Love Your Vet or Get Your Money Back!

A while back, an advertisement from a competing veterinary hospital crossed my desk. The glossy postcard was printed with the hospital’s logo on one side, and on the reverse, a statement indicating the surgeons were now offering “lifetime guarantees” on a particular commonly performed veterinary orthopedic procedure.

I don’t remember the exact details of what was promised, but I do recall the sour taste in my mouth I developed when I read the card. When I considered the implications of the above-mentioned “warranty,” I couldn’t help feeling a widening in the notch of disappointment regarding some aspects of my chosen profession.

As consumers, we’re constantly inundated with the concept of “Money Back Guarantees” for products or services. Nearly everything we purchase can be returned if we’re unsatisfied with the outcome, fit, taste, or performance. Though we are ingrained to be wary buyers, overly accommodating businesses and an overwhelming sense of entitlement pave the way for us to be lax in maintaining our end of the bargain.

We’re taught slogans like “the customer is always right” at a very early age. We expect “reward cards” at retail stores or fast food restaurants. Our competitive (and materialistic) society offers us advantages such as “perks,” “cash back,” “loyalty points,” or “rebates” for simply offering up our initial (and hopefully repeat) patronage.

We no longer simply accept an apology when dinner entrees are botched or flights are cancelled due to inclement weather. In addition to a full refund of our financial input, we demand further incentive for our “troubles.” “What’s in it for me?” pervades when we get anything less than our way.

Should these ideals apply to veterinary medicine?

As a veterinary oncologist, it would be impossible for me to offer any guarantees for how a patient might respond to any particular therapy. There are so few cancers I treat where I have enough evidence-based information at my disposal to offer owners an accurate sense of outcome. And I always have to keep in mind that patients can sometimes get better in spite of my intervention, rather than because of it.

The larger question is whether offering pet owners a lifetime guarantee on a particular procedure or treatment or therapy is actually detrimental to our profession.

I’m concerned that this approach to patient care further perpetuates an already damaged approach to the health care of our pets, where veterinarians are asked to offer gold standard medical care with a “car repair shop” mentality.

We’re often expected to determine a diagnosis without diagnostics, being accused of wanting to run every analysis in the book just for financial gain.

We are asked to treat based on possibilities rather than certainties when owners don’t want to put their pet “through anything,” even when the remedy could be far more toxic than the test.

Sick pets are “dropped off” with the hope of being restored to a state of wellness, not unlike an aging automobile in need of restitution.

People disapprove of the notion that medicine is an imperfect science, yet this is supported daily in exam rooms around the world.

Reality tells us patients can worsen despite our best attempts to heal them. Technological advancements designed to eliminate human error and streamline healthcare are ultimately subject to the fact that doctors are mere mortals. Repaired fractures break down. Incisions become infected. Samples get lost. Pets die. These are the bare truths of our profession.

Even when I’m certain the most appropriate treatment for a patient is drug “X,” I may prescribe that particular medication and the pet may wind up with a terrible and unpredictable allergic reaction. Statistics tell me a cat should be cured with a procedure I recommend, but they could experience relapse of disease within a few short months. I may offer a grave prognosis to a distraught owner, only to have them contact me a year later to let me know their pet is alive and well.

How can doctors offer a guarantee of services when dealing with a complicated living organism?

If we continue to treat veterinary medicine like other service industries, I’m certain all involved parties will wind up nothing short of disappointed.

Clients will not be happy when presented with the “fine print” that is sure to be tacked onto their warranties.

Veterinarians will not be happy feeling as though they must accurately predict an animal’s outcome or else be faced with refunding their fees.

The only guarantee veterinarians should offer is a commitment to upholding their oath taken upon graduation:

The Veterinarian’s Oath:

Being admitted to the profession of veterinary medicine, I solemnly swear to use my scientific knowledge and skills for the benefit of society through the protection of animal health and welfare, the prevention and relief of animal suffering, the conservation of animal resources, the promotion of public health, and the advancement of medical knowledge.

I will practice my profession conscientiously, with dignity, and in keeping with the principles of veterinary medical ethics.

I accept as a lifelong obligation the continual improvement of my professional knowledge and competence.

What if Cats Went to College?

This week, let’s take a break from medicine and look at pet caretaking from a lighter point of view. I present to you this farcical take on a college course catalog: If cats went to college.

Kitty Course Calendar: Spring 2015

We are excited to present our course offerings for the Spring 2015 semester at Kitty Kollege. We are delighted you have elected to enroll at our institution and welcome you with open arms (though we understand completely that you won’t stand being held for more than 0.7 seconds.)

We recommend you select your courses carefully and speak with your career advisors before registering. However, as we are well aware, you are cats; we know you will do what ever it is you feel like doing, with or without human input.

Good luck!

Vocational Courses
Artful Vomiting: Explore your creative side while learning to accurately expel gastric contents onto expensive pieces of furniture, bedding, and flooring. Having trouble aiming your partially digested kibble away from surfaces that are easy to clean on to more complicated fabrics? Want to learn how to produce up to six perfectly symmetrical, yet variably hued, pools of bile over a the space of a single living room? Need to learn the secrets to upchucking quietly under the bed so your special “present” won’t be found for years? This is the course for you!

Meets: Monday mornings, Thursday evenings, and randomly for three days in a row TBD.

Advanced Ants In Your Pants!: This upper level course is designed to teach agile felines how to perfect their technique of randomly running around at top speed while simultaneously making “bird noises” and then stopping to jump up on the wall while yowling like their tail is caught in an electric socket.

Meets: Nightly between 12 a.m. – 2 a.m.

Introduction to Picky Eating: Learn how to voraciously ingest a tiny sample of cat food one single time, then refuse to eat that product again only after your human has purchased a significantly large and expensive quantity of it. Perfect your ability to sit and stare disdainfully at a completely full bowl of dry cat food. Emphasis will be placed on learning to vocalize loudly whenever your human opens the refrigerator or pantry door.

Meets: Every Tuesday and random Thursdays only.

Credit Courses
Boxes Are Awesome!!!: This is an introductory course designed to teach kittens and young adult cats the wonders of four-sided cardboard containers. Participants will learn how to leap in and out of the boxes, beginning by randomly sitting on a flat piece of paper, then working your way up to larger, more elaborate structures such as sinks, shipping boxes, and suitcases. You will learn to love the feeling of being confined in a small space while peering eerily outward at your human.

Meets: Holidays, Birthdays, and Vacation Days.

Making Muffins!: Can’t get enough of kneading your claws on tingly and tantalizing tactile teasing fabrics such as fleece, velvet, or cashmere? This course will be devoted entirely to perfectly pleasing your paws as you learn how to gently extend and retract your toes and nails, while simultaneously squinting, purring dreamily, and snoozing. Warning: Due to hygiene concerns, droolers will not be permitted to take this course!

Meets: Daily during cat nap hour.

Knock It Off: Frustrated by your human’s incessant need to disrupt your valuable time spent aimlessly sitting on a kitchen countertop, desk, or TV stand by placing pesky objects like pens, drinking glasses, or remote controls directly in your path? This course will teach you everything you need to know to swiftly and deftly bat those annoying nuisances off the edge of what is rightfully your space. The first part of the semester will focus on the basics of swatting, with a focus on timing and speed of limb/tail movement, while the second half will dive deeper into techniques such as “wait to do it until the humans sit in another room,”, “keep pushing it off no matter how many times they replace it,” and the Kitty Kollege patented move of “turn your head away from the object, swipe, jump down, and knock it under the coffee table.”

Meets: Monday and Wednesday during dinnertime.

I’m Not Going In There!: This course is designed to desensitize students with phobias associated with the confined spaces of a cat carrier. You will learn relaxation techniques designed to suppress your urge to contort your body in physics defying directions when a human attempts to place you inside “The Box.” You will no longer feel the need to scream and empty all of your orifices of their biological contents at once when placed inside the carrier.

Meets: Saturday mornings at the local veterinary clinic.
Course prerequisite: Boxes Are Awesome!!!

Stranger Danger: Students will learn the basics of “Kitty Self Defense” from our accredited personal safety instructors. No cat is sheltered from the potential horrors that could be inflicted by the world’s most terrifying perpetrators, including all non-immediately recognizable human beings, the sound of a doorbell (including those from the television), other furry four-legged creatures humans refer to as “dogs,” and the most terrifying monster of all time: The Vacuum. Participants will learn how to puff up their tails, pin their ears back, and run swiftly under the nearest bed when presented with each of the aforementioned triggers.

Meets: Saturday mornings and randomly throughout the semester with no advanced notice.

Once again, we are so thrilled you have decided to matriculate at Kitty Kollege! We look forward to serving all of your needs, both academically and socially.

Please do not hesitate to stare at us disparagingly, sleep just out of our reach on our beds, and tear into our tender flesh as we continue to force our love on your precious furry bellies.

The complicated relationship between cancer and the immune system

There appears to be an association between the development of cancer and the ability of tumor cells to evade the immune system. A person’s (or a dog’s or cat’s) immune system is on constant surveillance for foreign substances in the body. Whether searching for rogue bacteria, viruses, or cancer cells, our immune cells constantly prowl for anything not considered “self.”

Tumor cells are devilishly and unexplainably clever, developing mysterious capacities to avoid detection by their host’s immune system. In fact, their existence is often predicated on an ability to co-exist alongside the same cells designed to eradicate them.

Cancer patients are considered to have altered immune systems. The question of whether this alteration is the catalyst for tumor development, or perpetuated by their disease or treatment, or a combination of each of those factors, is an interesting one.

There’s an increased risk of cancer in human organ transplant recipients. These patients are chronically medically immunosuppressed in order to prevent tissue rejection. This is thought to lead to an impaired ability for the recipient’s immune system to survey their body for mutated cells, leading to tumor development.

Organ transplants are infrequently performed in veterinary patients, however it is possible to perform kidney transplants in cats with chronic renal disease. Feline patients are also medically immunosuppressed, just like their human counterparts.

A 2002 study showed that about 10% of feline renal transplant recipients developed lymphoma, with a median time to tumor development of nine months.

A different study conducted in 2009 showed that cats that received transplants had more than six times higher odds of developing malignancy as compared to control cats.

A 2014 study showed a little more than 20% of cats that received kidney transplants developed cancer, over half of which developed lymphoma. The median interval between transplantation and diagnosis of lymphoma was nearly two years.

When examining the effects of cancer treatment on the immune system, a common consequence of chemotherapy or radiation therapy is something called myelosuppression. Myelosuppresion refers to a decreased number of white blood cells and occurs secondary to the treatment’s negative effect on the production of immune cells. Patients that are myelosuppressed have far fewer cells available to fight off antigens, making them more susceptible to infection.

Myelosuppression does not equate to immunosuppression, however. An immunosuppressed person has a poorly functioning immune system, regardless of the number of cells available at any given time, whereas a myelosuppressed person has normally functioning immune cells, present in greatly reduced numbers.

When it comes to cancer development, one must consider: Does myelosuppression lead to the ability of tumor cells to “slip by” undetected and progress within a host due to failure of adequate recognition?

Individuals with defects/deficits in their immune system may be potentially predisposed to tumor development. But the larger question in my mind is, “Does the connection between immunity and cancer extend to a point where the immune system can be manipulated to prevent or treat disease?”

A great deal of public attention is given to the implications of cancer and it’s relationship with the immune system. The number of available “success” stories where a person or pet’s cancer was cured with supplements, nutraceuticals, and/or diet changes designed to “boost” immunity suggest the answer is yes.

I’ve written before about my concerns regarding terms such “immune boosting” and why I know that it’s not really possible to do this medically, and why, even if it were possible, this would be a bad thing for the body.

I believe the immune system is a relatively untapped resource for preventing or treating cancer. The relationship is complicated and there is a staggering amount of research aimed at investigating this exact topic.

I appreciate the relationship between immunity and cancer development and possess a desire to further understand the link to be able to provide owners with evidence-based information to help them make the best choices for their pets.

Until that point is reached, I’ll continue to recommend the treatments I am confident in, and I’ll continue to reserve judgment on the alternative treatments until the evidence is on the table.

What are the uncommon questions I’m commonly asked?

In matters of pets and cancer, there are certain questions I encounter more frequently than others. Despite the myriad of diagnoses and their associated treatment options I am tasked with explaining, troubled owners have more typical concerns: How did my pet get cancer? Will he or she become sick from treatment? What is my pet’s prognosis?

Less common questions arise and are equally as important to address, mainly because they tend to surface after owners have already committed to a treatment plan. Assuaging an owner’s concerns once a pet has started receiving chemotherapy can be tricky at best, and near impossible at worst.

Here are some examples of the less routine questions I face:

1. “Why do different oncologists have different protocols/cutoff blood counts for treatments, or administer treatments differently?”

Owners are surprised to hear different recommendations from different oncologists. I’ve encountered this when owners see me after their pet has started treatment elsewhere and are continuing care with me, or after they’ve done some research and discovered protocols online or via other doctors. The expectation is that there’s a “precise” way to treat a particular cancer. However, this tends to be a major oversimplification for most of my patients.

Even for cancers considered to have a true “gold standard” of care, often the nuances of the protocols are slightly different for each attending doctor. Typically this varies with their training, personal experience, and familiarity with the disease in question.

I use the analogy of baking chocolate chip cookies. Everyone has their favorite recipe for doing so, but the outcome is typically the same as long as the major ingredients are kept equal.

2. “Can my dog/cat with cancer still receive vaccines and flea-tick/heartworm medication?”

I would consider this a “hot button” topic in veterinary oncology, meaning it’s one that is likely to evoke considerable emotion and opinion but lacks factual information to support an actual “correct” answer.

Other than injection site sarcomas in cats, no information exists to support the concept that vaccinations lead to cancer in pets. Yet, some oncologists do not advocate vaccinating their patients, while others are fine with doing so.

We know that dogs undergoing treatment with chemotherapy can mount adequate immune responses to vaccination, which supports the notion that their immune systems function adequately in the face of anti-cancer treatment.

What we don’t know is if the physical act of vaccination could result in some sort of stimulation of the immune system that could contribute to cancer progression or relapse of disease, or a patient becoming refractory to a previously successful treatment.

People with a history of cancer are instructed to receive influenza vaccines, not because they are more prone to developing the flu, but because they are more likely to develop complications resulting from infection. Other than this, veterinary oncologists have surprisingly little data from our human counterparts to help base our recommendations on.

I answer this question on a case-by-case basis with owners and discuss the pros and cons of vaccinating versus not vaccinating. It’s a decision we reach together in a truly holistic fashion, where concerns for the pet’s safety and the family members’ safety are considered together.

3. “Isn’t there a treatment for my pet’s cancer that comes in a pill form? I’ve heard oral chemotherapy is less toxic and less likely to cause side effects in my cat/dog.”

The vast majority of cytotoxic chemotherapy prescribed in veterinary patients is administered intravenously (IV). There are a few oral cytotoxic treatments available, but these forms are not considered any less toxic than their IV counterparts. In fact, the chemotherapy drug most likely to cause a lowered white blood cell count in dogs is an oral medication called CCNU (aka Lomustine).

The idea that oral chemotherapy is less noxious for a pet is false. Any chemotherapy has the potential for adverse effects. The good news is, when prescribed correctly, the risk is absolutely minimal.

4. “My dog/cat was recently diagnosed with cancer, but he/she is not acting sick. Isn’t it better to wait to start treatment until they are showing signs of their disease?”

I hear this question most frequently from owners of dogs with lymphoma, as many of those patients are diagnosed incidentally. Unfortunately, waiting to treat any pet with cancer until they are manifesting outward signs usually means a poorer outcome.

Pets who are self-sufficient, meaning they are eating well and not having vomiting, diarrhea, weight loss, breathing difficulties, or other adverse clinical signs, tend to have a better response to treatment and are also less likely to experience side effects. Therefore, the most ideal time to institute therapy is immediately following a diagnosis.

5. “Why do you draw blood samples from neck veins?”

For most pets with cancer, and nearly all pets undergoing chemotherapy treatments, routine blood samples are drawn from the jugular vein. This is a large vein located on either side of the neck, which drains blood from the head region.

Although it sounds somewhat barbaric, obtaining blood samples from the jugular vein is a common procedure in veterinary patients. Oncologists prefer to reserve smaller, more peripherally located veins along the limbs for the administration of injectable chemotherapy. Therefore, every attempt is made to reserve the integrity of these veins for administration of treatments and to avoid excessive scarring.

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I hope this is useful information for anyone researching his or her pet’s diagnosis and trying to make decisions about their care. As always, I urge you to seek consultation with a board certified veterinary oncologist in order to obtain the most up to date information as well as to establish the most appropriate treatment plan for your pet.

Visit these sites to find a board certified veterinary oncologist near you:

Veterinary Cancer Society

American College of Veterinary Internal Medicine