Telemedicine: Tele-terrific or Tele-terrible?

One of the main differences between advanced hospitals for animals and humans is that the majority of veterinary referral hospitals may lack one or more of the primary “on-site” specialists and outsource the activities they would typically perform to larger scale organizations through “telemedicine.” Only the largest private practice hospitals or veterinary schools have each of the sub-specialties physically represented in-house.

Telemedicine has many pros, including cutting costs, providing owners with access to specialists who would have otherwise been limited by geography, and a more rapid turn-around time for results due to increased throughput.

One of the cons to telemedicine is that the specialist who is working remotely is unavoidably physically and emotionally detached from the patient.

I was fortunate to complete my residency in medical oncology at a veterinary school where I had direct access to any specialist I needed. If I had questions about a biopsy report, or needed to discuss specific aspects of an MRI in further detail, I could walk down to the office of the doctor working on the case and talk to them face to face.

I could also ask for clarification regarding confusing wording in their reports in person. In many instances, I could even bring the patient directly to their office to show them tumors or surgical scars to help aid in their interpretation. There’s a lot to be said for the degree of personal attention and attachment this type of relationship creates.

In the “real world,” the pathologist who interprets the samples I submit works at a remote location and I couldn’t tell you much about their surroundings. The radiologist who reads out my imaging tests exists somewhere in time and space, but I don’t know them personally. Although I can call or e-mail them at any time to speak with them about specific aspects of my patient’s case, there isn’t the same personal attention to detail that comes from direct contact.

In the digital world we exist in, telemedicine doesn’t seem like such a bad idea. Why should we need to have everyone in the same building when we can each use our talents and experiences to their fullest capacities from the comforts of a remote location? Sure, we may lose out on the personal attention, but I can overcome this hurdle by providing my specialists with as much detail as possible on the submission forms that accompany my samples. That’s just as good as speaking with them directly, right?

Yes and no. Theoretically, telemedicine should work as well as “hands on” medicine. Yet, there are times when an incorrect diagnosis or interpretation is made as a direct result of a lack of “face time.”

As an example, I recently saw a case of a dog I was sure had a mass located in the front part of his chest, between his lung lobes and just in front of his heart. This is otherwise known as a mediastinal mass. My interpretation was based on radiographs (x-rays) performed to investigate the cause of a chronic cough.

We performed a CT scan of the patient’s chest cavity, and on the submission form to the radiologist, who would be responsible for interpreting the images from the scan, I indicated the pet had a mediastinal mass on radiographs. We also obtained a fine needle aspirate of the mass for cytological analysis. On the submission form for the aspirate sample, I also indicated the pet had a mediastinal mass.

The list of potential underlying causes of a mediastinal mass are short, and the most common causes would be either lymphoma or thymoma. The CT scan report confirmed the presence of a mediastinal mass. The cytology report showed thymoma. The pet was taken to surgery to remove the mass.

Surprisingly, at surgery the mass was actually found to be encompassing a portion of the right lung, and was not located within the mediastinum.

This finding made the original diagnosis of a thymoma incorrect, as this type of tumor would never be found within the lung tissue itself. This also made the radiologist’s report for the CT scan and the original cytology report incorrect.

More importantly, it showed me how both the pathologist interpreting the biopsy sample and the radiologist interpreting the CT scan were both nearly 100 percent biased by the information I provided on the submission form. My initial incorrect assessment created a domino effect of two other incorrect assessments. We are each equally responsible for the outcome.

Had I not provided any history to the pathologist or radiologist, would their answers have been different? If they both worked alongside me in my hospital, would they have interpreted the results in an alternative fashion? Should I have given less data rather than more? Did my actions result in a less than optimal outcome for this patient?

Fortunately, the treatment of choice for the majority of primary lung tumors would be the same as for a thymoma – surgery to remove the mass. And the patient is currently doing well.

But this case made me wonder: how often in veterinary medicine does a doctor’s bias influence the outcome for a case? And how often can this influence result in a less than optimal outcome for the patient? Fortunately, in the example I’ve given, the outcome was not adversely affected. But what about other times?

I still err on the side of giving more information, especially when submitting things to outside specialists. I’m certain it ensures a more thorough interpretation of the sample and a more accurate diagnosis. But I also recognize how important it is to avoid adding my biases to a submission form.

I also remain cautious about the progression of telemedicine for both people and pets and prefer to keep my interactions on a much more personal level. I urge my colleagues to consider the benefits of doing the same.

My pet has cancer… Now what?

Receiving a diagnosis of cancer in your pet is devastating. Amidst the anxiety and uncertainty, it can be difficult to process whether pursuing a consultation with a veterinary oncologist is the right choice.

Knowing what to expect from your appointment with a specialist ahead of time could help alleviate a portion of your fears and ensure that your overall experience is worthwhile.

Your oncologist’s office will request your pet’s records be sent prior to your appointment so they can be reviewed for content. This includes copies of lab work, aspirates, biopsies, or imaging tests. Ensuring the complete medical history is available ahead of time helps streamline the appointment as well as eliminates the need to repeat tests.

When you arrive for your appointment, you will be greeted first by a veterinary technician or assistant who will take you into an exam room. They will obtain your pet’s vital signs and ask questions about their medical history, current medications, and clinical signs.

Your pet may be briefly taken to another area of the hospital, where the oncologist will perform a thorough physical exam. Alternatively, the exam may be performed in the same room as the consultation. Owners may be confused or nervous when their pet is whisked away only a few minutes after arriving at the hospital. It’s normal to wonder what goes on “behind the scenes” and why you can’t be with your pet.

The area where this type of exam occurs has additional pieces of equipment that make it superior to the smaller consultation rooms where the appointment occurs. The larger areas often have specialized computers where data is entered as the exam is being performed. Additionally, many pets are calmer when away from their owners, which makes it easier to perform the exam and ensure nothing is overlooked, as well as helping to reduce their stress levels.

Once the exam is completed, the oncologist will talk to you about your pet’s diagnosis and make recommendations for further testing and treatment options. If you are prepared to move forward, steps can often be initiated that same day. If you need time to process the information before making decisions, your oncologist will support you as well.

There are some simple steps pet owners can take to help streamline their appointment with a veterinary oncologist. The most important part is not to panic.

If timing permits, call the oncologist’s office a few days before the appointment to make sure your pet’s records have arrived. If they have not arrived, consider calling your primary veterinarian and asking directly that the information be transmitted. Owners are often more effective at this task than the specialist’s office.

Bring your pet to the appointment (unless otherwise specified). It may seem intuitive, but there are times where owners are confused or assume the consultation is restricted to information only and leave their pets at home. The ability for your oncologist to examine your pet is a crucial part of the experience.

Ask if your pet should be fasted (food withheld) prior to the appointment. In many cases, if this is recommended, you will be informed ahead of time. But sometimes this small detail can slip through the cracks and could result in a delay of scheduling certain tests (e.g., if a sedation or general anesthesia is required and your pet has eaten that day, testing will need to be postponed.)

Write down your questions ahead of time. If you are having trouble thinking of things to ask, talk with your primary veterinarian and have him or her outline the kinds of questions you should be thinking about.

Talk about your concerns. If they are related to your pet’s quality of life, stress level, or even more personal issues, such as finances or your own health issues, feel free to voice your worries if you are comfortable doing so. Your oncologist will work with you and determine the best plan of action.
Don’t be afraid to ask if you can write things down. You will be inundated with information and statistics, and the heightened emotions you possess following your pet’s diagnosis can further confuse things. Writing down a few key points might prove invaluable to understanding the bigger picture.

Your appointment may not proceed exactly as I’ve outlined, but many of the points I’ve discussed are likely to be addressed at some point in the process.

The most important part is that you’ve committed to meeting with the person possessing the greatest experience and training in your pet’s diagnosis.

No matter your decision, the remainder will fall into place and the appreciation you will have after hearing accurate information will supersede your apprehensions by a wide margin.

It’s finally here!

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Can You Prevent Cancer in Your Pet?

Cancer prevention is certainly a “hot-button” topic in human medicine, and many of the same questions and responses surrounding this subject translate to veterinary medicine as well.

The first step in preventing disease is identifying what causes it in the first place. To say a particular variable “causes” cancer would require performing an accurately designed research study—a daunting task in veterinary medicine because of our inability to control for, or accurately record, the variables that could potentially influence a pet’s exposure to risk factors.

An example of a known etiological (causative) factor for a predisposition to cancer in animals occurs in cats infected with either the Feline Leukemia Virus (FeLV) or Feline Immunodeficiency Virus (FIV).

Cats infected with FeLV are 60 times more likely to develop lymphoma/leukemia compared with healthy non-infected cats. Cats infected with FIV are five times more likely to develop the same cancers. Cats co-infected with both FeLV and FIV are 80 times more likely to develop lymphoma than non-infected cats.

FeLV infection was the most common cause of blood borne cancers in cats during the 1960s – 1980s. During that time, approximately two-thirds of cats with lymphoma were co-infected with FeLV.

With the development of better screening tests to eradicate or isolate infected cats, as well as commercially available FeLV vaccines, the number of FeLV positive cats decreased dramatically after the late 1980s. However, cats still frequently develop lymphoma, and the overall prevalence of this cancer actually increased over time. The disease appears to be shifting to other anatomical locations, namely the gastrointestinal tract. What then, is responsible for causing lymphoma in cats now?

There are only a handful of research studies available that examine the causes of cancer in pets. To my knowledge, despite the large body of information on the internet suggesting otherwise, commercial diets, vaccination (other than for sarcoma developments as listed below), tap water, shampoo, or cat litter have not been accurately studied and proven to cause cancer in pets.

There are three “take home” areas I would like to highlight that summarize what we know about proven causes of cancer in animals.

Environmental exposures — The three biggest culprits included pollution, environmental tobacco smoke (ETS), and pesticides.
There is evidence supporting an association between exposure to ETS and lymphoma and nasal tumors in dogs and lymphoma in cats.
Exposure to pesticides containing dichlorophenocyacetic acid (2,4-D) is associated with increased risk of lymphoma in dogs; however, data is conflicting.
Dogs living in urban areas are at increased risk for developing lymphoma.

Neuter status — Hormones can act to promote or inhibit tumor development, depending on the specific cancer in question.
Female dogs are less likely to develop mammary tumors when they are spayed early in life, presumably due to lack of exposure of mammary tissue to ovarian derived reproductive hormones.
However, neutering may actually cause an increased risk of developing prostate cancer in male dogs, indicating a possible protective effect of hormones in such cases.
Neutering may also increase risk of developing osteosarcoma and transitional cell carcinoma of the urinary bladder in dogs, regardless of gender.

The administration of injections (not only vaccinations) can cause injection site sarcomas in cats, but the injection alone is not sufficient to create tumors. More and more evidence points to an inherent susceptibility to tumor development that is “set into motion” in response to the injection.

Despite not knowing the exact causes of cancer in pets, there are several preventative measures owners can take to help ensure their companions remain as healthy as possible for as long as possible.

One of the simplest preventative measures owners can do is to schedule regular physical exams for their pets every 6 to 12 months. This ensures that any changes in status, body weight, etc. are closely monitored and tracked over time so concerns can be addressed as soon as early signs are noted.

Any newly noted skin masses should be evaluated as soon as they are noted. It is impossible to determine if a skin mass is benign or malignant based on appearance or feel alone; a fine needle aspirate and/or biopsy should be performed to determine whether further action is necessary.

Routine lab work and imaging tests such as radiographs (X-rays) and ultrasound scan can also be helpful in assessing a pet’s overall health. Even when we are unsure about how to truly prevent cancer, such diagnostics can mean earlier detection of disease, and can often lead to a more favorable prognosis.

Cancer prevention is an important aspect of any pet’s routine healthcare, and these simple measures can help pet owners and their veterinarians work together to ensure that our beloved companions live longer, happier, and healthier lives.

Quality of life over life at all costs

Humans with terminal cancers or with widespread metastases are offered treatment with the hope of an extended lifespan, despite a grim prognosis. People are routinely administered second, third, fourth, and beyond treatment plans when they fail to respond to the frontline therapies. This is done with little to no evidence-based information that would suggest such interventions will actually result in a positive outcome.

The benefit of aggressive therapy in patients with terminal cancers is poorly described. The American Society of Clinical Oncology (ASCO) identified chemotherapy use among patients for whom there was no clinical value as “the most widespread, wasteful, and unnecessary practice in oncology.”

When I read those words as a veterinary oncologist, I had only one thought.

Ouch.

The majority of patients I treat with cancer will ultimately succumb to their disease. Pets are typically diagnosed at an advanced stage of disease, and a cure is nearly impossible. We also accept much lower rates of toxicity with our chemotherapy protocols than our human counterparts; therefore, with good reason, we can’t treat animals’ cancers to the “fullest potential.”

I would estimate that the premise of treatment for greater than 90% of cases I see is rooted in palliation (i.e., relief from pain) rather than a true belief of cure.

Yet, veterinary oncology is fundamentally based on principles of human oncology. So if the data for human oncology tells us that the treatment of terminally ill cancer patients is not only poorly beneficial but also wasteful (in terms of not only finances but resources), how can I justify the recommendations I make each day?

The answer is simple: Veterinary oncology is premised on the idea of treatment making our patients feel better, not worse. Rarely are animals diagnosed with cancer incidentally. Most show some sort of clinical signs prior to their diagnosis of cancer. Treatment, therefore, is aimed at relieving such signs and returning their quality of life to their baseline level.

A study recently published in the Oncology edition of the Journal of the American Medical Association examined the evaluation of the use of chemotherapy and quality of life for people with end-stage cancer. Specifically, researchers were interested in knowing whether chemotherapy had a positive or detrimental effect during the last week of life for human patients with cancer, and if the effect was dependent on the patient’s overall health status prior to treatment.

In people, performance status is used to evaluate a patient’s quality of life. There are several different scoring systems, with the Eastern Cooperative Oncology Group (ECOG) being widely accepted and outlined as follows:

143-ecog performance status

In the aforementioned study, a patient’s quality of life near death (QOD) was measured using a validated caregiver’s rating of their mental and physical distress during their final week of life.

Results from the study raise several interesting points:

There was no improvement in QOD scores for people with performance scores of 2 or 3 who underwent chemotherapy, compared to those who did not undergo chemotherapy.

People with performance scores of 1 showed a significantly worse score for quality of life near death with treatment.

Though difficult to compare side by side, how can the results of this study be translated to veterinary medicine?

We do have a modified performance scale we use in screening the overall health of dogs and cats, which scores pets’ activity level and ability to eat, drink, and eliminate as either normal (0), restricted (1), compromised (2), disabled (3), or dead (4).

We are able to have owners evaluate how their pets behave at home following treatment and their assessment of their quality of life in a subjective manner.

We have several veterinary studies examining an owner’s perception of their pet’s health status prior to, during, and after treatment. Results consistently showed owners were happy with their decision to treat their pets, most felt their pets’ quality of life increased, and they would pursue treatment again in the future if faced with a similar decision.

Despite the shared foundation of human and veterinary oncology, there is an enormous disparity between the end goals of each discipline.

Human oncology is based on the concept of treating patients with the mantra of “life at all costs,” while veterinary oncology accepts our limitations, choosing to “maintain or improve quality of life” over cure.

This is the message I attempt to relay during each new consultation I see.

This is the information I am passionate about dispersing with my written and spoken dialogue each day.

This is why I work so hard to help animals and their owners at every possible junction I am afforded.

The battle to dispel the misconceptions about cancer care in animals is never-ending but worth enduring, knowing I can make a difference if even for just a few.

Especially if the few are those who feel the “ouch” factor mentioned above just a bit deeper than all the others.