that could indicate disease progression?
- How will I know if my pet is having a reaction to treatment?
- What can I do at home to help my pet through treatment and what are the “triggers” I should use to know when I need to call my veterinarian?
- What is the expected cost of treatment and further testing?
Let’s talk gratitude.
The holidays are the time of the year when we’re supposed to focus on being grateful. It’s nearly an obligation. We give thanks for all the things we take for granted at all the other times. We’re thankful for our friends and family. For our health and happiness. We pause to connect to a different portion of inner selves and remember how blessed we truly are.
In reality, the holidays are probably the busiest and most stressful times for most of us. Whether it’s struggling to knock off a ridiculously long gift list, or planning how to travel to see the same family members we’re obligated to be taking the time to be appreciative of, or even if it’s just working full time and trying to maintain a semblance of treading above water and being a good employee and a good person. It’s overwhelming, to say the least.
I’ve never had trouble recognizing gratitude for the big picture things in my life. Despite the heartaches, I had a privileged childhood where education and achievement were drilled into my very being. I’m thankful to graduate from veterinary school and complete a residency training in my area of specialty. I’m thankful for my family and my husband and my friends (though I’ve moved so many times, I’ve lost touch with so many people over the years – not an intentional aspect of my life at all.) I’m happy I finally have a job I love and to be living in an area where I truly and finally see myself building a life. I could continue this list indefinitely. However, that’s not what’s prompting me to write today.
I’m feeling a compulsion to take time to acknowledge the little “happys” I seem to forget to pay much attention to on a daily basis. And what that translates to, is missing out these aspects of my life for weeks, to months, to eventually years on end. It has really hit me today that someone out wishes they could have all the things I take for granted. And that’s making me unhappy on the eve of the day I’m supposed to be most appreciative.
My tendency is to propel myself towards each “next best thing” once I’m able to check off a big-ticket from my life list of “things to do”. While not necessarily a bad trait, it doesn’t leave much for the in between time. I’m constantly concerned with the next goal or task – always looking ahead on the calendar and feeling consistently behind where I should be. It also means I’m disappointed. A lot. Because how often do I truly accomplish those big-ticket things? I fail to achieve the lofty goals I set far more often than I succeed. In the meantime, I tend to forget all the “goodies” that make it work waking up each day.
So today, I’ll choose to be thankful for those little things. I’m thankful for a sunny day that’s over 60 degrees. I’m happy to know I have a few days off work where I’ll be able to spend time just being me. I’m happy to have a working body that carries me to all the places I want to go. I haven’t had a good hair day in a long time, but the next time it happens, I’ll be sure to spend a bit more time dwelling on it. I’m not sure it will make a difference, but I’m willing to take a chance and see if spending time on the small things make the bigger things sweeter. Worst-case scenario, I’ll exponentially increase my mindfulness. Best-case scenario – we will have to see!
So are you in with me? Can you rejoice in finding that ten-dollar bill tucked in your coat pocket you forgot about from last winter? Will you spare a minute to take in the changing colors of the leaves? If you’re stuck in rush hour traffic and your favorite song comes on the radio, will you think about smiling? What little thing can you do today, and each day, to force yourself to find gratitude in the routine portion of your life? Consider if my challenge to you this holiday season. I promise I’ll keep challenging myself right there with you.
The skin is the largest organ of a dog, and tumors affecting this structure are common. Between 60 to 80 percent of skin tumors in dogs are benign, meaning if you notice a lump on your dog’s skin, there’s a good chance it won’t be anything to worry about. However, the visible appearance of a growth can’t be used to predict whether it’s cancerous. Therefore, any new lump or bump you detect on your dog’s skin should be evaluated by a veterinarian.
Many skin tumors can be cured with early surgical removal. If a growth is removed from your dog’s skin, it should be submitted for evaluation by a veterinary pathologist. This is the best way to determine if further treatment is necessary. The following is a list of the more common skin tumors seen in dogs, along with basic information about their behavior and recommended testing and treatment options.
Mast Cell Tumor
Mast cells are immune cells normally involved in allergic reactions. They contain packets of chemicals (called granules) that are released upon stimulation by an allergen. Mast cells are located throughout the body and dogs have a large proportion located within their skin. Mast cell tumors are found more frequently in Boxers, Boston Terriers, Labrador Retrievers, Golden Retrievers, Beagles, Pugs, Shar Peis, and Bulldogs.
A diagnosis of a mast cell tumor can usually be made via a fine needle aspirate. A small needle, the same size that’s used to draw a blood sample or give a vaccine, is introduced into the mass and a syringe is used to extract cells. These cells are distributed onto a slide and evaluated either by your veterinarian or submitted to a lab for analysis by a clinical pathologist.
Surgical removal is recommended for all confirmed mast cell tumors. A pathologist will review the sample and assign a “grade” to the tumor. The grade is the best predictor of whether follow-up testing and treatment is recommended. Low-grade tumors are usually cured with complete excision, whereas high-grade tumors are more likely to grow back and spread to distant sites in the body. In those cases, radiation therapy and chemotherapy are recommended to extend survival time.
Unlike people, most cutaneous (skin) melanoma tumors in dogs are benign. Melanoma occurs more frequently in dogs with dark pigmented skin. Cutaneous melanoma tumors are usually solitary and appear as small brown/black masses. They can also appear as large, flat, or wrinkled tumors. Fine needle aspirates can be done on such tumors; however, they are less likely to exfoliate (distribute into the syringe during aspiration), so the sample obtained in this manner might not be diagnostic. Most melanoma tumors are diagnosed after they are removed. Malignant (cancerous) melanoma occurs less frequently, but can be an aggressive disease. Distinguishing a benign melanoma from a malignant one is done via biopsy. Benign melanoma tumors are cured with surgery. Malignant melanoma tumors can spread to local lymph nodes and lungs and additional treatment with chemotherapy and/or immunotherapy for treating melanoma is recommended.
Squamous Cell Carcinoma
Squamous cell carcinoma is a rare form of skin cancer in dogs. Tumors are found more frequently in light-skinned, hairless, or sparsely haired portions of the skin. At-risk breeds include Dalmatians, Bull Terriers, and Beagles. Most squamous cell carcinomas of the skin appear as firm, raised, and often ulcerated plaques and nodules. Tumors can often grow outward into large masses and have a surface that resembles a wart. Squamous cell carcinoma occurs more frequently in Keeshonds, Standard Schnauzers, Basset Hounds, and Collies. Short-coated dogs who spend a long time outdoors also have a higher incidence of squamous cell carcinoma. Treatment includes surgery to remove the primary tumor. Incompletely excised tumors should be treated with radiation therapy to prevent regrowth. These tumors infrequently spread to local lymph nodes and the lungs. Some dogs develop multiple cutaneous squamous cell carcinoma tumors. These can be challenging cases to manage and may require medical treatment with either oral or topical drugs.
Tumors of the Skin Glands
Most glandular tissue tumors in dogs are benign (e.g. sebaceous hyperplasia or sebaceous adenoma). Malignant glandular tumors include sebaceous gland carcinomas, apocrine gland carcinomas, and eccrine carcinomas. Sometimes benign tumors can be recognized visually, but it is still best to remove any questionable mass and submit the tissue for biopsy. Most malignant glandular tumors can be treated with surgery alone. However, if the tumors are incompletely excised, radiation therapy is recommended to prevent recurrence. Dogs with malignant tumors should also be screened for any evidence of spread of disease via imaging tests (chest X-rays and regional lymph node aspirates).
Hair Follicle Tumors
Like glandular tumors, most hair follicle tumors are benign and cured with surgical removal, despite their intimidating assortment of names (e.g. keratinizing acanthoma, trichoblastoma, trichoepithelioma, pilomatricoma). Malignant hair follicle tumors include malignant trichoepithelioma and malignant pilomatricoma. Differentiating a benign tumor from a malignant tumor can only be done via biopsy.
While technically not a skin tumor, another common cancer that occurs in the superficial layers of the skin is epitheliotropic lymphoma. Lymphoma is a blood-borne cancer of lymphocytes, a type of white blood cell. Lymphocytes are found throughout the body, including the skin, where they offer protection against various pathogens that this organ can come into contact with. There are several forms of lymphoma in dogs, and epitheliotropic lymphoma is a specific variant diagnosed via biopsy of an affected region of skin. Treatment of choice is chemotherapy. The prognosis is usually guarded; however, dogs who are diagnosed earlier in the course of their signs and have not received previous treatment with steroids can do well long-term. Epitheliotropic lymphoma should be considered as a diagnosis in dogs with persistent and progressive skin lesions that do not resolve with typical treatment for more common skin issues (e.g. food allergies or skin infection).
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.
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
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.
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.
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?
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.
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.
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.
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.
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.
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.