Featuring Demian Dressler, DVM and Susan Ettinger, DVM, Dip. ACVIM (Oncology), authors of The Dog Cancer Survival Guide.

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Osteosarcoma and Amputation: myths and facts

In my last blog, I gave my recommendations about osteosarcoma (OSA) work up. Now it’s time to talk about treatment.

Conventional treatment for OSA targets:

  1. The primary tumor with local treatment (surgery and/or radiation)
  2. The likely micrometastasis with systemic treatment (chemotherapy)

Today, I am going to talk about amputation.

The Goal

The main goal of local treatment, whether surgery and/or radiation, is to prevent recurrence and control the pain dogs inevitably feel with OSA.  Osteosarcoma hurts.

The tumor destroys the normal bone — and that pain decreases the quality of life of the dog.

Remember, many dogs are stoic and hide their pain. As pack animals, they don’t want to be perceived as sick or weakened, so they will hide their symptoms for as long as possible. This is why it can seem like dogs “get sick overnight.” But the reality is that they only start acting sick when they can no longer mask their pain!

Amputation, as radical as it may sound, is usually the best treatment option for OSA. The complete removal of the affected limb prevents a possibly sudden and painful fracture, and effectively removes the source of deep, aching bone pain. It helps restore quality of life.

As a vet and oncologist, I know that amputation is a source of pain relief – it removes the  pain that a dog bears with each step and improves the comfort for the dog.  I was taught this in vet school and during my oncology residency: the affected bone cannot be removed, so the only way is to remove the cancer is to remove the whole leg.  I was also taught that dogs did amazing afterwards. I still remember the movie Dr Delahunta at Cornell showed us (on a projector and reel) of a Border Collie still herding sheep.  The dog ran so fast, you could barely tell a leg was missing.

I’ve been a vet for about 15 years,  and I am really comfortable making this recommendation. I see how much happier the dog is without the painful leg, and guardians tell me they have no regrets. But it is never an easy decision for the owner to make, at first.

While I was taught I needed to educate owners about the surgery, the recovery, and that most dogs adapt well, I was never taught was how uniformly negative the reaction is by pet Guardians to the concept of amputation. Guardians think it is cruel, barbaric, mutilating and unfair to amputate.

The Myths

I’ve learned there are a lot of myths out there:

Myth:  My dog has arthritis or had knee surgery, so they are not a candidate for amputation.

Fact: Most dogs, even older dogs with average, moderate arthritis, usually do well on three legs. The best thing to do is have an orthopedist do a good orthopedic exam prior to surgery.

Myth: The surgery is too painful.

Fact: While the surgery is painful, pain management is part of both surgery and post-op care. Patients are kept comfortable with injectable pain meds while in the hospital and oral pain meds at home. Since we know it is better to prevent pain than treat it, protocols are designed to be pre-emptive and include fentanyl skin patches, continuous rate infusions, and epidurals.

Myth:  Amputees have poor quality of life after amputation.

Fact: Amputation results in an improved quality of life since they are no longer in pain with each step they take. Dogs typically adapt very well to the loss of a limb, and can still use stairs, run, play, and even swim.

Myth: Large dogs do poorly as amputees.

Fact: While small dogs and cats do well across the board, large dogs also do well as a rule. There will be exceptions to this, but doing well after amputation is the norm. In addition, many dogs are already walking on three legs before surgery, due to the pain. I have many older patients and many large and giant breed dogs that have successfully undergone amputation. Do not let someone tell you that breed, size, age or weight is reason enough to avoid amputation.

Thinking It Over

If it is hard for you to contemplate amputation, you are not alone — most owners simply cannot imagine how their dog could live a good life without all four limbs. It’s important for you to know that most owners are happy they make this choice. There are many great online resources. Two that I really like are www.tripawds.com and www.bonecancerdogs.org

What You Need to Know

It’s also important to point out that your dog will have a LARGE amount of hair shaved for the surgery, and the incision will be large. In addition, the incision is often bruised and can actually get worse the first few days after surgery. This fades, of course, as natural healing takes place.

One idea to help with this is to ask your surgeon to put an old t-shirt of yours on your dog before they bring your dog out after surgery. I have a lot of clients who are uncomfortable seeing the incision and the t-shirt helps. They can avoid the immediate shock when they reunite with their dog, and then look at the incision after, when they are reassured that their dog truly is OK.

I recently posted a question on my FB page if you would consider amputation. Of the 95 responses, 72 (76%) did/would do the amputation, 17 (18%) would consider, and 6 (6%)would not or did not. While I am not claiming this to be scientific and my readers may be skewed towards those that would treat, I found the 58 comments really interesting. Most that did the surgery have no regrets. Here’s a sample:

  • Charlie’s eyes told he it was not his time to go. He has thrived on three legs. His quality of life is excellent and he is pain-free. I encourage all pet guardians given amputation as an option to consider it.
  • His recovery was amazing, and we have no regrets!
  • We chose amputation without a second thought and have no regrets. The surgery was 4 weeks ago and to see her running around, jumping up on the furniture and appearing very happy and pain free lets us know we made the right decision.
  • Off with the leg! Save our pooch!
  •  IT WAS THE BEST DECISION WE EVER MADE FOR HER!! She walked out of surgery and her pain was gone. We treated her with some chemotherapy, and prepared to spend our ‘last months’ with her – BUT THAT WAS 11 MONTHS AGO! She swims and runs and howls and climbs up on the couch even better than she did before she was diagnosed. Tomorrow is Lorrie’s 6th birthday, and she and her four legged Golden Retriever sister will be eating cake – if there’s any chance of living even a few months past the surgery, I would always recommend it; dogs have the most incredible resilience!
  • Oliver is a 40 lb Standard Schnauzer and 18 months post amputation. Although it was difficult to see him go through the surgery, it gave him his life back. His pain prior to surgery was so severe and difficult to watch. He went through 8 rounds of chemo and is now on metronomic therapy. He runs, plays, and is so happy. The interesting thing is, when we are out walking, people rarely notice he is missing his hind right leg. He can do everything he did prior to surgery and lives every day to the fullest. I have learned so much from him – resilience and determination. Amputation was the best option for us as Oliver has so much more life to live!
  • I will admit the first 2 weeks after the amputation are rough, but beyond that mine did SO well on 3 legs and everyone who knew him said that he seemed happier than when he was limping on 4. He had the amputation and 4 rounds of chemo and just recently died 6 months post op (cancer spread to spine). At first it was hard for me to believe that Sunny would live happy and pain free on 3 legs, but he hopped around with an endless smile on his face…it was a great 6 months and I have no regrets.
  • YES! WE WOULD DO IT! We have NO regrets, and want to let others who face this decision, that dogs adjust well after such surgery.

Amputation may not be right for every dog, however. Dogs with very severe arthritis and some neurological conditions may not be able to walk well after an amputation.

In the next blog we will talk about other conventional treatment options, including radiosurgery and palliative radiation. And don’t forget that The Dog Cancer Survival Guide is a must-read if your dog has osteosarcoma.

About the Author: Susan Ettinger, DVM, Dip. ACVIM (Oncology)


Susan Ettinger, DVM. Dip. ACVIM (Oncology) is a veterinarian oncologist at Animal Specialty Center in New York and the co-author of Dog Cancer Survival Guide: Full Spectrum Treatments to Optimize Your Dog's Life Quality and Longevity. She blogs about dog cancer at http://www.DogCancerBlog.com.

  • http://www.tripawds.com Tripawds.com

    Dr. Ettinger, we can’t thank you enough for helping to alleviate pet parent’s worst fears about amputation. Thanks to the forward-thinking vet professionals like yourself, more pets (especially giant breed dogs) will be given the opportunity to live a pain-free life even after a cancer diagnosis. We sincerely appreciate your taking the time to write this series.

    • Dr. Susan Ettinger

      And I appreciate this comment!! And all you do to help tripawds and their families.
      PS Can someone send me more cards with your info for my exam room? You are a great resource for my bone cancer patients!
      All my best, Dr Sue

  • mckellygirl

    Today it is 21 months to the day since my Golden Retriever Bailey had his right hind leg amputated, and except for his tear ducts ceasing production (treated with medication), he is doing GREAT. Once I made the decision to do it, I have never looked back or regretted it. At the time of the amputation, Bailey was nearly 10 years old with fairly bad hip dysplasia, 75-80 lb, and on Rimadyl for the dysplasia and arthritis; and he was still a good candidate for surgery. He was in a lot of pain, barely mobile, and seemed to have lost his spirit before the amputation. After surgery, it was a tough adjustment initially for him to figure out how to get around, pee, get into a particular spot, and it was some time before he could eat a meal standing up, and his adjustment was all happening during one of the hottest summers on record and he developed a terrible hotspot. I tried to figure out how to help him and get him up and down the flight of stairs to my condo. A Ruffwear harness was absolutely indispensable, and luckily I had it when I picked him up from surgery, not even knowing how to properly put it on. Putting throw rugs on the kitchen floor was another thing. Bailey can still run faster than me, he has figured out how to get into any spot he wants, he can climb the flight of steps without a harness (still use it for getting in and out the car, and steep or slippery terrain). His incisions healed very well in just a couple weeks, and we figured it all out over time. His spunk returned too. Now I can say that having to face that decision as a dog owner, I do think that when one is confronted with a serious diagnosis that is usually a big surprise, and all the options are really not good options for treatment, it does take some research and digesting the situation to reach a conclusion that a radical surgery such as limb amputation is the best option. I wish we could say that we had better options for osteosarcoma than that. To me, I was making the best decision from a bunch of bad options. One family member thought I was doing a terrible thing to my dog at first. The sites you referenced above were both very helpful to me along with Dr. Dressler’s first book, this site, and some other resources. I do think it is important for veterinarians to expect shock from guardians initially, because the idea of needing to amputate a limb as treatment is rather barbaric, but sharing experiences and helpful resources is a good way to help guardians digest the situation and really research the statistics and other’s experiences. I would have loved to have been able to talk to someone else who had gone through this surgery with their pet when I was faced with this decision. As a guardian who has gone through it, I would volunteer to talk to anyone at my vet’s office or by word of mouth referral about my experience, and I have done that a couple times. After the amputation, Bailey was given a life expectancy of 4-6 months without chemo, so my milestones were time: 6 months and I relaxed just a little bit; 1 year and I was overjoyed and celebrated with all of our friends and family. I realized that I had accomplished what I set out to do, which was to give Bailey a good quality of life and more time, and I stopped being stressed and am just so grateful for every single day he has. I have chosen not to get any chest x-rays since his amputation, and I still don’t think I will at this point in time, and his bloodwork has been good. I did not opt for chemo/radiation, but chose to feed Bailey a home-cooked anti-cancer diet and to work to build up his immune system with an assortment of anti-cancer supplements. I greatly appreciate this blog,as you are doing great work to educate us, dispel myths, and share our experiences!

    • Dr. Susan Ettinger

      McKellygirl,
      Thanks for sharing Bailey’s story, and all you went through to get to your decision to amputate, and your lives after. It took me awhile to appreciate how cruel and radical an amputation was perceived, because I have seen to many dogs adapt well and thrive. But I still think acknowledging the pet Guardians’ shock is important, and it should not be dismissed even if vets (like me) think they do well. It is a big decision!!
      I am overjoyed to hear how well Bailey has down. I wish her good health, and the 2 of you many wonderful times together.
      Thanks for reading and sharing!
      All my best, Dr Sue

  • Angela

    Hi, thanks for writing this informative post about amputation. My dog, Lefty, was diagnosed with osteosarcoma in his knee joint just three days ago. He is a 7 year old greyhound who is so energetic and full of life!

    Finding out about the best options for him is very important at this stage and it has been invaluable reading your helpful advice. Increasing my own awareness on the subject is just as important as listening to what my vet has to say.

    • Dr. Susan Ettinger

      Angela,
      Glad to hear that the post is helpful. That’s why I decided to contribute to the blog. Education is power to help make the nest decisions for our pets
      I hope Lefty does well with his treatments.
      All my best, Dr Sue

  • http://adamkhan.net Adam Khan

    A week after a diagnosis with osteosarcoma in the front right leg, we went ahead and did it for Jam, a more-or-less Belgian/German shepherd mongrel, then 11.5 years old. I changed her diet (no more dog food, now a great and economical mix that I often share with her for dinner and only regret not having given her for years before the cancer) and she had 4 rounds of platinum chemotherapy. 16 months and one stroke later she seems more or less as good as ever. Her back legs were never great and she bunny hops to walk and so it’s an effort, but she is herself and pain-free.

    She is old however and her eyes are not as clear as they were and her teeth no the amazing white color they were, and I wonder sometimes how bad her physical situation will get between one thing or another.

    But there’s no question this treatment saved her life and took away excruciating pain. It was strange and wonderful to take her out to a nearby semi-wild park a week or two after the amputation and see how happy she was to be out smelling the smells and for the pain to be gone.

    Thanks for the work you do promoting awareness of this option.

    • Dr. Susan Ettinger

      And thank you, Adam, for your feedback and for sharing your story. I wish Jam and you continued health, happiness, and wags!
      All my best, Dr Sue

  • Lynn Hopkins

    Please sign me up for your blog

    • Dr. Demian Dressler

      Dear Lynn
      If you signed up for “dog cancer news”, you will get blog updates …
      Dr D

  • Lynn Hopkins

    Interesting reading

  • Rick Vaughan

    It will be 4 years this July since my 9.5 year old rescue Lab, Molly, was diagnosed with OS and 5 weeks later died. I was given the option of amputating her right front leg or treating her with pain medication for as long as it would help. After x-rays of her lungs were taken, I had to make the dreadful decision to not amputate since the cancer had spread to her lungs and my Vet felt that she might not survive more than 6-7 seven months after amputation. I loved this dog with all of my heart, she was MY COMPANION…but the finances of an amputation and then the thought of her suffering from lung cancer which could not be healed, I prayed and prayed and finally decided to love her until she let me know it was time. After reading this article and the many posts, I’m sitting here with tears stinging my eyes and second guessing my decision. At the time, I would have robbed a bank to pay for the surgery, but I just felt that it was going to be too much for my girl. I have enjoyed reading all the happy endings to amputation and I’m playing the “what if” over and over in my mind. This was the hardest decision I have ever had to make in my 62 years…and now I wonder if I did the right thing????

    • Dr. Demian Dressler

      Dear Rick
      if there were already visible metastases in the lungs things were more advanced than a lot of the other cases.
      Here’s a post about that:

      http://www.dogcancerblog.com/signs-of-dog-cancer-and-decompensation/

      In the end, when we are dealing with dog cancer that has already spread, we have no “right” choice. You did the right thing for your dog.

      Best
      Dr D

    • Dr. Susan Ettinger

      Rick,
      I am so sorry about Molly. If I were her oncologist, I would NOT have recommended amputation if there was already metastasis to the lungs. Most dogs in that situation only live a couple of months. Please don’t second guess yourself and instead focus on the happy memories.
      With sympathy, Dr Sue

  • Lynda

    It’s not so easy. I am amazed when I read things that say, “I have no regrets”. It makes me wonder how long the dog lived with cancer prior to amputation. I have had two dogs – Rottweilers – with osteo one front- female, one rear leg, male. It is not easy- is it the right thing to do, yes, easy, no. For me the most difficult event of my dog life. I noticed limping and immediately sought treatment. My female, years ago did not have her amputation for 2 weeks after limping. Medical treatment, didn’t work, xray = cancer, amputation within four days. My male was amputated within 4 days of x-ray, which was completed the day following the limping.
    It’s hard for people and hard for the dog. My female was awesome and after 18 days of post op pain and depression, was on her way to a fun filled life for the next 17 months (3 rounds of chemo). My male, on many more post op medications, has physically had a much more difficult time. He is large and powerful, but it’s still difficult for him. He’s an amazing dog. He turned 6 years old two weeks after amputation. My female was diagnosed at 5 years old as well and lived to be one month shy of 8 years. It’s heartbreaking and stressful. Other dogs in the household need to change their routine to accommodate the amputee, or you need to leave the amputee behind. It’s not all wonderful and it’s misleading to only post those people who feel this way. I wonder do they really- it is difficult- I can’t imagine feeling so “terrific” about making a decision like amputating a limb for your dog.
    I do feel like it is the right thing to do, I do feel that the quality of life is improved and to live with bone cancer would be horrible. But please- “I’d do it again in a second”. No, I did do it again, but it was gut wrenching. Made harder by his physically difficulties. He is sweet and loving, and never lost his spirit. Chemo is another tough ride. Yes, it gives you time, and the “side effects” are not as “severe” however as stated by the Dr. — dogs mask symptoms. Do you really think it is that much of a breeze?

    I am not trying to talk anyone out of amputation as a treatment for osteo, however, I would never tell anyone it’s easy for the people or the dog. It is life changing- and it is what it is.

    • Dr. Demian Dressler

      Thanks for those important words, Lynda.
      Dr D

  • Susan Rice

    While I understand that the vast majority of dogs do well after amputation I will NEVER consider it in the future due to our experience. Our greyhound Sandy was diagnosed with OSA and given a very bright prognosis with amputation and chemo. The oncologist and surgeon were very upbeat about this surgery and we went ahead with hope in our hearts. About 4 hours post surgery Sandy crashed as her blood would not clot and we had to let her go as she was drowning in her own blood.My husband rushed to be with her in her last minutes and I never even got to say goodbye–only the hug and so long as we left her in what we thought were the capable hands of the surgeon and techs. She was doing VERY WELL on pain meds and we wish we had never gone ahead with this. We didn’t even have an entire dog to bury. Am I bitter–yes I am! For all of you that this has worked for you are fortunate.

    • Dr. Demian Dressler

      I am so sorry Susan.
      Dr D

  • Lynda

    Rick,

    For what it’s worth, I do feel you made the right decision.
    Amputation recovery is difficult for everyone, especially the dog. For the short time you would have had, I for one, would not have put her through it. You gave her your time, your heart and your love. That’s what she needed. It would have been more difficult and you would most likely be in the same place now wondering if you did the right thing- was it worth it.
    Nothing is easy about cancer- made more difficult when you need to make decisions for your dog- not for yourself.
    You did the right thing.

    Lynda

  • Carol Cure

    Rick: Please don’t second-guess yourself about the decision you made. With the cancer already in her lungs, you made the most compassionate decision you could possibly make. You are the best judge of what is best for your close companion, what she could or could not deal with. Please go get yourself another rescue dog to love.

  • Mary Emmons

    Rick V-
    Your story touched me so. Know in your heart that as a pet parent you did the right thing! It is so tough to not do the what if’s, but you had to make a decision and you did it. Remember all the good times and give yourself a break. You loved your dog immensely and that is all that counts in my book! They are like our children and no one can take that away.

  • mckellygirl

    Hi Rick, your experience about your dog Molly is heartbreaking. I am one of the lucky ones whose dog Bailey is doing well (posted on 3/13), and beyond grateful for every day we have together. But I know when I was trying to figure out my decision, I talked to other dog-owner friends and we concluded that as the dog owner, you are in the best position to make the right decision for your dog, and that any decision you make is the right one for you and your dog. Some of my friends said they would not amputate based on cost alone. How much care an owner wants to give–such as choosing to cook a dog’s food, is a decision that an owner needs to make. There isn’t necessarily a right or wrong choice for every decision, but if that is something you want to make a commitment to do or are able to sustain whether, physically, emotionally, or financially. Bailey showed no evidence of cancer in his lungs, but even so, it was made clear to me that this is a highly metastatic cancer that is likely to spread, and we just may not see the evidence yet. I would ask if you felt a moment of peace once you did make your decision. If so, I think you have to trust that you did the right thing. Going through this was one of the toughest things I’ve experienced, but once I made a decision, I never looked back or had any regret. I think you should realize that you made the very best decision you could for your dog based on your knowledge of her spirit and her prognosis. And it sounds like she did not suffer for a prolonged time. I wish you all the best!

    • Dr. Susan Ettinger

      Great advice. Thanks for sharing! It’s not easy to make such hard decisions for our pet. I was just talking to a pet parent yesterday whose friends thought he was crazy to treat his dog with CyberKnife. But he and his girlfriend felt it was the right the for them. I think its really hard when you friends and family don’t give you support in treating. I am so pleased to hear Bailey is doing well!
      All my best, Dr Sue

  • Melissa

    Hey Rick,

    My 12 year old Siberian Husky, was diagnosed with OS four weeks ago. I had her back left leg amputated right away. I opted not to do chemotherapy because I just felt it would make her sick and I didn’t want her to become nauseated due to the treatment. Her chest xrays were clear. I have been giving her a high protein diet, no more dog food. I used mainly APOCAPS as a natural treatment. But, that in combination with the fish oil, K9 immunity, and Transfer Factor caused her to have loose stool. So, I decided to give mainly the APOCAPS with her new diet.

    I wish I would have done the chemotherapy. Yesterday she had tumors on her shoulder removed and her chest xray showed small nodules in her lungs. The decision I made was the wrong one. Many veterinarians may get mad when I say this but….I want people to know. The local office that does chemo here in Louisiana charges $500 per chemo treatment, she was in need of 6 treatments for a total of $3000. My husband is a veterinarian. The vet cost of the chemo medicine is only $30 for the entire 6 treatments. That’s $5 a treatment!! I had the option of treating my dog with chemo…I chose the natural route and it didn’t work for me. I think it’s sad that the vet office is making such an enormous amount of money off of these poor dogs that have OS and other cancers.

    So sorry for your loss Rick. You did do the right thing. Once it has spread to the lungs, there’s not much else that can be done. My husky will not be around much longer. But, I will love her every day that she’s here.

    Melissa

  • Jane

    First, for Angela, and anyone else with greyhounds: Greyhounds have a very unique bleeding issue. All of the pre-surgery clotting factors will be normal. The dog will not have von Willebrands. Yet a large number of them will develop severe bleeding up to 5 days after a major surgery. Research done at OSU has determined that greyhounds, although they form clots, do not form strong clots. The greyhound experts in the OSU Greyhound Health and Wellness group very strongly recommend that greyhounds be treated with aminocaproic acid (Amicar) from the day of surgery for five full days. This is a human medication and is not used anywhere else in the veterinary world. The vet or owner would likely need to obtain it from a human pharmacy. I believe that OSU has not lost a greyhound to bleeding issues (they typically do about one greyhound surgery a day and one greyhound amputation a week) since they started this protocol. In addition, they have significantly reduced the need for blood products post surgery. I have found that many vets are unaware of the need for Amicar in greyhounds. Your vet can contact the OSU Greyhound Program for more information:

    https://greyhound.osu.edu/index.cfm

    And a link to their article on greyhounds and bleeding:

    https://greyhound.osu.edu/resources/freeresources/greyhoundbleeders/index.cfm

    For Rick: You did not make a wrong decision. First of all, when there are visible lung metastases, the prognosis is poor. Even if you amputated and did chemo, you would not likely get the median time of survival of 12-14 months that is typically quoted. Secondly, family finances must be part of the equation. Your dog wouldn’t want you to face hardship to get a couple of extra months. Lastly, a dog lives in the moment. They do not think about how long they will live. They just care if they are loved and feeling okay in the moment. As long as you adequately treat the horrible pain of osteo and euthanize before the pain is negatively impacting the dog’s quality of life, you are doing right by your dog. Any decision made out of love and caring is a good decision.

    I chose amputation and chemo for Joe. He was a great candidate and I got 20 more months with him. Because the median time of survival in his particular case was 14 months AND I had the money to provide aggressive treatment AND I had the ability to take care of him 24/7 during the recovery period, it was the right decision for us in this specific case. If he had had visible lung mets, I don’t think I would have done the amp.

    I think one of the key points of this article is the reluctance of owners to perform amputations based on the human viewpoint. Unlike humans, dogs don’t have an emotional attachment to the limb, nor do they worry about what others will think of them without that limb. In addition, dogs do far better on 3 legs than humans do with 1 leg. So from a dog’s perspective, losing a limb is usually better than living in pain. They typically recover quickly and get back to their normal routine in a remarkably short period of time. I know of a greyhound who beat most of the other greyhounds in a fun run just 8 weeks after amputation. She was clocked at 38 mph, just a few mph below the speed of a typical active racer with 4 legs. I am not saying that a 3 legged dog does everything the same as a 4 legged dog. Obviously this is not the case. They do learn to adapt though. Many people find that their gait takes more energy so that walks are necessarily shorter. A male dog that is used to lifting its leg may need to alter his bathroom stance. Front leg amputees have a harder time “fluffing” their bed. But these things are all workable.

    Choosing a treatment is a very difficult decision. This is a totally $%&* disease. It is almost always fatal. Statistically, amputation with chemo provides the best chance at a long pain free life. However, this does not mean that it is always the “correct” decision. As long as you ensure that your dog is not experiencing enough pain that it affects his quality of life, you are being a good dog parent.

    • Dr. Susan Ettinger

      Well said Jane. Thanks for reading my post and sharing your story! I love the part about the fun run. Dogs are just amazing – I am continuously impressed with their resilience and spirit.
      All my best, Dr Sue

  • Mary Emmons

    Nice honest post Melissa. I feel for everyone that has blogged about this. My heart goes out to you all!

    Mary

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