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?

Out of the mouths of animals…

Dogs and cats are frequently diagnosed with tumors of the oral cavity. This diverse group of cancers includes growths along the gingiva (gum), lips, tongue, tonsils, the bones and cartilage of the upper and lower jaws, and the structural components holding the teeth in place.

The most common oral tumors in dogs are melanoma, squamous cell carcinoma, and fibrosarcoma. In cats, the most common tumor is squamous cell carcinoma, above all others.

Oral tumors are typically diagnosed at a relatively advanced disease stage, when they are causing significant clinical signs for the patient. This can include drooling (with or without evidence of bleeding), halitosis (bad breath), difficulty eating and/or drinking, facial swelling, and/or signs of oral pain (pawing at the mouth or repeated opening/closing of the mouth.)

Oral tumors are very locally invasive, meaning they cause significant damage directly at their site of origin. Gingival tumors can invade the underlying bone, causing destruction of the jawbone and loss of support for associated teeth.

Certain oral tumors are more likely to spread to distant sites in the body. For example, oral melanoma has a higher chance of spreading to lymph nodes of the head and neck region via the lymphatic system, or spreading to the lungs via the bloodstream, whereas fibrosarcoma tumors rarely spread.

The treatment of choice for oral tumors in pets is surgical resection when possible. The feasibility of surgery will depend on several factors, including tumor size, patient size, the specific location within the oral cavity, and the degree of invasiveness to underlying tissue.

If surgery is performed, and the biopsy report indicates the edges of the submitted section are free from cancer cells, oncologists will consider such tumors having “adequate local control.”

If the report shows cancer cells abutting the cut edge of the tumor, regrowth of the tumor is possible, and therefore additional local control is recommended. Generally this entails radiation therapy.

When radiation therapy is performed following surgery, veterinary oncologists prescribe between 14-20 daily treatments administered over a several week period. This form of radiation therapy can lead to some significant, albeit transient, side effects in pets due to the incorporation of surrounding healthy tissue within the region being irradiated.

Side effects from radiation therapy in the oral cavity include ulceration of the oral tissue and skin and fur loss in the radiation field. A foul odor may develop as side effects occur in these areas and/or the tumor is destroyed by the radiation. This is usually temporary and decreases over time. If the eyes are included in the treatment field, the development of cataracts is possible.

Chemotherapy is variably effective for treating oral cancers in dogs and cats. Unfortunately, the most common oral tumors tend to be exceptionally resistant to this form of treatment. This means that when pets present with tumors that cannot be resected surgically due to size or location, the options are limited.

Oral melanoma in dogs is a special scenario that can be treated with immunotherapy, using a vaccine designed to target the patient’s immune system to attack residual cancer cells.

Some pets are diagnosed with oral tumors incidentally, meaning a growth is detected without the animal showing any clinical signs. Owners may visualize a mass in their pet’s mouth while they are panting or yawning. I’ve had owners detect a problem while their animal was lying on their back with their mouths open in a position where their tongue falls away from their bottom jaw.

There are no proven methods for preventing oral cancer in pets. However, earlier detection of disease would provide the best chance for long-term survival. Taking a look in your pet’s mouth once a month could aid in diagnosing oral tumors prior to their causing clinical signs. This task is easier said than done, as many pets are not too happy about having their mouths fussed with.

A thorough oral evaluation should be part of every routine wellness exam for dogs and cats. Veterinarians also struggle with successfully peeking in the mouths of our patients, but we’re generally more experienced with the process and also have more of an idea of what to look for and what could be concerning. When in doubt, it’s generally very safe to administer a touch of a sedative to facilitate oral exams.

Oral tumors can also be detected during routine dental cleanings or while pets are undergoing anesthesia for an unrelated reason. Those procedures allow for a more thorough evaluation of the oral cavity, and every attempt should be made to capitalize on the degree of visualization possible while an animal is anesthetized.

There are several clinical trials and many ongoing research studies for animals with oral tumors. Veterinary oncologists are the best reference point for owners looking for further information regarding this type of cancer, especially with reference to determining a pet’s eligibility for novel therapies.

Owners can find additional information on oral tumors, their diagnosis, and treatment options on the website for the Veterinary Society for Surgical Oncology.

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.