Sadly, a dog like Reese has a grim prognosis, typically 1 to 2 months to live from diagnosis, and Reese\u2019s cancer had been identified 2 months ago. What would I say to his family? There were no options. Or were there?<\/p>\n
Moving Beyond Misconceptions<\/h2>\n
Cancer<\/em> is a scary word that is often equated with death. To many, cancer also equals pain and suffering. People sometimes think there is no hope.<\/p>\n Because I am a cancer specialist, people are frequently surprised to hear that I love my job. They assume it must be depressing and hopeless, and that pets could not possibly handle cancer treatment or benefit from it. Treatment only makes pets more ill, right? <\/em><\/p>\n I disagree. Cancer is not a death sentence. While we all want a cure for cancer, I encourage us to consider many cancers as chronic conditions that may require chronic therapy, such as kidney or heart disease.<\/p>\n There are so many myths and misconceptions about cancer in pets, but one important fact is that treatment is often very well-tolerated. There are<\/em> treatment options, and a wide range of them, including surgery, radiation, chemotherapy, and palliative and supportive care.<\/p>\n As an oncologist, I recommend treatment when the pet is likely to live longer with it than without it. Thankfully, most pets feel good, if not great, during treatment. My motto is, \u201cLive longer, live well.\u201d My patients need to do both\u2014and they do. That is why I love my job.<\/p>\n There are frustrating and heartbreaking moments, especially when I lose a patient to cancer after sharing months or years working together with the pet and owners. But, most of the time, treating cancer in pets is about providing quality of life to the pet and more quality time to its owners, as well as hope.<\/p>\n Most of my cancer patients are quite healthy and treatment allows them to lead happy lives. Some even live longer and better than expected (see Speaking of Oprah<\/strong>).<\/p>\n Computed tomography confirmed 2 large thoracic masses (> 8\u201310 cm), thought to be metastatic lymph nodes, and cytology of the cranial mass confirmed carcinoma. Two additional smaller masses were noted in the pulmonary parenchyma. Oprah had a history of an intermediate-grade mammary carcinoma, which was resected 10 months earlier.<\/p>\n While it was not clear whether the thoracic nodules were metastatic, the presence of multiple masses precluded Oprah from surgery, and conventional chemotherapy is typically not effective for macroscopic disease. I started to feel anxious at the prospect of breaking the bad news\u2014that Oprah had multiple chest masses\u2014to her owner.<\/p>\n Oprah\u2019s story continues on later in the article.<\/div><\/div>\n Being a cancer specialist often means delivering tough news: The cancer has spread. The cancer has relapsed. The cancer is no longer responding to treatment.<\/em><\/p>\n However, in my opinion, the general practice veterinarian and team have the more difficult job\u2014they have to tell clients that the biopsy or aspirate of the mass is cancerous, or that there is a high suspicion of cancer. They must often say things, such as: I have bad news about the bone x-rays.<\/em><\/p>\n Talking about cancer is not fun, and it is stressful for clinicians, who carry the burden of responsibility for communicating bad news. When a pet has cancer, the human\u2013animal bond becomes strained and fragile, making communication between the veterinarian and the owner even more challenging than other clinician\u2013client conversations. Yet, this communication is critical to optimal patient care.<\/p>\n Sadly, guidelines and training to help veterinarians broach difficult cancer conversations about diagnosis, prognosis, treatment, and palliative care options are lacking. In addition, training for \u201ccancer communication\u201d in veterinary school varies with regard to content, duration, and methods. There is often a gap between veterinary school curriculum and the acquisition of the skills needed to be successful in practice. As a result, many veterinarians and specialists feel unprepared for these conversations, and most oncologists learn to \u201cbreak bad news\u201d by observing more experienced colleagues.<\/p>\n I am constantly improving my skills so that I can convey distressing news gently, and I help other veterinarians do this as well. However, in school and my residency I was taught the \u201cdata dump\u201d method\u2014delivery of a monologue of information. While owners told me I had done a good job and answered all their questions, I came to realize that we\u2014the veterinary profession\u2014can do a better<\/em> job when talking about cancer.<\/p>\n Better cancer communication begins by learning the following 3 words and what they represent:<\/p>\n I have found that these core communication skills save me time and allow more efficient clinician\u2013client 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 to cover the options, such as chemotherapy.<\/p>\n Most pet owners are surprised that dogs and cats do not experience chemotherapeutic side effects. I have watched human friends and family members get extremely sick after chemotherapy, and they are sometimes hospitalized from severe side effects. Thankfully, that is not how pets respond.<\/p>\n The overall toxicity rate is very low in veterinary chemotherapy patients. In my experience, the majority of pets, approximately 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.<\/p>\n Serious complications, such as severe inappetence, dehydration, vomiting, and diarrhea, occur in less than 5% of chemotherapy patients. These patients may require hospitalization for supportive care to address dehydration, infection, or sepsis. In my experience, with a dose reduction and prophylactic medications, most of these patients can successfully receive that same drug again.<\/p>\n Owners are also relieved to learn that most pets do not lose their hair. Alopecia (hair loss) occurs because chemotherapeutic agents target all rapidly dividing cells, including hair follicles. In dogs, some potentially affected breeds\u2014poodles, Scottish terriers, and West Highland white terriers\u2014have continuously growing coats. Alopecia is rare in cats, but they may lose their whiskers.<\/p>\n While undergoing chemotherapy, shaved areas on the pet (eg, for limb catheters, abdominal ultrasound) do tend to grow hair back more slowly. The good news is that hair and whiskers regrow once the treatments have completed. Occasionally, hair grows back a different texture or color and, in cats, the hair coat is typically softer and referred to as a chemo coat<\/em>.<\/p>\n It is important to remember, and remind clients, that pets do not care about cosmetic side effects, and these effects do not impact quality of life. However, I do recommend advising pet owners about the potential loss of whiskers and hair coat to avoid any unnecessary surprises.<\/p>\n Cancer treatment is not a binding contract. I always encourage clients who are considering chemotherapy to let me administer 1 to 2 doses and see how the pet reacts. Most clients are so pleased that they continue with treatment and I can adjust the dose and other medications to ensure quality of life during treatment.<\/p>\n I cannot tell you how often clients tell me their pets undergoing chemotherapy have more energy than they did 6 months or a year ago\u2014before they had cancer and before they began receiving chemotherapy. I think it is a testament to how well most pets feel during and after chemotherapy.<\/p>\n For patients receiving injectable chemotherapy that is likely to cause nausea or vomiting, such as doxorubicin, I administer antiemetics (e.g., maropitant) concurrently with the chemotherapy treatment.<\/p>\n All patients receiving chemotherapy are discharged with \u201cjust-in-case\u201d medications, including maropitant, metronidazole, and a probiotic, and detailed instruction sheets on when and how to use them. This leaves clients prepared in case the patient has gastrointestinal side effects at home.<\/p>\n <\/div><\/div>\n Another important aspect in veterinary oncology is to remember that the patients do not \u201cknow\u201d they have cancer. Of course, dogs and cats feel pain and do not enjoy feeling unwell but, unlike humans, pets do not deal with the psychological aspect of cancer. Pets live in the moment, and I think \u201cignorance is bliss\u201d in these situations.<\/p>\n Instead, it\u2019s the pet owners who must absorb all the cancer information\u2014remission rates, survival statistics, treatment options, treatment schedule, and costs. I advise my clients to avoid stressing about their pets\u2019 response to treatment and prognosis because stressing will not change the outcome. And I tell them to let me worry about the disease, treatment, doses, and response.<\/p>\n The client\u2019s role is to give me feedback on how the pet did after treatment and to give the pet its prescribed medications. Clients need to enjoy each day, for each day with a pet is a gift.<\/p>\n It is an exciting time to be an oncologist. New therapies are available and even more are on the horizon.<\/p>\n Newer radiation therapy options, such as stereotactic radiation, can treat some tumors (eg, brain, nasal) in 1 to 3 treatments (rather than 15\u201320), with fewer anesthesia episodes, side effects, and practice visits. We also now have targeted therapy, such as the tyrosine kinase inhibitor Palladia (toceranib phosphate; zoetisus.com<\/a>) for canine mast cell tumors and the melanoma vaccine Oncept (merial.com<\/a>) for canine oral and digit malignant melanoma.<\/p>\n Other new therapeutics are in earlier phases of development and clinical studies and, in some cases, we are waiting for published data on response rates. These include a monoclonal antibody immunotherapy for B-cell lymphoma (aratana.com<\/a>), a canine lymphoma DNA vaccine (merial.com<\/a>), and nucleotide prodrug from VetDC for dogs and possibly cats (vet-dc.com<\/a>).<\/p>\n A canine osteosarcoma vaccine (aratana.com<\/a>) is being studied at the University of Pennsylvania as an aid to treatment with amputation and chemotherapy. Early results look promising, with an increase in survival times and only mild to moderate adverse effects.<\/p>\n Other supportive medications in the pipeline include Entyce (capromorelin<\/a>; aratana.com<\/a>), an appetite stimulant, and Canalevia (crofelemer; jaguaranimalhealth.com<\/a>), which is for treatment of chemotherapy-induced diarrhea.<\/p>\n It is exciting to know that the near future may hold new tools for our cancer toolbox.<\/p>\n During my residency, I was taught that patients with advanced metastatic disease\u2014dogs like Reese\u2014would likely live 1 to 2 months, so I focused on palliative care and pain management. However, I no longer define cancer treatment success by complete remission. Partial response or even stable disease is successful if we improve or maintain a good quality of life.<\/p>\n In dogs and cats with advanced metastatic disease in which maximum tolerated dose (MTD) chemotherapy is no longer effective, metronomic chemotherapy<\/em> may inhibit tumor growth and, thus, stabilize disease. This \u201cpulse\u201d chemotherapy provides uninterrupted low doses of cytotoxic drugs at regular, continuous, and frequent intervals. Eliminating breaks between dosages reduces or eliminates the ability of the tumor cells to repair damage or alter their microenvironments. Instead of killing cancer cells directly with MTD (high-dose) chemotherapy, this therapy targets blood vessels that allow tumors to grow and metastasize.<\/p>\n This therapeutic approach is what I chose for Reese and Oprah, and both of them received off-label oral Palladia for its anti-angiogenic effects, with low-dose (metronomic) oral cyclophosphamide for its effect on regulatory T cells.<\/p>\n Two months later, follow-up chest radiographs showed smaller and less defined nodular opacities. More important, Reese\u2019s appetite had improved and his coughing was decreased, resulting in weight gain and great energy.<\/p>\n Even though Reese presented with advanced metastasis, he lived 10 more months<\/strong>. His protocol was well-tolerated, and Reese\u2019s owners were pleased with the quality of life that resulted from therapy.<\/p>\n Oprah\u2019s follow-up chest radiographs at 2 months showed stable disease, but I was shocked at her 7-month recheck radiographs\u2014the cranial mass was gone and the caudal one had decreased in size.<\/p>\n Oprah is still my patient today, 2 years and 11 months later<\/strong>. She has had some side effects from the cyclophosphamide, including sterile hemorrhagic cystitis. Most recently she developed idiopathic dilated cardiomyopathy that resulted in heart failure, but monitoring and care by a cardiologist has resulted in improvement.<\/p>\n Today, there are options for pets with cancer, even those with advanced metastatic cancer as demonstrated by Reese and Oprah. These options include new therapeutic modalities and a more preventive approach with treatment, complemented by improved communication about cancer. Do not think cancer is a death sentence. Think hope<\/em>, think options<\/em>, and think live longer, live well<\/em>.<\/p>\n","protected":false},"excerpt":{"rendered":" With a low tail wag, Reese slowly walked across my examination room to greet me.<\/p>\n","protected":false},"author":15,"featured_media":12247,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":2142,"footnotes":""},"categories":[348],"tags":[],"class_list":["post-12244","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-january-february-2017","column-features","clinical_topics-oncology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"\n![\"t1701c10fig01\"](\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/12\/T1701C10Fig01.jpg\")
<\/a><\/p>\nBreaking Bad News<\/h2>\n
\n
Treating With Chemotherapy<\/h2>\n
Living in the Moment<\/h2>\n
New Therapies Are Arriving<\/h2>\n
Continued: Reese and Oprah<\/h2>\n
Reese<\/h3>\n
Oprah<\/h3>\n
Summary<\/h2>\n