No Treatment: The Hardest Decision for a Veterinary Oncologist
Veterinary cancer specialists help pet families make hard decisions every day. For me, the hardest part is not making such end-of-life decisions or discussing the pros and cons of treating a beloved pet for cancer. The hardest decision for me is to recommend no treatment at all.
The Decision to Forgo Treatment
There are times when recommending against treatment is easy. When a biopsy shows a tumor has been completely removed and is unlikely to spread elsewhere in the body, the surgical removal of the tumor has likely cured this particular pet, making chemotherapy or radiation therapy unnecessary. Actually, pets like this have already had their treatment: It’s called surgery!
On the other hand, sometimes the decision is not as clear-cut. For example, take the case of Hulk, a strapping 8-year-old Staffordshire Bull Terrier who developed enlarged lymph nodes. No one knew for sure how long they had been enlarged, but possibly for as long as a year before I examined him. Aspiration cytology was inconclusive and a biopsy was obtained. The diagnosis was an uncommon form of lymphoma (lymph node cancer). Research has shown that indolent lymphoma progresses slowly and does not respond well to treatment, which fit with what we already knew about Hulk. I was anxious about not treating lymphoma in this dog, since the vast majority of dogs with lymphoma have a rapidly progressive form of the disease. I checked and double checked the biopsy, held my breath and recommended watchful waiting to his owner as the treatment. A year and a half later the tumor did worsen and require treatment, but initially no treatment was the right option for Hulk.
When Treatment Could Make Things Worse
Sometimes the decision whether or not to treat is influenced by other health problems the pet may have. Clawdius was a brown tabby cat who came to see me for a lump on the nape of her neck. She already had two other veterinary specialists on her medical team: a cardiologist who managed her heart failure and an internal medicine specialist who managed her chronic kidney disease. Based on aspiration cytology, Clawdius was diagnosed with an injection-site sarcoma. In a healthy cat, we typically recommend surgery, chemotherapy and radiation therapy. In Clawdius, we were concerned that chemotherapy and radiation therapy would further damage her heart and kidneys. Clawdius’ medical team and owner decided to remove the tumor but to forgo any additional therapy. The tumor never recurred, and about one year later she succumbed to her heart and kidney disease.
For his entire life, Jasper, a nice brown dog of no particular breed, had battled chronic kidney infections. During a flare-up, he was checked with an ultrasound and a tumor was discovered on one of his kidneys. Treatment for kidney tumors is removal of the kidney since one normal kidney can take over the job of two. Years of recurrent infections, however, had damaged Jasper’s kidneys. Tests showed the organ with the tumor was the better functioning of the two and removal of the kidney and tumor might push Jasper into kidney failure. His family decided against surgery. Jasper’s case was the biggest nail-biter for me, since oncologists find it hard to completely ignore the presence of a tumor. A few weeks later, Jasper’s kidneys took a turn for the worse, and his family and I knew we had made the right decision. Until then, though, I worried I had guided the family in the wrong direction.
A Last Word for Pet Owners
If your pet’s oncologist seems unclear about the management of your pet’s tumor, ask questions. Your questions help us to consider all options for your pet and guide you to the best collective decision. If your pet’s oncologist suggests you see another specialist for an opinion, such as a radiation oncologist or surgeon, please go. A different perspective may solidify the best plan for your pet. Finally, if we say we are not sure what the outcome might be, understand that we really wish we could be certain, but sometimes the only course of action left is to deliver the truth as best we see it.
More articles on cancer care by Dr. Ann Hohenhaus:
10 Questions to Ask Your Vet When Your Pet Gets the Big Cancer Diagnosis