Why I’m sometimes tardy for the party…

I am a person who thrives on organization. The clothes in my closet are not only color coordinated, but are subdivided into categories such as sleeve length, textile pattern, and type of fabric.

I’m one of the few standouts who prefer using day planners comprised of paper rather than electronic versions. I derive a deranged amount of pleasure in creating a multi-colored, sub-categorized to-do list.

My obsessive organizational skills carry over to how I approach my workday. I arrive at the same time each day. I have rounds set for 9 a.m. I have a set schedule of days I work per week, and I have set appointment times for new consultations and recheck appointments.
Despite my overwhelming need to appropriately “sort” my life and my agenda into well-ordered, compartmentalized portions, veterinary oncology is prone to chaos and unpredictability. My carefully structured schemes often fall to pieces, despite my best efforts to the contrary.

Innumerable variables lead to alterations in my day, the frequent consequence of which is appointments running behind and owners needing to wait.

I understand how frustrating this scenario can be. I value my time, and my aforementioned type A personality staunchly opposes tardiness when it comes to my own health care appointments.

On those occasions, I’ve caught myself considering what exactly it was my doctor or dentist was doing all day to be so far behind in their schedule. It’s easy to assume it’s because they were behaving in a lazy or inefficient or uncaring manner. How else could they manage to become so delayed?

I wish the reasons for lateness during my appointment days had to do with taking a break, resting my feet, or even just behaving rudely out of lack of concern about how my owners felt about me wasting their time. Unfortunately, if my well-oiled machine of promptness is falling off track it’s because of one or more far more serious conditions.

The most common reason for my lateness includes a patient presenting with complications related to their cancer, and/or owners needing more time from me than originally allotted by an already thinly stretched appointment book.

Most owners innately understand that tardiness on my part is a sign of something out of the ordinary. I’m also fortunate that my human doctor counterparts have set low expectations amongst pet owners of how medical appointments are “supposed” to flow. There’s also no arguing that some people are just exceptionally nice and remain persistently tolerant under such circumstances.

Doctor/client/patient confidentiality dictates that I am prohibited from revealing specific details about one owner or their pet to a different owner. However, when it is the case, I will apologize and explain that an unpredicted emergency arose and I try to assure owners that I will provide them with their fair share of my time once I’m able.

For some owners, however, urgency is still considered an insufficient excuse for tardiness and complaints are fired about terrible it is that they are being asked to wait. Ironically, these are typically the same people who would not only expect, but demand, that their pet be seen immediately should they be in the same position.

My schedule can also become backed up when owners are the ones running behind to their appointments. An owner showing up even 10 minutes late can turn a perfectly planned day into a frenzied mess.

I have no wiggle room built into my day. Unlike our human-care counterparts, I don’t have a policy of refusing to see a pet whose owner arrived more than a certain allotted time after their appointment time. I also always accommodate an owner who shows up on the wrong day or at the wrong time. Can you imagine your own physician or dentist’s office being so kind?

The fancy machinery I rely on to count blood cells or produce radiographic images undergoes mechanical meltdowns with enough frequency to make the category of “technical difficulties” another common cause of a delay.

I wish I had the luxury of taking a leisurely lunch or stopping mid-afternoon for a coffee break. I don’t particularly enjoy dealing with a distraught owner, or making follow-up phone calls to obtain records for my next appointment and subsequently causing a backlog in my appointments. I’d much rather sit down and catch up on my e-mail than race around the ICU looking for a helping hand to stabilize a patient.

If you’re at you veterinarian’s office and time is passing by, chances are your pet’s doctor is simultaneously juggling 4 or 5 different crises behind the closed doors of an exam room. They are also painfully aware of each minute that ticks past your appointment time, hoping you will not only be merciful about the delay but grateful for their attention to the other animals, knowing that yours will get the same.

It’s not easy to be patient, but keep in mind you may one day find yourself on the opposite site of the ticking clock, waiting to hear word from the veterinarian who is working tirelessly to help your pet.

What’s the one thing I absolutely cannot do my job without?

What tool is most critical for you to complete your job to your best and most efficient capability?

If you’re a graphic designer, is it a lightning fast computer processor equipped with the latest software? If you’re a pilot, is it a state of the art turbine engine propelling a multi-million dollar aircraft? If you’re a professional tennis player, do you require the most technologically designed tennis racket to play your best?

One could argue that a talented artist would be equally as creative with a piece of paper and a pencil as with a fancy computer, or that a pilot could fly a propeller plane with just as much expertise as a Boeing 787 Dreamliner, or that Serena Williams would still be a phenomenal tennis player using a wooden racket strung with yarn. But when those individuals are equipped with advanced tools designed specifically for their respective crafts, they are able to produce extraordinary outcomes.

As a veterinary oncologist, the equivalent of my high-tech-Dreamliner-graphite-tungsten tennis racket is an impeccably written, thorough, and all-inclusive biopsy report.

Biopsy reports are essential to my ability to make diagnostic and treatment decisions for my patients. Biopsy reports provide me not only with a diagnosis, but also an interpretation of how likely the cancer will be to spread and what that animal’s needs for further local and/or systemic treatment might be.

The pathologist interpreting the submitted sample is responsible for writing the biopsy report. Unfortunately, standardization is lacking regarding what information should be included, and vast variations exist in the quality of reported information.

At minimum, a biopsy report should include a portion (if not all) of the history provided by the submitting veterinarian, a morphologic description of what was observed under the microscope, and a finalized histological diagnosis.

Ideally, biopsy reports include so much more.

A report should break down the morphologic description into two parts: the gross description and the microscopic description.

The gross description would include information related to the tissue sample as visualized with the naked eye. This would include information about the color, weight, size, and consistency of the submitted sample. This is not a typical feature of most biopsy reports because instead of receiving the actual tissue sample, the pathologist receives a set of pre-processed slides.

The microscopic description should include descriptions of the cells, including whether they are consistent with a cancerous process or not. If they are cancerous, the report should indicate how different they appear from healthy cells. The size, shape, and staining characteristics of the cells should be indicated.

The pathologist should use this information to assign a grade to the tumor. When the cells are similar in appearance to healthy cells, this is consistent with a low-grade or well-differentiated tumor. High-grade, poorly differentiated, and/or undifferentiated tumors are comprised of cells that vary drastically in appearance from healthy cells.

A biopsy report should also include a numerical quantification of mitotic rate, which is a parameter that is thought to correlate with the rate of division of cancer cells. Tumors with a lower mitotic rate are usually low grade and correspond to a better prognosis, whereas high mitotic rates often correlate to a higher grade and more aggressive biologic behavior.

Reports should include a description of whether tumor cells can be found at the margins (edges) of the biopsy, and if not, there should be quantification of the distance between the last tumor cell observed and the cut edge of the specimen. If tumor cells are present at the edge, this indicates that the tumor was not entirely excised and that there is a potential for regrowth and/or spread.

The pathologist should also record whether they observe any cancer cells within blood or lymphatic vessels. The presence of cancer cells within either vessel raises concern for the possibility of the spread of disease to distant sites in the body.

Pathologists should also indicate if further testing to identify specific genes, proteins, or other factors could help better characterize the tumor. Many times I use the results from such tests to tailor a treatment plan specifically for the patient attached to the report.

Far too frequently I am asked to consult on cases where the biopsy reports lack one (or several) of the aforementioned aspects. This limits my understanding of a pet’s diagnosis and restricts my ability to fully treat its cancer. Not only does this render me unable to answer an owner’s questions about their pet’s disease, but also I am unable to determine the best plan of action for that patient.

I require a high-quality biopsy report to perform my job to the best of my abilities. Without this tool, I’m unhappy with the product of my efforts. It doesn’t take much for us to ensure that the outcome for our patients moves from subpar to superb.

So pathologists—I challenge you to let me release my inner Serena and send me the Dreamliner of biopsy reports!

Survival time isn’t the end…

Most owners of pets with cancer are fixated on the familiar phrase “survival time.” The words describe the approximate length of time a pet is expected to live following its diagnosis.

Survival time is a meaningful endpoint to measure for humans with cancer, where death occurs as a natural part of disease progression. In veterinary medicine, survival time is a complicated marker of outcome because of the bias introduced by euthanasia.

I struggle with answering owners when they ask me to predict their pet’s survival time. Despite being an expert in veterinary oncology, trying to anticipate how long a patient will live is nearly impossible.

Experience affords me the ability to describe the signs their pet will show as the disease progresses. I can forecast whether there will be issues related to appetite or pain, respiratory or gastrointestinal distress. I can usually pinpoint how long a decline will last on the order of days to weeks to months. But I cannot tell an owner how long their pet will live because that decision, in the vast majority of cases I see, is up to them. I’ve written about this topic before in an article describing Euthanasia Bias.

Consider the hypothetical scenario of two different sets of owners of dogs with an identical diagnosis of lymphoma. Lymphoma is a common blood borne cancer in dogs and cats.

Dog #1, a 5-year-old mixed breed, was diagnosed after his primary veterinarian palpated enlarged lymph nodes during its physical exam performed prior to routine vaccinations. Lymphoma is frequently diagnosed incidentally, as was seen in this dog that showed no adverse signs related to its cancer.

Dog #2, a 14-year-old shepherd, was determined to have lymphoma after his primary veterinarian performed a thorough diagnostic work up for a several week history of lethargy, vomiting, poor appetite, and weight loss.

Both dogs were diagnosed with the same cancer. Both owners underwent the same consultation with me and I made the exact same diagnostic and treatment recommendations in each case.

The statistics and data I memorized in order to become a board certified medical oncologist tells me that without treatment, dogs diagnosed with lymphoma live an average of one month. With treatment, survival time is about 12 months. This information was relayed to both owners, including expected quality of life, both with and without treatment.

Dog #1’s owners elected to pursue treatment. They felt their pet was young, otherwise healthy, and they possessed the emotional and financial reserves to move forward with all of my recommendations. Their pet underwent six months of treatment, attaining remission for a total of 14 months, and was euthanized when the cancer resurfaced and clinical signs caused a decline in quality of life unacceptable to their standards.

Dog #2’s owners elected to euthanize their dog the day after meeting with me. They knew their pet was geriatric and approaching the end of his normal expected lifespan. Their dog was also sick at the time of diagnosis, further reducing their interest in pursuing aggressive treatment.

In each instance above, despite the identical diagnosis, the survival times are vastly different—1 day versus 20 months.

These examples demonstrate several key points:

Despite what research studies suggest, neither dog lived to their expected survival. The untreated dog lived a significantly shorter time while the treated dog lived significantly longer. My predictions for survival time were incorrect in both cases

In both cases, the owners decided their pets’ survival time. Neither dog passed “naturally,” so we will never know an accurate numerical time frame for how long they would have survived.

Variables such as age, overall health status, finances, etc. always play a role in how long pets with cancer will survive. These are unpredictable influences that change outcome equally as often as the more controllable variables do.

I understand why survival time is a major consideration point for owners of pets with cancer. But I also understand my limitations in anticipating survival for the majority of animals I meet.

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Owners are often frustrated when I’m vague in my description of how long I believe their pet will live. Many are disappointed the information cannot be measured in more absolute terms.

The best I can do is honestly and openly guide owners through their journey with a pet with cancer and guide them toward the endpoints I consider essential in making decisions about life, death, treatment, palliative care, and quality of life.

Even if the journey is only a few hours long, my job is to ensure that time truly is the most sacred part of the phrase “survival time.”

A surprising risk of chemotherapy you may never have considered…

During the final year of my residency in medical oncology, I was required to give chemotherapy to my patients with cancer. One case that stands out is a cat I treated with intralesional chemotherapy for a recurrent fibrosarcoma.

As a typical resident, I possessed an inappropriate level of enthusiasm about this task and I asked one of my colleagues to take pictures of me performing the treatment.

In one picture I’m mixing two syringes: One contains sterile sesame oil, which provides a repository for the chemotherapy to remain in the tissue after injection. The other contains carboplatin chemotherapy.

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Improper mixing of chemotherapy using minimal personal protective equipment and incorrect syringes/adaptors

In the next picture, I’m injecting the sesame oil/chemotherapy mixture into the surgical scar on the cat’s head. The only personal protective equipment I’m wearing in either picture is a pair of nitrile gloves.

I had a healthy respect for the hazards related to chemotherapy, but I primarily focused on those related to side effects. I knew which drugs were vesicants versus irritants (i.e., severe blisters versus annoying rashes), and the deleterious effects they could wreak on bystander organ systems.

What I lacked was an understanding of the risks that unsafe handling of chemotherapy posed to my health. In fact, the bulk of my awareness of chemotherapy safety came following my board certification.

The treatment of cancer in pets is far more popular today than ever before. Yet there is a lack of concurrent education of the risk chemotherapy poses to the healthcare team during its preparation, administration, and cleaning of eliminations.

Studies characterizing the impact of secondary exposure to chemotherapy on human oncology health workers with regard to cancer prevalence, reproductive risks, and acute toxicities show little risk.

However, markers of toxicity and measurable levels of drugs and their metabolites have been found in the urine of healthcare workers exposed to chemotherapy. This occurs in highly trained and experienced individuals working in human medicine, where, unlike working with animals, contact with bodily eliminations (a major source of contamination) is minimal.

Veterinary studies regarding environmental risks from chemotherapy are lacking. We know dogs undergoing chemotherapy treatment for lymphoma and mast cell tumors have measurable levels of vincristine, vinblastine, and doxorubicin—all chemotherapy medications—in their urine at up to 3, 7, and 21 days after administration, respectively. This is a serious consideration for potential exposure.

Pet owners ask a lot of questions about chemotherapy and what to expect as their dog or cat goes through treatment. Surprisingly, I’ve never been asked about what ‘s done to ensure the treatments are done safely and without risk to their animal or to the staff. Either they haven’t considered the consequence of a lack of experience with the treatments or, more likely, they simply assume correct measures will be taken.
Here are some key points related to safe administration of medications that chemotherapy clinics should employ on a regular basis:

Experience is key:
Any technician or doctor giving chemotherapy must be adequately trained in the safe handling and administering of the drugs. Persons administering drugs need to be familiar with their mechanisms of action, correct dosage and route of administration, side effects, and potential routes of exposure.

Use a hood:
A class IIB or III, biological safety cabinet contained in a separate room, with venting to the outside should be used for the preparation of chemotherapeutic drugs, including oral medications. Using the appropriate biosafety hood ensures inadvertent contact does not occur through aerosolization during the preparation of drugs, or in case of accidental spill.

Use a closed, contained system:

Proper use of a commercially available closed contained system for administering chemotherapy

Proper use of a commercially available closed contained system for administering chemotherapy

There are several options for commercially available adaptors for syringes and vials used in the preparation and administration of chemotherapy. These systems reduce the risk of aerosolization of vapors from drug containers to ensure no drug leaks out of the syringe into the air or on the staff or pet’s skin during treatment. These systems do not circumvent the need to use a hood as mentioned above.

Dress for the Job:
Individuals should wear powder-free latex or nitrile gloves along with the appropriate chemotherapy resistant face shields and eye protection, and a closed-front, elastic cuffed, non-permeable, lint-free gown.

Be prepared:
Should a chemotherapy spill occur, commercially available spill kits are recommended, and staff must be trained in the appropriate way to clean bodily fluids from patients and also any surfaces coming into contact with chemotherapy during its preparation and administration.

 

I’ve always sought to deliver the highest standard of care for my patients. Time and experience allowed me to recognize the importance of extending that goal to provide the highest level of safety for my co-workers, owners, and myself. If your pet receives chemotherapy, I would urge you to inquire about the safety measures taken to ensure that those involved in your pet’s treatment are doing the same.