I do it for the 5 percent. What about you?

I’m reaching the end of my hour-long initial consultation with Princess’ owners and for the most part, I feel as though everything is going well.   I’ve discussed her diagnosis of lymphoma, went through the recommended staging tests, and outlined multiple treatment options for her disease. Her owners seem engaged, and asked insightful questions along the way. They didn’t flinch when I discussed the option of chemotherapy and even worked out a system where they would drop her off at our hospital before work so she could receive her treatments as planned.

 

When I detail the prognosis for Princess, an eerie quiet fills the exam room. Dogs with lymphoma typically survive about a year with treatment. A fair subset can live two years, but for most pets, especially those of middle age such as Princess, the expectation of living a “normal” lifespan is unrealistic. As is the case for many veterinary cancers, we are able to prolong a good quality of life for a long time, but our cure rates are low.

 

It’s at that precise moment, Princess’ male owner says to me, “So what you’re telling me is, the best case scenario is she will live a year?”

 

It’s easy to see how the emotional barometer has plummeted. Both of her owners begin tearing up and I’m losing eye contact. They are spending more time focusing on her rather than my words. Though I’ve been in this position hundreds of times, I still feel the heat rise to my face and my heart rate increase. Princess’ owners are creating anxiety for me. I don’t want them to focus on the terminal nature of her condition. I want them to continue to focus on how treatable her disease is.

 

“I’ve seen dogs with lymphoma live years after a diagnosis!”, I exclaim with probably more enthusiasm than the situation calls for. Instead of being the practical and sensible doctor, I find myself grasping at the outliers – searching for the random cases where I can offer hope for a “better than average” scenario.

 

Anticipatory grief describes the grief reaction occurring prior to an expected loss.   It’s easy to understand how cancer patients or their loved ones would feel emotions associated with mourning future loss. It’s easy to understand how this would translate to veterinary medicine. Pet owners can experience sadness when thinking about loss of their companions.

 

What may be less easy to understand is how anticipatory grief factors in to the healthcare provider.

 

According to The National Cancer Institute, the following aspects of anticipatory grief have been identified amongst survivors:

  • Depression
  • Heightened concern for the dying person
  • Rehearsal of the death
  • Attempts to adjust to the consequences of the death

 

As doctors, we experience each of these same emotions when working with terminal patients.

 

Advanced treatment options allow us to manage many cancers in pets as chronic diseases. In some cases, this can mean 2 or more years of treatments, with multiple examinations, lab tests, and ups and downs.
During this time, I not only become “attached” to the pets, but also to their families. We travel calendar years encompassing holidays, life cycle events, and the ups and downs inherent to life in general. It’s easy to push aside the terminal nature of the cancer, and experience the pure joy of emotion associated with helping pets live longer and happier lives with their families.

 

Regardless of the diagnosis, pets will not live forever. Even if they are able to outlive their cancers, there are other disease processes that will eventually reduce their quality of life. This could result from the failure of another vital organ or severe orthopedic or neurologic disease, or even the development of a second (or even third) more aggressive form of cancer.

 

When we know pets will die from disease, we are obligated to provide owners with realistic expectations of their outcome. My mentor during my residency would often say “We do it for the five percent.” At the time, as a fledgling oncologist, I don’t think I truly understood the magnitude of his lesson.

 

Now, with a few years of experience under my lab coat, I see one interpretation of his wisdom would be we keep ourselves in this crazy profession for a small proportion of our patients and their families that we will truly feel connected to.

 

This does not translate to mean we don’t care about 95% of our patients. It means we are able to truly connect and maintain the connection with such a small proportion.

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What is my pet’s cancer stage? What does that even mean anyway?

Veterinary oncology is raft with confusing terminology. We toss around intricate multi-syllable words such as metronomic chemotherapy, radiosensitizer, and remission with little regard for their complexity of definition. I constantly need to remind myself to remember to simplify the language and take the time to explain the details thoroughly.

 

As an example, owners will often ask me what stage of disease their pet has at the onset of their diagnosis, when all we know at that point is they have a tumor that was previously biopsied or aspirated to be cancerous. When this happens, I have to remember to pause and take the time to define the term “stage” carefully so they can truly understand the question they are asking.

 

Stage refers to where in the body we find evidence of cancer. In veterinary medicine, we model our staging schemes off of those available for humans.  The World Health Organization (WHO) is the institution that establishes the “rules” for staging disease for people with cancer. Veterinary medicine lacks a similar governing body, however we use the paradigms established by the WHO and modify them for our needs.

 

We have accurate staging schemes for many of the common cancers occurring in primarily dogs and a few of the more common cancers in cats. Beyond that, we often lack information regarding stage, and for many cases the term simply does not apply to the case.

 

The most important aspect to consider for veterinary patients with regard to stage of disease is that to accurately assign a stage to their case, the pet would need to undergo all of the essential diagnostic tests required to provide the information.

 

The best example would be lymphoma in dogs. The modified WHO staging scheme for this disease is as follows:

 

STAGE FINDINGS
1 Single lymph node on one side of the diaphragm
2 Multiple lymph nodes on one side of the diaphragm
3 Multiple lymph nodes on both sides of the diaphragm
4 Liver and/or spleen involvement (+/- any lymph node involvement)
5 Extra nodal involvement (e.g. bone marrow, peripheral blood, skin, eyes, etc.)

 

 

In order to truly know what stage a dog with lymphoma would be, we would need to do the following diagnostics: Physical exam, complete blood count with pathology review, chemistry panel, urinalysis, lymph node biopsy, three view thoracic radiographs or thoracic CT scan, abdominal ultrasound or abdominal CT scan with sampling of the liver and spleen, and bone marrow aspirate.

 

These diagnostics range in terms of invasiveness, ease of performance, availability, and cost. For the average canine patient with lymphoma, the results of these tests would ultimately also not change our recommended treatment plan and could wind up costing thousands of dollars that would better be spent on battling their disease.
Therefore, in most cases, we find ourselves “picking and choosing” the diagnostic tests we need to have performed in order to best assess that particular patient’s disease status and to provide reasonable expectations as to prognosis, while maintaining resources for treatment.

 

Though I recommend full staging for all patients with lymphoma, I can recognize this may not be an option for all owners. For some cases we will move forward with treatment based solely on lab work and some sort of test on an enlarged lymph node whereas for others I will more strongly urge for biopsy or imaging tests or a bone marrow aspirate. In an ideal world we would have all the available information we could about our patients, but in reality, this just isn’t possible.

 

Some studies show the higher the stage of disease, the poorer the outcome for dogs with lymphoma, however my clinical experience starkly contrasts such information. To me, it’s not how “widespread” the disease is in the patient’s body, but rather how they are feeling at the time of diagnosis and whether we see it in specific anatomical areas or not.

 

For other tumors types, performing staging tests to examine for spread of cancer is often very important as it will dictate my treatment recommendations and will allow me to better determine a patient’s chance of response to treatment.   For owners, knowing how advanced their pet’s disease is at the time of diagnosis allows them to make decisions about their care and to be realistic about their outcome.

 

What can be most surprising is that in some cases, stage simply doesn’t seem to make a difference at all.   A dog with a very large brain tumor may theoretically have stage 1 disease, but may have a very guarded prognosis due to the size and inoperability of the their tumor. A dog with stage 5 lymphoma may have a prognosis of  1 or more years with treatment.

 

I’m not one to become hung up on terminology or numbers, so I try to focus on the individual characteristics of the animal I am treating. Yes, stage matters, but what matters more is how the pet is feeling and what realistic options we have for them.

 

The tests are important, but what is more important is the actual patient. That’s often the only stage that truly matters in the end.

 

 

 

“Doctor, what would you do if this were your pet?”

One of the most difficult questions I am asked by owners is “What would you do if this were your own pet?” Though intellectually I understand why my answer would be perceived as meaningful, I find it challenging to respond and feel as though I’m speaking truthfully because the time it would take to answer their question would likely surpass the hour I have allotted for the appointment. My dilemma is as follows: It’s impossible to approach my own pet’s health without simultaneously examining the situation through the lenses of my life as a doctor and as a doctor I am afforded insight and opportunities not available to the typical pet owner. I am simply unable to separate being a pet owner from being a veterinarian when it comes to decisions regarding the care of my own animals.

 

Despite the variety of diagnoses and prognoses I discuss, the majority of owners have the exact same concerns when considering whether to pursue treatment for their pet. Their primary concern centers on what can be done to maintain a good quality of life for their pet while not acting selfishly with regard to decisions, and their secondary concerns include the emotional, time, and financial considerations the decision would entail. I would want all of the same things for my own pets if placed in a similar situation and I know these are all surprisingly subjective scenarios.

 

Quality of life in veterinary oncology is a gray area. Sometimes it may appear straightforward: pets that are no longer self-sufficient or clearly exhibiting signs of pain have a poor quality of life. Other examples are less clear-cut: a dog with a bladder tumor that continually strains to urinate but still can empty her bladder, or a dog with a brain tumor that has occasional but controllable, seizures. Are their lives poor and should I recommend euthanasia for those cases? Even with the more obvious scenarios, it’s not exactly black and white upon further consideration. I have the ability to place feeding tubes in animals to bypass an unwillingness to eat and I can prescribe strong pain medications to sedate a pet and relieve pain temporarily.  In each of the above-mentioned scenarios, I struggle with what’s right and what’s wrong and what I might do if I were in those owners’ shoes.

 

More specifically, when it comes to decisions about pursuing chemotherapy for pets, as an oncologist I have a very different (and possibly skewed) view of what the expected side effects from a particular treatment could entail. For example, with all the different chemotherapy drugs I prescribe, I know mild side effects are seen in about 25% of pets, and severe side effects are seen in less than 5%.  I recognize what is considered in objective medical terms to be a “mild” side effect may mean something completely different when the pet is your own. No one wants to see their pet experience even a single moment of sickness, especially one secondary to a treatment they chose to administer.

 

I have so much firsthand experience with chemotherapy, and medical knowledge about what signs are typical and what are atypical, I know I would feel comfortable administering chemotherapy to my own pet. This is not true for the average pet owner – signs can be confusing and stressful, and not every owner is equipped with the ability to handle complications related to treatments. Were my pet to become sick from their treatment or from cancer, I could easily bring them with me to work and provide care for them, without concern for how it would impact my employment. This makes it difficult to be impartial about some of the concerns typical owners would face regarding pursuing treatment and potential side effects.

 

I also (fortunately) have very limited personal experience owning a pet with cancer. My cat was diagnosed with an aggressive form of leukemia when I was a first year vet student, and although I was far more balanced on the “pet owner” side of the bar than the clinician’s side , there weren’t really any options available for him, so my decision was ultimately not at all difficult in the end. I cannot begin to imagine the emotional rollercoaster owner’s face, especially while undergoing treatment. Remissions can be temporary, complications can arise in the middle of a plan, and sometimes it just seems as though bad news follows certain pets around like a shroud. The emotional aspect surrounding the role a pet plays in their particular household is so unique and complex that I feel it’s virtually impossible for me to impart my own thoughts on someone else’s situation.

 

I think the best I can do is attempt to assure owners the recommendations and discussions I make would not be any different if I were talking to myself versus talking to them. My objective is to be honest regarding my opinions, without feeling as though I’m trying to predict the future, and remain open to deviations from the “ideal” plan. If I accomplish this, then I am doing my job to the best of my abilities. In other words, I need to be able to sleep at night feeling comfortable knowing I’m being true to my chosen career, and ultimately, to myself, regardless of whether I feel comfortable or not in my specific answer to that difficult question.

 

What would I do if this were my own pet?

 

I’ll think about it and get back to you.

 

 

Winners never quit. Or do they?

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A discussion circulated on our veterinary oncology list serve last week about potential further treatment options for a pet with obvious end-stage cancer. The patient previously failed numerous standard of care chemotherapy protocols, as well as a few I would consider “not so standard of care”.

 

The oncologist posting on the list serve was inquiring about whether any of us had any anecdotal therapeutics we could offer. They acknowledged that although the pet’s disease was extensive and thus far refractory to all previously tried drugs, the animal’s quality of life was considered overall to be good, and as such, they were looking for advice.

 

As is typical for our list serve, a myriad of responses slowly trickled in. There were the usual “I’ve had success using xyz chemotherapy”, or “One time I used xxx drug and had a good response” messages, and I read though with mild interest, until one particular reply caught my interest.

 

The individual writing their retort essentially offered up the question: “Why do we feel compelled to try to treat these cases in the first place?” Though somewhat abrupt and crass in the wording, I paused to consider their inquiry.

 

On one hand, we have to consider that without trying novel treatments and without attempting to discover options never previously utilized, medicine would never advance. If we maintain the status quo, we can never expect progress and we will never hope to achieve a cure.

 

On the other hand, when it comes to animals with cancer that cannot voice their wants and needs, medical plans that possess risk of causing morbidity and/or mortality, and owners committing towards financing the recommendations we make, how can we in good faith and morals, discuss unconventional treatments?

 

Some colleagues suggested that not offering additional treatment options for owners is akin to “quitting” or “giving up”. I read those responses with mixed feelings, and surprised myself when I leaned towards feeling angry rather than in agreement with their sentiments.

 

Am I quitter when I tell an owner, “It’s time to stop” when I feel strongly any further treatment would be not only unlikely to help their pet, but could harm them? Do I give up too easily when a certain plan is not producing the results I anticipated? Am I not working as hard as some other oncologists to try to help my patients? Should I always be looking to push the proverbial bar? More importantly, why am I not interested in pushing things further and further when my gut tells me the outcome is likely to be poor and/or no different from if we did not pursue a particular plan?

 

There are times when I feel that when I was a less experienced doctor, I was more confident in talking with owners about diagnostic and treatment options. I think I truly believed in the “system”, meaning my faith came from textbooks, research studies, and previously established success rates. The more I’ve learned as I’ve practiced my craft, the more I recognize that animals do not care much for research or textbooks, and they tend to ignore the rules of physiology. I’ve also discovered there can be a distinct point of diminishing returns when it comes to cancer care for pets, which may or may not correspond to their owner’s designs and motivations.  In such cases, stopping treatment, even if an animal feels absolutely fine, is okay.

 

Ironically, I struggle with answering the question of how can we truly push the line of progress for veterinary oncology? The most obvious answer lies in our desperate, never-ending, and infinite need for well designed, controlled, and randomized clinical trials. Without such information, we are all literally spinning our wheels, spending owner’s money, and probably not helping patients in the long run.

 

But history tells us some of the greatest pioneers in medicine operated using only their ideas and brainpower, without funding for major research studies. These individuals were typically scorned as heretics and ultimately chastised for their ingenuity.

 

In fact, when the first multi-drug chemotherapy protocols were initially suggested as treatment options for a variety of childhood cancers back in the 1950’s, oncologists were deemed as “cruel” and “heartless”. These same protocols revolutionized the treatment of such diseases to the point of actually leading to cure.

 

Obviously those of us who wish to try different therapies for our patients should not be burned at the stake or tried for our convictions. What we must keep in mind for cases of terminal diseases it is our obligation to have a serious and realistic conversation with owners about everyone’s expectations and the potential outcomes.

 

As a solo oncologist in a busy private practice referral hospital, I’m not in the position to design my own studies or publish my own anecdotes. The limitations I face in making such an impact on my profession are innumerable. I can, however, use my experience and my judgment to assist owners in making decisions about their pet’s care, making sure everyone’s goals are achieved, including my own need to feel assured I am offering reasonable and fair options for my patients.

 

That doesn’t make me a quitter, but it also doesn’t make me a pioneer. It simply makes me the person who will make sure the quality of life for the animals I care for is the most important consideration in any treatment plan I devise.

 

 

 

 

 

When compassion leads to fatigue…

There is a quote from a prominent veterinary oncology text taped above the computer monitor in my office stating: “True oncological emergencies are rare. Emergencies of emotion, however, are quite common.” I realize this expression may not resonate well with an owner of a pet with cancer, and could even be misconstrued in an offensive manner. Yet, I personally do not see vindictiveness in the words, and I certainly do not display them with any malicious intent. For me, they serve as a reminder of how important it is to “Keep calm and carry on” as they say. Truth is, I find it far too easy to become caught up with the circulating emotions of my day and allow them to influence my life at and outside of work, and to lose sight of how my chosen profession represents only one aspect of the person I am. Those two sentences help ground me when I otherwise feel helpless to the turmoil of the day.

 

Compassion fatigue is defined as a deep physical, emotional and spiritual exhaustion accompanied by acute emotional pain. It can also be described as an extreme state of tension experienced by individuals helping people in distress, including preoccupation with the suffering of those being helped to the degree it is traumatizing for the helper.  Typically, compassion fatigue is thought of as a condition pertaining to people working in the human medical field, but is now becoming more recognized in veterinary medicine.   I often wonder, how can it be discerned when the line is crossed between caring enough and caring too much?

 

Veterinary medicine, as a whole, is a profession not built on gratitude. Veterinarians do not garner the same respect and admiration as our human MD counterparts, yet our degree requires similar undergraduate and graduate school degrees. Veterinary specialists complete internships and residency programs of similar caliber to human doctors, while competing for far fewer positions in each category overall, and once completing those programs, compete for far fewer jobs. I also find some owners are quick to find fault with veterinarians for a misdiagnosis, or what they perceive as a poor recommendations or communication, or worse yet, claim vets are more interested in generating revenue than maintain the best interests of their pet. Although there are probably some truly dishonorable veterinarians out practicing medicine, having worked in several hospitals over the past few years, I can’t say I’ve met one myself.

 

Veterinary oncology is not a glamorous specialty by any means. In fact, on the worst of days, it can be downright draining. Obviously the good far outweighs the bad, or else none of us could continue on this path for our livelihood. But there are many times when an owners feelings trump rational thinking, and in an instant, I am forced to step out of my role as medical advisor and transform into a psychologist or grief counselor. From experience, I can say this is not something taught from a book or a lecture in vet school. It’s learned experience combined with basic emotional capabilities, as well as a little bit of luck at times.   We may be able to give ourselves to our owners and our patients, but I have to question to what expense are we doing so?

 

I think people associate veterinary oncology with negativity because of a perceived increased proportion of patient-related deaths, but death is actually a rare event on our service. And often, when it is time to say good-bye to one of our patients, though absolutely heartbreaking, it is something owners know is the right thing for their pets and the emotional toll for me is tempered by knowing humane euthanasia is the kindest option for that animal. I’m not saying it doesn’t hurt to lose a patient, because it does. But the pain related to relieving suffering from a cancer diagnosis stems mainly from the loss itself, and is mitigated by knowing what I am doing is exactly what I am trained to do: relieve suffering and pain.

 

What I personally find far more emotionally impacting is finding a way to console owners, distraught over a recent diagnosis of cancer, who are only able to feel the urgency imparted by the diagnosis itself.   We recognize the strain this causes and we will do everything we can to fit the pet right away because we know it is not only important to help the animal, but sometimes even more so, to help their owners cope with the diagnosis and to educate them about what would be the next recommended steps. We continually work and re-work our schedules to fit patients in on emergency bases. Truth be told, there are few cancers so aggressive where waiting a day or two to schedule an appointment would truly make a difference in the pets outcome. And for cases of extremely sick pets with cancer, there are often very limited options for what can be done to help them, so that when we do fit those patients in on a last-minute basis, I have nothing to offer.  True oncological emergencies are rare indeed. But we are patient and understanding to the feelings and needs of our clients, sometimes to the detriment of our own.

 

The same is true for owners of pets currently undergoing treatment for their cancers. A single episode of vomiting or diarrhea, or a missed meal that typically would go virtually unnoticed now evokes a sense of urgency. I know it can be difficult for owners to discern what would be considered severe side effects from treatment versus “normal” mild adverse signs in their pets and we make ourselves overly available to help with their questions and concerns. This means we are continuously busy with phone calls and emails from owners, including days where we are not in the office seeing appointments. We field inquiries as rapidly as we can in order to assuage fears and triage emotions to the best of our abilities, keeping in mind on days we are seeing appointments, we are simultaneously usually dealing with new and equally distraught owners as mentioned above.

 

My standard of care is a proverbially impossible double-edged sword: I want my owners to feel as though their pet is the only pet I am concerned with at all times, yet simultaneously I want them to somehow understand and be cognizant of the fact that I treat dozens of patients a week who matter just as much to me as their own pet does.  I can tell you from experience, it is virtually an impossible task to keep everyone happy all the time.

 

A diagnosis of cancer is emotionally provoking on so many different levels. It’s certainly easy to see how this is true for the pet owner, and as a veterinary oncologist, I know part of my role is to help people cope with their concerns and be an advocate for their animal throughout their treatment plans. I would hope with the information provided above, I could offer some insight into the feelings encountered by the medical caretakers of pets with cancer. It’s hard for us too, but we accept our responsibilities gratefully, even when it feels as though the appreciation for our role wears thin. The good days far outweigh the bad days, and the true emergencies are rare.

 

Please remember that we do care, often more than we are comfortable showing outwardly. It’s all a part of what makes us so good at what we do.

When the doctor becomes the client: My experiences as the owner of a sick pet…

I recently attended a continuing education event on feline cardiac disease. The presenters were two cardiologists who work in the same building where I practice.

 

During the lecture, we were introduced to a “cageside” test called the Cardiopet feline pro-BNP assay. This is a blood test designed to screen cats for occult heart disease.

 

BNP is the acronym for “brain natriuretic peptide”, a protein originally isolated from the brain of pigs, designed to tell the body to excrete sodium when it is present in excess.

 

We now understand the primary source of BNP is not the brain, but rather the ventricles of the heart, and the main signal for the release of the peptide is excessive stretching of the heart muscle.

 

One such signal for stretch is the overload that occurs with increased blood volume secondary to increased salt intake. BNP promotes sodium excretion through the urine, and subsequently fluid will flow along with the salt. This helps reduce the body’s blood volume, reducing the stretch on the heart, and the BNP signal is turned off.

 

BNP levels will be inappropriately elevated in cats with heart disease due to pathological stretch of the heart muscle. The Cardiopet feline pro-BNP assay can measure the level of BNP in the bloodstream and serve as an assay for disease.

 

As I listened to the cardiologists describe the myriad of heart problems cats develop, I found myself wondering, “When was the last time I did a physical exam on my own cats?” I turned to my husband and declared, “We need to check the kids out!”

 

My two kitties" Nadir (left) and Sepsis (right)

My two kitties” Nadir (left) and Sepsis (right)

 

A few days later, when I actually remembered to bring my stethoscope home from work, we set out on the task of ausculting our three cats. “Sepsie” and “The Black Cat” were fine, in both demeanor and examination. When it came to my big, fat tabby man “Nadir”, whether a hunch, or a mother’s intuition, something told me he was going to have a problem.

Does this look like a problem child?

Does this look like a problem child?

 

I gently placed my stethoscope along his chest and listened intently. Immediately, my ears picked up an irregular rhythm.

 

Instead of the normal “lub dub” sounds, there were strange pauses in the cadence, intermixed with relatively rapid beats, followed by several seconds of regular heart sounds. My husband, who is also a veterinarian, verified my findings. All signs were pointing to Nadir having a heart problem manifested by an arrhythmia (abnormal heart beat.)

 

We immediately scheduled a consultation with the cardiologist.  We also decided to run basic labwork, including a measurement of his BNP level.

 

We assumed (incorrectly) since we were both vets, we could just draw the blood at home and bring it to work for submission. However, our many years of school, training, studying, loans, and experience were worth absolutely nothing when it came to dealing with our own pet.

 

My husband restrained Nadir, while I set up to draw his blood. Within 5 seconds, my calm, collected angel of a cat detonated into a “kitty bomb” replete with an abnormal amount of claws, teeth, and fur.

 

He screamed, kicked, bit, and fought his way out of our plan, ultimately leading us to abort our mission and forced us to bring him to work so the experts (read: veterinary technicians) could do the job we so incorrectly thought we were equipped to do.

We may look innocent, but we are most definitely not!

We may look innocent, but we are most definitely not!

 

Nadir’s labwork results returned later that afternoon, showing all values within the normal range with the exception of his BNP level. This was recorded as over 10 times the normal level. This finding, plus his arrhythmia all pointed towards an underlying heart problem.

 

His echocardiogram was scheduled for a few days later, and confirmed he had significant cardiac disease. He was ultimately diagnosed with unclassified cardiomyopathy with borderline severe left atrial and ventricular dilation. He also had fluid building up in the sac around his heart, indicating a mild to moderate degree of heart failure.
Nadir’s diagnosis was particularly frustrating as very little is known about the progression, treatment, and prognosis of his condition. I found myself in the same position as so many of the owners I deal with who have pets diagnosed with rare cancers. The cardiologist was able to offer several therapeutic options, but we really didn’t know what they would do to help him, or what his outlook would be. He literally could die tomorrow or in several years. There’s simply no way to predict what will happen.

 

Heart disease won't kill me, but plastic bags might!

Heart disease won’t kill me, but plastic bags might!

Nadir is now receiving 4 oral cardiac medications, divided amongst 5 daily doses. We are on a learning curve of successful administration, but we are exceptionally fortunate that (for now) he will take them all with treats. Cat owners of the world, please do not hate me for this. I truly recognize how lucky I am in this capacity.

 

My experience as the doctor who became the client was certainly humbling.    Whether cancer or cardiac disease or a simple skin infection, our responsibility as owners is to take care of our pets and make decisions regarding their health care with the greatest combination of scientific evidence, intuition, and love.

 

The focus in our home is not on prognosis – it’s on the “here and now.” And right now Nadir is sleeping soundly next to me while I write articles that hopefully help other pets live longer , healthier lives.

Good thing this guy knows how to take it easy!

Good thing this guy knows how to take it easy!

 

We both wouldn’t want it any other way.

Can you REALLY boost your immune system? Why this might not be such a great idea anyway…

Owners often ask me what can be done to help “strengthen” their pet’s immune system following a diagnosis of cancer. Whether it’s a result of clever Internet advertising, heeding the advice of friends or family members, or any number of personal motivations, I find this often posed question both challenging and humbling.

 

In veterinary school, we learn the immune system exists akin to a seesaw in perfect balance. Disease exists when one end of seesaw transfers too far towards either extreme.

 

If the balance falls towards the ground, the immune system is depressed, leaving pets susceptible to infection, and disease is an inevitable consequence. If the balance rises towards the sky, the immune system essentially operates in overdrive, attacking healthy cells what are known as immune-mediated diseases.

 

A “boosted” immune system (if such a thing existed) could therefore be just as harmful as a depressed one. The goal should be for patients to maintain a perfect balance, rather than tipping too far towards either extreme.

 

The expression “immune booster” suggests the immune system is akin to any other muscle of the body that can be worked out and supplemented in such a way as to strengthen it with conditioning and time. Unfortunately, such a view of this complicated body system is not only overly simplistic, but also completely inaccurate.

 

The immune system consists of innate protection, which is something organisms are born with. This consists of physical barriers to pathogens (e.g. the skin or mucous membranes). Signs of a healthy innate immune system include the itchy red bump you develop in your skin following a bee sting, or the annoying runny nose you have during a cold. I’m not sure boosting either of those reactions result in anything beneficial; in fact an overzealous allergic reaction to a bee sting causes what is known as an anaphylactic reaction, which in it’s most aggressive form, can be fatal.

 

The other major components of the immune system include passive immunity and adaptive immunity.   Passive immunity includes the transference of antibodies to a newborn from its mother during nursing.   Passive immunity tends to be temporary, lasting only a few short weeks to months in duration. Therefore, it’s impossible to “boost” passive immunity in an adult organism.

 

Adaptive immunity occurs when antibodies are generated following vaccination or natural exposure to pathogens. I imagine this would be the “sole target” for enhancement in an adult organism. But when we delve deeper into the design and organization of the adaptive immune system, we find it is so incredibly complicated and so difficult to understand that the first question we must consider is what part exactly are we trying to boost?

 

Are we trying to enhance the efficacy of B-lymphocytes as they produce immunoglobulins to attack pathogens? Are we working towards making T-lymphocytes work more efficiently to lyse foreign particles? Are we attempting to create more effective cytokines to stimulate immune reactions?   Do we want to fight intracellular or extracellular pathogens?

 

These are just a handful of the multitude of cellular and chemical reactions comprising the adaptive immune system. I would venture it’s impossible to simultaneously target all of these reactions and components with simple herbs and vitamins. Even if we could, would this be something beneficial for our cancer patients?

 

An “over boostered” immune system would be more likely to attack the body’s own healthy cells (e.g. what occurs in auto-immune disorders.) So, if it truly is possible to stimulate immunity, is it really something desirable for a cancer patient?

 

Special consideration should be given to patients battling cancers of the immune system (e.g. lymphomas, leukemias, etc.) If we were truly successful in making a patient’s immune system work harder and more efficiently, could we somehow be compromising our patients’ health in the long run? Could we be working towards making cancers of the immune system “stronger” and more resistant to our therapies?

 

We must also consider how one of the hallmarks of cancer biology is that tumor cells develop, proliferate, and spread as a result of their ability to evade their hosts’ immune system. Cells committed to a cancerous lineage develop clever ways to avoid being detected by their hosts’ immune cells. Regardless of how much training and stimulation the immune system engages in, it remains unable to detect the “wolfish” cancer cells existing amongst the “sheepish” healthy cells.

 

I’m not suggesting cancer develops as a result of an inherent problem with the host’s immune system. Rather, disease occurs because cancer cells discover ways to avoid the immune cells designed to survey for their existence. Yes, certain cancers are more common in immunocomprimised individuals, however these tend to be the exceptions rather than the rules for most tumors. In many cases, once cancer develops, the immune system has already lost a battle it never even knew it was supposed to fight.

 

I’ve said it before, but I think it’s worth repeating my advice to owners to heed the proverbial “buyer beware” when it comes to those companies claiming their products will “boost” your pet’s immune system. They may only serve to weaken your wallets in the long ru

But first, do no harm…

Primum non nocere is a Latin phrase that translates to “first do no harm.” This is the fundamental belief ingrained into doctors that, no matter the situation, our primary responsibility is to the patient.

 

The origin of the saying is uncertain. Examining the Hippocratic oath, the words uttered by physicians as they are sworn into medical practice, we find the expression “to abstain from doing any harm.” Though close in inference, this phrase lacks the impact associated with ensuring the first and principal consideration is the patient.

 

Ultimately, “first doing no harm” means in some cases, it may be better to not do something, or even to do nothing at all, rather than create unnecessary risk.

 

Veterinary medicine is no exception to the principle of primum non nocere. Like all doctors, I am expected to maintain the best interests of my patients above all else. Yet, unique to my profession, my patients are the property of their owners, who are the individuals responsible for decisions regarding their care.

 

One could argue medicine is medicine regardless of the species. Critical patients need stabilization.   Sick patients need remedies. Suffering patients need relief. Literal translation of the quote is not the problem. Difficulties arise when my ability to provide care for my patients is questioned by an owner, or when they surprisingly request treatments I feel are not in their pet’s best interests.

 

As an example, most dogs with lymphoma are often diagnosed ‘incidentally’, meaning their owners (or veterinarian, or groomer) detect enlargement of their lymph nodes, but the pets are otherwise acting completely normally at home and feeling well.

 

Some dogs will have some minor clinical signs associated with lymphoma, and an even smaller subset will be exceptionally sick at the time of their diagnosis. Cats seem to show signs of illness more frequently, and their diagnosis is usually made at what would be considered fairly advanced stage of disease.

 

Patients who are “self sufficient” meaning they are eating and drinking on their own, and are active and energetic, are much more likely to respond to treatments and much less likely to experience adverse side effects compared to those who are sick. Therefore, it’s remarkably easier to recommend treatments to with owners of pets showing no signs related to their diagnosis, than those who are. My confidence for a good outcome for such a case is high and my concern for doing harm to that pet is minimal.

 

For sick patients, I definitely struggle with the clichés of knowing “how much is too much?” and “when to say when?” My logical mind understands if we do not try to treat the underlying cancer, the patient has no chance of improving. Yet, this is exactly when the concept of “primum non nocere” enters my mind.

 

If the code of ethics I’ve vowed to uphold tells me I shouldn’t advocate anything that would cause harm to my patients, how can I determine what is reasonable to recommend and what crosses the line?

 

My mentor during my residency would often say “You have to break a few eggs to a make an omelet.”   Though the wording may seem crass, the take home message was simple: There will be times patients will become sick directly because of a decision I made about their care.

 

Of course, I also observe the opposite end of the spectrum –owners who seek approval to not move forward with treatments even when a good outcome would be nearly certain.

 

I’ve encountered many dogs with osteosarcoma whose owners refuse to amputate because they fear this surgery would ruin their pet’s quality of life. I’ve sat before countless numbers of owners who elect to bypass chemotherapy for their pets with lymphoma, for fear their lives would be miserable during treatment. I’ve euthanized animals where we were suspicious of a diagnosis of cancer, but made insufficient attempt at proof because owners are consumed with concern about what their pet would “go through” during testing.

 

As a veterinarian I interpret primum non nocere with a certain twist. I will tell owners “Just because we can, doesn’t mean we should.”

 

Advances in veterinary medicine afford opportunity to treat diseases previously considered incurable. We have specialists in nearly every field imaginable. We can place pets on ventilators. We can perform cardiopulmonary resuscitation. We can remove organs and even transplant kidneys. We can perform diuresis. We can give transfusions. And yes, we can even give pets chemotherapy to treat cancer.

 

All of these advancements make me consider, just because we can, does that mean we should? How do I decide if it’s more injurious to treat a patient versus not treat them? When it comes to health care in pets, who ultimately defines “causing harm?” It’s not an easy concept to answer, and I’m certain I’m not the only one who struggles with the question.

 

My responsibility and training tell me it’s my job to be my patient’s best advocate, even when that means disagreeing with their owner’s decisions. Even when I know there is more I could do, but cannot do because of external constraints placed on me.

 

Even when it means I not only first do no harm, but also do nothing at all.