How this veterinary oncologist learns more about her specialty when cancer crosses species to her owners.

I’m seated across from one of my favorite owners and her endearing 9-year-old Lhasa Apso, Sparky. I’m reviewing Sparky’s medical record, determining when he’s due for repeat chest x-rays to make sure his there’s no evidence of his cancer resurfacing. Sparky is customarily unimpressed, making no attempt to stifle an uninterested yawn. Mrs. Baker, Sparky’s owner, patiently awaits my decision.

Sparky was diagnosed with a form of skin cancer that was removed about eight months ago. Since recovering from the operation, I see him every month for routine examinations. Though his type of cancer wouldn’t typically spread to distant sites in the body, the probability is not zero, therefore routine monitoring is important.

“It looks like we last checked for spread of his tumor about three months ago. This would be a good time to see if anything has changed. We could perform the x-rays today, or during his check up next month,” I say.

“Let’s do the x-rays now,” Mrs. Baker states emphatically.

I’m grateful for her dedication to Sparky’s care. One of the biggest struggles I have with owners of pets with cancer is relaying the importance of monitoring for recurrence or spread of disease.

As I’m finishing up with writing my notes about the checkup, Mrs. Baker casually adds, “You know, they found another lump and I need to go for more testing.” My pen stutter-steps along the page as I immediately look up, unable to find the words to express my concern.

I knew Mrs. Baker was previously diagnosed with breast cancer over 30 years ago. We had discussed her disease numerous times over the course of Sparky’s visits. She’d told me all about the invasive surgery she underwent and the subsequent six weeks of daily radiation therapy she’d endured.

I heard details of the horrendous long-term side effects she had from her treatments, including persistent lack of sensation along the right side of her chest, a chronic cough, and an intolerance to strenuous activity.

I knew she was as diligent monitoring her own health as she was about her dog’s. She underwent regular mammograms and CT scans and previously always received encouraging news that her cancer was non-existent.

However, over three decades after her initial diagnosis and treatment, she’d developed not only one but two new tumors. One in each breast. Her treatment would be a double mastectomy followed by chemotherapy. Her prognosis was unknown, but the initial biopsies suggested the two tumors were not related to each other and were each likely aggressive.

In some cases, owners of animals with cancer who are diagnosed with cancer themselves are reluctant to pursue treatment for their pets. Their own experiences negatively influence their perception of what their companion would experience.

While there are many similarities between a diagnosis of cancer in animals and people, and the drugs I prescribe are the same used to treat humans with cancer, the dosages are lower and the interval between treatments is extended so as to avoid side effects in pets. This conservative plan of action affords a much lower cure rate for most veterinary cancers. However, we consider this an acceptable consequence because animals with cancer experience an exceptionally low rate of treatment related complications.

More frequently, I encounter owners such as Mrs. Baker, who search for options for their pets on par with what they’ve experienced themselves. I don’t have to go into the details of chemotherapy, or the importance of staging tests or monitoring with cancer survivors. They are already acutely aware of which information is crucial for making optimal decisions about their animal’s care.

While I’m prepared for discussing cancer care in animals, I lack confidence in my capabilities for providing the same support for the human beings attached to those pets facing a similar diagnosis. I’m humbled and honored when owners of pets with cancer open up to me about their own diagnosis. Whether doing so helps them to better understand their pet’s diagnosis, or simply provides them with a sounding board to express their own concerns and fears, I’m appreciative of their disclosure.

I was thrilled to let Mrs. Baker know Sparky’s x-rays turned out to be clear. We spent several additional minutes discussing how happy we were with how well he was doing and joking about his propensity to ingest acorns before she could pry them from his tiny, genetically stunted jaws. We concluded the appointment as we always do, with a quick hug and a few parting sentiments about Sparky’s cuteness, and with me letting her know I looked forward to seeing the both of them next month.

As Mrs. Baker and Sparky exited the hospital, given the recent news regarding her health, I felt just a tiny bit guilty knowing I’d be happier to see her rather than him at their next visit.

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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

What’s the most commonly uttered phrase in veterinary school? The answer may surprise you.

There are several phrases one is guaranteed to hear on nearly a daily basis in veterinary school, ranging from “What a cute puppy!” to “That’s really gross!” to “Have you seen my rectal thermometer?” These expressions are commonly uttered as students cross from lecture hall to lecture hall, or wander down the corridors of the teaching hospital, or even as they wait in line at the coffee cart. But perhaps the most frequently encountered saying, guaranteed to spew forth from the mouths of even the most articulate students, is “Will this be on the test?”

Whether agonizing over the details of a recent lecture, watching an instructional video of how to halter a cow and lead it safely from it’s stall, or sifting through infinite piles of notes, concern centers on what is necessary to memorize for testing purposes, and what can be discarded as unimportant.

Admission to veterinary school is difficult. It’s estimated that only about 40-45 percent of applicants will be accepted and enrolled. I’m sure the ratio of people who aspire to become veterinarians to those who actually pursue application to school is equally skewed in a negative direction.

Not only is it challenging to commit to and finally achieve the elusive acceptance letter, one must then consider the exceptional rigors of the curriculum itself. Veterinarians must become proficient in the diagnosis and treatment of multiple species over their 4-year tenure of learning, while our human counterparts, given the same time frame of education, are only expected to focus on learning about a single organism (i.e., human).

The upshot of all of this strain is that veterinary medicine is an extremely competitive field. To even be considered a candidate for admittance, students must not only achieve high grades, they must also possess vast experience working within the veterinary field, hold excellent letters of recommendation, and even maintain a great deal of volunteer experience. The aggressive nature of the admissions process and the stressors associated with the curriculum tends to select for individuals who are exceptionally driven.

For many students, the competitiveness doesn’t stop once they’ve entered the halls of the vet school. Constant pressure to maintain an excellent GPA along with stellar co-curricular activities are necessary evils for individuals looking to pursue post-graduate training with an internship and/or residency program — or nowadays, even to secure a job in general practice.

For some, this translates into an irrational and unhelpful focus on tests and grades, rather than an assessment of ability to exist and thrive in the “real world.” The very act of the constant questioning of “Will this be on the test?” illustrates the poorly focused attention of even the most stable of students.

When I look back with the hindsight of several years of work experience and think about what it truly means to be a veterinary specialist in clinical practice, I now see that those facts I spent hours agonizing over are often quite meaningless. More so, I now recognize there were several voids in my educational process that I would now consider essential aspects of the career we need to be teaching to students.

In all my time spent poring over textbooks and class notes, you may find it surprising to know I was never trained on the proper way to tell an owner their pet had a terminal diagnosis. I was never examined on my ability to discuss how to pick and choose diagnostic tests when owners do not have unlimited funds to spend on testing. No one ever assessed my ability to maintain composure while simultaneously calming a distraught owner, or to manage an overbooked schedule when my first appointment runs 20 minutes late.

I wasn’t taught how to speak to co-workers when I felt they treated me poorly. I wasn’t primed on how to negotiate a contract or ask for a raise. I never learned the true meaning of hospice and the myriad of difficulties associated with end of life care.

Sometimes I can’t help but feel that my deficiencies have actually grown with time, but it’s likely only because I’ve been exposed to more and more situations that have made my inadequacies stand out.

I’m not suggesting the didactic portion of veterinary school is worthless. Obviously the basics of form and function, anatomy and physiology, and function and dysfunction must be taught and committed to memory. However, when the concern is placed on quantifying things related to detail rather than the bigger picture, I’m afraid of exactly what we are losing along the way.

So for those of you considering veterinary medicine as a profession, whether you are young and in pursuit of this as your first career, or older and coming to the decision after soul-searching and trading in your existing job for a new path, my best advice is to gather as much practical experience as possible not only prior to applying, but also maintain as much hands-on work as you are comfortable with during your time at school.

Exposure to practical experience in the field is the best way to garner ways of communicating that you think will work, and the ways that don’t work. It will help you learn how to have those difficult discussions, and what types of things you may face on a daily basis. Moreover, it may be the thing that helps you know whether this profession is really the right choice for you.

These things may never show up on an exam, but they will be an integral part of your day-to-day life as a veterinarian.

I can think of no better preparation for the biggest test you’ll face as a veterinarian: The day you become the doctor instead of the student.

If you liked this article, please take a look at “What In the World is My Vet Talking About?