Those that can do. Those that can do it better, teach.

This past September I was hired as an adjunct faculty member at a local community college, teaching several classes in the veterinary science technology program. As someone notoriously unable to say “no,” I agreed to tackle the responsibility on my days off from clinical work.

I entered this endeavor thinking, “No big deal, I’ve got this.” I’m a serial multitasker and I enjoy keeping busy. How hard could it be?

It wasn’t too long before I realized just how much I had underestimated the commitment I had made. And now, just a few short weeks before final exams will be distributed and students will break for the summer, I find myself counting down the credit hours, willing the time to come where I can resume my “normal” bustling schedule rather than my current “way out of control, not a second to myself” situation.

Several years ago, I temporarily abandoned my plans to attend veterinary school and entertained the idea of working in biomedical research. To achieve my new goal, I enrolled in graduate school to pursue a master’s degree in biology.

One of the requirements for the program included teaching. Specifically, I was assigned to teach the laboratory portion of the anatomy and physiology course for non-biology majors.

I possessed no previous teaching experience and was terrified at the prospect of stepping over to the other side of the classroom. I wasn’t comfortable with public speaking, and wasn’t sure how I would explain complex biological terminology to individuals lacking a background in the subject.

My anxiety was only slightly tempered by the eager faces of my students, thirsty to learn about the intricacies of the human body. The learning curve was exceedingly steep, for both my students and myself, but if I’m being completely honest, the pressure I placed on myself far exceeded anything generated by the co-eds I was in charge of for a few hours, twice a week

Especially during those initial weeks of my first semester, I stumbled and made mistakes and faltered more times than I’d like to admit. But I also experienced some remarkable achievements watching students synthesize, memorize, and comprehend. It didn’t take long before the teaching bug bit me and I decided to pursue my PhD in biology, with a goal to focus a portion of my training on developing curriculum objective for more effectively teaching the biological sciences to non-majors.

I enrolled in a program and commenced my curriculum, only to nearly instantly discover my ideals didn’t mesh with those of the department I’d signed on to. It turns out people don’t pursue PhD degrees in neurobiology to teach science. They do it because they are passionate about research and writing papers and grants, and those were aspects of earning the degree I never could align with.

Veterinary medicine was thus my “fall back” plan. I gave up one dream to pursue another and placed teaching on the way back burner as I spent four years focusing entirely on memorizing minutia and resuming my role on the receiving side of the classroom.

Opportunities related to teaching arose here and there during my residency and my professional career as a medical oncologist working in private practice. In fact, I’d argue nearly every appointment I see represents a chance to educate pet owners about cancer. Though it has not been in the formal setting of a classroom, over the years I’ve trained dozens of veterinary students, interns, and residents, as well as motivated veterinary technicians and assistants.

When the chance arose to teach in the tech program this year, I willingly accepted, somehow failing to remember the struggle of my days of working as a newly minted lecturer.

Many years later, I find myself re-experiencing the same stumbling and faltering I did back in graduate school. Though I’m hypercritical of my capabilities (or lack thereof), I’m masochistically happy when I am attempting to make topics such as antibiotics and record-keeping enthralling, and when I am painfully, yet joyfully, spending my free time writing lectures, grading papers, and creating exams.

As a good friend of mine who is a kindergarten teacher says, “When you’re a teacher, you have to be ‘on’ all the time. There’s no taking a break.” I give her a ton of credit. I only need to be “on” for one day a week.

When I was on the other side of the classroom, I assumed breaks in curriculum were designed to relieve students from the stressors of their constant study. I now understand how essential the pauses are for maintaining sanity and mental health for teachers as well.

Those that can, do. Those that can do it better, teach.

Who will you vote for?

The 2016 presidential election is shaping up to be a remarkable and unforgettable event. There are numerous controversial political topics being addressed, including typical “big ticket” items such as healthcare, gun control, and national security.

I raise no concern with a country that prioritizes the aforementioned matters with respect to political affiliation. However, I’m disappointed that our current candidates rarely voice opinions regarding their agenda for supporting animal welfare or veterinary medicine. I therefore must question our values when we place greater emphasis on deciding which presidential candidate’s wife would make a more attractive first lady than caring about matters related to animals, their healthcare, and their caretakers.

With a bit of probing, I successfully uncovered several political issues related to animals that have direct bearing on the lives of both veterinarians and pet owners that are currently up for consideration. Not surprisingly, however, I failed to discover exactly where the individuals vying to be the next president stand on the topics.

Of the concerns I came across, the following represent those where a “veterinary favorable” stance from a potential candidate would certainly positively influence my vote towards supporting their campaign:

The first consideration is the “Fairness to Pet Owners Act.” This piece of legislation was introduced in the House in July 2015 and “Directs the Federal Trade Commission to require prescribers of animal drugs to verify prescriptions and provide copies of prescriptions to pet owners, pet owner designees, and pharmacies, without the prescriber demanding payment or establishing other conditions.”

Proponents of the bill argue veterinarians discourage pet owners from filling prescriptions outside of their office in order to promote their own financial gain.

Many veterinarians feel this bill is unnecessary because they already offer owners the option of filling prescriptions elsewhere. They also are concerned about how it creates an administrative burden for themselves and their staff in cases where a certain medication is only available through a veterinarian or when an owner wishes to have the medication dispensed from their vet. The is because the bill requires veterinarians to write a prescription and present it to the owner first, then take the script back and dispense the medication if that is the owner’s choice.

Another proposed regulation is the “Pet and Women Safety Act.” This legislation will “expand federal law to include protections for pets of domestic violence victims and establish a federal grant program that will help ensure that victims have access to safe shelters for their pets.”

Specifically, the bill aims to assist both female and male victims with pets by: making threats against pets a stalking related crime, providing grant funding to increase the availability of housing for victims and their pets, encouraging states to provide coverage for pets under protection orders, and requiring abusers who harm pets to pay veterinary and other expenses incurred as a result.

The link between animal abuse and domestic violence is well established. Human victims of abuse often face the decision of leaving their current situation without their pets or staying to ensure their companions receive the veterinary care they require. This bill would provide protection for animals, increase availability of sheltering options for pets, and shift the financial responsibility towards the abuser.

There are also several proposed bills related to veterinary professional and educational issues, including the Veterinary Medicine Loan Repayment Program (VMLRP), which provides educational loan repayment to veterinarians who agree to practice in areas of the U.S., as designated by the USDA, where there is a shortage of veterinarians.

This legislation would make the VMLRP loan repayment awards exempt from a federal withholding tax, allowing more veterinarians the opportunity to participate in the program. Currently, awards are subject to 39 percent withholding tax.

The Student Loan Interest Deduction Act and Student Loan Refinancing Act are examples of proposed legislation designed to lessen the burden recent veterinary school graduates face regarding their educational debt.

The current candidates vying for nomination for their respective political parties do not have animal welfare issues on the forefront of their campaign trails. Therefore it’s difficult to determine where each stands on the above mentioned proposed legislations.

According to the Humane Society Legislation Fund, Hillary Clinton and Bernie Sanders hold the highest ratings regarding their voting record in the U.S. Senate. Whether that would translate to anything positive should they be elected president remains to be determined.

How a particular presidential candidate stands on animal welfare issues wouldn’t be the primary measure of whom I would decide to vote for, but it does allow the opportunity to gain a better understanding of what is personally important to each candidate.

And it helps to provide a sense responsibility, integrity, and value for those of us who dedicate our lives towards promoting the importance of the human-animal bond and the sanctity of healthcare for pets.

Ode to the Oldies…

I have a soft spot in my heart for geriatric pets. I’m a sucker for the graying muzzle of an elderly Labrador retriever. I relish scratching the fuzzy face of a cranky senior cat. All pets are special, but the extensive history and regal personalities attached to the aged ones is something I simply can’t resist.

As a veterinary oncologist, older pets are a substantial part of my professional life. Cancer occurs most frequently in pets over the age of 10 and companion animals are living longer now than ever before. I encounter animals of all ages, but most of my time is spent with the elderly.

On a personal level, I love senior pets for all they represent: unconditional love, steadfast loyalty, and sensible temperaments. They’re guaranteed to stand by their owners at all times and diligently maintain their roles as guardians, companions, and soul mates, even when their bodies become less capable of maintaining their self-designated responsibilities.

When I meet with owners of older pets, I love to hear them tell stories of their pets’ lives. Whether owned since they were puppies or kittens or acquired later on in life, as mature dogs and cats, there’s infinite opportunities for me to discover the role that animal played in their family’s lives.

I frequently encounter owners who feel their pet’s age is a barrier to cancer treatment. A diagnosis of cancer is devastating regardless of age, but can be especially difficult when an animal is older and an owner faces making diagnostic and treatment choices. They are often concerned about putting their beloved companion through too much at their advanced age. They will often equate it to what they would consider medically and ethically appropriate for an elderly human being.

I understand the apprehension about pursuing intensive medical care for animals in general, and certainly can appreciate how magnified these worries would be for owners of older pets.

I try to reassure owners that the majority of information about risks for side effects and prognosis were determined on older animals. I’ll also often recommend additional testing to ensure the overall health of their pet is intact prior to making definitive recommendations for their cancer care. I’m equally as concerned as they are with their pet’s health and with confirming they are good candidates for treatment.

Fortunately, when the primary recommendation isn’t a reasonable plan for an individual pet, veterinary oncologists are usually able to offer anxious owners several different options. It’s my job, in such cases, to recognize when to discuss alternatives to the standard of care.

For example, when aggressive surgery is not an option because an owner feels their pet is too old to withstand the operation, veterinary oncologists are able to offer less intensive chemotherapy therapies, most often designed to slow tumor growth and metastases while maintaining an excellent quality of life. Though we may compromise our chance for a cure, we are able to extend an animal’s expected lifespan and simultaneously ensure that their remaining time is spent as happy and healthy as possible.

Many owners attribute some of the earliest signs of cancer to “old age” or on an assumption their pet is “slowing down” as it ages. Routine visits to the animal’s primary care veterinarian may provide the opportunity to detect disease at an earlier stage, further supporting the concept of extending its quality of life for as long as possible.

Senior pets ask so little from their owners. Their mellow demeanor and relaxed personalities remind us of the remarkable nature of the human-animal bond and just how impenetrable that bond can be.

If you’re an owner of an older pet facing a diagnosis of cancer, I urge you to consider consultation with a veterinary oncologist. Express your concerns and discuss your goals with your veterinarian. There’s a great chance that together you will be able to determine an option that fits both your goals and your pet’s best interests; one that takes their age into account but isn’t limited by a single physical characteristic.

Why I think about Will Rogers every day…

American humorist Will Rogers once stated that in the 1930s, “When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states.”

This quote, though obviously swathed with wit and sarcasm, has surprising applicability to several real world scenarios. The Will Rogers Phenomenon is used to explain what happens when the movement of an element from one set to another set raises the average values of both sets.

The Will Rogers Phenomenon is extrapolated to describe an observation in medicine called stage migration. In simplest terms, stage migration occurs when improved detection of disease leads to patients being reclassified from “healthy” to “unhealthy.”

For any given patient, disease may be present, but if we’re unable to identify it, patients will erroneously be classified as “negative” or “healthy.” Increasing the sensitivity of a diagnostic test allows doctors to capture disease at an earlier stage. Therefore it’s possible to reclassify a previously “healthy” patient as “unhealthy” simply by running a “superior” test. That patient would therefore “migrate” from a healthy group to an unhealthy group because of improved detection of disease.

An important consideration is that despite migrating, nothing has changed about the patient itself. Its true prognosis was previously determined before any test was done. The new test simply allowed for better detection of their disease status.

As an example, I can answer the question of “Did my pet’s cancer spread to its lungs?” by recommending radiographs (x-rays) or a CT scan of the patient’s chest. CT scans will pick up on tumors that are only a few millimeters in size, whereas radiographs will only find lesions that are closer to a centimeter.

If the same patient underwent radiographs and a CT scan, it’s possible the former test could return negative for spread and the latter test could return positive. If we’d only done radiographs, I would offer that owner a better prognosis than if I’d done the CT scan. I would characterize that patient as “healthy” when it truly was “unhealthy.”

Patients diagnosed with more advanced disease are generally not expected to live as long as their truly healthy counterparts. Therefore, “migration” of a newly detected “unhealthy” patient from the healthy group would cause an increase in the average survival time of the healthy group.

Likewise, the migrated patients are generally healthier than the patients previously segregated to the unhealthy group because their disease is considered “less noticeable.” Therefore, their movement to the unhealthy group will increase the average lifespan of that population as well.

Regardless of whether early detection of disease results in an actual difference in patient outcome, the average survival times of both the healthy and unhealthy groups are increased. The Will Rogers Effect holds true!

Stage migration pertains to many aspect of medicine, but there’s distinctive applicability to the discipline of oncology.

Cancer patients are assigned a particular stage of disease depending on where in their body the disease can be detected. For most cancers, stage is predictive of survival. The higher the stage of disease, the more advanced the cancer, and the shorter the anticipated survival time.

Many pet owners are concerned with determining what stage of cancer their dog or cat has without fully understanding what the term stage means or what information it provides.

In order to accurately assign a stage to a pet with cancer, veterinary oncologists must perform all of the recommended staging tests. For example, complete staging for dogs diagnosed with lymphoma includes a complete blood count with pathology review of a blood smear, serum chemistry panel, urinalysis, three view thoracic radiographs, abdominal ultrasound, biopsy of affected tissue, immunohistochemistry for phenotyping purposes, and bone marrow aspirate cytology.

Though I recommend complete staging for all pets diagnosed with lymphoma, very few owners agree to this plan. Further complicating the decision is that although stage is an important predictor of outcome; it generally doesn’t influence the initial treatment recommendations.

Factors such as finances, perception of what the pet will “go through” in terms of testing, timing, and availability of resources all influence whether a pet will have full versus partial staging.

Many patients have some of the tests performed, but it’s rare that they will have all of them done. This means that I’m often making educated guesses about a patient’s stage, and therefore their expected prognosis.

Stage migration is a useful tool to remind doctors to consider every patient as its own separate entity. Generalizations are helpful; however, they do not predict what will happen specifically to your pet.

An open and honest dialogue is the best way to understand what tests your pet needs and what information the results will provide.

This reminds me of another one of Will Rogers’s best quotes: “If there are no dogs in Heaven, then when I die I want to go where they went.”

Is it too late to say I’m sorry now?

“I’m sorry.”

Consider the magnitude of impact these two simple words can have.

Apologies, when uttered from a place of sincerity, are remarkably meaningful. They are capable of erasing negativity, clarifying misconceptions, and easing hurt feelings. They also convey understanding, solidarity, and compassion. When we are sincerely sorry, we are also truly humbled.

For medical professionals, saying “I’m sorry” may have the opposite result. When a doctor offers words of apology there may be perception of culpability for an inappropriate action. It’s questioned as an omission of guilt. Are we looking for forgiveness for our inadequacies? Are we searching for absolution for our inability to heal or cure? Or worse, are we somehow admitting to negligence or neglect?

There are examples where expressions such as “I’m sorry” or “I apologize” were used as evidence of wrongdoing or guilt in a court in the context of medical liability/malpractice cases. Doctors and other members of a patient’s medical team have been penalized for declaring their regret. As a result, individuals are advised, if not ordered, to refrain from making such statements on the off-chance the case in question ends up in court.

Fortunately, legislation is being structured to exclude expressions of sympathy, condolences, or apologies from being used against medical professionals in court. Proponents of these so-called “I’m sorry” laws believe that allowing medical professionals to make these statements can reduce medical liability/malpractice litigation. Currently, several states in the U.S. have pending laws to prevent apologies or sympathetic gestures uttered by medical professionals from being used against them in a legal forum.

For example, Massachusetts enacted a statute that

“provides that in any claim, complaint or civil action brought by or on behalf of a patient allegedly experiencing an unanticipated outcome of medical care, any and all statements, affirmations, gestures, activities or conduct expressing benevolence, regret, apology, sympathy, commiseration, condolence, compassion, mistake, error, or a general sense of concern which are made by a health care provider, facility or an employee or agent of a health care provider or facility, to the patient, a relative of the patient, or a representative of the patient and which relate to the unanticipated outcome shall be inadmissible as evidence in any judicial or administrative proceeding and shall not constitute an admission of liability or an admission against interest.”

From the perspective of a veterinarian actively working in the trenches, apologies are a routine part of my day. I frequently say “I’m sorry”; not to compensate for an inordinate amount of errors but rather as a means to offer a semblance of sympathy and understanding to owners who are often anxious, confused, and searching for kindness and hope.

I offer an apology to an owner after bearing unfortunate news or following the death of their pet. I say I’m sorry when a treatment plan has failed and a pet’s cancer has resurfaced or when lab work indicates that I need to alter my recommendations.

I offer regrets when I’m running behind in my schedule, when we’ve run out of a particular medication, or when a pet can’t have an ultrasound done that same day because the doctor who performs such exams is unavailable.

When I do make an error, I apologize for this as well. I’m not perfect and mistakes happen. My words are never stated lightly and I would never choose only admitting regret when it’s convenient for my own need.

When I say I’m sorry, I truly am sorry. There’s no alternative interpretation of my message. I’m not indicating anything more than a modest sense of compassion and care.

My idealistic soul desperately believes the majority of pet owners appreciate authenticity from their veterinarian over a lack of disclosure borne out of fear of legal retribution. The fact that laws are being developed to protect medical professionals suggests the opposite is the more factual scenario.

I urge you to consider which veterinarian you would prefer: the one who apologizes out of kindness or the one who remains silent out of fear?

Have you ever had an apology from your veterinarian (or other medical care giver)? How did you feel and respond?

Out of the mouths of animals…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When veterinarians care too much…

Compassion fatigue is known by many alternative terms: vicarious traumatization, secondary traumatic stress, secondary stress, and even second-hand shock. Most often, we associate compassion fatigue with the emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events.

Every person working in a “helping profession” is at risk for developing compassion fatigue. Sufferers can exhibit several symptoms, including hopelessness, a decrease in experiences of pleasure, constant stress and anxiety, sleeplessness or nightmares, and a pervasive negative attitude.

Compassion fatigue is prevalent in veterinary medicine. Veterinarians verbally promise to dedicate their professional lives to diagnosing and treating disease in animals and relieving pain and suffering when necessary upon reciting their oath during graduation. But far too often, this responsibility drains our emotional resources, leaving us with little reserve to combat our own struggles.

Much attention is (appropriately) devoted to the negative impact compassion fatigue has for veterinarians. However, relatively little focus is given to the role this condition has on veterinary technicians, an overlooked population of caretakers that is equally susceptible to its damaging effects.

Veterinary technicians aren’t precisely veterinarians, but we consider them the “next best thing.” Veterinary technicians administer medical care, assist veterinarians with all aspects of their daily responsibilities, and communicate with and instruct pet owners on all aspects of both preventative and therapeutic care.

Veterinary technicians help with routine examinations, administer medications, and conduct laboratory tests and understand how to interpret the results. Technicians also assist with surgeries, perform radiographs (x-rays), and assist in restraint for various procedures.
One of the primary roles veterinary technicians play is in the care of sick, hospitalized patients. The technicians spend countless hours administering treatments or performing diagnostic tests on those pets. They collect and run the laboratory samples. They clean up after, bathe, and hand feed the animals.

Technicians caring for hospitalized pets are the primary advocates for that animal’s care. When a technician alerts me to a patient they think is in pain, I trust their assessment. When they discuss a particular pet’s poor appetite or breathing rate, I heed their words entirely. While I am ultimately responsible for decisions regarding my patient’s care, I trust the technician’s opinions and use them in shaping my choices.

Working at a 24-hour emergency and critical care facility, I’m accustomed to seeing extremely ill or injured patients. We routinely admit the sickest of animals and use all of our expertise and talents to try to help restore their health. Despite (or perhaps because of) the regularity that we encounter such severely ill pets, it’s not unheard of for someone working the clinic to pass by the cage of such a patient, and comment that “He looks really bad,” or “That poor animal,” or “She needs to be euthanized.”

The phrases slide out of our mouths without much thought for consequence related to their impact. They are not meant to carry the weight of the negativity they imply. Yes, they are exceptionally abrasive and lack any element of constructive criticism or help, but are stated in a fleetingly passive sense. One designed to elicit camaraderie rather than disconnect.
However, the impact those words have on the technicians taking care of such patients can be condescending at best, and at worst push someone towards the emotional depths of compassion fatigue. Imagine being tasked with such an uphill battle.

The technicians assigned to caring for those particular animals are hyperaware of the degree of severity of illness or injury of their patients. They understand the gravity of the prognosis. They understand that the outcome will likely be poor. But they still pour every ounce of their dedication, energy, compassion, and effort into ensuring that pet is cared for to the best of their ability.

Negative comments can chip away at a technician’s capability for caring and contribute significantly to developing compassion fatigue. They can incite feelings of insecurity and depression. They could even cause a questioning of integrity or morals.

We focus on the impact of compassion fatigue on veterinarians, but we cannot dismiss the role it plays on the technicians caring for our patients each day. Even when we’re unable to diminish the impact, we can take steps to avoid worsening an already emotionally fueled situation.

We are all in this together. Regardless of the credentials following our name.

All about Prognostic Factors

Prognostic factors are characteristics possessed by a patient, its tumor, or both. They predict the likely course of the cancer, and ultimately, your pet’s prognosis, or final outcome.

Prognostic factors could help estimate a patient’s survival time, chance of success with a particular treatment plan, or risk for recurrence of disease following surgery, radiation, or chemotherapy.

Prognostic factors are designed to help owners and veterinary oncologists decide on the need for additional testing, potential treatment options, and also to provide a realistic expectation of outcome. Most studies investigating various cancers in pets include an analysis of specific prognostic factors in some capacity.

Much weight is given to the statistical significance of prognostic factors and they largely influence meaningful medical decisions, including those related to life and death. For example, immunophenotype is a prognostic factor for dogs with lymphoma. For dogs being treated with chemotherapy, those who have a B-cell phenotype tend to have a longer lifespan than dogs with a T-cell phenotype. Some owners will therefore base their decision to pursue treatment based solely on the result of the phenotype testing.

Unfortunately, many times prognostic factors fail to provide clinically relevant information. Dogs with nasal tumors who experience nosebleeds have a significantly shorter survival time than dogs without nosebleeds (88 days vs. 224 days). At first glance, one might assume dogs with nosebleeds have more aggressive tumors, or are sicker from their disease. Yet clinically, my observations tell me this is untrue.

I would argue that a bleeding nose is a negative prognostic factor for a dog with a nasal tumor primarily because the nosebleed is perceived as producing a negative impact on the pet’s quality of life. The nosebleed also negatively impacts the owner’s lifestyle, as these events can be dramatic, messy, and difficult to manage.

I still explain to owners of dogs with nasal tumors and nosebleeds that research tells me their dog’s expected lifespan is about three months. However, I am clear that most of those dogs are euthanized because of the physical issues caused by the nosebleed itself, rather than because of outward signs of pain, illness, or other concerns.

As another example, data tells me the tumor size is a prognostic factor for dogs with oral melanoma, with differences in outcome for dogs with tumors less than 2cm, those with tumors between ,2-4 cm and those with tumors >4cm. Logically, we can make sense of the concept that the larger a tumor is, the more impacting it would be for the pet.

Does this mean I offer the same prognosis for a tiny Chihuahua as I would for a Great Dane if both were diagnosed with a 2cm oral melanoma tumor? Logic dictates that although tumor size would be important, so would the size of the mouth hosting the tumor. Veterinary patients exist on an enormous spectrum of shapes and dimensions, therefore tumor size must be interpreted in light of patient size.

A particular characteristic determined to be a statistically significant prognostic factor in one study can be refuted with additional study. For example, age was shown to be a prognostic factor for dogs with osteosarcoma in one research study, but had no impact on survival in another.

When we focus too much on specific prognostic factors, we lose sight of the bigger picture. My patients are more than a simple set of descriptive values or categorical characteristics. Generalizations are valuable to an extent, but they cannot predict individual response.

I always consider known prognostic factors when making recommendations about my patients’ care. I’m also humble enough to remember that every animal is a uniquely created organism with unpredictable responses and outcomes, and that treating the individual is far more important than treatments based solely on statistics and probabilities.

Prognostic factors have value, but they certainly aren’t the bottom line. I urge owners to keep this in mind when considering pursuing treatment for their pet with cancer.

The good thing about science is…

While recently searching for information on the role of evidence-based information in medical decision-making, I came across the following quote by Neil DeGrasse Tyson:

“The good thing about science is that it’s true whether or not you believe in it.”

My initial impression of the statement was one of complete agreement. I approach both my professional and personal life with fairly rigid factual standards, constantly searching for proof and examining probability with regard to making important decisions or tackling difficulties.

With further consideration, I wondered how well the assertion actually holds up in the “real” world. Human nature imparts a desperate need to make sense of the things we don’t understand. It would be wonderful if everything we did could be categorically isolated into true or false statements. But reality dictates this is rarely ever the case.

We frequently encounter something we lack sufficient knowledge or information about. When we do, we use a combination of education and experience in our struggle to comprehend the unknown. This becomes particularly pronounced when we lack scientific comprehension of a particular topic and we allow experience to be the major contributor to our knowledge. When this occurs, we are participating in what is known as “conformation bias.”

Conformation bias occurs when we search for or interpret information in a way that confirms one’s preconceptions. Phrases such as “I believe,” “I think,” “this makes sense to me,” or “it’s logical that…” typically precede statements raft with conformation bias.

As an example, nearly every canine patient I see wears a collar. Many of the canine patients I see also have lymphoma. I might therefore conclude that collars were a cause of lymphoma in dogs. As I’m unaware of any research study designed to examine the presence of a collar as an independent risk factor for developing cancer in dogs, my assertion would be made from conformation bias, rather than scientific basis.

Unfortunately, those lacking a strong command of medical terminology and principles of physiology can be targets for slick marketing techniques, especially in relation to issues relating to their health or the health of their pets.

I think of this every time I come across a new product claiming to “detoxify the body,” or “cleanse the system,” or “boost the immune system.” My scientific mind knows those phrases are absolutely meaningless. I know my liver and kidneys already do all the detoxifying and cleansing that I need. I know if my immune system were to be boosted, it would probably start furiously attacking my own cells.

I also struggle because I know scientific discovery is borne out of questioning unproven observations and ideas. What we know as being scientifically true was, at one point, unknown. And even scientifically proven concepts can be refuted with additional study.

Every research project I’ve been a part of was derived from abstract concepts and experience and thought. They were designed to question whether the observations precipitating the study occurred via pure chance or from evidence based information. Of course scientific reasoning played the biggest role in actual design of the study, but an inquiring mind was responsible for thinking of initial hypothesis.

Statistics are our barometer for assessing the validity of a theory. When statistics show significance, we accept the hypothesis as truth. If significance is not achieved, it is rejected and considered scientifically false.

Experience tells me that accepting statistical significance or insignificance isn’t always the most accurate path to follow. Statistics can be manipulated and studies can be flawed. Remarkable conclusions can be drawn off of extremely small sample sizes or curiously designed studies. I also value my experience and how important it is in making decisions about my patients—even when no evidence-based data exists to prove that my theory is correct.

Is science true whether you believe it or not? It’s an interesting question to ponder, even for this scientist.

When cancer hurts, but only part of the time…

People readily associate a diagnosis of cancer with severe adverse clinical signs. I’m not speaking of the effects of chemotherapy or radiation; rather I’m referring to the decline in a patient’s quality of life occurring secondary to progression of disease.

Regardless of whether the patient is a human or an animal, we’re equally capable of visualizing a person or pet experiencing vomiting, diarrhea, inappetance or lethargy directly because of a diagnosis of cancer.

As a veterinary oncologist, my responsibility is to guide owners in deciding whether to pursue treatment versus palliative (comfort) care versus euthanasia following a diagnosis of cancer. Those conversations are difficult, but can be a bit more straightforward in cases where pets are obviously sick from disease, versus when they are diagnosed incidentally or with minimal signs.

When an animal’s quality of life is poor and is manifested by major symptoms such as weight loss, lethargy, or breathing difficulties, it’s not difficult to explain to an owner that their options are limited and heroic measures are not in their pet’s best interests. With rare exception, such poor quality of life is considered an absolute “endpoint” for pet owners.

However, pets with locally advanced forms of cancer, rather than systemic disease, are more likely to only sporadically show dramatic adverse signs from their condition, rather than constantly behave sick or painful. For those patients, the line in the sand of “good versus bad” health is blurred. It’s challenging to discuss the profound impact a temporary, but consistent, deterioration in behavior has for a pet.

The best examples of such tumors are those affecting the urinary bladder and perianal/rectal regions. The most common tumors of the urinary tract include transitional cell carcinoma, leiomyosarcoma, lymphoma, and squamous cell carcinoma. The most common tumors of the perianal/rectal region include anal sac adenocarcinoma, perianal gland adenomas and adenocarcinomas, rectal carcinoma, and lymphoma.

Cancers arising from these specific anatomical areas do not cause the typical, systemic signs of illness mentioned above, at least in their early stages. However, tumors of the urinary bladder can obstruct the flow of urine out of the bladder. Likewise, tumors of the perianal region are significant because they can inhibit the pet’s ability to pass fecal waste.

Tumor growth within the urinary bladder or perirectal/perianal region causes signs such as straining to urinate or pain and difficulty while passing stool. When tumors are small, signs are usually subtle and occur only a few times per week. Over time (weeks to months), signs progress to include more extreme discomfort when attempting to eliminate urine or feces on a regular basis.

During the specific time period the pet is attempting to void, I know their quality of life is exceptionally poor. The pain associated with elimination, though intermittent, drastically impacts their lives. However, at other times, affected animals will eat, drink, sleep, play, beg for treats, and wag their tails in the same way they would prior to their diagnosis of cancer. They don’t look sick, but are they truly healthy?

Owners struggle with assessing quality of life in those situations. The temporary, but intensely negative impact makes answering the question of “How will I know when it’s time?” so much more fluid. The conversations are complex. The answer lies in the gray area between the extremes of health and illness.

We never consider cancer a “good” diagnosis to face. We associate the word “cancer” with swiftly growing tumors that spread rapidly throughout the body, leading to a patient’s hasty demise.

Unfortunately, tumors located in a place where their presence interrupts vital processes necessary for survival may never need to travel farther than their anatomical site of inception to cause equally devastating effects.

Pet owners and veterinarians bear tremendous responsibility in ensuring that the needs of animals affected by any type of cancer are met. Even if symptoms occur intermittently, we must remember that quality of life is measured both quantitatively and qualitatively. Are we truly keeping an animal’s quality of life at the forefront of our decision making if we allow suffering to occur?

You never forget your first…

His name was Ali, as in Mohammed Ali. He was a handsome 1½-year-old tan and white Boxer with a sweet and playful disposition and a ton of energy crammed into the tiny makeshift exam room. Though Ali was only one of dozens of dogs evaluated at the Southside Healthy Pet clinic that evening, I’d forever remember him as the most exceptional dog I’d ever met, because Ali was the first “real patient” of my veterinary career.

The Southside Clinic was a veterinary student run “well pet” clinic offering low-cost exams, vaccines, and preventative medicine to pet owners demonstrating financial need in the community my veterinary school resided in. Ali’s owner brought him in for a recheck examination and booster vaccines, and on that particular evening, I was entrusted to obtain his history and perform a physical to assess whether Ali was healthy enough to receive his scheduled vaccinations.

As I began my systematic approach to his exam, I experienced the same anxiety I’d encountered during the times my mind blanked while answering routine questions on a final when I was sure I’d known the correct choices not more than ten minutes prior.

I’d previously practiced performing physicals numerous times; on my own pets, the friendly dogs and cats from the local shelters, and on my colleagues’ critters. But the challenge of doing the same task on an actual patient with an actual owner holding the other end of the leash was an entirely new experience for me.

I felt unprepared and ill-equipped for the task. I was sure I would forget to examine some crucial aspect of a critical body system. I worried I would miss a heart murmur or an abdominal mass or lameness.

I was paired up with a second year student who restrained Ali while I struggled to complete my tasks in an awkward and completely non-systematic fashion. Fortunately, both the dog and the student were exceedingly patient with my clumsiness and I was grateful for my partner’s assistance in reminding me of the things I should be looking for.

Ali’s exam was rather unremarkable (a term that, when applied to a medical record, denotes signs of health rather than implied mediocrity), but I’d discovered some sores and redness along the skin between his toes. The lesions weren’t noted during his exam the previous month, but the senior student had noticed similar red “bumps” between Ali’s shoulder blades during that previous visit. Those lesions had since resolved, but given the appearance of dermatologic changes in two distant anatomical locations, I wondered if unremarkable wasn’t the best term to describe Ali’s status.

But what was I supposed to do about it?

I consulted with the senior student, who made a suggestion based on her knowledge, but I wasn’t confident that it was the correct plan for Ali. The two of us spoke with the veterinarian supervising the clinic and he presented several potential diagnostic and therapeutic options for me to consider. Together, we discussed the pros and cons to each approach. I listened attentively, eager for instructions on how to proceed. More than a few moments of awkward silence passed before I realized I wasn’t going to be told what to do next.

Those passing seconds are etched in my mind, as they represented the first time I was treated more as a doctor and less as a veterinary student. The shift in responsibility lacked fanfare, but was palpable nonetheless. I’d need to stop thinking of myself as a task-oriented individual. I would need to learn how to become comfortable with taking charge of my patients’ care.

I quickly learned that the point of this clinic was not to be perfect, but rather to apply my flawed skills and imperfect knowledge in a “real world” setting. This was the time to make mistakes because I had backup available during every step of the process.

I reentered the exam room with increased bravado and assuredly discussed my findings and recommendations with Ali’s owner. I drew confidence from the reserve supplied by the staff veterinarian and his surety in my capabilities. A plan was set into action based on my conclusion as a primary caregiver rather than an intermediary whose role is to enact orders from someone else.

Looking back, Ali’s case was a bit of a no-brainer, but for a “first veterinary patient” I’m still inspired by the experience and what it represented for me in my educational process. I’d only been a veterinary student for three months, but I’d already begun the subtle process of transforming myself into a doctor.

Patients such as Ali made that transition all the more wonderful each time I encountered them.

I can’t take all the credit…

Have you ever heard of laparoscopic (minimally invasive) surgery? Here’s a great article written by my husband, Dr. Marc Hirshenson, on this interesting topic!

http://veterinarynews.dvm360.com/surgery-stat-finer-points-laparoscopic-liver-biopsies

Brain tumors in dogs and cats

One of the less common cancers I’m asked to consult on are brain tumors. Though such tumors occur with fair frequency in both cats and dogs, optimal diagnostic and treatment plans are not well established. Thus brain tumors are considered a challenging disease for both veterinary neurologists and oncologists.

Brain tumors are either primary or secondary, with about equal chance of either of them being the diagnosis. Primary brain tumors originate from cells normally found within the brain tissue itself, or the thin membranes lining its surface. The most common primary tumors are meningiomas, astrocytomas, oligodendrogliomas, choroid plexus tumours, central nervous system (CNS) lymphoma, glioblastoma, histiocytic sarcomas, and ependymomas.

Secondary brain tumors occur when either a primary tumor located elsewhere in the body spreads to the brain (a process known as metastasis) or extends into the brain via invasion from adjacent tissue (e.g., bones of the skull, nasal cavity, eye, etc.).

Brain tumors occur most often in older pets, with the median age of affected dogs and cats being 9 and 11 years, respectively. Certain breeds show a predisposition for developing primary brain tumors: Boxers, Golden retrievers, and domestic shorthair cats are at increased risk.

Brain tumors that originate from the membranes covering the brain (known as meningiomas) occur more often in dolichocephalic breeds—those with long heads and noses—such as Collies. Conversely, brachycephalic breeds, with their short-nosed, flat-faced appearance, are more likely to develop gliomas, which are tumors of the interstitial tissue of the central nervous system.

The most common clinical sign of a brain tumor in dogs is seizures. Cats are more likely to show a sudden onset of aggression. Other signs suggestive of a brain tumor include behavioral changes, altered consciousness, hypersensitivity to pain or touch in the neck area, vision problems, propulsive circling motions, uncoordinated movement, and a “drunken,” unsteady gait. Non-specific signs such as loss of appetite, lethargy, and inappropriate urination are also seen.

There are several recommended staging tests for pets suspected to have brain tumors. These tests are designed to examine for widespread disease in the body, are considered part of a general health screen, and can establish baseline information with which we can compare to in the future.

Staging tests include complete blood count (CBC), chemistry panel, thoracic radiographs, and abdominal ultrasonography. These tests are used rule out an extracranial primary tumor that has metastasized to the brain, or the possibility of another primary tumor located in a distant site. These tests provide owners with peace of mind for moving forward with advanced imaging (MRI/CT) of their pets’ brains. In approximately 8% of cases, results from such tests will ultimately lead to a change in the anticipated diagnostic and treatment plan.

When a brain tumor is suspected, and staging tests are considered clear, the recommended next test is typically magnetic resonance imaging (MRI). The exception would be cases where a pituitary tumor is suspected, as these tumors are better visualized using CT scan.

The only way to definitively diagnose a brain tumor and determine its exact tissue of origin would be through biopsy. While it is ideal to have a diagnosis before proceeding with therapy, veterinarians often recommend treatment based on a presumptive diagnosis from the imaging characteristics of an intracranial mass This is due to the increased risk associated with the procedure and the negative impact the clinical signs seen in affected patients has on their overall quality of life.

There are three primary treatment options for dogs that have been diagnosed with brain tumors: surgery, radiation therapy, and chemotherapy. The objectives of such therapies are to or reduce the size of the tumor and to control secondary effects, such as fluid build-up in the brain. Surgery may be used to completely or partially remove tumors, while radiation therapy and chemotherapy may help shrink tumors or reduce the chance of regrowth following surgery. Medications are also often prescribed to manage the side effects of brain tumors, such as seizures.

The prognosis for dogs with brain tumors is considered guarded to fair. Survival times of 2-4 months are expected with supportive care alone, 6-12 months with surgery alone, 7-24 months with radiation therapy alone, 6 months to 3 years with surgery combined with radiation therapy, and 7-11 months with chemotherapy alone.

As is typical for many aspects of veterinary oncology, accurate prognostic information for cats with brain tumors is lacking.

If your veterinarian suspects your pet has a brain tumor, please consider seeking a consult with a board certified veterinary neurologist or oncologist in your area to understand your options for both diagnosis and treatment.

You can find more information at the website for the American College of Veterinary Internal Medicine.

It won’t hurt to try? Or will it?

There are many gray areas in veterinary cancer care. Rarely am I certain that a particular treatment option or surgical strategy or chemotherapy protocol is “the absolute best” plan of action for any given patient.

My uncertainty stems not from a lack of knowledge or experience; it arises from a dearth of evidence based information to guide my decision making process.

Practicing evidence based medicine means I would conscientiously explore only the current best proof in making decisions about the care of my patients. This requires scouring research summaries and scrutinizing details contained within the reports to define the applicability of such work to the specific pet presented to me in the exam room.

As an example, evidence based tells me that the optimal treatment plan for a dog diagnosed with multicentric lymphoma is a multidrug chemotherapy protocol administered over a six month period. This combines the lowest chance of side effects with the longest anticipated survival time. Similarly, research tells me the patient’s prognosis without treatment is only 2-3 months.

These statistics are based off of data accrued during studies designed specifically to look at the outcome of many dogs diagnosed with lymphoma treated in a similar fashion, allowing conclusions to be drawn that are applicable to a wider subset of patients.

The contrary of evidence based medicine is incorporating the idea that “anything that could help, and doesn’t hurt” is a valid option for a patient’s treatment regimen. This approach relies not on factual information but on “soft findings,” such as personal experience, anecdotes, or even ambiguous best guesses.

There are several flaws with this latter approach to practicing medicine, namely the assumption of a failure to cause harm. Even when there is a lack of a positive response to therapy, this doesn’t imply an absence of a potentially negative outcome.

Owners frequently approach me with questions about untested remedies they’ve read about on the internet or that were suggested by a caring friend, relative, breeder, therapist, etc. While some of these purportedly “harmless” options are likely to be truly harmless, my concern is that the negative effects of others are potentially vastly underestimated.

For example, owners inquiring about feeding their dogs Gatorade when they are feeling ill are unlikely to harm their pets by doing so. I inform them that the small volume of fluid they are able to feed to their pet orally will not provide enough glucose (sugar) and electrolytes to reverse acute dehydration, but as long as there’s no artificial xylitol sweetener in the product, the chance of causing harm is minimal. I can’t think of a specific study proving my assumption, but I’m comfortable with my conclusion nonetheless.

The bigger problems are those seemingly innocuous therapies where evidence based information in scarce but questionable enough to raise concern for a detrimental effect. Consider the supposed benefits of antioxidant supplements for dogs and cats.

Research supports the concept that antioxidants are able to protect cells from free-radical damage — in test tubes and living animals. However, opposing research has shown that antioxidants can potentially increase risk for disease (e.g., cancer), as well as counteract the beneficial effects of treatments such as chemotherapy.

It’s surprisingly difficult for a doctor to know how to keep the evidence-based medicine in check and ensure that the optimal standard of care is offered for their patients. I may not always be able to use research based information to make decisions about my patients’ care, but I also am wary of accepting an option simply because “it couldn’t hurt.”

I spend a lot of time researching options, hitting walls, and being frustrated in the lack of confirmative data to guide the decision making process. This process allows me to maintain the greatest responsibility I have to my patients: to “first, do no harm.”

My vet did all these tests and we still don’t know anything…

Diagnostic tests are essential to my daily activities as a veterinary oncologist. For example:

I require a complete blood count (CBC) test before every chemotherapy treatment.

I analyze results from fine needle aspirates and biopsies in order to formulate therapeutic plans.

I use radiographs (x-rays) to look for metastasis (spread) of cancer to internal organs.

I request ultrasounds to compare tumor size before and after therapy to ensure success.

Every test I order requires interpretation. The expectation is that I will always know precisely how to do so. The reality is I typically do. But sometimes I struggle to decipher the precise “next best step.”

Results typically exist either on a quantitative (yes or no) or qualitative (sliding scale) basis. Most owners assume I’ll present them with the former. Their dog’s CBC will either be good or bad. The aspirate will show cancer or a benign growth. The radiographs will depict metastases or be clear. The ultrasound will measure growth or shrinkage.

Unfortunately, with few exceptions, nearly all results possess some degree of intrinsic qualitative characteristics.

The patient’s platelet count on their CBC may be considered adequate for administering chemotherapy, but if the numerical value is 50% lower than it was the week prior, I’ll pause to ask “why?” before ordering their drug.

Aspirates can show cancer but still not provide enough information to give me the exact tissue of origin, precluding a specific treatment plan.

Radiographs can suggest spread of cancer, but the pattern could also result from pneumonia or asthma, offering three completely different diagnoses and prognoses.

The ultrasound might reveal a change in the appearance, but not size, of a tumor, leading to the possibility that the cancer is not as well controlled as the measurements imply.

Ambiguous outcomes are, at minimum, frustrating for both veterinarians and owners. More often, if owners are unaware of the possibility of an indeterminate result, they could over interpret the equivocal diagnostics, inappropriately assuming an incorrect positive (or negative) conclusion.

The utmost unfortunate situation occurs when owners, unprepared for the possibility of inconclusive results, leave the clinic focused on how they’ve spent a great deal of money on tests they feel showed “nothing.”

Through personal experience, I’ve learned the importance of explaining anticipated uncertainties prior to an owner committing to any given test. The most important warning I can offer to an owner is, “absence of evidence is not evidence of absence.”

Consider the usefulness of thoracic radiographs (chest x-rays) for predicting metastasis in a dog diagnosed with appendicular osteosarcoma (a form of primary bone cancer).

Evidence based information based on studies with hundreds of dogs tells me that 1) greater than 90% of dogs with osteosarcoma will have negative thoracic radiographs at the time of diagnosis, and 2) within 4-5 months following amputation of the tumor-containing limb, 90% of those same dogs will develop radiographically detectable tumors in their lungs.

We conclude that the metastatic tumors were present when the first set of x-rays was taken, despite the report indicating the scans were clean. Clearly, the absence of evidence on the first set of x-rays is not absolute evidence of the absence of tumors for the majority of dogs.

To make a medically appropriate choice for their dogs with osteosarcoma, owners need to be aware of the predictive value of the first set of radiographs, and that the lack of initial spread of disease doesn’t preclude future metastasis. This also underscores the importance of repeating x-rays at specific time points following surgery.

Medical analyses are a necessary part of the treatment plan for my patients. They are an essential part of monitoring and ensuring pets are healthy enough to withstand further procedures and therapeutics.

I rely on my experience and intuition to fill the gap when results are confusing or inexact. Those same attributes allow me to predict the possibility of an uncertain answer and to talk about those possibilities with owners before reports are entered into their pet’s chart.

Owners should also feel comfortable enough to ask their veterinarian about the expected possible outcomes of recommended tests, including the positive, negative, and “in between” results.

This will ensure that expectations are clear on both sides, so that we can each contribute to the optimal treatment plan for the pet.