When specialization becomes too specialized

The common cancers we see in companion animals (e.g. lymphoma and mast cell tumors) are what I affectionately refer to as the “bread and butter” of a veterinary oncologist’s therapeutic repertoire. There’s a wealth of available information about the ideal ways to treat those diseases and solid information regarding prognosis and outcome for the majority of cases.

Despite common things happening commonly, I’ve noticed a peculiar trend over the few years I’ve been practicing as an oncologist. It seems lately I tend to see less and less of those “straightforward” cases, and more and more unusual types of tumors.

Mast cell tumor cytology

mast cells from an aspirate of a mast cell tumor

One might assume this is a result of decreasing/increasing disease frequency, however, dogs and cats still develop the “usual” cancers as often as they did in previous years. So what is happening to my bread and butter cases?

It seems, for more of the “straightforward” cases, owners are electing to treat their pets with their primary care veterinarians rather than a specialist.

On the surface, several factors likely influence this trend including:

Geography: Though you may find several specialty hospitals within a relatively short radius of where I work, for many other regions this isn’t the case and access to specialists can be difficult. Lack of convenience is a major contributing factor to lower referral rates and lower compliance by owners.

Owner comfort: In many cases their primary veterinarian is someone they have trusted their pet’s care with since their puppy or kitten hood. Despite my advanced training and experience, their faith remains higher in their regular vet and if their doctor exudes confidence in the treatment plan, they won’t even consider referral.

Owner finances: The overhead for running a veterinary specialty service is far greater than a general veterinary office, and this is transmitted in pricing scheme. It’s never easy to talk money with owners, and I can’t really argue when an owner asks, “Won’t it be less expensive to have the treatments done by my vet?”

It’s difficult to translate to an owner that the increased price at my hospital covers so many hidden aspects of their pets care from the high cost of the specialized closed containment system we use to make sure our chemotherapy treatments are administered safely to the maintenance for the biosafety hood we use to draw up the drugs.

P1040111

Drawing up chemotherapy using a closed contained system in a biosafety hood

The higher price covers not only the salaries of the technical staff available 24/7 to treat their pet should a complication arise from treatment to making sure I can afford to attend continuing education seminars to stay current on the most advanced therapies available for their pet’s care.

Referring veterinarian finances: If a primary veterinarians is comfortable and confident managing common cancers ‘in house’, they tend not to refer patients to specialists as keeping cases closer to home maintains not only revenue, but a close relationship with the owners.

In some cases, owners may not even be aware that referral is an option because their primary care veterinarian doesn’t suggest it. A recent study showed (among other reasons) veterinarians were more likely to refer cancer cases when they had positive perceptions of 1) the pet’s health status, 2) the interaction between the client’s bond with the dog and 2) the client’s financial status. The study also showed about half of the primary care veterinarians did not even feel cancer was as worthwhile to treat as other chronic diseases. Those factors are extremely subjective and not things doctors should be deciding for owners.

The issue of not offering a referral to an oncologist isn’t limited to general veterinarians, but also can be a problem amongst non-oncology boarded specialists (e.g. internists, neurologists, surgeons, veterinary dentists, etc.) who routinely prescribe chemotherapy treatments for their patients. When one of “my own” fail to stress to owners the benefit of seeing me for even what would be considered a routine cancer case, it further contributes to the lack of valued perception of my profession.

A reasonable question to ask is does it make a difference if a pet is treated with a specialist versus their primary care veterinarian? Though I’m not aware of this question being asked directly for tumors treated solely with chemotherapy, an older study examined the outcome of cats undergoing surgery for presumed injection site sarcoma found the prognosis was significantly longer when surgery was performed by a veterinary surgeon versus a primary practitioner. I would venture a similar benefit would be seen in pets with cancer treated by an oncologist versus a general practitioner.

Ideally every pet that developed cancer would be afforded the chance to be treated by a specialist. The reality is, for the vast majority of pets this is not an option. When finances or geography are the main contributing factors, I can accept those as being out of our professional control.

However, if the issue is simply a lack of owner’s perception of the value of undergoing treatment with a specialist versus a primary veterinarian and we wish to pride ourselves with offering standard of care on par with our human counterparts, don’t we owe it to our patients and owners to discuss all options and empower them to make the best decision possible for their pet?

Close up

Wouldn’t you want the same care for your pet as you expect for yourself?

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3 thoughts on “When specialization becomes too specialized

  1. pam956 says:

    It is possible to work with your primary vet and vet oncologist for some cancers. I have been using this strategy while caring for my cat who has small cell gi lymphoma. They each have their particular strengths, opinions and levels of experience.

    Like

    • jintiledvm says:

      Absolutely – here you go:

      Vet Surg. 1997 Jul-Aug;26(4):265-9.
      Prognosis for presumed feline vaccine-associated sarcoma after excision: 61 cases (1986-1996).
      Hershey AE1, Sorenmo KU, Hendrick MJ, Shofer FS, Vail DM.

      Median TFR for tumors treated with excision performed at a referral institution (274 days) was significantly longer than that for tumors excised by a referring veterinarian (66 days).

      J Am Vet Med Assoc. 2013 Nov 15;243(10):1415-25. doi: 10.2460/javma.243.10.1415.
      Factors influencing veterinarian referral to oncology specialists for treatment of dogs with lymphoma and osteosarcoma in Ontario, Canada.
      Stoewen DL1, Coe JB, MacMartin C, Stone EA, Dewey CE.

      Like

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