Quality over quantity

Last week, I made the final decision to have my own dog humanely put to sleep. Skeeter was 15 years old and had been part of my life since 2001. She was diagnosed with cancer almost 2 years ago. In the end, it wasn’t the cancer but her overall quality of life that was the deciding factor. Let me explain.

Skeeter found her way into my life when I was living on St. Kitts for veterinary school. As a stray dog, she was a little under weight but overall healthy. And throughout the first 12 years of her life, she pretty much stayed out of trouble health-wise.

In December of 2013, I was in Florida taking the final exam for my acupuncture certification. Skeeter was staying at the emergency room where I worked. They were looking to get a new ultrasound machine and had a demonstration model in one day. They used her to check out the machine and accidently found a mass on her spleen. There was no evidence of rupture (many splenic masses, benign or malignant will rupture and bleed internally).

Since she was otherwise in good health, the doctors waited for me to return from my exam to fill me in on their findings. I was concerned but needed to know more information. I ran baseline blood tests (all normal) and took chest x-rays (also normal). This was the week of Christmas and I was uncertain about what to do next. So, I reached out to some friends for help.

Louie-Philippe de Lorimier is one of the world’s leading veterinary oncologists. I am lucky enough to know him as both a colleague and a friend. When I told him what was going on, I took a drive up to his office the next day in Montreal for an ultrasound and consult. We checked out and measured the mass on her spleen. We also found a few small suspicious areas in her liver. The ultrasound images were not conclusive, so we did an aspirate of the questionable areas to find out what cells were inside of them. An ultrasound of her heart didn’t show any masses (some forms of cancer spread here as well).

A few days later I got the results. The spleen samples showed no cancer cells but further testing was recommended. The samples from the liver showed cancer cells of hemangiosarcoma. This means that the mass in the spleen probably was also. Either way, the spleen had to be removed. If the mass (benign or malignant) continued to grow she was at risk for rupture and bleeding internally.

Later that week, I removed Skeeter’s spleen and biopsied her liver. Lucky for me I didn’t see any other masses in her abdomen and there was no evidence of internal bleeding. She did great through anesthesia and recovery. I then sent the liver samples (to confirm) and the spleen (to double check) out to the lab.

About a week later, I got the news. The spleen was also cancerous. This happens on aspirates vs. biopsies. When you get larger amounts of tissue, you get a better chance to know what is going on. Sometimes aspirates don’t get the base of the mass and just the outer shell.

Stage 3 hemangiosarcoma. One of the toughest types of cancer to deal with. It likes to spread from the spleen to places like the liver, lungs, heart and bone marrow. Average survival time with chemotherapy is about 9 months.

Time for a side bar. Cancer in pets. A few things about this. A dog’s life expectancy is much shorter than a person’s. So, if the dog would live to be 13 and got diagnosed with cancer at 11 we would only expect 2 years anyway. That influences how we treat cancer in veterinary medicine. Most importantly, we always aim for quality over quantity. We want whatever time for our patients and their families to be positive. In human medicine, they aim as best they can to cure you, or to get you 10, 20, 30 years or more from the time of cancer diagnosis. This means using much different doses of chemotherapy and other treatments. And when we talk about average survival time, it’s just that, an average of all the patients we have records on. It’s our best guess. Some live less, some more.

Most veterinary chemotherapy patients don’t lose their fur. Most don’t even know they are sick. Even fewer have vomiting or diarrhea from their treatment. And if they do, they usually respond well to supportive care and we can adjust doses of chemo. Again, always for quality over quantity.

Back to Skeeter. Having Dr. de Lorimier in our corner was a huge help. I had access to all the latest research, journals and studies. If I did nothing, I would have on average 3-6 months; with chemo, 9-12 months. Chemo would be one different medication each week for 3 weeks, (this would be one cycle) we would aim for 3-6 cycles. That means 9-18 weeks (3-4 months) of chemotherapy to get maybe another 4-6 months past that.

It took me a week to make my decision. I went back and forth. Read articles on low dose oral chemo (less invasive, but also less survival time). I added in acupuncture and Chinese herbal therapy to help support her while I pondered. The benefit of being a veterinarian is not only having access to all this information but also being able to do my own chemo. Some of the medications in her 3week protocol I was comfortable with. One I was not.

Ultimately, I asked Dr. de Lorimier for one more summer with my island dog. We both knew this meant going forward with injectable chemotherapy. In order to give the best chance, we also added in a new option. There is a mushroom derivative that has shown very promising results in hemangiosarcoma treatment. Hemangiosarcoma literally means blood vessel tumor. It likes to “seed” a patient similar to how you lay down grass seed. It then grows tiny tumors of cancerous blood vessels that can grow and grow until they rupture. This mushroom derivative has been shown to slow down the rate of growth of those new blood vessels.

So here is my 13-year-old dog, who had barely been sick a day in her life, now taking a literal pharmacy. She was on acupuncture and Chinese herbal therapy to support her immune system. She took Deramaxx (an arthritis medication) because hemangiosarcoma has been theorized to use the same receptors that joints use for arthritis to grow itself new tumors. To minimize her risk of getting an upset stomach following her chemotherapy, she took an anti-nausea medication the day before and a few days after one of her chemo drugs. She also had to take antibiotics if her white blood cell count was too low. And she was awesome about it. I got lucky. She liked canned dog food, so we just mixed it all together.

Her first drug in chemo was Adriamycin (doxorubicin). This was the one I traveled up to Dr. de Lorimier to have him calculate, adjust and administer for me (with his awesome team of nurses, Nancy and Carol). It is a great medication but I was not comfortable enough with it to give it at home.

A week later, I would check her blood count and if all was okay she got cyclophosphamide. This is an oral medication but it had the potential to irritate her bladder. So with it she got furosemide (Lasix, a diuretic) to help her make urine to flush out her kidneys and bladder. That also went well.

The third week, I gave her Vincristine as an injection into her vein. This she also tolerated very well.

And we repeated this, after 2 cycles her liver lesions (I couldn’t remove all the cancer in her liver at surgery) had shrunk by 50%.

After 4 cycles, the liver lesions were completely gone. We were in remission. This was springtime. There were a few problems along the way. She had some coughing and vomiting occasionally but otherwise was her happy, cheerful self. The coughing and vomiting is a story for another day.

We did 6 total cycles of chemo. After that, most patients still have some visible evidence of cancer in them. Being that she was still in remission, there was no indication to continue chemo or an oral chemo (lots of patients will benefit from low dose oral chemo after injectable chemo to keep the cancer cells from growing).

At this point, I slowly weaned her off the mushroom extract and Chinese herbs. Partly because there was no indication for her to be on them, and partly because her appetite was not that great. After a few months of medications, herbs and such, her body needed a break.

Now, we were into summer and Skeeter had a great time. Fall came, she was still going strong. Got through winter with the help of arthritis medications. The following spring came and we checked for any evidence of re-growth of cancer (we had checked every 3 months since ending chemo) and still she was in remission.

This summer, she was noticeably slower and enjoyed napping more than going for walks. She got to visit some of her favorite places (a beach trip, hiking in the park and a trip to Ithaca, NY).

This fall, I checked again for cancer and still she was in remission. She turned 15 a few weeks ago. For a person, that’s roughly 110 years old. She would get confused about things, get stuck in corners, pace late at night. Tried some simple adjustments and treatments with her, not much improvement. Right along, I had kept her on arthritis medications, a joint supplement and a special food.

Finally the time came where it was a decision of quality over quantity. Sure I could keep her going, but last winter was rough enough on her. A year older would be just as tough, if not worse. In the last months, she stopped being active in the house. She would not greet people; she would not let them pet her. She just lay in her bed.

That was not the quality of life Skeeter had ever led. It was not the dignity she had filled my life with. It was time to change that.

With the help of friends and family near and far, I processed all these thoughts. With the love and support of those people, I came to the decision I had been avoiding since we had started down this road almost two years ago. And on a quiet day, I sat by the water with my dog, my friend and fed her BBQ ribs. I thanked her for the amazing good times and stories. She napped, curled up in a circle around my arm.

Later that afternoon, my friend Dr. Andrea Kitson helped me lay Skeeter to rest. The quality at which Skeeter lived her life is exactly how her life came to a close. Her story though lives on.

I can’t guarantee you an outcome like mine. I am lucky and thankful for all the 22 months I got with Skeeter. Dr. de Lorimier modified the chemo protocol specifically for her. With other patients, we may or may not see similar results. Talk with your veterinarian about options. It’s always best to get a referral to a specialist to find out about what’s available.

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Cage: What goes down must get up

There is a saying: You can’t teach an old dog new tricks. I am currently working on a few cases that disprove that. But, what most of rehab is, is teaching injured pets OLD tricks like standing, walking and playing with toys. These are all things Cage’s spinal cord “forgot” how to tell his legs to do. His mind, however, remembered.

Now that we had found his motivation (the proper toy), I was fairly confident Cage would walk on his own again. His mind had been clouded by frustration and depression. With those cleared out of the way, he could focus on what he enjoyed doing.

His parents did their best to remain positive, but while Cage mentally progressed they had a slight regression. This happens in almost all intense neurological recoveries. Caregiver fatigue is a problem in veterinary and human medicine.

Where I saw the small improvements, they saw their beloved pet losing weight, falling down and taking forever to walk. At that same time, I saw a pet that was trying, giving his effort day in and day out to work against the gravity that was keeping him down.

At each drop off and pick up, I reassured them of the progress I was seeing. With each passing day, Cage could walk for longer times and distances in the underwater treadmill. Now I just had to open the treadmill door and he would walk over and voluntarily get in to workout. Cage was also now following Rebecca and myself around the rehab room to play fetch.

Cage’s time in the underwater treadmill was steadily rising. He started out barely doing 5 minutes at 0.5mph before needing a break. Over the next two months, he would improve to 60-80 minutes at 1.2-1.5 mph! He stopped losing weight and started maintaining it. In the last few weeks, he had gained weight back.

All of this work is extremely tiring. Muscles, joints, ligaments need rest. So does the mind. After ten weeks of rehab at 4 days a week in the hospital, I felt that Cage needed a little holiday. He had been resting at home on Wednesdays but on weekends was walking in the lake and yard at home.

His parents schedule didn’t allow for him to go home on Tuesday night, so he stayed and rested here on Wednesday. We did a lighter rehab session on Thursday and he went home that night. His instructions were: Rest Friday, have FUN Saturday and relax Sunday. By doing this, he would be ready for work on Monday. They asked me for more details other than “fun” for Saturday. I told them to make it up, figure out what he wanted to do, involve him in activities and just enjoy the day.

When Cage was dropped off that Monday morning, I was greeted by smiles and laughter. A three-day weekend was exactly what everyone needed. A little bit of rest did the whole family good, and Cage had a great time playing in the water and walking around the yard. His folks saw the proverbial “light at the end of the tunnel”.

The next few weeks of rehab flew by. Each day Cage seemed stronger, more willing to be involved with daily activities. We had set him up in the middle of the large rehab room so that we could interact with him. Now I had to start closing doors behind me because he would interrupt the consults or phone calls in my office. He wanted to be involved with what Rebecca and I were doing. And, for the most part, we gladly let him.

Even the simple act of typing up charts at my desk would have Cage strewn across my feet. He was back doing his old tricks and being part of life.

As he continued to gain weight, his independence improved. He could do more outside and steadily learned how to step over objects in his way (as opposed to tripping over or going around them). As we approached Labor Day, we gave him another long weekend to recharge his batteries.

In mid September, Cage and his family moved back to the Boston area for a few months. He still has a ways to go in recovering but I am sure he will continue to improve under the watch of his family and his neurosurgeon while out there.

Here is a link to video of him walking to his car to go home.

I look forward to seeing him walk in to see me in a few months.