Why Is There No Standard of Care?
Updated: January 7th, 2019
I was recently sent an interesting question from a reader about the right way to deal with a lump.
The question revolved around standard veterinary practices upon finding an external mass in a dog. Is it correct to simply monitor and wait for a cancer to grow before doing something about it?
The first point I’d like to make is, in many cases, veterinary medicine is still art and not science. Because of the still-present legal precedents viewing animals as property instead of beings, the protocols for veterinary care are neither truly standardized nor enforced by the AVMA, unless there is true negligence.
So there is no published standard of care when dealing with a mass on the outside of a dog. Some vets will try to get a history of growth rate, as most malignancies (but not all) tend to grow at the site they are found.
Many vets will note the appearance or the feel of a mass on palpation. This can often yield information as well.
However, the truth is that neither is 100% reliable. Far from it.
Now we get to the juicy bits. Suppose I am a veterinarian who advises a fine needle aspirate on a soft mass under the skin. I tell the owners it is better to be safe. While it is true that soft masses are most often benign fatty tumors (lipomas), they also can be mast cell tumors, hemangiopericytomas, subcutaneous hemangiosarcomas and others.
The dog’s guardian declines, and gets a second opinion from another vet, who states it is silly to aspirate a “lipoma” (without actually knowing it is one). True, 80% or so, in my estimation, of these tumors are lipomas, But what about the remainder?
So now this person is angry with me. Why? Because I tried to sell something that “was not needed”. Emphasis on “sell”. The perspective is that I attempted to gouge someone and take their money. Now I have alienated another human and I am worried they will hurt my professional reputation.
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The financial aspects of the scenario explain why some vets do not always recommend the safest options to owners. We enter the unpleasant land of money, guilt, business, and catering to the needs of the client but not the patient.
The financial aspect of the vet-client-patient bond makes things very messy!
The way that I most often deal with this quandary is to do my best to give odds and percentages, based on my clinical experience or data if I am aware of it. That way the guardian of the dog is empowered and responsible for the outcome.
On top of that, I will give my opinion, which is not the same as simply giving the facts as I see them. Many times people are not aware of the reality of some consequences, and I have a responsibility to try to guide a decision in the best interest of the dog.
Not getting a diagnosis is always a gamble. While it is true that, practically speaking, one may get away with a dice roll if the odds are high enough, this is not always the case.
The safest option is always to try to get a diagnosis on a mass, whether by fine needle aspirate or by surgical biopsy. And that cannot be disputed.
Best to all
Dr. Demian Dressler is internationally recognized as “the dog cancer vet” because of his innovations in the field of dog cancer management, and the popularity of his blog here at Dog Cancer Blog. The owner of South Shore Veterinary Care, a full-service veterinary hospital in Maui, Hawaii, Dr. Dressler studied Animal Physiology and received a Bachelor of Science degree from the University of California at Davis before earning his Doctorate in Veterinary Medicine from Cornell University. After practicing at Killewald Animal Hospital in Amherst, New York, he returned to his home state, Hawaii, to practice at the East Honolulu Pet Hospital before heading home to Maui to open his own hospital. Dr. Dressler consults both dog lovers and veterinary professionals, and is sought after as a speaker on topics ranging from the links between lifestyle choices and disease, nutrition and cancer, and animal ethics. His television appearances include “Ask the Vet” segments on local news programs. He is the author of The Dog Cancer Survival Guide: Full Spectrum Treatments to Optimize Your Dog’s Life Quality and Longevity. He is a member of the American Veterinary Medical Association, the Hawaii Veterinary Medical Association, the American Association of Avian Veterinarians, the National Animal Supplement Council and CORE (Comparative Orthopedic Research Evaluation). He is also an advisory board member for Pacific Primate Sanctuary.
Our dog has been participating in a lymphoma clinical trial at UW-Madison. She achieved remission after one dose of chemo. She had such terrible side effects that she had to be hospitalized for two nights. She recovered and has gone through her second round of chemo (at a 20% reduction). She has been doing better this time around, but it is still hard to get her to eat much. I would also like to know about quitting the chemo treatments since she has already achieved remission. Thank you.
One of the most frustrating things to deal with while we try to manage our pets’ illness is sometimes figuring how to pay for their treatment. Especially when it comes to oncology, vet bills can add up very quickly. We did a number of things to raise money ourselves as well as make personal sacrifices. There are a number of websites and resources that help owners with the cost of their pet’s treatment. Just try searching for “veterinary financial resources.”
This didn’t get posted in my above post — I guess I formatted it wrong:
Mark, to the first question I quoted above, about why they continue with the chemotherapy, this is what I wrote:
Mark, I don’t know the rational in the veterinary world, but I know that it takes about 1 million (or is it a billion? I think it’s a million), cancer cells clustered in one area in order for any of our equipment to pick it up. So while *no evidence of disease* can be determined (if we are looking in the right spots), they really can’t say that there is no cancer — there is just no active disease that our instruments can pick up.
It makes sense to me that she does better off the chemo — chemo is a poison – it kills cells and doesn’t discriminate between good and bad. The key is to protect and support the good cells during the chemo while letting it kill the bad. During my Dad’s chemo, we had him on IP6, though I also wanted him to take a mushroom formula and curcumin (he had enough pills).
Here is an inspiring story:
>>>>>My questions to you, why is chemotherapy continued after a complete remission is obtained? If the goal is complete remission and it is achieved…why continue with the treatments? I know remission does not mean cured, but it means no clinical signs of cancer in the body. If this is the case, then why is the dog subjected to weeks more chemo and expense if the cancer is in remission?<<<<>>>>Are there any facts or studies showing longer survival times if chemotherapy is continued after remission is achieved? She does much much better on the weeks she doesn’t have chemo and if no significant increase in survival time is achieved by doing further chemo then I asked why do it? Why cause further harm, discomfort, stress and financial woes to both the dog and owner?
I would just like to know if anyone has ever quit and had success?<<<<<
I sure would like to know the answer to your questions too. I personally think that the only way you are going to get longterm survival and remission is by following chemo with alternative methods (supplementation, etc.), and I think chemo is easier and works better this way too, but that’s just my opinion.
For a really depressing book, which is perhaps a bit outdated, Ralph Moss’s “Questioning Chemotherapy” is really an eye opener on the cancer industry.
CLou, I’m sorry to hear about your Tillie.
For her brother, it seems to me that you need to be more assertive with what you want to do for him. I have found, that each time I hand over responsibility for decisions to a vet, I end up regretting it for some reason or another. Find a vet, see how easy the lump would be removed, and get an estimate to see if you can swing it. I think most vets like to aspirate the lump first, particularly if they suspect mast cell. I don’t know about other kinds of tumors. If it’s a fatty tumor, the needle will show a lot of fatty oily stuff in it.
If you can’t afford the surgery,look into the things that help with cancer — a good diet, supplements, etc. If it’s a mast cell, don’t forget the tagamet and curcumin.
Best of luck to you.
My heart goes out to you also. I lost my sweet Tillie, my little Shih Tzu on February 28, 2009 to a mass cell tumor that wasn’t diagnosed by my vet. It sounds like the exact same tumor your dog had. It was on her abdomen too. My vet saw it last summer but ignored it. We didn’t have the funds to do anything for my little sweetheart. I attempted some natural means but by that time it was too late. I am dealing with alot of guilt and there isn’t a day that I don’t miss her. I have the brother to Tillie still and I have just discovered a strange fatty like tumor on him and I don’t know what I should do to help him. I don’t even know what veteranarian I can trust. I took Tillie to three different vets and all gave different opinions. I wish there were more vets that really cared about our furry friends!
My heart goes out to you and your loss. I lost mmy beloved Chance exactly a year prior to you loosing your sweet baby. I wish more vets would take our four legged children more serious. Wish we could do more to enforce it also.
I am taking my golden son into the vet tomorrow for two lumps. One is a pea sized one under his arm pit (relly concerns me too!!!!) and the other one is very large and on the base of his tail. I lostone of my beloved goldens April 13, 2008 to spleenic cancer with no warnings. Therefore, I am very concerned for my young golden son.
Our 12 year old yellow lab mix was diagnosed with lymphoma about 2 months ago. The treatment she has been on is the Wisconsin-Madison 25-week protocol. She went into complete remission 29 days after starting the chemo/prednisone treatments and is currently on week 9 of the schedule. She is doing great except for the first few days after each chemo treatment when she is understandably lethargic before recovering just in time to get chemo again the next week.
My questions to you, why is chemotherapy continued after a complete remission is obtained? If the goal is complete remission and it is achieved…why continue with the treatments? I know remission does not mean cured, but it means no clinical signs of cancer in the body. If this is the case, then why is the dog subjected to weeks more chemo and expense if the cancer is in remission?
Are there any facts or studies showing longer survival times if chemotherapy is continued after remission is achieved? She does much much better on the weeks she doesn’t have chemo and if no significant increase in survival time is achieved by doing further chemo then I asked why do it? Why cause further harm, discomfort, stress and financial woes to both the dog and owner?
I would just like to know if anyone has ever quit and had success? Also, do you know of any studies on survival rates quitting after remission is achieved? Your thoughts please.
Thank you for your time,
Dear Dr. Dressler,
Thank you for your recent blog, “Why is There No Standard of Care?” In it you answered the questions I raised in your blog of 5-17-09.
In October 2007 I took my six-year-old Han (a Lab/Newfoundland mix) to an oncologist for several lumps and bumps. She aspirated them and said that they all appeared to be benign. However, she did state that the one she was most concerned about was a cyst-looking growth on his abdomen. She said that we would need to “watch” it and gave no further information. No mention of the possibility of a malignancy.
In February 2008 I took my Han back to the oncologist for a recheck and to check a couple of new lumps. Again, she aspirated the new ones, but she DID NOT aspirate the one on his abdomen that she had said she was concerned about. I even asked her to do so, but she insisted that it was not necessary because it had been benign in October. Although it had grown a little, she said we would just “watch” it.
In July I took Han back for a recheck because the growth had gotten bigger, was ulcerated, and he was licking it a lot. The oncologist’s exact words were, “Now would be a good time to take it off.” No hint of alarm in her voice. No mention of possible cancer. We were getting ready for a trip to the East Coast, and I asked her if we should have the surgery done before we went; I told her we could easily postpone our trip. She said that there was no rush and that we could do it when we returned. She DID NOT even aspirate it!!!! If only I had insisted!!!
By the time we got to Delaware, Han was in apparent distress. We located a vet who took one look at his abdomen and said that it looked like a mass cell tumor. I did not know anything about mast cell tumors. She aspirated it and confirmed her suspicions. We were devastated. We had traveled three thousand miles to be told by a strange vet (not an oncologist) that our dog had cancer. We headed back for Arizona the same day.
To make a very tragic story short, our beloved Han had surgery (a grade 3 mass cell tumor), thirteen rounds of chmotherapy, seven radiation treatments, and three weeks of Palladia (a new cancer drug) over an eight-month period. He did just fabulously with no side effects except diarrhea near the end of the radiation treatments. You would never know that anything was wrong with him – he was happy, energetic, had a huge appetite, never lost weight. Not until the third week of the Palladia. He got very ill on April 12, 2009, and passed away on the 13th, presumably from the Palladia.
Not only am I having to deal with my overwhelming grief and loss that no words can begin to express, but I am also having to deal with the angry, bitter feelings I have toward the oncologist who was so reckless, so overly confident in her profound knowledge, so negligent, and who took a gamble on my dog’s life – and lost. She never mentioned the possibility of cancer. She robbed my beloved Han of his wonderful life, and she took one of my life’s greatest blessings and gifts from me. I am also overcome with guilt and regret that I just accepted her word and trusted her judgment from day one. I did not ask enough questions. I should have gotten another opinion. I should have insisted on an aspirate of the growth in February 2008. I should have demanded that Han have surgery in July before our vacation or took him to another vet. I paid a terrible price for my ignorance and my complete trust in someone else, and I have to live with it every day of my life.
I hope someone who reads this blog can benefit from my tragic story.