On situational awareness and veterinary oncology…

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

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

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

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

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

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

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

How does this relate to veterinary oncology?
Remarkably well.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I’d expect the same from any professional individual.

Especially a pilot.

When the bottom line is about the bottom line…

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

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

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

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

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

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

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

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

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

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

 

 

 

 

Why is my veterinarian NOT recommending chemotherapy?

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

The facts tell us:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I’m an imposter?

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

When you can’t make up your mind…

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

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

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

Personal Experience Influences Decision

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

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

Chemotherapy Side Effects and Quality of Life

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

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

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

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

Placing Your Trust in Medicine

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

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

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

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

Chemotherapy for Dogs: Everything you need to know!

I recently participated in an interview with a fellow writer for petmd.com on what pet owners need to know about chemotherapy in dogs.  You can find the link to the full text here and a transcription of the article below.

By: Carol McCarthy

“Your dog has cancer” might be the four scariest words a pet parent can hear. After you get that diagnosis, chances are you scarcely hear your vet lay out the treatment options, which likely include chemotherapy. Understanding exactly what this treatment is and how it works, however, will ensure that you make the best decision for your dog. Learn more about what chemotherapy for dogs is, how much it may cost, and what the process will be like for your pet, below.

What is Chemotherapy and Why Would My Dog Need It?

Chemotherapy is a term given to a group of drugs that have the ability to kill cancer cells in dogs. The specific medication or combination will depend on the type of cancer your dog has, as well as his overall health. Your vet will monitor the chemotherapy treatment to ensure that it is working well with minimal side effects. If not, he or she might try another drug or change the dosage and frequency.

Chemotherapy is often prescribed for one of the most common cancers in dogs, lymphoma, as well as for some other malignancies.

“Chemotherapy is recommended for cancers that either have already spread to other areas of the body (metastasized) or are known to have a high potential for metastasis,” said Dr. Lisa Barber, assistant professor of oncology and chemotherapy at Tufts University’s Cummings School of Veterinary Medicine.

Dr. Joanne Intile, staff oncologist at the East End Veterinary Emergency and Specialty Center in Riverhead, N.Y., said that the use of chemotherapy depends on the type of cancer and other factors. “The ultimate recommendation depends on whether it is a single tumor on the skin, whether we can do surgery, if it is more widespread or the dog isn’t a good candidate for surgery,” she said.

If surgery is advised, the doctor will remove the cancerous tumor. The tissue containing the cancerous cells will be sent to a laboratory where a pathologist (a veterinary specialist) will examine the cells under a microscope. The pathologist will look at the edges of the cancerous tissue to determine if they are likely to regrow in that location and will grade the cancer on its likelihood for metastasizing. Cancers considered “high grade,” that is, those that have the likelihood to metastasize, often are treated with chemotherapy, Barber said.
The goal of chemotherapy in animals is different from for humans, which is why treatment is less aggressive. With pets, the primary goal of chemotherapy is to provide your cat or dog with the best quality of life for as long as possible.

“We hope for a cure,” Intile said. “But we don’t see a lot of cures because we don’t treat them as aggressively. Their quality of life is most important. Unlike human oncology, it’s quality-of-life [treatment], not life-at-all-costs [treatment].”

How Much Does Chemotherapy for Dogs Cost?

As with any medical treatment, chemotherapy cost can vary widely depending on the frequency and duration of the treatment, the drug(s) used, the medical facility and geographic location.

“At Tufts, a standard chemotherapy protocol for lymphoma is likely to cost $3,500 to $4,500. At other clinics, the cost can be $10,000 or higher,” Barber said. A commonly referenced standard treatment for this type of cancer is the Madison Wisconsin Protocol, which combines three drugs over a 25-week period of time.

A least expensive option would be an approximately $30 charge per injection, Intile said, with costs rising into the thousands for more comprehensive treatments that require a duration of many months and/or more frequent injections. When describing treatment plans to pet parents, “we never say ‘this is the only way to do it,’” she said. “We always come up with options based on their budget, lifestyle and how often they can come in.”

Barber and Intile said that pet insurance should cover some of the costs of chemotherapy, but it depends on the company and the policy. “For some dogs that are particularly prone to cancer, insurance companies may require a specific cancer rider,” Barber said.

A rider provides an insurance policy holder with additional coverage for a specific illness or situation. Insurance companies typically offer these policy options at an additional cost, which can vary widely.

What Can I Expect During My Dog’s Chemotherapy Treatment?

How chemotherapy is administered depends on the drug given. Intile said most treatments are administered by injection and last just a few seconds (similarly to a vaccination) to a few minutes. Some intravenous drug infusions can take all day but are rarer, she said. Other chemotherapy treatments are given orally, in the office or at home.

Intile allows an hour for a chemotherapy treatment appointment, which includes time for paperwork, bloodwork, an exam and follow-up instructions. These appointments are similar to a typical vet visit, she said, and are designed to minimize stress for both dog and pet parent.

What Are the Side Effects of Chemotherapy in Dogs?

Side effects for dogs are milder and generally last for a shorter period of time than for humans receiving chemotherapy because dogs are given less-aggressive treatment, Intile said. In fact, 75 to 80 percent of dogs have no side effects, she said. When present, typical side effects include loss of appetite, vomiting and diarrhea.

Less than five percent will suffer those effects more severely and will need to be brought into the vet to receive fluids, she said. “There may be little windows of time to restrict activity, maybe days three to five (after treatment). But we don’t want you to put your dog in a bubble. Our goal is for your pet to have a totally normal lifestyle,” she said.

If symptoms do not resolve in a day or two, call your veterinarian.

What causes side effects is the indiscriminate nature of chemotherapy drugs, which kill both normal and abnormal cells in an “innocent bystander” effect, Barber said. Such indiscriminate destruction can affect your dog’s bone marrow, which produces blood cells. “The most common problem that we see is low white blood cell counts. The white blood cells are the first line of defense against infection,” and a low white blood cell count can put dogs at risk for infections, she said.

Unlike people, dogs typically do not go bald from chemotherapy, although they might lose their whiskers, Intile said. Breeds that have hair that grows constantly, such as Poodles, Yorkshire Terriers, Portuguese Water Dogs, can lose some hair, which might grow back in a different color, she said.

How Often Will My Dog Need Chemotherapy?

Frequency of treatments will depend on the type of cancer, the dog’s overall health, the specific drug and family wishes. Most treatments are given in intervals ranging from once a week to once every three weeks, Barber said. That frequency can last a couple of months, followed by every four to six weeks.

The duration of the treatment is also dependent on the type of cancer and can last from a few months to a few years.

“For lymphoma, most standard chemotherapy protocols last between 16 and 24 weeks. However, unless the client wishes to stop, this often is not the end of treatment. Once the initial protocol is completed and the animal is in complete remission (no cancer detected), we give the animals a rest from treatment and wait until we see that the cancer is back. We then start chemotherapy again,” Barber said.

For other types of chemotherapy, particularly when a malignant tumor has been removed and prevention or delay of a reappearance is the goal, a typical course of chemotherapy lasts about three months, she said.

Is it Safe to be Exposed to my Dog’s Chemotherapy Drugs?

The drugs remain active in your dog’s waste for the first few days after treatment, so pet parents are advised to be cautious and to wear gloves when cleaning up after their pet. Intile said her practice provides pet owners with chemo-proof gloves to wear if administering oral drugs and advises them to always wash their hands after administering the drugs and cleaning up, even if wearing gloves.

Women who are pregnant or breastfeeding and those with weakened immune systems, such as the elderly, should be particularly careful around their pet’s waste, she said. However, you do not have to worry about your other pets sharing water bowls, food dishes or utensils with your sick dog, she added.

When storing chemotherapy drugs in your fridge, be sure to keep them in a container within a container away from your own medications. If you do accidentally ingest any of your dog’s medication, call your doctor, not your vet, who by law cannot dispense medical advice to people.

Are There Alternative Treatments for Dogs with Cancer?

Adding to your vet’s cancer arsenal of surgery, radiation and chemotherapy is another option: immunotherapy. This is a type of vaccine that is used to stimulate your dog’s own immune system to attack the cancer. “Right now the main focus for that is in dogs with melanoma (and osteosarcoma),” Intile said.

Some of the larger veterinary university research hospitals are also using bone marrow transplants to treat some cancers, Intile said. To be sure you and your pet have access to the latest treatments and possible clinical trials, consider bringing your dog to a facility that specializes in veterinary oncology.

Snake Oil or Cure All? How Can We Tell The Difference?

Have you ever heard of snake oil? It’s an expression generally reserved for unproven remedies for various ailments or maladies, but is also often used to describe any product with questionable or unverifiable benefit.

Chinese workers, building the First Transcontinental Railroad in the mid-19th century, used snake oil to treat the painful inflammatory joint conditions resulting from their labors.

The workers began sharing the tonic with their American counterparts, who marveled at the positive effects it had on ailments such as arthritis and bursitis. Rich in the omega-3 fatty acids that are now known to possess anti-inflammatory properties, Chinese snake oil likely provided some comfort for workers experiencing job-related soreness and swelling.

Looking to capitalize on the financial gain, American “healers” gave their Chinese counterparts a bad name when they developed their own “snake oil” concoctions, which they claimed provided equal benefits to the Chinese remedies, yet lacked the necessary ingredients.

Over time, the term “snake oil” has become synonymous with substances whose ingredients are considered proprietary and marketed to provide a miraculous cure-all for a variety of maladies. Unfortunately, I can’t help but think about the phrase when pet owners ask me about complementary or alternative medicine treatment options for pets with cancer.

Many owners discover information which suggests the beneficial effects of various herbs, anti-oxidants, “immune boosting treatments,” and dietary supplements via searching the internet.

The more common products owners will inquire about include Tumexal, Apocaps, K9 Immunity, K9 Transfer factor, coconut oil, turmeric, essiac tea, and wormwood products (Artemisinin). A primary appeal is these substances are touted as “natural” and “non-toxic,” making their usage relatively inarguable.

What most owners fail to recognize is that supplements and herbal products are not subject to the same regulations by the FDA that prescription drugs are. Owners are also unaware that carefully worded claims to efficacy are not backed up by scientific research in the vast majority of cases, despite the plethora of supportive testimonials listed on product inserts or on websites.

One of the most popular products I’m asked about is K9 Immunity, a dietary supplement manufactured by Aloha Medicinals, reportedly “the industry’s leading company in the cultivation of medicinal mushroom species.” The product’s website includes several impressive logos: USDA organic, Quality Assurance International Certified Organic, and even one for the Food and Drug Association (FDA) as well as sweeping statements related to an ability to “strengthen and balance your dog’s immune system so the body recognizes and destroys damaged cells” and an assurance that the product “has no known side effects.”

This latter statement is my biggest concern with the animal supplement industry; the lure of alternative and complementary options centering on the ideology that these options are benign. Countless times, owners mistakenly assume these products have undergone testing to determine purity, safety, and efficacy. Despite the lack of specific data proving these products are bioavailable, safe, and/or effective in pets (other than what is put forth on their respective websites), owners elect such treatments.

With minimal probing, I discovered a warning letter from the FDA addressed to Aloha Medicinal dated 4/6/10 outlining numerous violations the company made regarding potential beneficial claims related to several of their manufactured products. Yes, this example is out dated; however smart owners have to consider what it means.

The American Veterinary Medical Association (AVMA) is the organization tasked with protecting, promoting, and advancing a strong, unified veterinary profession that meets the needs of society. Within their code of ethics you will find the following statement:

“It is unethical for veterinarians to promote, sell, prescribe, dispense, or use secret remedies or any other product for which they do not know the ingredients.”

This simple sentence provides me with the entire pause I need when it comes to the owner asking whether or not a particular supplement would help their pet. I cannot, and I will not, promote such a thing until the data tells me to do so.

My concern is that “alternative” products are marketed as panaceas. We cannot accurately report efficacy because the substances were never scrutinized in any sort of clinical trials (despite the hundreds to thousands of animals they are stated to be helpful for); it’s all anecdotes and testimonials.

I believe many of the companies marketing these supplements are preying on the emotions of owners who are desperate for a shred of hope. This isn’t a new concept, the internet just makes it easier for them to do so.

What is often most difficult for owners to understand is that words like “miraculous” play no role in medicine. I’m not arguing against the existence of outliers—there will always be patients who live longer than we expect. Conversely, there will be many who succumb to disease before their time. However, products should refrain from including unrealistic claims and using words such as “cure” or “prevent.” Likewise, they shouldn’t only report testimonials and should offer scientific data supporting their assertions.

Complementary treatments work alongside conventional ones, whereas alternative treatments act as a substitute for them. I adhere to the ideology that there is no alternative medicine. “Alternative medicine” that works is called medicine, period.

Top 10 medical conditions affecting dogs and cats

Nationwide Insurance recently reported the top ten medical conditions affecting dogs and cats and their associated costs based on data from claims from over 1.3 million owners for more than 550,000 pets.

I assumed cancer would be the top disease on the list for both species. It is the most frequently diagnosed illness in older pets and treatments can be expensive, therefore making it a “model” disease to be represented on a survey for pet insurance.

I was stunned to discover that not only was cancer not the top disease reported, it didn’t even make either list.

The top ailments in dogs included:
Allergic dermatitis
Otitis external
Benign skin neoplasia
Pyoderma and/or hot spots
Osteoarthritis
Periodontitis/dental disease
Gastropathy
Enteropathy
Cystitis or urinary tract infection
Soft tissue trauma

The top medical conditions for cats included:
Feline cystitis or feline lower urinary tract disease (FLUTD)
Periodontitis/Dental disease
Chronic renal disease
Gastropathy
Hyperthyroidism
Enteropathy
Diabetes mellitus
Upper respiratory infection
Allergic dermatitis
Inflammatory bowel disease

The results of the Nationwide report undeniably represent several areas of bias.

Though pet insurance is becoming more popular, a rise in the number of pets covered by insurance over the past 5-10 years is a relatively recent finding. Most owners purchase policies for their pets when they are puppies or kittens. As cancer is more frequently diagnosed in older animals, a disproportionate number of animals currently covered by insurance would be of a younger age than those expected to develop cancer.

Another confounding factor is that some insurance companies do not automatically provide reimbursement for diagnostic tests and treatment plans related to cancer unless owners have a specific rider for such coverage. Therefore, despite being insured, pets may not be eligible for reimbursement for cancer care simply as a result of lack of coverage.

Another possible reason for cancer not showing up on the survey is that despite the frequency that this disease is diagnosed in companion animals, owners are reluctant to spend money on the necessary recommended treatments.

This could result, at least in part, from the higher costs associated with medical care for pets with cancer. The diagnostic and therapeutic options I endorse can run into thousands of dollars. Few owners have such resources, regardless of what sort of assistance comes from an insurance company that is helping with the bottom line.

Setting these possibilities aside, I’m concerned that the absence of cancer on the list of frequent diseases covered by an insurance company is the result of owners who avoid seeking consultation with a veterinary oncologist out of fear, anxiety, or misinformation.

Each time an animal is diagnosed with cancer, veterinarians are responsible for disseminating information to the owner about the specifics of the disease, including potential causes, testing, and treatment options.

It is imperative the information put forth is accurate. Misinformation and miscommunication lead to distortion of the facts and could contribute to lack of treatment.

As an example, I recently met with an owner who, upon leaning of a diagnosis of lymphoma in her dog, described to me how her veterinarian instructed her that chemotherapy would cost upwards of $15,000 and would likely result in her pet experiencing significant illness from treatment for the remainder of its life, which would only be for a few short months.

Though she was provided with information, nearly every aspect of what this owner was told was incorrect.

While chemotherapy may be costly, protocols vary and treatment plans can be tailored for individual patients and their owner’s financial capabilities. Even so, $15,000 is a gross overestimation of the cost of a typical protocol.

Dogs undergoing chemotherapy for lymphoma are not constantly sick. In fact, more than 80% experience no side effects whatsoever. Those that do have a bad reaction are typically treated supportively and recover. And veterinary oncologists would never continue to treat a pet that is constantly sick from treatment.

The prognosis for dogs with lymphoma may be variable; however, most pets are living between 1-2 years after diagnosis rather than “only a few months,” as suggested by my owner’s veterinarian.

When myths and misconceptions prevent owners from seeking options for their pets with cancer, animals may not be afforded the opportunity to receive potentially beneficial care.

I don’t necessarily wish to see cancer topping the list of diseases covered by insurance companies, but I’d like to see every owner and animal have a fair chance at survival when this devastating diagnosis is made.

Those that can do. Those that can do it better, teach.

This past September I was hired as an adjunct faculty member at a local community college, teaching several classes in the veterinary science technology program. As someone notoriously unable to say “no,” I agreed to tackle the responsibility on my days off from clinical work.

I entered this endeavor thinking, “No big deal, I’ve got this.” I’m a serial multitasker and I enjoy keeping busy. How hard could it be?

It wasn’t too long before I realized just how much I had underestimated the commitment I had made. And now, just a few short weeks before final exams will be distributed and students will break for the summer, I find myself counting down the credit hours, willing the time to come where I can resume my “normal” bustling schedule rather than my current “way out of control, not a second to myself” situation.

Several years ago, I temporarily abandoned my plans to attend veterinary school and entertained the idea of working in biomedical research. To achieve my new goal, I enrolled in graduate school to pursue a master’s degree in biology.

One of the requirements for the program included teaching. Specifically, I was assigned to teach the laboratory portion of the anatomy and physiology course for non-biology majors.

I possessed no previous teaching experience and was terrified at the prospect of stepping over to the other side of the classroom. I wasn’t comfortable with public speaking, and wasn’t sure how I would explain complex biological terminology to individuals lacking a background in the subject.

My anxiety was only slightly tempered by the eager faces of my students, thirsty to learn about the intricacies of the human body. The learning curve was exceedingly steep, for both my students and myself, but if I’m being completely honest, the pressure I placed on myself far exceeded anything generated by the co-eds I was in charge of for a few hours, twice a week

Especially during those initial weeks of my first semester, I stumbled and made mistakes and faltered more times than I’d like to admit. But I also experienced some remarkable achievements watching students synthesize, memorize, and comprehend. It didn’t take long before the teaching bug bit me and I decided to pursue my PhD in biology, with a goal to focus a portion of my training on developing curriculum objective for more effectively teaching the biological sciences to non-majors.

I enrolled in a program and commenced my curriculum, only to nearly instantly discover my ideals didn’t mesh with those of the department I’d signed on to. It turns out people don’t pursue PhD degrees in neurobiology to teach science. They do it because they are passionate about research and writing papers and grants, and those were aspects of earning the degree I never could align with.

Veterinary medicine was thus my “fall back” plan. I gave up one dream to pursue another and placed teaching on the way back burner as I spent four years focusing entirely on memorizing minutia and resuming my role on the receiving side of the classroom.

Opportunities related to teaching arose here and there during my residency and my professional career as a medical oncologist working in private practice. In fact, I’d argue nearly every appointment I see represents a chance to educate pet owners about cancer. Though it has not been in the formal setting of a classroom, over the years I’ve trained dozens of veterinary students, interns, and residents, as well as motivated veterinary technicians and assistants.

When the chance arose to teach in the tech program this year, I willingly accepted, somehow failing to remember the struggle of my days of working as a newly minted lecturer.

Many years later, I find myself re-experiencing the same stumbling and faltering I did back in graduate school. Though I’m hypercritical of my capabilities (or lack thereof), I’m masochistically happy when I am attempting to make topics such as antibiotics and record-keeping enthralling, and when I am painfully, yet joyfully, spending my free time writing lectures, grading papers, and creating exams.

As a good friend of mine who is a kindergarten teacher says, “When you’re a teacher, you have to be ‘on’ all the time. There’s no taking a break.” I give her a ton of credit. I only need to be “on” for one day a week.

When I was on the other side of the classroom, I assumed breaks in curriculum were designed to relieve students from the stressors of their constant study. I now understand how essential the pauses are for maintaining sanity and mental health for teachers as well.

Those that can, do. Those that can do it better, teach.

Who will you vote for?

The 2016 presidential election is shaping up to be a remarkable and unforgettable event. There are numerous controversial political topics being addressed, including typical “big ticket” items such as healthcare, gun control, and national security.

I raise no concern with a country that prioritizes the aforementioned matters with respect to political affiliation. However, I’m disappointed that our current candidates rarely voice opinions regarding their agenda for supporting animal welfare or veterinary medicine. I therefore must question our values when we place greater emphasis on deciding which presidential candidate’s wife would make a more attractive first lady than caring about matters related to animals, their healthcare, and their caretakers.

With a bit of probing, I successfully uncovered several political issues related to animals that have direct bearing on the lives of both veterinarians and pet owners that are currently up for consideration. Not surprisingly, however, I failed to discover exactly where the individuals vying to be the next president stand on the topics.

Of the concerns I came across, the following represent those where a “veterinary favorable” stance from a potential candidate would certainly positively influence my vote towards supporting their campaign:

The first consideration is the “Fairness to Pet Owners Act.” This piece of legislation was introduced in the House in July 2015 and “Directs the Federal Trade Commission to require prescribers of animal drugs to verify prescriptions and provide copies of prescriptions to pet owners, pet owner designees, and pharmacies, without the prescriber demanding payment or establishing other conditions.”

Proponents of the bill argue veterinarians discourage pet owners from filling prescriptions outside of their office in order to promote their own financial gain.

Many veterinarians feel this bill is unnecessary because they already offer owners the option of filling prescriptions elsewhere. They also are concerned about how it creates an administrative burden for themselves and their staff in cases where a certain medication is only available through a veterinarian or when an owner wishes to have the medication dispensed from their vet. The is because the bill requires veterinarians to write a prescription and present it to the owner first, then take the script back and dispense the medication if that is the owner’s choice.

Another proposed regulation is the “Pet and Women Safety Act.” This legislation will “expand federal law to include protections for pets of domestic violence victims and establish a federal grant program that will help ensure that victims have access to safe shelters for their pets.”

Specifically, the bill aims to assist both female and male victims with pets by: making threats against pets a stalking related crime, providing grant funding to increase the availability of housing for victims and their pets, encouraging states to provide coverage for pets under protection orders, and requiring abusers who harm pets to pay veterinary and other expenses incurred as a result.

The link between animal abuse and domestic violence is well established. Human victims of abuse often face the decision of leaving their current situation without their pets or staying to ensure their companions receive the veterinary care they require. This bill would provide protection for animals, increase availability of sheltering options for pets, and shift the financial responsibility towards the abuser.

There are also several proposed bills related to veterinary professional and educational issues, including the Veterinary Medicine Loan Repayment Program (VMLRP), which provides educational loan repayment to veterinarians who agree to practice in areas of the U.S., as designated by the USDA, where there is a shortage of veterinarians.

This legislation would make the VMLRP loan repayment awards exempt from a federal withholding tax, allowing more veterinarians the opportunity to participate in the program. Currently, awards are subject to 39 percent withholding tax.

The Student Loan Interest Deduction Act and Student Loan Refinancing Act are examples of proposed legislation designed to lessen the burden recent veterinary school graduates face regarding their educational debt.

The current candidates vying for nomination for their respective political parties do not have animal welfare issues on the forefront of their campaign trails. Therefore it’s difficult to determine where each stands on the above mentioned proposed legislations.

According to the Humane Society Legislation Fund, Hillary Clinton and Bernie Sanders hold the highest ratings regarding their voting record in the U.S. Senate. Whether that would translate to anything positive should they be elected president remains to be determined.

How a particular presidential candidate stands on animal welfare issues wouldn’t be the primary measure of whom I would decide to vote for, but it does allow the opportunity to gain a better understanding of what is personally important to each candidate.

And it helps to provide a sense responsibility, integrity, and value for those of us who dedicate our lives towards promoting the importance of the human-animal bond and the sanctity of healthcare for pets.

Ode to the Oldies…

I have a soft spot in my heart for geriatric pets. I’m a sucker for the graying muzzle of an elderly Labrador retriever. I relish scratching the fuzzy face of a cranky senior cat. All pets are special, but the extensive history and regal personalities attached to the aged ones is something I simply can’t resist.

As a veterinary oncologist, older pets are a substantial part of my professional life. Cancer occurs most frequently in pets over the age of 10 and companion animals are living longer now than ever before. I encounter animals of all ages, but most of my time is spent with the elderly.

On a personal level, I love senior pets for all they represent: unconditional love, steadfast loyalty, and sensible temperaments. They’re guaranteed to stand by their owners at all times and diligently maintain their roles as guardians, companions, and soul mates, even when their bodies become less capable of maintaining their self-designated responsibilities.

When I meet with owners of older pets, I love to hear them tell stories of their pets’ lives. Whether owned since they were puppies or kittens or acquired later on in life, as mature dogs and cats, there’s infinite opportunities for me to discover the role that animal played in their family’s lives.

I frequently encounter owners who feel their pet’s age is a barrier to cancer treatment. A diagnosis of cancer is devastating regardless of age, but can be especially difficult when an animal is older and an owner faces making diagnostic and treatment choices. They are often concerned about putting their beloved companion through too much at their advanced age. They will often equate it to what they would consider medically and ethically appropriate for an elderly human being.

I understand the apprehension about pursuing intensive medical care for animals in general, and certainly can appreciate how magnified these worries would be for owners of older pets.

I try to reassure owners that the majority of information about risks for side effects and prognosis were determined on older animals. I’ll also often recommend additional testing to ensure the overall health of their pet is intact prior to making definitive recommendations for their cancer care. I’m equally as concerned as they are with their pet’s health and with confirming they are good candidates for treatment.

Fortunately, when the primary recommendation isn’t a reasonable plan for an individual pet, veterinary oncologists are usually able to offer anxious owners several different options. It’s my job, in such cases, to recognize when to discuss alternatives to the standard of care.

For example, when aggressive surgery is not an option because an owner feels their pet is too old to withstand the operation, veterinary oncologists are able to offer less intensive chemotherapy therapies, most often designed to slow tumor growth and metastases while maintaining an excellent quality of life. Though we may compromise our chance for a cure, we are able to extend an animal’s expected lifespan and simultaneously ensure that their remaining time is spent as happy and healthy as possible.

Many owners attribute some of the earliest signs of cancer to “old age” or on an assumption their pet is “slowing down” as it ages. Routine visits to the animal’s primary care veterinarian may provide the opportunity to detect disease at an earlier stage, further supporting the concept of extending its quality of life for as long as possible.

Senior pets ask so little from their owners. Their mellow demeanor and relaxed personalities remind us of the remarkable nature of the human-animal bond and just how impenetrable that bond can be.

If you’re an owner of an older pet facing a diagnosis of cancer, I urge you to consider consultation with a veterinary oncologist. Express your concerns and discuss your goals with your veterinarian. There’s a great chance that together you will be able to determine an option that fits both your goals and your pet’s best interests; one that takes their age into account but isn’t limited by a single physical characteristic.

Why I think about Will Rogers every day…

American humorist Will Rogers once stated that in the 1930s, “When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states.”

This quote, though obviously swathed with wit and sarcasm, has surprising applicability to several real world scenarios. The Will Rogers Phenomenon is used to explain what happens when the movement of an element from one set to another set raises the average values of both sets.

The Will Rogers Phenomenon is extrapolated to describe an observation in medicine called stage migration. In simplest terms, stage migration occurs when improved detection of disease leads to patients being reclassified from “healthy” to “unhealthy.”

For any given patient, disease may be present, but if we’re unable to identify it, patients will erroneously be classified as “negative” or “healthy.” Increasing the sensitivity of a diagnostic test allows doctors to capture disease at an earlier stage. Therefore it’s possible to reclassify a previously “healthy” patient as “unhealthy” simply by running a “superior” test. That patient would therefore “migrate” from a healthy group to an unhealthy group because of improved detection of disease.

An important consideration is that despite migrating, nothing has changed about the patient itself. Its true prognosis was previously determined before any test was done. The new test simply allowed for better detection of their disease status.

As an example, I can answer the question of “Did my pet’s cancer spread to its lungs?” by recommending radiographs (x-rays) or a CT scan of the patient’s chest. CT scans will pick up on tumors that are only a few millimeters in size, whereas radiographs will only find lesions that are closer to a centimeter.

If the same patient underwent radiographs and a CT scan, it’s possible the former test could return negative for spread and the latter test could return positive. If we’d only done radiographs, I would offer that owner a better prognosis than if I’d done the CT scan. I would characterize that patient as “healthy” when it truly was “unhealthy.”

Patients diagnosed with more advanced disease are generally not expected to live as long as their truly healthy counterparts. Therefore, “migration” of a newly detected “unhealthy” patient from the healthy group would cause an increase in the average survival time of the healthy group.

Likewise, the migrated patients are generally healthier than the patients previously segregated to the unhealthy group because their disease is considered “less noticeable.” Therefore, their movement to the unhealthy group will increase the average lifespan of that population as well.

Regardless of whether early detection of disease results in an actual difference in patient outcome, the average survival times of both the healthy and unhealthy groups are increased. The Will Rogers Effect holds true!

Stage migration pertains to many aspect of medicine, but there’s distinctive applicability to the discipline of oncology.

Cancer patients are assigned a particular stage of disease depending on where in their body the disease can be detected. For most cancers, stage is predictive of survival. The higher the stage of disease, the more advanced the cancer, and the shorter the anticipated survival time.

Many pet owners are concerned with determining what stage of cancer their dog or cat has without fully understanding what the term stage means or what information it provides.

In order to accurately assign a stage to a pet with cancer, veterinary oncologists must perform all of the recommended staging tests. For example, complete staging for dogs diagnosed with lymphoma includes a complete blood count with pathology review of a blood smear, serum chemistry panel, urinalysis, three view thoracic radiographs, abdominal ultrasound, biopsy of affected tissue, immunohistochemistry for phenotyping purposes, and bone marrow aspirate cytology.

Though I recommend complete staging for all pets diagnosed with lymphoma, very few owners agree to this plan. Further complicating the decision is that although stage is an important predictor of outcome; it generally doesn’t influence the initial treatment recommendations.

Factors such as finances, perception of what the pet will “go through” in terms of testing, timing, and availability of resources all influence whether a pet will have full versus partial staging.

Many patients have some of the tests performed, but it’s rare that they will have all of them done. This means that I’m often making educated guesses about a patient’s stage, and therefore their expected prognosis.

Stage migration is a useful tool to remind doctors to consider every patient as its own separate entity. Generalizations are helpful; however, they do not predict what will happen specifically to your pet.

An open and honest dialogue is the best way to understand what tests your pet needs and what information the results will provide.

This reminds me of another one of Will Rogers’s best quotes: “If there are no dogs in Heaven, then when I die I want to go where they went.”

Is it too late to say I’m sorry now?

“I’m sorry.”

Consider the magnitude of impact these two simple words can have.

Apologies, when uttered from a place of sincerity, are remarkably meaningful. They are capable of erasing negativity, clarifying misconceptions, and easing hurt feelings. They also convey understanding, solidarity, and compassion. When we are sincerely sorry, we are also truly humbled.

For medical professionals, saying “I’m sorry” may have the opposite result. When a doctor offers words of apology there may be perception of culpability for an inappropriate action. It’s questioned as an omission of guilt. Are we looking for forgiveness for our inadequacies? Are we searching for absolution for our inability to heal or cure? Or worse, are we somehow admitting to negligence or neglect?

There are examples where expressions such as “I’m sorry” or “I apologize” were used as evidence of wrongdoing or guilt in a court in the context of medical liability/malpractice cases. Doctors and other members of a patient’s medical team have been penalized for declaring their regret. As a result, individuals are advised, if not ordered, to refrain from making such statements on the off-chance the case in question ends up in court.

Fortunately, legislation is being structured to exclude expressions of sympathy, condolences, or apologies from being used against medical professionals in court. Proponents of these so-called “I’m sorry” laws believe that allowing medical professionals to make these statements can reduce medical liability/malpractice litigation. Currently, several states in the U.S. have pending laws to prevent apologies or sympathetic gestures uttered by medical professionals from being used against them in a legal forum.

For example, Massachusetts enacted a statute that

“provides that in any claim, complaint or civil action brought by or on behalf of a patient allegedly experiencing an unanticipated outcome of medical care, any and all statements, affirmations, gestures, activities or conduct expressing benevolence, regret, apology, sympathy, commiseration, condolence, compassion, mistake, error, or a general sense of concern which are made by a health care provider, facility or an employee or agent of a health care provider or facility, to the patient, a relative of the patient, or a representative of the patient and which relate to the unanticipated outcome shall be inadmissible as evidence in any judicial or administrative proceeding and shall not constitute an admission of liability or an admission against interest.”

From the perspective of a veterinarian actively working in the trenches, apologies are a routine part of my day. I frequently say “I’m sorry”; not to compensate for an inordinate amount of errors but rather as a means to offer a semblance of sympathy and understanding to owners who are often anxious, confused, and searching for kindness and hope.

I offer an apology to an owner after bearing unfortunate news or following the death of their pet. I say I’m sorry when a treatment plan has failed and a pet’s cancer has resurfaced or when lab work indicates that I need to alter my recommendations.

I offer regrets when I’m running behind in my schedule, when we’ve run out of a particular medication, or when a pet can’t have an ultrasound done that same day because the doctor who performs such exams is unavailable.

When I do make an error, I apologize for this as well. I’m not perfect and mistakes happen. My words are never stated lightly and I would never choose only admitting regret when it’s convenient for my own need.

When I say I’m sorry, I truly am sorry. There’s no alternative interpretation of my message. I’m not indicating anything more than a modest sense of compassion and care.

My idealistic soul desperately believes the majority of pet owners appreciate authenticity from their veterinarian over a lack of disclosure borne out of fear of legal retribution. The fact that laws are being developed to protect medical professionals suggests the opposite is the more factual scenario.

I urge you to consider which veterinarian you would prefer: the one who apologizes out of kindness or the one who remains silent out of fear?

Have you ever had an apology from your veterinarian (or other medical care giver)? How did you feel and respond?

When veterinarians care too much…

Compassion fatigue is known by many alternative terms: vicarious traumatization, secondary traumatic stress, secondary stress, and even second-hand shock. Most often, we associate compassion fatigue with the emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events.

Every person working in a “helping profession” is at risk for developing compassion fatigue. Sufferers can exhibit several symptoms, including hopelessness, a decrease in experiences of pleasure, constant stress and anxiety, sleeplessness or nightmares, and a pervasive negative attitude.

Compassion fatigue is prevalent in veterinary medicine. Veterinarians verbally promise to dedicate their professional lives to diagnosing and treating disease in animals and relieving pain and suffering when necessary upon reciting their oath during graduation. But far too often, this responsibility drains our emotional resources, leaving us with little reserve to combat our own struggles.

Much attention is (appropriately) devoted to the negative impact compassion fatigue has for veterinarians. However, relatively little focus is given to the role this condition has on veterinary technicians, an overlooked population of caretakers that is equally susceptible to its damaging effects.

Veterinary technicians aren’t precisely veterinarians, but we consider them the “next best thing.” Veterinary technicians administer medical care, assist veterinarians with all aspects of their daily responsibilities, and communicate with and instruct pet owners on all aspects of both preventative and therapeutic care.

Veterinary technicians help with routine examinations, administer medications, and conduct laboratory tests and understand how to interpret the results. Technicians also assist with surgeries, perform radiographs (x-rays), and assist in restraint for various procedures.
One of the primary roles veterinary technicians play is in the care of sick, hospitalized patients. The technicians spend countless hours administering treatments or performing diagnostic tests on those pets. They collect and run the laboratory samples. They clean up after, bathe, and hand feed the animals.

Technicians caring for hospitalized pets are the primary advocates for that animal’s care. When a technician alerts me to a patient they think is in pain, I trust their assessment. When they discuss a particular pet’s poor appetite or breathing rate, I heed their words entirely. While I am ultimately responsible for decisions regarding my patient’s care, I trust the technician’s opinions and use them in shaping my choices.

Working at a 24-hour emergency and critical care facility, I’m accustomed to seeing extremely ill or injured patients. We routinely admit the sickest of animals and use all of our expertise and talents to try to help restore their health. Despite (or perhaps because of) the regularity that we encounter such severely ill pets, it’s not unheard of for someone working the clinic to pass by the cage of such a patient, and comment that “He looks really bad,” or “That poor animal,” or “She needs to be euthanized.”

The phrases slide out of our mouths without much thought for consequence related to their impact. They are not meant to carry the weight of the negativity they imply. Yes, they are exceptionally abrasive and lack any element of constructive criticism or help, but are stated in a fleetingly passive sense. One designed to elicit camaraderie rather than disconnect.
However, the impact those words have on the technicians taking care of such patients can be condescending at best, and at worst push someone towards the emotional depths of compassion fatigue. Imagine being tasked with such an uphill battle.

The technicians assigned to caring for those particular animals are hyperaware of the degree of severity of illness or injury of their patients. They understand the gravity of the prognosis. They understand that the outcome will likely be poor. But they still pour every ounce of their dedication, energy, compassion, and effort into ensuring that pet is cared for to the best of their ability.

Negative comments can chip away at a technician’s capability for caring and contribute significantly to developing compassion fatigue. They can incite feelings of insecurity and depression. They could even cause a questioning of integrity or morals.

We focus on the impact of compassion fatigue on veterinarians, but we cannot dismiss the role it plays on the technicians caring for our patients each day. Even when we’re unable to diminish the impact, we can take steps to avoid worsening an already emotionally fueled situation.

We are all in this together. Regardless of the credentials following our name.

All about Prognostic Factors

Prognostic factors are characteristics possessed by a patient, its tumor, or both. They predict the likely course of the cancer, and ultimately, your pet’s prognosis, or final outcome.

Prognostic factors could help estimate a patient’s survival time, chance of success with a particular treatment plan, or risk for recurrence of disease following surgery, radiation, or chemotherapy.

Prognostic factors are designed to help owners and veterinary oncologists decide on the need for additional testing, potential treatment options, and also to provide a realistic expectation of outcome. Most studies investigating various cancers in pets include an analysis of specific prognostic factors in some capacity.

Much weight is given to the statistical significance of prognostic factors and they largely influence meaningful medical decisions, including those related to life and death. For example, immunophenotype is a prognostic factor for dogs with lymphoma. For dogs being treated with chemotherapy, those who have a B-cell phenotype tend to have a longer lifespan than dogs with a T-cell phenotype. Some owners will therefore base their decision to pursue treatment based solely on the result of the phenotype testing.

Unfortunately, many times prognostic factors fail to provide clinically relevant information. Dogs with nasal tumors who experience nosebleeds have a significantly shorter survival time than dogs without nosebleeds (88 days vs. 224 days). At first glance, one might assume dogs with nosebleeds have more aggressive tumors, or are sicker from their disease. Yet clinically, my observations tell me this is untrue.

I would argue that a bleeding nose is a negative prognostic factor for a dog with a nasal tumor primarily because the nosebleed is perceived as producing a negative impact on the pet’s quality of life. The nosebleed also negatively impacts the owner’s lifestyle, as these events can be dramatic, messy, and difficult to manage.

I still explain to owners of dogs with nasal tumors and nosebleeds that research tells me their dog’s expected lifespan is about three months. However, I am clear that most of those dogs are euthanized because of the physical issues caused by the nosebleed itself, rather than because of outward signs of pain, illness, or other concerns.

As another example, data tells me the tumor size is a prognostic factor for dogs with oral melanoma, with differences in outcome for dogs with tumors less than 2cm, those with tumors between ,2-4 cm and those with tumors >4cm. Logically, we can make sense of the concept that the larger a tumor is, the more impacting it would be for the pet.

Does this mean I offer the same prognosis for a tiny Chihuahua as I would for a Great Dane if both were diagnosed with a 2cm oral melanoma tumor? Logic dictates that although tumor size would be important, so would the size of the mouth hosting the tumor. Veterinary patients exist on an enormous spectrum of shapes and dimensions, therefore tumor size must be interpreted in light of patient size.

A particular characteristic determined to be a statistically significant prognostic factor in one study can be refuted with additional study. For example, age was shown to be a prognostic factor for dogs with osteosarcoma in one research study, but had no impact on survival in another.

When we focus too much on specific prognostic factors, we lose sight of the bigger picture. My patients are more than a simple set of descriptive values or categorical characteristics. Generalizations are valuable to an extent, but they cannot predict individual response.

I always consider known prognostic factors when making recommendations about my patients’ care. I’m also humble enough to remember that every animal is a uniquely created organism with unpredictable responses and outcomes, and that treating the individual is far more important than treatments based solely on statistics and probabilities.

Prognostic factors have value, but they certainly aren’t the bottom line. I urge owners to keep this in mind when considering pursuing treatment for their pet with cancer.