What makes us so special?

It’s difficult to entertain the thought of an appointment with a healthcare professional and not consider the significance of the myriad of letters you find following the name of the person attending to your needs.

We’re all familiar with MDs, DDSs, and EMTs. When you have something more than a typical case of “sniffles” you head to your ENT (Ear, Nose, Throat) specialist. If you’re expecting a little bundle of joy, you probably will schedule an exam with your OB/GYN (Obstetrics/Gynecology). For a routine checkup, sometimes you see the NP (Nurse Practitioner), while other times you meet with the DO (Doctor of Osteopathic Medicine). All those years of experience and training are seemingly readily distilled down to a relatively insignificant string of characters.

Veterinary medicine is no exception to this rule. Graduates of veterinary schools in the United States possess either a DVM (Doctor of Veterinary Medicine) or VMD (Veterinariae Medicinae Doctoris) degree. Veterinarians who graduate from overseas schools could be BVM, BVSc, MVSc, or even BMVS.

Veterinarians can be rather modest about their qualifications. It’s not unusual for owners to be on a first name basis with their pet’s doctor, skipping the typical formality afforded to our human counterparts. Our accomplishments can be diminished, perhaps by virtue of the fact that our preferred position in the exam room is usually on the floor, rolling around with our patients.

Obviously, the letters following a medical professional’s name have no bearing on their ability to practice good medicine. Plenty of people possessing advanced degrees and impressive certifications are simultaneously terrible at their chosen career path. Likewise, many highly competent individuals who would have likely excelled at advanced academic training are perfectly content to avoid jumping through the hoops necessary to acquire a complex combination of letters preceding or trailing their surname.

I’m here to argue that when it comes to ensuring that the right person is providing care for your pets, there are times when the letters following a veterinarian’s name are exceedingly important.

Specifically, I’m referring to cases where animals should be afforded advance diagnostic and therapeutic care under the guidance of a board-certified veterinary specialist. These are individuals who possess the appropriate credentials indicating they are diplomates of the respective college governing their field.

I say this not to garner validation for the time, energy, and tears I’ve put into earning my title as a boarded veterinary oncologist. My motivation lies in the same place I’d like to believe all those who embarked on a career in the care and welfare of animals share: the desire to do the right thing for my patients.

Though I’m passionate about my campaign to advance awareness of veterinary specialty medicine, there are times when it’s surprisingly difficult to articulate the significance of a specialist’s qualifications. This does not result from an inability to provide accurate information supporting our role, but rather occurs secondary to what I would consider a “hot button” topic in veterinary medicine. Therefore, my language must always be chosen carefully.

Some specialists argue that general practitioners fail to offer referral for fear of losing the client because they are looking to keep the revenue associated with that pet’s care in their own pockets. Specialists feel they are better equipped, trained, etc. to manage the case and that general practitioners do not recognize their abilities.

General practitioners argue that referrals are offered but refused by owners because specialists are too expensive, and they can manage cases equally as well as another doctor without the unnecessary extras afforded by the specialist mentality.

No matter the opinion, the days of veterinarians being the “James Herriot Jack-of-All-Trades” kind of doctor are long gone. The idea that one person is best trained in all aspects of medicine and surgery in all species is outdated and downright dangerous.

We currently possess the ability to treat our animal patients on par with how we treat humans and should offer owners every opportunity to do so when feasible. I am aware that not every owner can afford to “do it all” for their pets, but as many as possible should be given the opportunity to hear the options from the appropriately credentialed doctor.

I’m proud of all the letters that follow my name. They represent innumerable hours and days spent studying, practicing, and learning how to be the best veterinarian, oncologist, writer, and, ultimately, person I can be.

Those letters were costly, not only in the literal sense of the word when my student loan payment is automatically drawn from my account, but in a figurative sense, where time spent studying, reading, writing, and treating patients took away from time spent with friends and family.

Those letters push me to want to be a better veterinary oncologist and to keep current on newer options for treating cancer in pets so I can offer the most advance diagnostic and therapeutic plans for the patients I meet. They force me to never settle for the status quo or the “cookbook” option anyone can look up in a textbook.

You could argue that anyone with a veterinary degree feels the same way about the significance of his or her own letters, but reality tells me a disparity exists.

So I will continue to promote specialty medicine, even when it feels as though the effort isn’t apparently succeeding. And I will continue to urge owners to investigate a bit more into just what the letters after their doctor’s name truly mean.

Advertisements

Can performing a biopsy cause cancer to spread?

Many times I am referred a patient where there is a strong suspicion of cancer, but a definitive diagnosis has not yet been achieved.

Whether a mass was palpated externally, visualized on a radiograph, or seen arising from tissue within the mouth, concern is raised that the cause of the growth is cancer, and the recommendation is made to seek oncological care.

After evaluation of the patient, I generally advise one of three procedures to determine a definitive diagnosis: a fine needle aspirate (FNA), an incisional biopsy, or an excisional biopsy.

Obtaining samples from a tumor, whether by a FNA or biopsy, is an essential step most of our cancer patients will undergo. The level of invasiveness required to perform such tests depends on where the tumor is located anatomically.

For tumors located within or just below the skin, FNAs or biopsies can be routinely performed, and with minimal invasiveness.

For internal tumors, for example those located within the abdominal or chest cavity, FNA or biopsy is still generally considered a routine procedure. Most often these procedures are done via ultrasound guidance in order to maximize diagnostic yield.

In some cases, a more intensive surgical procedure is necessary. This includes laparoscopic surgical procedures, which are considered minimally invasive. The benefit to this form of surgery is it requires tiny incisions; therefore recovery is rapid. The downside to laparoscopic surgery is it does not allow for complete evaluation of the entire cavity in question and therefore does not substitute for full exploratory surgery.

Open thoracic or abdominal surgery entails creating a large incision. This method can procure biopsy samples by either taking small pieces from the affected tissue(s) or by removing tumors in their entirety (e.g., tumors of the spleen can be removed during a splenectomy surgery). This type of surgery also allows for complete visualization of the entire cavity in question, which is essential for examining for evidence of other abnormalities or potential spread of disease.

One of the first questions I’m asked by worried owners when I mention the words “aspirate” or “biopsy” is, “Won’t the act of performing that test cause the cancer to spread?”

Oncologists generally consider this line of thinking to be a “myth,” meaning something that is widely believed but false in origin. What’s interesting is our lack of ability to say with certainty that this is really a myth (versus an understudied phenomenon).

A recent large-scale study at the Mayo clinic in Fort Lauderdale, Florida, was designed to answer the question of the risk of spreading cancer associated with a biopsy procedure. In this study, researchers looked at the outcome for patients with non-metastatic pancreatic cancer who either did or did not undergo a FNA prior to more definitive surgery for their tumors.

Results showed patients who underwent an aspirate procedure actually had a better outcome than those who did not, with an overall survival time of 22 months compared to 15 months. Though numerically unimpressive, the results were statistically significant.

Researchers concluded that the act of procuring a sample from the tumor was not associated with spread of disease. Additionally, previously reported isolated case reports of instances where tumors did spread following a biopsy or aspirate procedure should be considered such rare events that the risk does not out-warrant the benefit.

Another study examined the relationship between FNA, incisional, or excisional biopsy of a specific form of breast cancer, and the risk of spread of the tumor to a regional lymph node. This study contradicted the Mayo clinic’s results. Researchers found a correlation between “fine-needle aspiration and an increase in the incidence of sentinel node metastases.”

What conclusions can we draw from the opposing results of these two studies? The answer lies in the inference.

After reading the Mayo clinic’s report, it’s easy for a reader to decide biopsy procedures are safe and possess a low rate of complications. More importantly, they may even go as far as to infer that refusing a biopsy or surgery out of fear of causing spread of cancer could worsen a pet’s outcome. Is this exactly what the paper states? No, but if given the latitude of “reading between the lines,” such statements wouldn’t be stretching the truth all that far.

The results of the breast cancer study tell a reader there may be an association between the act of physically manipulating a tumor and the presence of tumor cells within lymph nodes that drain the area where the tumor is located. If they were to make such an inference, they would not be saying aspiration caused the tumor cells to spread, but rather acknowledging a correlation between the two events.

When objectively evaluating studies with disparate results, it’s easy to understand why confusion persists in the general public regarding complicated medical issues. Unfortunately, this situation abounds in research. This is likely one of the main reasons why myths and misconceptions regarding cancer are so prevalent in both animals and people.

My take on these less than clear-cut situations is to allow clinical experience to guide me in bridging the gap between the myths and the statistics. Inference is good, but it won’t help me make recommendations to a distraught owner who is nervous about their pet’s care.

If you’re wondering what my opinion is when it comes to concerns about a FNA or biopsy resulting in spread of cancer, my familiarity with these procedures and their risk tells me the myth is incorrect. I will continue to await the evidence that strongly points toward a causal relationship between the two events.

National Cancer Institute: Common Cancer Myths and Misconceptions

If you were diagnosed with cancer, to whom would you entrust your care?

The obvious answer is: an oncologist.

Most people understand an oncologist’s expertise in the diagnosis, treatment, and management of various cancers. Regardless of the expertise of the initial physician suspecting this dreaded disease, once cancer is on the radar the average person would be referred to, and actively seek consultation with, an oncologist.

Unfortunately, cancer is as common a disease in animals as it is in people. Approximately one in four dogs will develop this disease during their lifetime and more than half of animals over the age of 10 will be diagnosed with a tumor.

Statistics also tell us that two out of three American households own a pet, nine out of ten owners consider their pet part of their family, and over 75 percent of owners admit to talking to their pets as if they were “real” people. About 60 percent are comfortable referring to themselves as their pet’s “Mommy” or “Daddy,” and an additional 10 percent celebrate Mother’s Day and/or Father’s Day with their pets.

A quick summary of all these details tells us that 1) people understand the value of an oncologist for their own health care needs, 2) pets are more often than not considered a part of the household, and 3) cancer is a very common diagnosis in our furry family members.

So why am I, a board-certified veterinary oncologist, not completely booked with appointments every day? How do I explain the blank spaces in my schedule?

It’s frustrating for me to think about the disparity between what surveys and statistics tell us and what transpires in reality. It also affords me the chance to try to dispel some of the myths and misconceptions I think are (at least partially) responsible for the gap.

One major issue is the overriding, and incorrect, public perception that treating a pet’s cancer is akin to “torturing” them. I recognize the negative connotations associated with words like cancer, chemotherapy, and radiation therapy. I understand the gravity imparted by the diagnoses I deal with on a daily basis. I’m completely aware that my days are not filled with happy puppy and kitten visits or routine wellness exams.

However, I assure you that if I were to list the myriad of reasons why I selected veterinary oncology as my specialty, “a want and desire to torture animals and make them sick” would never even be on my radar.

I’m here to help pets with cancer live longer, happier lives. The treatments I prescribe have low side effect profiles and our patients are amongst the happiest and healthiest pets you will find in our waiting room. Many cancers are now managed as chronic diseases similar to diabetes or kidney failure. When it comes to cancer care for pets, the idea that I’m here to impart “torture” is absolutely absurd.

Likewise, I also struggle with primary care veterinarians who do not offer owners a referral or, worse yet, dissuade owners from pursuing consultation with an oncologist because they feel the option is inappropriate for the pet.

The numbers of vets who do not embrace specialty care or who adhere to the line of thinking that cancer is an untreatable condition in animals is remarkable. While I agree that it may not be the right choice for every pet or for every owner, the number of instances where oncological care can improve and extend a pet’s quality of life is no exaggeration.

Paradoxically, there are many general practitioner veterinarians who administer chemotherapy treatments without offering, or discouraging referral to, a specialist because they can treat cancer “equally” as well.

Though I understand the utility of such practice in areas where specialists are not available, I’ve encountered this practice in each area where I’ve worked, making it difficult to reconcile geography as the sole rationale.

In most of those cases, I’m told that owners are reluctant to pursue referral to an oncologist and choose to treat locally because of perception of increased expense. But experience tells me that in many instances the cost differential between my treatments and a primary care veterinarian’s is nominal.

Everything I’ve talked about thus far points toward an “outward” cause for my concerns. I’d be remiss not to look internally and ask what it is that I do or, conversely, don’t do, that contributes to a lack of referrals filling up my schedule.

Perhaps the most obvious answer is a lack of accessibility. I am one person, and I’m someone who values my personal time and quality of life outside of the clinic immensely. As such, although I work full time and make myself available as often as I can, I don’t see appointments on weekends or have late evening hours.

This means I’m not always available to see a case on a moment’s notice or offer instant advice to a distraught owner. In a world where immediate gratification is the norm, the fact that I’m not always there for owners or veterinarians’ questions has been called into question more than once during my career. Though I understand the hindrance, I must do what I can to maintain a semblance of normalcy in a profession where the expectation of doing so is far from ordinary.

I’ve mentioned a lot about statistics and odds, but what might be more important to note is that surveys also consistently tell us that owners of pets who elect to pursue advanced oncological care for their pets are happy with their decisions and would do so again in the future if faced with a similar decision.

With this information on board, I challenge owners, veterinarians, and specialists alike to keep the dialogue open and maintain our responsibility towards ensuring that we each work to support what is in the best interests of the animals we all love.
I’d bet if we did, there would never be a blank space in my schedule to speak of.

It’s heeeerrrrrrreee!

Happy New Year!  2015 is off to a great start so far!

The newest edition of the textbook entitled “Clinical Veterinary Advisor for Dogs and Cats” is now available, including a chapter on rescue chemotherapy protocols for canine and feline lymphoma written by yours truly!

I am so happy to be a part of this wonderful resource for veterinarians.

Looks like Sepsie is in full support of all her mom’s hard work!

IMG_1321