Who really controls Cancer?

In cancer, cells undergo a series of mutations leading to immortality. Cell division occurs uncontrolled, leading to tumor growth. In it’s final stages, cancer spreads throughout the body, ultimately leading to death of the host.

 

This leads me to think of cancer as the ultimate betrayal by one’s own body. Little can be done to reverse changes once they start, and treatments are designed to eradicate the aberrant cells, while sparing the healthy ones. All of this speaks to a complete lack of control over the disease process itself.

 

The lack of control extends to what owners feel once faced with a diagnosis of cancer for their pets. Some owners will feel guilty, wondering if they caused their pets cancer because of the type of diet they fed them, or the vaccines they chose to administer, or blame flea and tick medicine. Many want to know what can be done (beyond the surgical, radiation, chemotherapy, or immunotherapy recommendations I make) to slow the cancer progression or reverse the disease process now that it has started.

 

Some owners search for aspects they can control to help their pet battle their cancer, strengthen their immune system, and aid them through their more conventional treatments. I find the main thing owner’s feel they can control during this process is their pet’s diet and nutrition. They are generally helpless from stopping progressing of disease and they can’t prevent side effects from treatments, but they can control what their pet ingests and they can tangibly monitor things like body weight and the proverbial “ins and outs” of their pet.

 

The problem is the lack of evidence based information to suggest changing diet and/or adding supplements or nutriceuticals will make a difference in outcome. The other problem is adding too many variables into the “mix” can result in unexpected side effects where we can’t say for certain it’s the cancer, the treatment, or the new diet/supplement/vitamin/etc. causing the signs. The last problem with some of the nutritional aspects of treating cancer is they may work against the more conventional treatments (e.g. anti-oxidants may counteract the mechanism of action of some chemotherapeutics and radiation therapy). When I discuss these aspects with owners, I realize I’m taking away some of their hope and certainly some of their feelings regarding being able to actively change the progression of disease for their pets.

 

As an oncologist, I also feel the frustration of not being able control cancer. My concerns are different from the average pet owner though – I don’t spend as much time worrying about what caused the cancer to happen, but rather what can I do now to control the cancer from growing, spreading, and ultimately making that dog or cat not feel well. I’m trying to stay one step ahead of a disease we barely understand, and are continually discovering new things about.

 

It seems the only one in the scenario not concerned with controlling the situation is the actual patient. Cats and dogs diagnosed with cancer have no concept of their disease. They know no difference between today and tomorrow or next week or next summer. They have no desire to control their disease, and cannot comprehend words like “metastases” or “median survival times.”
Veterinary cancer patients live in the moment – enjoying each minute for what it brings. In most cases that is joy and happiness. In some cases it is illness from disease or from the treatment. But there is never resentment or anger, or concern for what the future may bring. They don’t have interest in learning what caused their disease, and it is their lack of understanding about their condition that makes their battle so bittersweet.

 

I think about the emotional aspects of cancer care a great deal, and I see firsthand the unique aspects related to veterinary oncology and the differences we face as compared to our human counterparts. The more I consider it, the more I think we have a lot to learn from animals and their approach to health and disease.

 

Yes, it would be great to have better control over our health or to better regulate for risk factors, or once diagnosed with a devastating disease such as cancer, be able to maintain power over progression. But wouldn’t it also be a beautiful thing to still enjoy each moment of each day for exactly what it’s worth rather than dwell on those things we cannot change?

 

Once again, I think animals have the upper hand in how they deal with cancer. Time and again, I seem to consistently learn more from them than any textbook or research article. Though I’m still compelled to conquer disease, I feel the need to give consideration to relinquishing some of the control for the sake of simply enjoying the opportunity to help our patients and use their “philosophies” as examples. Not an easy task given the field I’ve chosen to pursue, but I have some pretty good role models to look towards for help.

 

 

 

 

 

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How to make the most of your appointment with a Veterinary Specialist

As a veterinary specialist, I rely on a steady stream of referrals to keep my schedule full and maintain an active caseload. Sometimes pets are referred by their primary veterinarian, or another specialist, and in other cases, owners refer themselves.

 

As soon as the appointment is booked, we begin requesting the animal’s medical records so they can be reviewed ahead of time. This includes all pertinent labwork, exam notes, radiology reports, medications, etc. This seemingly simple task often turns out to be one of the most challenging aspects of the job.

 

The more information I have available at the time of a consult, the more valuable the time will be for owners. Knowing more about the patient before they arrive allows me to plan things such as reserving ultrasound times with our radiologist, or preparing surgeons in case we need a consult, or even plan time in our schedule for a biopsy or other more intensive procedure.

 

Most owners expect “same day service” for our diagnostics, and this can be greatly facilitated by planning things based on the information obtained from the records. Otherwise, I’m left to navigate the possibilities without guidance, leading to further time delay, expense, and even disappointment from owners.

 

Often, the most important component of the pet’s record would be the cytology and/or biopsy report. This will contain information about the diagnosis to date and help me understand the nature of the pet’s cancer. However, if this is the only piece of information available, it’s impossible for me to make a thorough assessment of their condition.

 

In those cases, owners are surprised when I ask them basic questions such as “Where was the tumor located?”, or “How big was the tumor when it was removed?”, or “Did your primary veterinarian perform any bloodwork or radiographs?” Their standard answer is usually, “Well, isn’t in the record?”

 

They are typically stunned when I tell them, “No. The only thing I have is the biopsy report.” Imagine how complicated thing can be when more than one tumor was removed at the same time. Or when animals have been seen at more than one hospital. Even when I do have the actual exam notes, many times those exact details have never been recorded, so ultimately, I can’t make a correct assessment.

 

Every once in a while I will receive a biopsy report where the only reported information is the “bottom line” diagnosis, and no microscopic description of the tissue is included. Some pathology services offer this as an option for veterinarians, presumably at a reduced fee.

 

What owner’s do not realize is the information garnered from the actual explanation of what is seen is so valuable for making further diagnostic and treatment recommendations. I would urge owners to reconsider selecting the less expensive options, even when they initially feel they would not consider further care for their pet should a diagnosis of cancer be obtained.

 

When I don’t have the entire description available, I never hesitate to tell owners they should consider having a second read on the biopsy so we can obtain the missing information. This can obviously delay definitive treatment, but ultimately leads to choosing the correct option for that particular pet.

 

For every new case I see, I write a thorough discharge summary including the patient’s history, medications, physical exam findings, results of any diagnostic tests we perform that day, and a prognosis. It’s my practice to write the history portion of the discharge on the day prior to the actual appointment.

 

Writing the summary ahead of time helps me organize my thoughts about the case, and also ensures that we have all the important information in place before the pet actually steps inside the hospital. If I catch missing lab reports or discover that the pet may have been seen at a different hospital, we can try to obtain that information before they are seen.

 

There are two main issues I face as an oncologist when portions of a pet’s records are not present at the time of their consultation.

 

The first is that it’s very difficult to rely on owners to provide the necessary details necessary to complete the picture. Most people do not possess the medical background required to understand their pet’s condition, so it’s unfair to expect them to know the exact details of specific portions of their pet’s healthcare. Even when they are able to provide the background information, emotions can cloud their recall and reliability.

 

The second concern is that if we are trying to obtain records once the animal arrives for their appointment, this can wind up wasting a good portion of the time assigned for the consultation. This not only wastes pet owner’s time, but also places me behind schedule, leaving me with less time to spend helping other owners and their pets.

 

If your pet is referred to see a specialist, one of the most important things you can do is make sure your pet’s records arrive at the specialty hospital prior to your appointment. This may mean you have to take the extra step to call both your primary care veterinarian and the specialist’s office to make sure everything is in place.

 

It may require a little more input than you would expect for a typical veterinary appointment, but it will be well worth the effort in the long run for both you and your companion.

The darker side of medicine…

I recently read an article (http://goo.gl/oBdfWm) written by a human physician about her personal feelings and other people’s reactions to her decision to quit practicing medicine.

 

The author frames the article around how her choice was made after she recognized how detrimental her career was to her own health. The irony of a doctor abandoning her profession because it was causing her to become physically and emotionally ill was not lost on me.

 

Through eloquent text, she explains how stressors she encountered as a doctor on a daily basis negatively impacted her quality of life, and also how her perceptions of what her profession should have been differed so much from the actual reality of what her life actually was.

 

To quote the author directly, “I no longer believe it was weakness or selfishness that led me to abandon clinical practice. I believe it was self-preservation. I knew I didn’t have the stamina and single-mindedness to try to provide high-quality, compassionate care within the existing environment. Perhaps, due to temperament or timing, I was less immune than others to the stresses of practicing medicine in a health care system that often seemed blind to humanness, both mine and my patients’.”

I read her words, and contemplated, “Why is there such a discrepancy between the public’s perception of what we (as medical professionals) are capable of, and what we (as medical professionals who are also human beings) are truly able to sustain?”

 

Doctors, regardless of the species they concentrate on, possess certain typical personality traits that enable our success, but also contribute to our fallibility:

 

We are individuals who are driven to succeed, but in many cases this is because we have been told all along how difficult our paths would be.

 

We are healers, who we wish to alleviate pain and suffering, but this often comes at the expense of our own best interests.

 

We are persistent, because we have endured years of educational training far beyond those of our friends, but this comes with the sacrifice of maintaining those same friendships.

 

We are martyrs, because we so rarely bring these characteristics to the forefront, but rather bury them behind simply “enduring” the need to accommodate more and more appointments, complete endless piles of records, answer emails, return phone calls, and remain constantly on call during our days off.

 

My concern is our sacrifice likely happens more out of fear of not living up to beliefs without consideration to how this impacts our ability to practice our craft successfully. As the author of the article so movingly stated, doctors never wish to feel weak or selfish. Public perception demands we are the exact opposite, and we feed the perception (willingly or not)

 

But at some point, we must ask ourselves, “Is this a healthy way to endure?”

 

Why is it acceptable for our quality of life to decline in order to support those we commit ourselves to caring for?  At what point do we notice the diminishing drive and drain of empathy affects not only our patient care, but also our own lives to the point we are losing sleep about our cases on a nightly basis? And why should veterinarians face the additional burden of doing all of the above while simultaneously keeping costs at a minimum, or otherwise being labeled as “in it just for the money”?

 

We all complain about the cold and impersonal side of medicine. We’ve all had experiences with doctors devoid of any sense of bedside manner. Outsiders may contend emotional distancing is as an inherent trait of medical professionals.   I would argue it might be a byproduct of the career itself.

 

As someone working directly from the trenches of the exam room, I can tell you the pressures and expectations are great, the rewards are low, and it’s far more common than you might expect we take things home with us and sleep uneasy (if at all) because of our concerns about not only our patients, but our job security. The very nature of the personality traits, which at their best enabled us to achieve our goals of becoming doctors, can, at their worst, also be our Achilles heel.

 

I’m not suggesting all doctors possessing compassion will eventually burn out, as there are many capable medical professionals who can retain their souls through years of practice. However, if you are fortunate enough to work alongside a doctor or veterinarian you feel retains kindness, patience, empathy and intelligence I would urge you to take a moment to let them know how much you appreciate their perseverance, dedication, and talent.

 

Those simple words may be just what they need to hear to weather them through their day.

 

In memory of a weird dog…

This week marked the passing of a particularly special oncology patient and I wanted to use this entry as a means to tell his story.   It may sound cliché when we say each and every one of our patients are important to us, but it really is true. We do not discriminate, even when our patients literally try to kill us. But some find a way to squirm their way into our hearts just a little deeper than others, and Bear was one such dog. I’m not sure if it was his incredibly fuzzy and untamable hairdo, or his propensity to bolt out of our chemotherapy room and race down the hallway if you left the door open just a split second too long, or the way he would always find a way to position himself for a nap just behind the wheels of my desk chair. Maybe it was the fact Bear had an outstanding appointment with our service pretty much 3-4 times a month over the past year or so for various issues and clinical signs probably better served by a psychologist than a veterinarian.

 

Bear was only 5 years old when he was diagnosed with lymphoma, a blood-borne cancer that occurs all too commonly in dogs. Bear’s case was quite unusual: He was initially seen by our emergency service for the acute onset of a severe nosebleed. Nosebleeds can occur in dogs as a result of several reasons, and although cancer would be one potential cause, for a young dog such as Bear, it would certainly not be the top concern.

 

Bear’s bleeding was so severe he needed to be hospitalized for several days. During this time, he underwent many different tests to try and investigate why it occurred, including blood work, blood pressure testing, a CT scan of his nose, and a procedure called rhinoscopy. This is where a small camera located on the end of a flexible tube is inserted into the nose so the sinuses can be visually examined and evaluated. During these latter procedures, we discovered a mass in the left side of Bear’s nasal cavity and a very enlarged left tonsil. Surgery was performed to remove as much of the mass as possible, and biopsies of the affected tissue showed lymphoma.

 

Soon after, Bear’s owner met with me to discuss treatment options for his disease.   We performed further testing, and found no evidence of lymphoma anywhere else in his body. I talked with his owner about how unusual Bear’s presentation was, and how I was always taught by my mentor: “weird lymphomas behave weirdly”, simply meaning I wasn’t really sure how things were going to go for him. She elected to move forward with treatment, and Bear started on chemotherapy soon after.

 

Bear was a very quirky dog who liked to hide in corners, roll over for belly rubs, and refused to open his mouth for his exams, which was particularly irritating for me since I needed to pay close attention to his tonsils to monitor his disease state. He also loved to flop all 90+lbs of his body to the ground without warning, making it extremely difficult to perform basic tasks such as listening to his heart and lungs. It was also extremely fun to watch him spring from recumbency the second I exited a 2 foot radius from his body. Bear hated confinement, and it would literally take 3 people to manipulate his oversized body into a cage. Once located safely behind the confines of the metal bars, however, he would immediately fall asleep, snoring loudly and peacefully in his slumber. Bear was not a huge fan of other dogs, but for some reason they loved him and would constantly run up to greet him, while he patiently sat and started at the ceiling. I swear if he could whistle a tune and tap his paw in complete denial, he would have.

 

Bear was treated with 6 months of chemotherapy, and towards the end of his protocol, developed unusual wounds on his limbs, likely from an adverse reaction to medication. The wounds required regular care and monitoring, and through it all he never complained (other than the flopping) and spent his summer wearing decorated bandages and specialized braces for his front limbs.

 

This fall, during a routine “Bear checkup”, I noticed his left tonsil was slightly enlarged.   Since he was feeling great at home, we initially decided to monitor him but it wasn’t too long before he started showing signs of illness, and further testing confirmed relapse of his disease. As an oncologist, I know this happens in 95% of dogs with lymphoma, and the timing for when it occurred was exactly when it would be expected. Still, I think for Bear’s case I was hoping the adage of “weird lymphomas behaving weirdly” would hold out in his favor.

 

Bear’s owner elected to try further chemotherapy for him, and we were able to successfully treat his disease. As with most cases, Bear’s second remission was shorter than his first remission, and a few months after starting treatment, I found his stubborn tonsil was enlarged again. Despite additional treatments and short-lived responses, ultimately his disease proved too aggressive, and he crossed over the rainbow bridge this past weekend.

 

Bear wasn’t the most outgoing dog, or the smartest dog, or even the most attractive dog. He never performed tricks, he didn’t wag his tail, and I can’t recall him ever stooping so low as to lick a face or accept a treat. But he had so much personality and so many idiosyncratic behaviors; you couldn’t help but fall in love with him over and over again. And probably what I admire most about him was his ability to undergo his treatments and visits with dignity and patience. I never had the impression he was enduring things, but rather tolerating them. As if he possessed a greater understanding of what we were trying to do for him.

 

We will miss Bear a great deal, and I feel fortunate to have the opportunity to have known him and worked with him and learned from him. And although he may be a good example of how weird lymphomas happen to weird dogs, he still will remain a favorite in our hearts for many years to come.

 

 

 

 

 

The inhumane side of human medicine…

I recently had an appointment with my dermatologist to examine a small lump on the back of my right knee.

 

I arrived exactly at the scheduled time of 1:45pm. When I stepped up to the receptionist, rather than be asked my name, I was abruptly questioned, “Do you have an appointment?”
I was then told to take a seat and wait. Fifteen minutes later, a woman who failed to introduce herself or offer up her credentials, called me into an exam room. I assumed by her colorful scrub top that she worked in the office, but I had no way of differentiating her as a nurse or a serial killer.

 

During the walk to the exam room, her eyes remained fixated on an iPad, which had equal chance of containing my medical history or her top score on Candy Crush. I was impolitely told to have a seat on the exam table and wait.

 

Another 15 minutes passed before the door was abruptly opened without a knock. In walked the dermatologist and individual he introduced as “Karen”. Karen looked to be somewhere between 20-30 years old, nervous, and wore a white coat. Without proper presentation I placed her as a medical student, an intern, or his daughter.

 

Dr. Dermatologist asked to see the lump, and he bent down to take a look. He palpated the back of my knee for about 3 seconds and then turned to Karen and asked, “What do you think?” Karen looked terrified, but stooped to take a feel.

 

Several seconds of awkward silence passed before Dr. Dermatologist repeated his question, “Karen, what do you think?” More silence. “Superficial or deep?” he prodded in a bored monotone. More silence. “You have a 50/50 chance of a correct answer”, he explained.

 

“Well, it’s kind of superficial, but it’s also kind of deep”, was Karen’s confidant, yet completely non-committal, answer.

 

“Nope, it’s completely superficial.”

 

I found it reassuring to know his brusqueness wasn’t reserved for only his patients.

 

Dr. Dermatologist informed me the lesion was consistent with a scarred cyst. Without eye contact, he said, “We can do one of several things; we can leave it alone, we can inject it, or we can cut it out.” He then returned to his own iPad and resumed typing (or possibly, his own game of Candy Crush.)

 

“Um, well, you see, I’m a big runner, so if we cut it out, would I need to restrict my activity, because…”

 

An irritated voice interrupted my stammering, “Yes, you would have to refrain from running of exercise for 10 days.” More silence. More typing.

 

“Um, ok, well then we can try and inject it?” I said, not really sure what those words meant or what I was about to subject myself to.

 

Dr. Dermatologist reached in to a cabinet and retrieved a bottle of a milky white substance I immediately recognized as an injectable form of a steroid.

 

I tensed up, just prior to his poorly timed warning that “this will burn”.

 

The syringe was withdrawn, deposited in a medical waster container, and as he walked out, Dr. Dermatologist stated, “Karen, can you put a Band-Aid on that?”

 

Karen started awkwardly opening random drawers and cabinets before she found an adhesive bandage, which she gently applied to my skin. She exited unassumingly, and I was left to show myself out of not only the exam room, but also the office.

 

I could have called out the poor bedside manner of the dermatologist, or asked him to more clearly explain his surety for what my lesion was, or to go over the pros and cons to each of the options he provided me. But it was exceedingly clear that I was not the priority – his time was. As such, we both moved on with our day.

 

I couldn’t help but contrast my experience at the dermatologist’s office to what would happen if an owner booked a similar appointment with me to examine a lump on their dog or cat.

 

In such instance you would (at minimum!):

 

Enter our hospital and be immediately greeted by your name and your pet’s name.

 

Be offered coffee or tea, and a comfortable seat.

 

Meet one of our outstanding oncology technicians who will take you to one of our exam rooms within moments of your arrival.

 

Arrive at the exam room, and see a sign on the door specifically welcoming your pet (by name) to the hospital.

 

Be guaranteed eye contact and a compliment about how cute Fluffy or Fido is, even if they are growling or barking right at their face.

 

Have a complete physical exam performed on your animal, not just a quick look at the lump you are worried about.

 

Undergo a thorough consultation with me personally, where I will present several options for how we can proceed. Including a discussion of the pros and cons of the diagnostic and treatment options, including associated costs.

 

Rather than dwell on the shortcomings of my dermatologist, my experience forced me to look at myself and wonder, where is it I am letting my patients and owners down? What can I do better to make owners feel their experience is personalized and their time is valuable? I left the office thinking, “What can I do better?” I actually felt bad about myself professionally after a relatively miserable medical experience.

 

The ironic part is Dr. Dermatologist probably left thinking he did a pretty good job that day.

 

And he would also be the first one to complain about the high price of veterinary care if his own pet became sick.
Next time, maybe I’ll see if my pet’s dermatologist has an opening…

 

What are your experiences with your own doctor versus your veterinarian?  Who do you think does a better job when it comes to healthcare?

 

 

How biased are you?

One aspect of veterinary oncology that makes it difficult to talk with owners about the expected survival time of their pets is something called “euthanasia bias.” Or, as I like to phrase it, “What one owner will tolerate, another will not.” It’s something that especially confounds my ability to predict a patient’s outcome for a tumor type where a pet’s signs may not be outwardly debilitating, but still markedly noticeable.

 

As an example, many dogs with nasal tumors are often diagnosed with their cancer after they develop nosebleeds. They may have shown signs of chronic nasal disease for weeks or months prior to developing a nosebleed, but one of the single most prompting events for moving forward with advanced diagnostics necessary to obtain a biopsy of the nasal tissue is the relatively innocuous (though visibly scary) event of a bloody nose.

 

Owners may tolerate chronic sneezing, snuffling, and noisy breathing from their dog for a long time. They may endure nasal discharge if it’s clear or yellow or green in color. However, the instant blood is seen in the fluid, their level of concern is raised, and they are more likely to seek veterinary attention, or concede to a referral to a specialist for further work up.

 

Alternatively, it may be that the primary care veterinarian initially treats the pet for an allergy or infection (which occur far more commonly than nasal tumors), but may only suspect a nasal tumor once bleeding starts.

 

One study of dogs with untreated nasal tumors showed that if a dog experienced a nosebleed prior to diagnosis, their prognosis was shorter than if they were diagnosed before nosebleeds developed.

 

Nosebleeds in dogs can be dramatic, prolonged, messy, and inconvenient, but are not typically fatal events. So why then do dogs with nosebleeds from nasal tumors live shorter than those that do not develop nosebleeds?

 

Is it because dogs with nosebleeds have nasal tumors that are truly more aggressive? Does the nosebleed itself indicate a poorer physical status for the patient? Though either answer is reasonable, I believe that euthanasia bias factors largely into play for such cases.

 

While an owner may endure a bloody nose once in a while, I think it’s much more common that many would consider euthanasia after the first or second episode due to a few factors including (but not limited to):

 

A perception of a nosebleed indicating a poor quality of life

 

The urgency seen behind visualization of manifestation of cancer in the form of blood

 

An intolerance of blood being sprayed over their carpets/walls/etc.

 

I think the survival time for dogs with untreated nasal tumors that develop nosebleeds is shorter than dogs without nosebleeds simply because the bloody nose is the event that precipitated the diagnosis in the first place.

 

In other words, dogs with nasal tumors and nosebleeds are more likely to be euthanized than their “non bloody nosed” counterparts, because of the issues associated with the nosebleed in and of itself, rather than anything inherent to the qualities behind the cancer itself. This is the essence of euthanasia bias for our patients.

 

Euthanasia bias is a unique aspect of veterinary medicine that makes my job just a little bit tougher than I would like. The “gray zone” cases will always be the ones I struggle with the most.

 

However, it allows me to have a candid conversation with owners about what they could expect as their pet’s cancer progresses. This enables them to start to think about their quality of life issues with a completely different sense of awareness.

 

Bias isn’t always a bad thing when it comes to pets with cancer – it’s just another challenge we face when fighting against an invariably frustrating disease. In some cases it’s fine to manage the disease chronically, while in others, ending life well before the “line is crossed” is the primary goal.

 

Your bias may be just the thing that helps you make the best decision for your pet in the end.

“What happens when we don’t do anything?”


This is a natural question to ask when presented with an abundance of treatment options for a pet recently diagnosed with cancer. It’s easy to understand how, regardless of tumor type, in order to make the most informed decision about what is the correct choice for their companion, owners need to know the theoretical choices designed to help their pet live a longer life, and the alternative of what might happen if no further therapy is pursued.

 

I can absolutely appreciate why an owner would want to know about the “what if we do nothing” option and I’m surprised if it doesn’t come up at some point during a consultation. Of course, there are some owners who simply want to do everything possible for their pets, trusting in my opinion and/or experience. In many of these cases, I often find I am recommending chemotherapy protocols on a theoretical basis rather than evidence based information, and it’s almost as if we are embarking on a voyage into the unknown.

 

As alluded to in last week’s column, it’s very difficult for me to predict what the outcome might be for dogs and cats that don’t undergo treatment. Few veterinary studies focus on what happens to untreated cases, and those that do are often limited in follow-up information so conclusions are somewhat unclear.

 

Studies are generally designed to focus on a therapeutic plan designed to extend an expected lifespan or time to progression of disease. These parameters are often reported in terms of absolute time durations rather than comparing the outcome for treated pets with the outcome for untreated pets. Ideally, studies would include a control group of patients receiving a placebo treatment, or at minimum, a group of pets not receiving further therapy, with a long-enough follow-up time for the untreated group for results to be meaningful. Since most studies lack adequate such control groups, it’s often difficult to know if a treatment truly affords a benefit.

 

There are certain instances where I discuss the possibility of close careful monitoring in lieu of pursuing treatment. This typically consists of recommending monthly physical exams and periodic labwork and imaging tests to examine for recurrence and/or spread of their disease. It’s uncommon for owners to pursue strictly observational exams with me, electing usually to follow-up with their primary care veterinarian, which also makes it difficult for me to know what happens in cases where definitive treatment is not pursued.
Even when I do have untreated pets follow-up with me, I’m somewhat limited in my experience since I’ve changed my location of where I’ve worked as a veterinary oncologist three times over the span of less than 7 years. I’ve not been located in one geographical area for consistently long enough to have adequate long-term follow up untreated cases to feel as though I really have a good handle on what “typically” happens. But I do believe there is something to be learned from every patient who walks through our hospital’s doors, and I really value the opportunity to be a part of their care, whether definitive, palliative, or simply just carefully watching them over time. When owners do elect to pursue diligent monitoring with me directly, I’m extremely appreciative of their efforts and trust in my care.

 

I often tell owners their best resource for knowing what happens if they don’t elect to pursue additional treatment is often their primary care veterinarian. They are often the individuals who have the most follow-up information on such cases and can provide more accurate information as to how things might transpire.

 

I also really appreciate when owners update me as to how their pet is doing weeks to months (or in rare cases, even years) after I’ve seen them as an initial appointment, but we haven’t proceeded with more definite treatment and I haven’t been the veterinarian examining them during the interim.   I actually learn a great deal from such cases, and can use that information to help other owners make decisions about what is right for their pets when a similar situation arises in the future. In other words, I never take it personally when an owners tells me “You said Fluffy wouldn’t live past 3 months, and here we are 10 months since surgery, and she’s doing great!”

 

And typically, neither do the owners.

 

 

Are you average, or are you just median?

Doctors often interchange the word “average” for “median”, when discussing survival times for patients with cancer, but in reality, these are two different terms with two very different meanings.

 

People are most familiar with the definition of an “average” from their time spent in academic classes, where a numerical average of test scores translated into your grade for a particular class. If you scored 50 on your midterm, but a 100 on your final, your average grade was a 75. The high score offset the low score, and in the end, though you technically failed the midterm, you ultimately pass your course.

 

“Median” refers to the number that occurs directly in the middle of a series of numbers, splitting the lower half from the higher half.  In the following series of numbers:

3, 5, 7, 8, and 700

The median would be 7.

 

At first glance, after examining the explanations of the two different statistical terms, you might expect survival times for studies looking at pets with cancer to be reported in averages. However, what is truly a more relevant measure for the average pet is actually the median.

 

The problem with simply reporting an average survival time is that this number will be skewed by what are known as outliers. Outliers are cases who live extremely short, or exceptionally long, periods of times after a diagnosis. When you factor their longevity into a survival pattern, they can skew the average in one direction or another. The median will account for the outliers and essentially dismiss them, serving as a better representation for the outcome of the population as a whole.

 

For example, consider 10 pets diagnosed with a certain type of cancer. If the survival time for 9 of the 10 pets is 50 days, and 1 of the 10 pets is 4 years, the average survival time for that particular cancer would be 191 days, whereas the median survival would be 50 days. Though 191 days is certainly numerically more appealing to report to an owner, when you look at the population of pets with cancer we are discussing, it would represent an unrealistic expectation. We know 9/10 pets will live only 50 days.

 

Despite knowing that medians are more accurate for populations as a whole, it’s always hard to discredit my personal experience with the outliers. Specifically, I’m referring to the patients who outlive their expected survival times and quite literally “beat the odds.” These few cases are the ones that stand out in my mind when I’m talking to owners.

 

Dogs with lymphoma live about one year with treatment. Their feline counterparts live 6-9 months. Dogs with hemangiosarcoma live about 4-6 months with treatment. Dogs with nasal tumors treated with radiation therapy live about 1 year, as do those with osteosarcoma treated with amputation and chemotherapy. For each of these scenarios, the median survival times are well established, and very predictable for the “average” patient.

 

Yet for each example, I can think of patients who lived much longer than the odds suggested.   Sometimes my natural tendency is to question the diagnosis in the first place (“the biopsy must have been wrong because there is no way that dog/cat could be alive right now!”) It’s funny how quick I can be to discredit that the treatments I prescribe could create an outlier.

 

It’s hard not to think of those long-lived cases when talking to owners of pets newly diagnosed with cancer. This is especially true for when I talk about a median survival time and owners seem disappointed in the statistics.

 

The best explanation for most cases in veterinary oncology is our numbers may seem short because our treatment protocols are less intensive than those created for humans. Our trade-off for inciting less toxicity in our patients is a much lower cure rate, and shorter overall survival times.

 

The hardest part is when I know I’ve seen pets experience extraordinary outcomes. I was trained to accept that “we do it for the 5%”, meaning veterinary oncologists know the statistics and probabilities, but 5% of the time, we will have an outcome that far surpasses our expectations. One hundred percept of the time I want my patients to experience the 5% chance of cure.

 

Regardless of what the medians tells us, we always say, “There’s nothing average about your pet” on our service.

 

 

 

 

Answers to the top 5 questions from owners of pets with cancer:

1. What caused my pet’s cancer?

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The short answer to this question in many cases is “We don’t know”.  I recognize this is a heated question in veterinary medicine and owners are inundated with theoretical causes of cancer (in people and an animals) in the media, in print, and on the Internet.   In general, the best answer I can give is cancer results from a combination of genetic and environmental factors. Evidence for a genetic cause of cancer in animals is supported by examples of breed predispositions to certain tumor types.  There are also heritable forms of cancers that result from mutations in sperm and egg cells. The majority of genetic alterations leading to cancer to occur because of spontaneous mutations. These mutations may occur as a result of chronic exposure to known cancer-causing substances (e.g. sunlight or chemicals.) Environmental causes of cancer have been established in veterinary patients, but I think it’s very important to recognize  how difficult it is to truly prove causality when it comes to tumor development and environmental factors. Although we often do not know the underlying cause of the cancer, advances in surgical, medical, and radiation oncology allow us the opportunity to provide treatment options for owners and help their pets live longer as a result.

 

2. Will performing an aspirate/biopsy cause the cancer to spread/become more aggressive?

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Though tumor cells can disseminate into the bloodstream during surgical manipulation, the ability of these cells to actually arrest within a distant anatomical site and grow into new tumors is poor, and fortunately, most circulating tumor cells are rapidly destroyed by the host’s immune system.  Pretreatment biopsies are typically recommended in order to obtain a diagnosis prior to making more definitive treatment recommendations.   Exceptions would include cases where the biopsy procedure is associated with a high degree of morbidity (e.g. biopsy of the brain/spinal cord) or when knowing the tumor type would not change the
choice of therapy (e.g. biopsy of a splenic mass or primary lung tumor.)

 

3. Will my pet become sick from chemotherapy?

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The goal of veterinary oncology is to preserve quality of life for as long as possible, while imparting the least amount of adverse effect to the patient. In general, approximately 25% of all animals receiving chemotherapy will experience some sort of side effect. This generally entails what are considered mild and self-limiting gastrointestinal upset and/or lethargy during the first few days after treatment. If side effects should occur, they are usually well controlled using over the counter or prescription medications. Approximately 5% of chemotherapy patients will have severe side effects that require hospitalization. With appropriate management, the risk of these side effects causing the death of a patient is less than 1%. If a patient experiences serious side effects, the dose of chemotherapy is reduced to avoid similar complications in the future.  In general, the quality of life for patients receiving chemotherapy is excellent.  Studies have indicated that the majority owners are happy with their decisions to pursue treatment for their pets and their outcomes and would elect to pursue treatment again, after seeing how well their animals did during therapy.

 

4. Does my pet’s age factor in to his/her ability to withstand treatment with chemotherapy/radiation/surgery?

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Cancer is a disease of older animals, and most of the information available for how pets will respond to treatment, risk of side effect, and outcome are based on studies where the average age of patients is in the geriatric (>10 years) range.  Every precaution is made to be sure that patients are healthy enough to undergo treatment prior to instituting therapy, which is the rationale behind the recommendation to perform baseline staging tests and lab work. These tests will ideally allow us to know everything about a cancer patient from nose to tail before starting treatment, and can help us better predict outcomes, side effects, and even tailor treatment plans.  The age of the patient typically does not factor in nearly as much as their overall health status does.


5. Can my pet be around family members or other animals while undergoing treatment?

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In general, while a pet is receiving chemotherapy, it is considered safe for that animal to interact with all family members.  Depending on the chemotherapy drug(s) that the pet is receiving, there may be certain times after a treatment that the pet would be considered at a higher risk for picking up an infection, so precautions may be necessary during a very specified time period. For oral chemotherapy drugs administered at home, it is important that the capsules or pills are kept out of the reach of children. Individuals who are pregnant, trying to become pregnant, nursing, or considered immunocompromised should not handle chemotherapy drugs.  We recommend owners wear non-powdered latex or nitrile gloves when handling chemotherapy drugs and that the person handling the drugs washes their hands afterwards. It is very important never to split or crush drugs, or open the capsules, as this can increase the risk of exposure.  Metabolites of chemotherapy drugs are present in urine and/or feces for up to 72 hours after an animal has been treated. Dogs should be walked away from public areas during this time period. Gloves should be worn when handling an animal’s feces, litter, vomit, etc.  Hands should be washed thoroughly after handling and potentially contaminated fluids/waste.

This entry is paraphrased from a lecture designed for veterinary students originally written by one of my mentors who probably would rather remain anonymous, but somehow manages to come through in my voice more often than would be expected.

 

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.

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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?

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