What’s the scariest word this oncologist ever heard?

The vernacular surrounding a diagnosis of cancer is intense: We speak of fighting the disease. Those who endure treatment are survivors and warriors. We battle against it, and ultimately, we dream of a world where cancer is eradicated.

 

I’m a proponent of the concept of a war on cancer. I know we need to be aggressive in order to have any success in beating this disease. I’m happy to be a part of the frontline of defense and I toil hard to treat patients and provide them with longer and happier lives. Yet, there’s one term related to cancer that’s guaranteed to fracture my assertive exterior and cause me to stumble in my dialogue with owners. The word is cure.

 

Owners will ask me what the cure rate for a particular tumor is, or if their pet will ever be cured, or when and how I will know their beloved companion is cured. When the topic comes up, I always feel somewhat anxious and unsettled. The irony isn’t lost on me: How can the one word that embodies the very thing I wish for my patients simultaneously instill such intense insecurity within my soul?

 

To answer candidly, it comes down to the pressure imparted by the accurate meaning of the word cure that’s most overwhelming. Cure implies the disease was eradicated from the body, and will never return. To me, stating a patient is cured from cancer is akin to offering an impossible guarantee of future health.

 

I’m not being negative and I’m not trying to perpetuate the pervading sense of hopelessness surrounding a diagnosis of cancer. Believe me, I’m there fighting just as hard as the next doctor. But if I treat a patient, and find their cancer is in remission, it’s extremely difficult to say if or how long the remission will last. Remission simply means I’m unable to detect the disease using conventional diagnostic tests. It doesn’t guarantee eradication of every last tumor cell and it doesn’t equal a cure.

 

I’m not alone when it comes to my careful word choice in relation to my patients. Human oncologists speak more frequently in terms of 5, 10, and 20-year survival rates rather than label people as cured. Though I appreciate how frustrating it would be to hear a physician say, “You have a greater than 80% chance of living 20 years from your diagnosis”, instead of “You’re cured”, I also know what it feels like to face someone who desperately wants to hear me say their pet is cured and know deep down I can’t reliably mean it.   It’s not because I’m afraid of being wrong. It’s because I’m afraid of not being honest.

 

I would urge pet owners to be wary when they hear phrases such as “We got it all” or “There’s no evidence of spread” or “We caught it early”. Though they may be exactly what you are so desperately hoping to hear, these “cancer colloquialisms” are likely inaccurate representations of your pet’s health.

 

The only way we can say a patient is cured from cancer is for them to pass away from an unrelated cause with their cancer being completely undetectable at the time of their death. Many owners are surprised at my candor when I tell them this is my definition of cure, but I would rather be authentic and considered forthright than to give an owner a false sense of optimism.

 

This doesn’t mean we should lose sight of the most important term related to a diagnosis of cancer: Hope.

 

If we didn’t have hope, we would lose our motivation to attempt to treat patients.

 

If we didn’t have hope, we would not have the motivation to try to battle this disease.

 

And most importantly, if we didn’t have hope, we would never even have the ability to envision the concept of cure.
I hope one day the word cure no longer instills a sense of apprehension within me and I’m able to utter it with confidence and candor. Until then, I’ll keep fighting the battle along with the remarkably brave four-legged warriors I have the privilege to meet.

 

What’s the scariest word your veterinarian could ever say to you?

 

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Confused by veterinary oncology terminology? Let me help you figure it all out!

Chemotherapy and radiation therapy are confusing topics. When complicated terminology is combined with the anxiety associated with a diagnosis of cancer, it’s easy to understand how things become blurry.   Further complicating things are those veterinarians who cross specialties. How can an owner keep be expected to keep it all straight?

 

Chemotherapy is defined as the use of chemical substances to treat disease. Conventionally, we think of chemotherapy in relation to treating cancer. Chemotherapy can be administered intravenously (through a vein), topically (on the skin), subcutaneously (under the skin), intramuscularly (into a muscle), orally, intratumorally (injected directly into a tumor), or intracavitary (given directly into a body cavity.)

 

Adjuvant chemotherapy is prescribed after a tumor is removed and we are hoping to treat any microscopic residual cancer cells that may have spread from the tumor prior to surgery. An example of adjuvant chemotherapy is treating a dog with osteosarcoma with a drug such as carboplatin following amputation of their affected limb.

 

Neoadjuvant chemotherapy is used prior to surgical removal of a tumor or treatment with radiation therapy. The goal is to reduce the size of the tumor, affording the patient a less complicated “next step.” Neoadjuvant chemotherapy plays a big role for many human cancers, but unfortunately, has a fairly limited role in veterinary medicine. Neoadjuvant chemotherapy can be helpful is in treating cutaneous mast cell tumors, reducing the size of a tumor, thereby making it more “amenable” to surgery.

 

Induction chemotherapy is used to cause remission of disease. This would be the treatment of choice for blood borne cancers such as lymphoma or leukemia. Induction chemotherapy is often combined with consolidation and/or maintenance chemotherapy, to maintain a long-term remission.

 

Regardless of how it’s used, chemotherapy is considered to be first line when the efficacy of the drug(s) was proven during previous clinical trials and is the most effective treatment known for the particular disease in question.

 


Second line chemotherapy (otherwise known as “rescue” or “salvage chemotherapy) – is prescribed when first line treatment is ineffective, or recurrence of disease is detected following initial treatment.

 

Radiation therapy involves the use of ionizing radiation to treat tumors. Radiation therapy is most commonly delivered by a machine outside of the body (external beam radiation), but also can be administered from a handheld source very close to the body (Strontium-90), via implantable radiation sources (brachytherapy), or even systemically, where radioactive substances that travel in the bloodstream (e.g. 131I for treating feline hyperthyroidism.)

 

Radiation therapy can also be used in the adjuvant or neoadjuvant setting. Prior to starting radiation treatment, patients typically undergo a CT scan of the affected area. The images obtained by the scan are used to plan the number and specific site of administration of the radiation treatments, as well as delineate any anticipated side effects.

 

Patients must be positioned exactly the same way for each treatment, which means pets must be anesthetized every time they receive radiation. Various molds, “bite blocks”, or other devices may be constructed to facilitate accurate patient positioning. Markings are made along the skin and regions of fur may be clipped as well.

 

Chemotherapy can be administered simultaneously with radiation therapy in what are known as radiosensitizing protocols. This goal of this form of therapy is to increase the efficacy of the individual radiation treatment. Patients are monitored carefully, as side effects can be more pronounced.

 

A board certified medical oncologist is trained in the safe handling, use, and administration of chemotherapy drugs, as well as the treatment of patients with chemotherapy. Medical oncologists spend time learning the principles of radiation oncology and are capable of managing radiation cases, but they are not considered board-certified radiation oncologists. In the US, veterinarians achieve board certification via meeting requirements put forth by the American College of Veterinary Internal Medicine (www.acvim.org).

 

Radiation oncologists are specifically trained in the physics and biology of ionizing radiation and the treatment of cancer patients with radiation therapy. They are specialized in art and science of radiation treatment planning. Radiation oncologists spend time learning medical oncology during their training, but are not considered board certified in medical oncology. To achieve board certification in radiation oncology in the US, veterinarians must complete requirements put forth by the American College of Veterinary Radiology (www.acvr.org.)

 

It’s common for medical oncologists to offer radiation therapy to patients, while not having a radiation oncologist on site at the facility where the treatments are being administered. Those facilities most often use remote treatment planning, where either a veterinary radiation oncologist or human dosimetrist (who is not a veterinarian) receive the images generated by the pre-treatment CT scan and devise the treatment plants. The plans are sent to the medical oncologist, who oversees the treatments.
Likewise, some radiation oncologists elect to administer chemotherapy or immunotherapy treatments, either with or without having concurrent medical oncologists on staff.

 

In a perfect world, pets would always be treated by the veterinary specialist possessing the most specialized training for their disease. This isn’t always possible based on geography or finances or other unforeseen circumstances. However, far too many times pets are not offered ideal treatment because a lack of communication and education. This can occur when an owner or primary care veterinarian is unsure or unaware of the qualifications of the attending veterinary specialist or even when there’s a misrepresentation of what a facility has to offer (e.g. specialty or primary care hospitals with no medical or radiation oncologist on staff that offer “oncology” as a service.)

 

Owners should not be afraid to ask about the credentials of the doctor taking care of their pet. Specialists should do a better job of educating the public about the pros and cons of when they acting outside of their “board certified” role. And primary veterinarians must be honest with owners about their limitations when it comes to practicing specialty medicine.

 

We are responsible for making sure owners know exactly what we can, and can’t, do. And to let them know when someone could do it better.

 

 

 

Diet, Dogs, and Cancer: Some general guidelines to think about…

Nutrition can play a significant role in the management of dogs and cats with cancer. Pets with cancer could experience weight loss because of decreased intake of food secondary to physical obstruction (e.g. a tumor growing within the oral cavity) or because of decreased appetite secondary to side effects from various treatments. However, some pets with cancer will lose weight even though they are ingesting adequate amount of calories per day. Cancer cachexia is the specific terminology that applies to weight loss despite adequate nutritional intake seen in patients with tumors. The weight loss comprises both the loss of both lean body mass and fat stores. This can lead to problems with healing wounds, immunosuppression, and organ dysfunction.

 

Surprisingly, studies indicate many pets with cancer are actually overweight or obese at the time of their diagnosis. It is unclear whether over conditioning contributes to the development of cancer. The nutritional management of these patients can be a challenge. There are many concurrent health risks associated with obesity including musculoskeletal disease, diabetes, glucose intolerance, and immunosuppression. Therefore weight loss in these patients would certainly be beneficial for long-term survival. However, balancing planned weight loss in the face of treatment is difficult, and the typical weight-loss plans used for healthy animals are not appropriate for our cancer patients.

 

The major building blocks of any diet include carbohydrates, fats, and proteins. Several different metabolic alterations in these nutrients have been discovered in pets with cancer:

 

With regard to carbohydrates, tumor cells readily use glucose as a source of energy, and the by-product of this metabolism is lactate. Lactate is a cellular waste product that can be converted back to glucose, but this occurs at the net expense of energy by the animal, contributing to a cachectic state. Dogs with various types of cancers have elevations in blood lactate levels and elevated blood insulin levels, compared to healthy control dogs, and these changes do not always resolve following treatment of the tumors.

 

In one study, dogs with cancer had alterations in several different blood levels of amino acids, the building blocks for protein synthesis. Like carbohydrates, these alterations in amino acid levels did not normalize following removal of the tumor, suggesting long-lasting effects in protein metabolism are caused long before treatment is initiated. This could contribute to immune system dysfunction and poor wound healing.

 

Similarly, another study showed that dogs with cancer have altered lipid profiles that favor the catabolism of fat tissue, which may contribute to the development of cachexia. In one study, a small number of dogs with lymphoma were fed an experimental diet supplemented with enhanced levels of n-3 fatty acids. Results indicated for a specific subset of dogs with lymphoma (Stage III only undergoing treatment with single-agent doxorubicin chemotherapy), dietary supplementation with n-3 fatty acids contributed to longer disease-free intervals and survival times. In another study, dietary supplementation with n-3 fatty acids decreased radiation-induced damage to the skin and oral mucosa in dogs with nasal tumors.

 

The ideal nutritional requirements for pets with cancer remains unknown, however as indicated above, we know that these animals show signs of alterations in the metabolism of carbohydrates, fats, and proteins, and that changes in the metabolism of these nutrients will often precede any clinical signs of disease and/or cachexia. Therefore, general recommendations for dietary requirements for cancer patients typically consists of a combination of:

 

  • Small amounts of complex carbohydrates (crude fiber levels > 2.5% of dry matter)
  • Minimal quantities of rapidly absorbed simple sugars
  • High quality but modest amounts of digestible proteins (30-35% of dry matter for dogs and 40-50% of dry matter for cats)
  • High amounts of unsaturated fats (>30% of dry matter)
  • Omega-3/DHA essential fatty acid supplementation – consult with your veterinarian for appropriate dosages

 

These components can be achieved through various commercially available diets or via home cooked diets that have been properly reviewed by a veterinarian.

 

It is very important to keep in mind is additional research is necessary before making sweeping generalizations with regarding the ideal diet to feed a pet with cancer. The optimal dietary requirements will vary based on individual patients needs, their type of cancer, and also the presence and severity of concurrent diseases (e.g. diabetes or hyperthyroidism).  Many owners are Internet savvy and a quick Google search using the terms “diet, pets, and cancer”, returns thousands of websites containing a tremendous amount of information, unfortunately, most of which is unproven, over-interpreted, and not evidence based.

 

One of the most important thing I always stress to pet owners is that it’s never a good idea to implement any diet change and/or addition of supplements or nutraceuticals at the same time their pet is scheduled to be starting chemotherapy and/or radiation therapy, as we want to limit the number of variables that could cause adverse side effects. Once the pet has started on their treatment plan as long as they are doing well, that is the time to consider any type of diet modification. Important considerations to make when thinking about any kind of change would be to serve foods that are highly bioavailable, easily digestible, and also are highly palatable with a good smell and taste in order to avoid food aversions and encourage appetite.

 

I also stress to owners that many of the terms used to describe pet foods on labels and in advertising materials are not legally defined. For example, there are no regulatory meanings for the terms holistic, premium, ultra- or super-premium, gourmet, or human grade. Therefore it is important to be educated about reading labels and to be swept in by some of the claims made by pet food companies regarding the integrity of their products.

 

I also make it clear to owners that as a medical oncologist, I am aware of research within the field of veterinary nutrition, but I strongly feel expert opinions are best obtained via consultation with a board certified veterinary nutritionist, and therefore I urge them to seek information and advice available through the American College of Veterinary Nutrition (http://www.acvn.org).

Further information on lymphoma

Can you really be anything you want to be?

During the most recent annual convention of the American Veterinary Medical Association (AVMA), a panel entitled “Veterinary Oversupply: Issues and Ethics” was held. Though I did not attend the conference, I discovered several summaries of the events that transpired during this session, written by its various participants and observers. I read the reports with equal parts enthusiasm and anxiety. Unfortunately, they did little to encourage a positive opinion.

Citing results from the AVMA workforce study published in April 2013, recording a 12.5% excess capacity of veterinarians, one side of the panel put forth the opinion that “the veterinary profession is in or near acute crisis, with its constituents facing poverty and despair in a few short years.”

The opposing side “theorized that the expanding number of veterinarians is just what the profession needs to serve society’s needs as pet ownership and population numbers soar in the near future.”

How can we have completely opposing outlooks on the current status of veterinary medicine and what should be done to influence it’s future? Is this a simple scenario of having two sides to every story? How is it possible, in matters related to something that should be black and white, that there are clearly disparate points of view? How can veterinarians be simultaneously facing a miserable future and immense prosperity?

Facts tell us things are skewing towards the more unfortunate side of the spectrum. The trend over the past 15 years shows a disproportionate increase in veterinary student loan compared to increase in salary. The average new vet carries about $150,000 in debt and can expect to earn a median income of about $65,000 for their first year of work. This translates a debt to income ratio of 2.4. Contrast this with comparable professions, including physicians (starting debt-to-income ratio is 1), dentists (1.7), and attorneys (1.7), and things can start looking more than a little scary.

There are 28 veterinary schools accredited by the AVMA, with two new schools having opened their doors to students this past fall. Consistent loss of state funding has crippled some schools financially, leading to increased tuition rates and increased class sizes. There are currently nearly 4,000 new graduates each year, up from about 2,500 in 2010. We’re certainly prolific at producing more doctors, but one must question, where are they going to work and how will they pay off their debt?

More and more new graduates elect to purse internships and/or residency programs. Many of those candidates carry the perception that the job market for specialists/internship-trained vets is better and they will be compensated financially at a higher level in the long run. Data suggests the opposite may be true; where their debt accrues further interest during a period of time of minimal income, pushing doctors further behind financially.

Despite the overabundance of veterinary graduates and oversaturation of clinics in certain regions, many geographical areas remain underserved for both primary care and specialty veterinary medicine. Sadly, there is little incentive for veterinarians to work in these areas, resulting in little opportunity for change.

Simultaneously, there are far too many pets lacking veterinary care despite easy access to primary care and specialty medicine because of a continued lack of perception of the value of what the profession can offer.

Suggestions put forth to remedy the economical downturn are to freeze current tuition rates, to reduce the time required for obtaining a veterinary and/or pre-veterinary degree, and to reduce the number of graduates per year.

Those measures are all potential solutions, but I also strongly urge us to consider our responsibility towards educating prospective veterinary students about the reality of student loan debt and what it contributes to their long-term goals.

When I decided to change careers and become a veterinarian, like so many of my peers, the concept of taking on triple digit student loan debt was negated by my pure and noble intentions. This was my calling. This was my aspiration. And there simply was no price to be placed on my ability to follow my dream.

As I’ve matured, I’ve come to appreciate how dreams are plastic and apt to change. They expand and morph, bending and flexing with time and experience. I now wish for such things as owning a home, taking a vacation, raising a family, and (gasp) retiring one day. Before committing to vet school, these were only fleeting images on the distant horizon of my lifetime. Now, considering my debt and that of my husband (a fellow veterinary specialist), they are much more tangible, but also infinitely more complex in nature.

We teach children that they can be anything they want to be as long as they work hard and persevere. Inspirational quotes tell us we’re never too old and it’s never too late. We repeat phrases such as “Love what you do, and you’ll never work a day in your life.” But we must also ask ourselves, at what point and in what capacity, when it comes to a career, does money really matter? The bigger question is this (paraphrased from an article I read): “Is it ethical to encourage children to enter a profession where financial freedom is only available to a select few?”

We all share the joy of success stories related to veterinary medicine — in fact, at the time of this writing there’s a story going viral on social media about the wonders of a pet goldfish whose owners elected to have surgery to remove a tumor from its head.

I argue that we have just as much responsibility to give attention to the darker aspects of the career as we do the positives. Though less palatable, we’re at least being honest with ourselves about the current state of affairs.

Otherwise, the debt we owe may be even bigger than anyone could have originally anticipated.

Quality of death in real time

Mornings are when I catch up on current events and scan social media for trending topics.  While the news streams live on my TV in the background, I give cursory review to the headlines along my Twitter and Facebook feeds and The Huffington Post.  I’m aware of the dubious nature of those sources with regard to authenticity and content, but nine times out of ten, by the time my husband and I sit down to watch Nightly News, I’m surprisingly well versed in the journalistic “hot topics” of the day.

This morning, before I’d even made it through half of my first cup of coffee, I came across an article that stirred my consciousness and pushed my emotional barometer towards its most uncomfortable point.  The headline read “Terminally Ill 29-Year-Old Woman: Why I’m Choosing to Die on My Own Terms.”  The bait worked well, and I eagerly clicked on the link.

The story unfolded about  a young woman named Brittany Maynard, a newlywed diagnosed with a terminal form of brain cancer this past Spring.  Her initial treatment was aggressive, but her cancer rapidly progressed.  Her prognosis is now considered grave and the side effects from her disease are exceedingly painful and debilitating.  Her death, predicted by her doctors to occur within a few short weeks, will be “a terrible, terrible way to die.”

Though incredibly sad, it’s not Brittany’s back story prompting this post.  Rather, it’s her current status that is resonating so deeply with my emotions.  You see, once she was deemed terminal, Brittany researched her further options for treatment, and ultimately made the decision to actively end her own life in just a few short weeks.  Brittany and her family moved to Oregon, one of five states in the US where assisted death with dignity is legal.  Her plan is to obtain a prescription from her doctor for a lethal dose of medication, which she will take at home, and she will die surrounded by her family and loved ones.

Brittany is using her remaining time to be an advocate for death with dignity in her home state of California (where the process is currently not legal), as well as for Compassion and Choices, a nonprofit organization committed to providing a quality of death to patients facing end of life choices.  She will launch an online video campaign starting on Monday designed to fight to expand death with dignity laws nationwide.

I read the article with a quiet sense of awe and a mixture of compassion, sadness, inspiration, and empathy.  Here, was a real life and real-time example of the question I’ve asked numerous times: “How can we maintain a dignified death for cancer patients?”

As a veterinary oncologist, I deal with death on a regular basis.  I’ve written numerous articles on the difficulties I face in talking about death with pet owners and my concerns about how to best provide a quality of death for my patients.  I in no way wish to discredit Brittany’s struggle by comparing my profession to her situation.  Though I am a veterinarian, I will always hold human life in a higher regard than animals.  However, I am compelled to capitalize on the opportunity raised by Brittany’s story to further the understanding of the complex topic of death with dignity as it relates to cancer.  Whether we speak of animals or people, the strains faced by those dealing with a diagnosis of cancer are so similar.

We dedicate the month of October to raising awareness for breast cancer, and by honoring and commemorating stories of survivors who bravely battled this horrific disease, individuals currently fighting against it, and those who succumbed to its aggression.  This is an invaluable endeavor, especially when we consider not too long ago that a woman diagnosed with breast cancer was stigmatized with shame.  It’s remarkable what an open dialogue has done to demystify and to humanize patients with this terrible disease.

As such, I issue a challenge people to step outside of their comfort level, and recognize it’s equally as important to celebrate the difficult topic of death as it relates to cancer, as it is to honor the more obvious success story.  Death is not an easy thing to talk about, but if we work on it together, we can, at minimum, ensure individuals like Brittany, die with dignity, respect, and with the merit they deserve.

More about the Brittany Maynard Fund and the story inspiring this post: The Brittany Fund

More about Mast Cell Tumors

I’ve recently discussed some of the basic information about diagnosing canine cutaneous mast cell tumors and the inherent challenges related to this particularly frustrating cancer. So what do we do once we know we are dealing with this chameleon of tumors? As mast cell tumors are so unpredictable in their behavior, each patient must be approached on an individual basis and treatment recommendations can vary remarkably from case to case.

 

The most straightforward example would be a dog presenting with a solitary mast cell tumor. With rare exception, in such cases, surgical removal with wide margins is the treatment of choice. We recommend the surgery entail the removal of 2-3 cm of “normal” appearing skin surrounding the tumor, and one layer of tissue below the tumor.

 

Owners are often surprised when I show them exactly how wide and deep these surgical margins should be in a quantitative sense. However, this is the best way to ensure the entire tumor is removed in order to limit the potential for regrowth of the tumor, and/or assure cells are not left behind that could spread to distant sites in the body.

 

Such wide surgical margins may translate into biopsy margins of only a few millimeters (meaning only a small region of “normal” tissue is present between the last visible tumor cell and the edge of tissue where the scalpel blade cut). When a biopsy returns, we hope to see more than 5 millimeters of clear tissue in all directions – anything less is generally considered an incomplete excision. It’s very important the biopsy include surgical margins so oncologists know what to recommend to owners.

 

Even if a dog presents with more than one mast cell tumor at the same time, surgery will be the recommendation. Sometimes it can be tough to know “how many tumors are too many”, and I must use my best judgment as to when to recommend intervention with medical therapy instead of surgery.

 

Radiation therapy plays a large role in the treatment of canine mast cell tumors, primarily for tumors unable to be entirely removed with surgery.

 

In its most simplistic form, radiation therapy entails bombarding the remaining tumor cells with high-energy beams of radiation. Treatments are usually administered daily, and each is performed under a short period of anesthesia. Dogs tolerate radiation therapy very well, and side effects are usually limited to some transient changes within the skin, although this will vary depending on the location of the tumor.

 

Radiation therapy is most effective when used after surgery, but in some cases it can be used prior to surgery (e.g. for very large tumors or tumors in regions where surgery is not feasible.) This tends to be a more palliative option, and the best outcomes occur when radiation is combined with chemotherapy (see below).

 

Chemotherapy has a role for mast cell tumors, but is often less effective than surgery or radiation therapy. I recommend chemotherapy for all grade 3 mast cell tumors, any tumor has already metastasized to a distant site, and for some cases of narrowly excised “high-risk” grade 2 tumors (though the role of chemotherapy for such cases remains somewhat controversial).

 

Chemotherapy can also be used to treat dogs who present with multiple mast cell tumors at the same time, or who have tumors too large to be removed surgically.

 

There are typically two main avenues of chemotherapy for treating mast cell tumors in dogs: the more “traditional” chemotherapy drugs (e.g. CCNU, vinblastine, prednisone), and the newer class of drugs called tyrosine kinase inhibitors (Palladia and Kinavet).

 

Traditional chemotherapy drugs work by causing damage to DNA within cells, without regard to whether the cell is a tumor cell or a healthy cell. This is the reason for some of the side effects seen with chemotherapy, including adverse gastrointestinal signs and lowered white blood cell counts.

 

The mechanism of action of tyrosine kinase inhibitors (TKI’s) is very different. These drugs work primarily by inhibiting the action of a receptor on the surface of mast cells that is mutated in about 20-30% of tumors. When the receptor is mutated, it causes uncontrolled cell division, leading to tumor growth.

 

TKI’s can also work by inhibiting the growth of blood vessels to tumor cells (this is called anti-angiogenesis therapy). This mechanism of action is separate from the previously mentioned mechanism, which means tumors without the specific receptor mutation may still have a good response to treatment.

 

TKI’s are orally administered medications given chronically at home. Dogs need to have “steady state” levels of these drugs in their blood stream to continually keep the receptor turned off. The receptor is present on other cells in the body, so side effects can occur with TKI’s as well, but are generally fairly limited in their spectrum.

 

The take home messages for canine mast cell tumors are:

  • They are very unpredictable in their behavior.
  • The biggest predictor of behavior is the grade of the tumor, which can ONLY be determined via biopsy.
  • Staging tests are important to look for spread of disease and should include labwork, regional lymph node aspirates, an abdominal ultrasound, and in some cases, a bone marrow aspirate.
  • Surgery is the mainstay of treatment for most dogs.
  • Radiation therapy and chemotherapy play roles for dogs with mast cell tumors – consult a veterinary oncologist to be sure you know all the options available for treating your dog!

How much does it cost just to walk through the door of your vet’s office?

Imagine you bring your pet to your primary care veterinarian because s/he’s recently shown some abnormal signs. Your veterinarian examines your pet, performs some few basic diagnostic tests, and suddenly, you find yourself on the receiving end of unimaginable news. Your veterinarian tells you your pet has cancer.

What do you do? Where do you turn for more information? How can you determine what your plan of action should be?

Your veterinarian recommends you schedule an appointment with a veterinary oncologist as your next step. You accept the referral and call to set up an appointment.

When you contact the specialists’ office, you are transferred to a scheduling coordinator who informs you of the doctor’s next available appointment. They explain what to expect during the time you’ll spend at the hospital. Lastly, they inform you of the consultation fee.

The price of the appointment may seem shocking to many owners. It’s not unusual for specialists to charge anywhere from $100 to $300 or more “just to walk through the door”

This can be a turning point in the conversation between the pet owner and coordinator. Most owners continue on with the scheduling process, while others ask the coordinator specific questions regarding their pet’s prognosis or options or what the cost of further diagnostics and/or treatments will be. Some owners will then ask if they could speak with the doctor prior to coming in, to determine if they feel consult will be “worth it.”

Owners are informed the specialist will not speak to them without having previously seen their pet and they will have all their questions answered during the appointment. For some owners, this leads to the misconception the doctor is chronically unavailable, inaccessible, or solely “in it for the money.”

There are numerous complications associated with a veterinary specialist consulting with owners of pets they’ve never actually examined. I’ve tackled this topic in a previous article, for those of you who may not necessarily immediately understand the connection.

I want to raise awareness of a different explanation why vets refuse to provide medical advice for pets they’ve never seen.

In 1994, Congress passed the Animal Medicinal Drug Use Clarification Act (AMDUCA), which outlines three essential components of what is known as the

Veterinarian-Client-Patient Relationship (VCPR):

  1. A veterinarian has assumed the responsibility for making medical judgments regarding the health of (an) animal(s) and the need for medical treatment, and the client (the owner of the animal or animals or other caretaker) has agreed to follow the instructions of the veterinarian
  2. There is sufficient knowledge of the animal(s) by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition of the animal(s)
  3. The practicing veterinarian is readily available for follow-up in case of adverse reactions or failure of the regimen of therapy. Such a relationship can exist only when the veterinarian has recently seen and is personally acquainted with the keeping and care of the animal(s) by virtue of examination of the animal(s), and/or by medically appropriate and timely visits to the premises where the animal(s) are kept.

(Reference)

This means legally, veterinarians cannot make medical recommendations to owners when they’ve never actually examined their pet. This is also the reason why your vet may refuse to authorize refills for heartworm preventative, pain medications, or even more critical prescriptions such as anti-hyperthyroid drugs or insulin, when they haven’t seen your pet in a while. Though this may be perceived as a way vets look to charge owners more money, they’re actually doing so because it’s the law.

I would urge owners to rethink the idea they are “paying ‘X’ amount of dollars just to walk through the door” of a veterinary specialist’s office. The fee quantitates years of extensive training, hard work, and expertise regarding your pet’s condition. Above and beyond the comprehensive physical exam, your specialist will thoroughly review your pet’s medical record and all prior diagnostic test results, and most importantly, provide the information you need to make a decision about how to proceed regarding your pet’s care.

For most specialists, the appointment fee also includes accessibility for themselves and/or their support staff long after you’ve left the exam room. The average persons’ ability to recall medical information disseminated during appointments is often poor and inaccurate, especially when they are anxious, as would be expected when dealing with a diagnosis of cancer.  The capability to contact a doctor with follow-up calls or emails is extremely important, providing owners with the opportunity to ask questions they didn’t think about during the initial appointment.

I’m not suggesting the fees associated with veterinary specialty medicine are inconsequential. What I want to emphasize is the value of the information you receive will far surpass the price you initially pay, even if you ultimately decide to not pursue any further diagnostics or treatment.

In those cases, I always stress, you’re not electing to do “nothing”. On the contrary, you’ve already done so much for your pet by seeking out specialty care. Just as you’ve done so much more than simply walk through the door.

Which, by the way, is still a free thing to do.

Losing my patience when I can’t find my patients!

From time to time I will be scheduled a new appointment, and in our database, in the “comment” section below the client and patient information portion, there will be a note stating “Owner not bringing pet to appointment.”

 

I’m always surprised when I see this, as it seems to counterintuitive towards the goal of what I do for a living.

 

How can I provide owners with accurate information about their pet’s cancer without having examined them? How can I provide treatment options when by law, I need to have an active client-patient relationship and can’t even prescribe an antibiotic to an animal I’ve never actually seen? How can I answer honestly if they ask me if their pet is in pain? How do I determine if an animal is a good candidate for surgery, radiation therapy, or chemotherapy?

 

Most of the time, owners who elect to not bring their pet to an appointment do so because they feel traveling to and from the hospital is too stressful for their animal. Having two cats of my own who do not travel well (one is guaranteed to yowl incessantly, scrape his nose along the front of the carrier until it bleeds, and urinate no matter how short the trip, while the other drools uncontrollably until she is a soaking wet mess) I understand this completely.

 

Yet, this past week when I saw another appointment on my schedule indicating the owners would be present, but the pet would not, I jokingly said, “I would never think of going to my dentist without bringing my teeth!” So why do owners feel satisfied just listening to me talk?

 

The majority of time spent during a consult is dialogue between owners and myself. I begin by asking questions about their pet’s past medical history, what signs they notice prompting a visit to their vet, how was the cancer diagnosed (if coming to see me with a diagnosis already), and going over what tests were already performed. I also spend a lot of time describing the pathology behind their pet’s diagnosis and the different treatment options, including expected side effects, prognosis, and what we look for to decide if a treatment is successful, or not.

 

The verbal portion definitely takes up a great deal of time, but I also gather so much information from my physical examination of the patient. Sometimes I discover secondary or tertiary health problems completely unrelated to the animal’s cancer (e.g. heart murmurs, cataracts, orthopedic disease, etc.) These conditions may influence recommendations for treatment or even prompt me to recommend additional testing before moving forward with more definitive care.

 

As an example, this past week I was referred a dog whose primary veterinarian was worried had leukemia. Leukemia is a “catch-all” phrase used to describe a cancer of white blood cells that usually stars in the bone marrow. The patient had a moderately high white blood cell count on several repeated blood tests.

 

When I examined the dog, I noted that her lymph nodes were all enlarged as well. This was not recovered on her previous exams. Though dogs with leukemia can have enlarged lymph nodes, this is far more common with a different type of cancer called lymphoma. Leukemia and lymphoma can look very similar on blood tests, but can potentially have different therapeutic options and have very different prognosis.

 

If I never examined this dog, I never would have felt her lymph nodes and I never would have had a suspicion she may have a different disease process going on than what she was referred for. My diagnostic recommendations changed based on my exam findings, and we ultimately diagnosed her with cancer, but a far less aggressive variant of disease than she was originally referred for.

 

What would have happened if her owners had not brought her along to the appointment? I likely would have just discussed the form of cancer she was referred for – telling her owners about the grave prognosis of only a few weeks with or without treatment. Would they have considered euthanizing her before she started showing significant signs of illness? Thinking about this outcome certainly prompts concern for the absence of the animal during a consultation.

 

I truly am flattered people feel the time spent hearing my opinion and knowledge about veterinary cancer is so valuable. When owners come to see me, they are looking for accurate information they can use to make decisions about their pet’s care. Their primary veterinarian is often the frontline educator, and it’s fantastic when I hear owners say, “My vet told me some of the basic information, but said I should really meet with you to learn all of my options.”

 

We always encourage owners to bring their pets to appointments when they are apprehensive about doing so. For most cases, we are able to successfully convey the importance of the exam, that if the pet is present we can perform recommended diagnostic tests that same day, and if appropriate, get started on treatment protocols right away.

 

I’m sure there are some specialists out there who would decline to see appointments without the animal being present for an exam out of concern the appointment may not be productive on their end or because they are concerned about offering advice for a pet they’ve never seen.

 

For me, it’s just another part of deciding what kind of oncologist I want to be. As is true for so many aspects of my career (and life in general), as long as we (the pet owner and myself) are all on the same page about the limitations of me not examining their pet, I would never refuse the occasional appointment without the pet present.

 

I want to be the kind of oncologist who always remembers the most important aspect of any appointment is the patient. For now, I am content knowing this means sometimes I never actually meet them in person.

 

If you liked this article, take a look here: What’s the most commonly heard phrase in veterinary school?