A Cancer Diagnosis Is Not a Death Sentence | Today&039s Veterinary Practice

With a slow wag of her tail, Reese walked slowly across my exam room to greet me. I realized that her cancer was taking its toll. Before the consultation, I reviewed his medical history, which told me that my patient was a dog with advanced metastatic cancer. While I am often amazed at how well dogs with advanced cancer look, Reese was not one of those pets.

Two months earlier, Reese, a 9-year-old neutered male pit bull/mixed dog, had been diagnosed with right-sided anal sac adenocarcinoma by her primary care veterinarian. Reese was also hypercalcemic, a well-documented negative prognostic predictor.

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Two weeks later, Reese was evaluated by a medical oncologist, who performed staging diagnoses to determine the severity of the cancer. the oncologist found metastases in the sublumbar lymph nodes and lungs and started oral prednisone therapy for hypercalcemia and chemotherapy.

the first in a series of articles by dr. sue ettinger, chief of the department of oncology at animal specialty & emergency center in wappinger falls, new york. dr Ettinger’s mission is to promote pet cancer awareness and education. In these articles, she will combine her experience in oncology with her experience in practice to detail how physicians can better care for cancer patients.

reese became my patient when the oncologist moved across the country. despite 6 weeks of therapy, he had not improved. his owner reported tenesmus from the large anal sac tumor and markedly enlarged sublumbar lymph node. Reese had little appetite and his family fed him by hand.

reese’s x-rays were shocking: her chest was littered with wall-to-wall overlapping lung nodules, often described as like a snowstorm or lungs full of cotton balls. These images explained Reese’s shortness of breath and frequent coughing, which occurred throughout the night.

Sadly, a dog like Reese’s has a poor prognosis, usually 1-2 months to live from diagnosis, and Reese’s cancer was identified 2 months ago. What would he say to his family? there were no options. or were they there?

go beyond misconceptions

Cancer is a scary word that is often equated with death. For many, cancer also equates to pain and suffering. people sometimes think there is no hope.

As a cancer specialist, people are often surprised to learn that I love my job. they assume it must be depressing and hopeless, and that the pets could not stand or benefit from cancer treatment. treatment just makes pets sicker, right?

I disagree. cancer is not a death sentence. While we all want a cure for cancer, I encourage you to consider many cancers as chronic conditions that may require chronic therapy, such as heart or kidney disease.

There are so many myths and misconceptions about cancer in pets, but one important fact is that treatment is usually very well tolerated. there are treatment options, and a wide range of them, including surgery, radiation, chemotherapy, and palliative and supportive care.

As an oncologist, I recommend treatment when the pet is likely to live longer with it than without it. Fortunately, most pets feel fine, if not great, during treatment. my motto is, “live longer, live well”. my patients need to do both, and they do. That’s why I love my job.

There are frustrating and heartbreaking moments, especially when I lose a patient to cancer after sharing months or years of working together with the pet and owners. But, most of the time, treating cancer in pets is about providing quality of life for the pet and more quality time for their owners, as well as hope.

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Most of my cancer patients are in good health and their treatment allows them to lead happy lives. some even live longer and better than expected (see talking about oprah).

give bad news

being a cancer specialist often means delivering bad news: the cancer has spread. the cancer has relapsed. the cancer no longer responds to treatment.

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however, in my opinion, the general practice veterinarian and team have the hardest job: they have to tell clients that the biopsy or aspirate of the mass is cancerous, or that there is a high suspicion of cancer . They often have to say things like: I have bad news about bone X-rays.

Talking about cancer isn’t fun and it’s stressful for doctors, who have a responsibility to deliver bad news. When a pet has cancer, the human-animal bond becomes strained and fragile, making communication between veterinarian and owner even more challenging than other doctor-client conversations. however, this communication is critical to optimal patient care.

Unfortunately, guidelines and training are lacking to help veterinarians navigate difficult cancer conversations about diagnosis, prognosis, treatment, and palliative care options. furthermore, “cancer communication” training in veterinary school varies in content, duration, and methods. There is often a gap between the veterinary school curriculum and acquiring the skills necessary to be successful in practice. As a result, many veterinarians and specialists feel unprepared for these conversations, and most oncologists learn to “break bad news” by observing more experienced colleagues.

I am constantly improving my skills to be able to convey disturbing news with kindness, and I help other vets do this as well. however, in school and in my residency I was taught the “data dump” method: delivering a monologue of information. Although the owners told me that I had done a good job and answered all their questions, I realized that we, the veterinary profession, can do a better job when it comes to cancer.

Better communication about cancer starts with learning the following 3 words and what they stand for:

  1. aware. be aware of the challenges that both you, as a veterinarian, and the client face.
  2. where. where they are are you giving bad news? go to a private place, like an exam room, and do it in person, not over the phone. make sure you have enough time and attention.
  3. how. how do you prepare? ask open questions, be empathic, use inclusive language and turn it into a dialogue, a conversation. use the “chunks and check” approach: provide a chunk of information; then check that you have understood.

I have found that these basic communication skills save me time and allow for a more efficient doctor-client interaction. Breaking bad news may not be easy or fun, but we can improve the experience for the veterinary team and the pet owner. once we break the news, we start covering options, like chemotherapy.

treatment with chemotherapy

Most pet owners are surprised that dogs and cats do not experience chemotherapy side effects. I’ve seen human friends and family become seriously ill after chemotherapy, and are sometimes hospitalized for serious side effects. Fortunately, that’s not how pets respond.

The overall toxicity rate is very low in veterinary chemotherapy patients. in my experience, most pets, about 80%, have no side effects. only 15% to 20% experience mild to moderate side effects that last a few days, and side effects are less common in cats than dogs.

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Serious complications, such as severe loss of appetite, dehydration, vomiting, and diarrhea, occur in less than 5% of chemotherapy patients. these patients may require hospitalization for supportive care to treat dehydration, infection, or sepsis. In my experience, with dose reduction and prophylactic medication, most of these patients can be successfully returned to the same drug.

Owners are also relieved to learn that most pets do not shed. alopecia (hair loss) occurs because chemotherapy agents target all rapidly dividing cells, including hair follicles. in dogs, some potentially affected breeds (poodles, Scottish terriers, and western highland white terriers) have continuously growing coats. alopecia is rare in cats, but they can lose their whiskers.

While undergoing chemotherapy, shaved areas of the pet (eg, for extremity catheters, abdominal ultrasound) tend to grow hair more slowly. The good news is that hair and whiskers grow back once treatments are complete. occasionally the hair grows back in a different texture or color, and in cats the coat is often softer and is called a chemo coat.

It is important to remember, and remind customers, that cosmetic side effects are not a concern for pets and that these effects do not affect quality of life. however, I recommend warning pet owners about potential whisker and fur loss to avoid unnecessary surprises.

cancer treatment is not a binding contract. I always encourage clients considering chemotherapy to let me give 1 or 2 doses and see how the pet reacts. most clients are so pleased that they continue treatment and I am able to adjust dosage and other medications to ensure quality of life during treatment.

I can’t tell you how often clients tell me that their pets receiving chemotherapy have more energy than they did 6 months or a year ago, before they had cancer and before they started chemotherapy. I think it’s a testament to how well most pets feel during and after chemotherapy.

live in the moment

Another important aspect in veterinary oncology is to remember that patients do not “know” they have cancer. Of course, dogs and cats feel pain and don’t enjoy feeling bad, but unlike humans, pets don’t deal with the psychological aspect of cancer. pets live in the moment, and I believe that “ignorance is bliss” in these situations.

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Instead, it is pet owners who must absorb all the information about cancer: remission rates, survival statistics, treatment options, treatment schedule and costs. I advise my clients to avoid stressing about their pet’s response to treatment and prognosis because stress will not change the outcome. and tell them to let me worry about the disease, treatment, dose and response.

The role of the client is to give me feedback on how the pet did after treatment and to give the pet the prescribed medications. customers need to enjoy every day, because every day with a pet is a gift.

new therapies arrive

It’s an exciting time to be an oncologist. new therapies are available and there are even more on the horizon.

Newer radiation therapy options, such as stereotactic radiation, can treat some tumors (eg, brain, nasal) in 1 to 3 treatments (instead of 15 to 20), with fewer episodes of anesthesia, secondary and office visits. we now also have targeted therapy, such as the tyrosine kinase inhibitor palladia (toceranib phosphate; zoetisus.com) for canine mast cell tumors and the melanoma vaccine oncept (merial.com) for oral and cervical malignant melanoma. the canine fingers.

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Other new therapies are in earlier phases of development and clinical trials, and in some cases, we are awaiting published data on response rates. these include a monoclonal antibody immunotherapy for b-cell lymphoma (aratana.com), a canine lymphoma dna vaccine (merial.com), and a nucleotide prodrug of vetdc for dogs and possibly cats (vet-dc.com ).

a vaccine against canine osteosarcoma (aratana.com) is being studied at the university of pennsylvania as an aid to treatment with amputation and chemotherapy. Early results look promising, with increased survival times and only mild to moderate adverse effects.

Other supportive medications in development include entyce (capromorelin; aratana.com), an appetite stimulant, and canalevia (crofelemer; jaguaranimalhealth.com), which is for the treatment of chemotherapy-induced diarrhea.

It’s exciting to learn that the near future may hold new tools for our cancer toolbox.

continued: reese and oprah

During my residency, I was taught that patients with advanced metastatic disease (dogs like Reese’s) would likely live 1-2 months, so I focused on palliative care and pain control. however, I no longer define successful cancer treatment as a complete remission. partial response or even stable disease is successful if we improve or maintain good quality of life.

In dogs and cats with advanced metastatic disease where the maximum tolerated dose (mtd) of chemotherapy is no longer effective, metronomic chemotherapy may inhibit tumor growth and thus stabilize the disease. This “pulse” chemotherapy provides uninterrupted low doses of cytotoxic drugs at regular, continuous, and frequent intervals. eliminating pauses between doses reduces or eliminates the ability of tumor cells to repair damage or alter their microenvironments. Instead of killing cancer cells directly with mtd (high-dose) chemotherapy, this therapy targets the blood vessels that allow tumors to grow and metastasize.

this therapeutic approach is what i chose for reese and oprah, and both received off-label oral palladia for its anti-angiogenic effects, with low-dose oral (metronomic) cyclophosphamide for its effect on regulatory t cells.

reese

Two months later, follow-up chest radiographs showed smaller, less well-defined nodular opacities. More importantly, Reese’s appetite had improved and her cough had subsided, resulting in weight gain and great energy.

Although Reese had advanced metastasis, she lived an additional 10 months. Her protocol was well tolerated and Reese’s owners were satisfied with the quality of life that resulted from the therapy.

oprah

Oprah’s follow-up chest x-rays at 2 months showed stable disease, but I was surprised by her review x-rays at 7 months: the cranial mass had disappeared and the caudal had shrunk in size.

oprah is still my patient today, 2 years and 11 months later. she has had some side effects from cyclophosphamide, including sterile hemorrhagic cystitis. more recently, she developed idiopathic dilated cardiomyopathy resulting in heart failure, but monitoring and care by a cardiologist have resulted in improvement.

summary

Today, there are options for pets with cancer, even those with advanced metastatic cancer, as reese and oprah have shown. these options include new therapeutic modalities and a more preventive approach to treatment, complemented by better communication about cancer. don’t think cancer is a death sentence. think about hope, think about options, and think about living longer, living well.

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