Why seeking a veterinary specialists could just mean the difference between life or death for your pet

I’ve recently returned from the annual forum for the American College of Veterinary Internal Medicine (ACVIM), held in Nashville Tennessee.

For those not familiar, the ACVIM (www.ACVIM.org) is the non-profit organization dedicated to the education, training, and certification of veterinary specialists in the fields of small and large animal internal medicine, as well as cardiology, neurology, and oncology.

This was the third conference I’ve attended this year. Each time, I’ve returned feeling renewed and invigorated about being an oncologist. I’ve felt more confident in my career path and my knowledge base. I’ve felt assured I’m doing the best job I can do, and that I was adequately adhering to my responsibility to keep current in my field. Sadly, within just a few short days of arriving home from each occasion, I’ve found my enthusiasm become re-routed as I tackle events that completely question my faith in the public’s perception of veterinary specialty medicine.

I’d barely arrived home when my husband excitedly told me the wine store near where we lived was having it’s grand opening that afternoon. Though I am an avid lover of animals, I also really enjoy wine, so I was equally enthusiastic about the event.

Within a few minutes of our arrival at the store, we met two gentlemen who struck up a conversation with us about a baseball game we all were watching on the large flat screen TV. My husband and I have an unwritten rule that we will not voluntarily bring up our profession in social situations unless asked directly, as inevitably the tides of conversation will change and then simply become monopolized by animal talk. So we happily discussed the game, the wine store, and things to do around the area with our newfound friends.

As is so often the case, it somehow came up in conversation that we were both vets and immediately the topics shifted from discussing pitching stats and the merits of beer flavored with Old Bay, to questions about our new friend’s pets, breed specific illnesses, and then once they found out I was an oncologist, stories of their dogs who were previously diagnosed with various tumors and their outcomes.

I listened intently as one owner recounted the events surrounding the death of his older Golden retriever. He accurately recounted how his dog became acutely weak and inappetant one morning, with no premonitory signs of illness. His owner knew enough to know the behavior wasn’t normal, but figured his dog had contracted a stomach bug or ate something he shouldn’t have. He diligently brought him to his primary care veterinarian for evaluation that same day. That’s when the story took a disheartening turn for me.

Turns out his dog’s signs were not due to a simple virus, but rather a bleeding tumor along his spleen. Given the age, breed, and presentation of his pet, the most likely diagnosis was an aggressive tumor called hemangiosarcoma. However, other possibilities existed. The only way to know would be to perform an immediately life-saving surgery and remove the spleen and submit the tissue for biopsy.

The owner recalled the story with the following chain of events: 1) the primary care veterinarian diagnosed his dog with a bleeding tumor that had a > 90% chance of being a type of cancer, 2) that he would live only 3 months with an immediate life saving surgery, 3) the life saving surgery needed to be done at a specialty veterinary hospital and would cost no less than $10,000, and 4) the dog had a less than 50% chance of surviving the surgery. He ultimately elected for humane euthanasia.

As he told the events of his pet’s death to me, I could feel myself struggling between a strong sense of sadness over the sudden loss of his beloved companion and a growing sense of frustration and anger towards the misconceptions he had about what may have been the outcome for his dog.

Yes, there is a strong likelihood of a diagnosis of splenic hemangiosarcoma, but I will stand by my conviction that so many dogs are euthanized prior to surgery, that we actually do not know the true prevalence of benign vs. malignant splenic tumors.

Yes, if the diagnosis is splenic hemangiosarcoma, the prognosis is considered very guarded with surgery alone, but chemotherapy following surgery can be effective in prolonging survival.

Yes, the surgery is expensive, but likely would range between about 1/3rd to ½ the amount quoted by the primary veterinarian.

And yes, though the dog was quite ill at the time of diagnosis, the survival rate for splenectomy surgery is far higher than 50%.

At the time, I silently agreed with the owner as he told the story, as nothing I would say or do could change the events of what transpired with his dog. But I made a mental note that although I am only one small voice for my profession, I have the potential to be a proverbially powerful one. Therefore I put forth two main suggestions for our profession at this time:

I sincerely urge owners to seek referral to a specialist when offered, but also consider asking for a referral when they want to learn more about their pet’s health.

Likewise, I urge primary care veterinarians to discuss cases with your local specialists to be sure, as frontline consultants; you are providing the most accurate information to owners.

In the triad of owner, primary care veterinarian, and specialists, don’t we owe to it to the one thing we all share in common? The voiceless companions dependent on our care would never ask for anything more than this.

What would you do if your dog suddenly collapsed and it could be from cancer?

Imagine taking your dog for it’s usual morning walk. Nothing seems out of the ordinary; your companion’s energy level and demeanor is perfectly normal, as it’s been for as long as you can remember. Imagine leaving for work, or to run errands for a few hours, and returning home to find your pet completely lethargic and unable to rise, breathing shallow rapid breaths, with a distended abdomen, pale gums, and an exceedingly rapid heart rate.

 

Imaging rushing to the nearest open veterinary hospital, and within moments of arriving, hearing the devastating news your pet is suffering from internal bleeding from a mass associated with its spleen, and will require emergency surgery in order to have any chance of survival.

 

Now imagine hearing the mass very likely represents a deadly form of cancer called hemangiosarcoma. And that with emergency surgery, this disease is typically fatal within 2-3 months, and even with aggressive chemotherapy after surgery, survival is extended to only about 4-6 months. While trying to wrap your head around this information, imagine hearing there is a smaller chance the bleeding results from a completely benign tumor that will be cured with surgery alone. And there is no way to know whether your dog has a cancerous or benign tumor before making the decision to go to surgery. What do you do when all you can think is “My dog was completely normal this morning when we went for a walk”?

 

Hemangiosarcoma is a fairly common cancer diagnosed in dogs. It arises when mutations occur in the endothelial cells lining blood vessels. The most common primary sites of tumor development include the spleen, the right atrium of the heart, and the skin. The liver is also a common site for a tumor to form, and also a frequent site for metastases from other locations. Hemangiosarcoma occurs more commonly in older dogs, especially larger breeds such as Golden retrievers, German shepherds, pointers, Boxers, and Labrador retrievers.

 

As hemangiosarcoma tumors grow, rapidly dividing endothelial cells try to form blood vessels and vascular channels, but their growth is erratic and abnormal, and tumors are fragile and prone to bleeding. If bleeding occurs while a tumor is small, or the cancerous vessels can be repaired, dogs will usually be asymptomatic. Once a tumor reaches a critical size, bleeding will typically be more severe and dogs will show signs related to massive internal blood loss. In most cases, owners have no way of knowing their pet is afflicted with this type of cancer until it is very advanced and they are literally faced with a life or death decision about how to proceed.

 

The statistics surrounding a diagnosis of hemangiosarcoma are fairly abysmal. It is estimated over 80% of affected pets have microscopic metastases at the time of diagnosis, therefore even though the surgery to remove the immediate source of bleeding is life-saving, it is generally not curative. Chemotherapy can prolong survival, but typically only for a short duration.  Even when dogs are diagnosed with hemangiosarcoma “incidentally”, meaning tumors are discovered before dogs show signs of bleeding, the average survival time with surgery alone is about 6-8 months.   The unluckiest dogs have visible metastases in multiple organs at the time of their diagnosis. Survival times for those dogs may only be on the order of a few short weeks.

 

What I find most problematic is there is little information to help determine whether a splenic mass is cancerous or not before a tissue biopsy is obtained, so owners are forced to make a decision about pursuing emergency surgery without having all the information they might need to feel completely educated about their choice. Although most splenic tumors are ultimately diagnosed as hemangiosarcoma, other types of cancers can occur within this organ, many of which carry a more favorable prognosis than the odds I’ve listed above. I’ve also seen dogs “diagnosed” with hemangiosarcoma within their spleen, with spread to their liver, based on images obtained with an ultrasound, yet biopsy showed the masses in both organs were completely benign.   Hemangiosarcoma is uniquely challenging for this exact reason: owners are forced to make major decisions with limited evidence-based data to feel comfortable they are truly making the “right” choice for their dog.

 

I’ve treated many dogs with hemangiosarcoma, and happily continue to monitor a small number of patients who are alive a year or more after their diagnosis. I’ve talked with their owners about the spectrum of emotions they experienced when deciding whether or not to proceed with the initial emergency surgery. The most common answer I hear is they just knew they had to give their dog a chance.  They felt should something happen during or after surgery, they would be content knowing they made their decision with their pet’s best interests in mind.   And they knew even though the odds for long-term survival were not in their favor, the odds for a chance to have a few more usual morning walks were great enough to warrant the risk of a diagnosis of cancer. Of course, there was always the hope the tumor would be benign, but even when hemangiosarcoma was confirmed, they were comfortable knowing it wasn’t the duration of time that mattered for them, but the time itself.

 

Whether dealing with cancer, or with any other of life’s infinitely challenges, I think we could all stand to benefit from approaching things from a “quality over quantity” standpoint. And really figure out what it means to enjoy the moment while it lasts.