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

Prednisone for Dogs: When to Start with Lymphoma

Updated: June 2nd, 2020

Summary

Prednisone for dog lymphoma may be recommended. It’s true, it treats lymphoma, and is used a lot in chemo. BUT … using it too soon could be a mistake.

prednisone for dog lymphomaUsing prednisone for dog lymphoma too soon happens all the time, so don’t beat yourself up if you’ve done it. But if you can, avoid the use of steroids (such as prednisone) before chemotherapy, and also before you have a confirmed lymphoma diagnosis.

Why? This common steroid is used in lymphoma protocols … and can also interfere with lymphoma protocols.

This is a little weird, so let me explain.

Prednisone’s Uses

Now, I’m not bashing prednisone across the board. Steroids are used for many things in veterinary medicine.

For example, your dog has probably been on prednisone. It’s a great anti-inflammatory for use with itchy skin, allergic reactions, and allergies.

Prednisone is also immunosuppressive at higher doses, which means it is great for immune disorders. That’s why it is used for things like inflammatory bowel disease and immune-mediated diseases like anemias and platelet disorders.

Prednisone is also part of most lymphoma treatment protocols because prednisone actually kills lymphoma cells. In fact, it can be a standalone treatment: if a pet Guardian decides against chemo, I recommend prednisone. Survival times for lymphoma without chemotherapy treatment are about one month, but using prednisone increases median survival times about two to three months, with about 50% response rate.

Sounds great, right? Why not start prednisone for dog lymphoma right away?

Mistake: Using Prednisone Right Away

It’s tempting for a lot of general practice veterinarians to start dogs on pred immediately if they see lymphoma on an aspirate. But this is a mistake if you are going to consult with an oncologist or use chemotherapy. Why?

Our current lymphoma protocols can be very effective. The median survival time for dogs receiving chemotherapy is thirteen to fourteen months. Compare that to one month with no treatment, or two to three months with prednisone alone, and you see why we oncologists are keen to use UW CHOP for your dog’s lymphoma.

A graph illustrating the median survival times of dogs with lymphoma on chemotherapy, prednisone only, or no treatment, as just listed in the above paragraph.

They are definitely worth a chance if you choose chemotherapy.

Which means you should avoid the use of prednisone for dog lymphoma until AFTER you have confirmed the diagnosis, and ONLY if your oncologist prescribes it.

Why? Prednisone complicates diagnostics, and interferes with chemotherapy treatments. Let’s look at diagnostics first.



Prednisone for Dog Lymphoma Complicates Diagnostics

If you start prednisone (often shortened to “pred”) before we complete other tests like chest X-rays and abdominal ultrasound, those tests will now be less accurate. Why? Because you’re already treating cancer, so we don’t know as much about the illness your dog has.

Staging Lymphoma Is Affected

For example, if your dog is already on prednisone before a liver and spleen ultrasound, that ultrasound image is not very useful. We can’t tell if lymphoma has invaded those organs or not. The lymphoma may have been there before the prednisone, or may not have been. We just can’t tell.

Why is this important? Well, how much lymphoma has spread tells us what stage cancer we’re dealing with. And knowing the stage helps us to determine treatment, monitor response, and make a more accurate prognosis about the probable outcome of treating your dog.

Side Effects Are Affected

Here’s another fact: if your dog is on prednisone before we finish testing and staging his or her cancer, he or she is probably having few side effects from the lymphoma. Of course, that’s great for the dog’s comfort, but if symptoms and side effects pop up later after we start treatment, it may be difficult for me to distinguish whether those are due to the chemotherapy or to the cancer itself. (This is one reason to see an oncologist RIGHT AWAY if you find out your dog has lymphoma!)

SubType Diagnostics Are Affected

And another thing: prednisone can affect the test for the lymphoma phenotype, also known as the subtype. There are two subtypes of lymphoma: B-Cell, which means the lymphoma is in the B-cells, and T-Cell, which means the lymphoma is attacking the T-cells. Whether your dog’s lymphoma is B-Cell or T-Cell matters, a lot: B-cells usually respond better to chemotherapy and have a longer survival time. If I can’t tell whether your dog has B-Cell or T-Cell lymphoma, I’m not going to be as accurate in my prognosis, and it will be harder for you to make a decision about whether and how to treat.

For this reason, I don’t test for the subtype if a dog is already on pred and the lymph nodes are already in remission.  The subtype test is the very best predictor we have for lymphoma: it helps us predict both the cancer’s likely response to treatment and the likely survival time we’re working with.

Lymph Node Aspirates Can Be Affected

In order to confirm your vet’s diagnosis, I take an aspirate of a lymph node. But if your dog is on pred, and the aspirate is inconclusive, we have to delay confirmation while I re-aspirate or actually biopsy a lymph node to confirm the diagnosis. This happens often when a dog has already started on prednisone before they arrive in my office.

Once again, starting prednisone before getting a diagnosis confirmation, makes getting a diagnosis a challenge.

And if diagnosis is a challenge, and I don’t have the good data I need to make a protocol choice, it can interfere with treatment.

It’s Harder to Choose a Chemo Protocol with Confidence

Knowing all of the above, particularly the B-Cell or T-Cell subtype of your dog’s lymphoma, helps me to choose which protocol to use. The UW CHOP multi-agent protocol (the best protocol we have) does not work as well for T-cells as is does for B-cell lymphomas, so the protocol has to be adjusted, and our expectations have to be adjusted, too.

I’m really flying blind — and therefore less accurate in terms of my advice — if your dog is already on pred and we can’t test for the subtype.

So, we’ve established that prednisone can really complicate diagnostics. But what about what it does to chemo treatments themselves?

Prednisone Used Too Soon Can Trigger MDR

Unfortunately, steroids like pred potentially make treatment with chemo less effective.

Prednisone can trigger a mechanism in the cells called Multi-Drug Resistance (MDR). I cover this at length in The Dog Cancer Survival Guide, because it’s an important concept for you to understand if your dog is undergoing chemotherapy for any cancer.

There’s a bunch to know, but in short, MDR is something some cancer cells can do to evade chemotherapy. Basically, some sneaky cells turn on pumps that literally eject chemotherapy agents OUT of the cell. No matter how much chemo we throw at them, they just keep throwing it back.


For more helpful tools and information, get a copy of the Dog Cancer Survival Guide


MDR can develop during normal chemo treatments, but just using prednisone alone can also trigger MDR.

As you can imagine, dogs with lymphoma who have MDR have a much worse prognosis than those who don’t.

The use of pre-treatment prednisone has been demonstrated to be a strong negative-predictor for dogs with lymphoma. In plain English: dogs who are on pred before they start chemo don’t respond as well.

Bottom Line: Wait to Use Prednisone for Dog Lymphoma

Lymphoma is a very aggressive dog cancer, and the pressure to start treatment right away is (and should be) enormous.

Every day you delay treatment is a day lost, and time is really short with lymphoma. (Most cancers do NOT have such tremendous pressures!)

However, that urge to treat does NOT mean you should start prednisone immediately.

Wait to see what the test results are. That way, you can choose from ALL of the relatively good options we have for treatment.

Jumping right in with prednisone can take options off the table.

Live longer, live well,

Dr. Sue



 

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  1. Boni Maclaurin on October 25, 2021 at 2:21 pm

    I am confused about what you are saying about prednisone. I also saw on the websites of both Purdue and Colorado State not accepting dogs in trials if they had prednisone. Is this an issue of effectiveness of the chemotherapy or just the ability to accurately test and identify the cancer? My dog has a potential lymphoma case, she is hypercalcemic with elevated small and intermediate lymphocytes from the aspirate. Additional Flow Cytology has been requested as well as a lymph node biopsy. She was put on prednisone following these last set of testing. Is this old protocol or the current standard of care?

    • Molly Jacobson on October 25, 2021 at 2:46 pm

      Both are true. As Dr. Ettinger notes above, using prednisone BEFORE diagnosis basically starts treating the lymphoma right away — which means they can’t accurately assess just how widespread it is, or what grade it is, or where it is in the body. So it complicates diagnosis.

      Prednisone is used in most lymphoma protocols, because it does have anti-cancer effects, and it is a powerful anti-inflammatory, which is highly desirable in lymphoma. But the timing of each agent in CHOP (the gold standard) is important. The P in CHOP is for prednisone … and it’s last in the lineup.

      Pred can trigger a response in the cancer cells to start pumping chemo out as soon as it enters — also called MDR. “Multi-Drug Resistance.”

      So if you start prednisone first, other chemo agents may not get a chance to work at all.

      For all the reasons in the article above, you may not be accepted in trials because prednisone is being used already. They just won’t be able to tell what is helping your dog — or not.

  2. Maria Burr on September 29, 2021 at 8:12 pm

    Dear Dr Sue, please respond to me as soon as possible as time is of the essence . My local Vet has put my 14 year old dog in Prednisone for diagnosis of Lymphoma . She has recommended chemotherapy for him . However, after reading your article , it’s not a good idea for him to be on Prednisone .

    Kingman,Arizona

    • Molly Jacobson on September 30, 2021 at 10:11 am

      Hi Maria! Dr. Sue doesn’t always check in on comments regularly. You can always reach her through her website: https:drsuecancervet.com. Please don’t panic! Check-in with your veterinarian about seeing an oncologist to get details about how to proceed with chemo/pred for your dog. Warm wishes, Molly

  3. Lou on August 15, 2021 at 3:54 pm

    Thank you for this information my buddy has been doignosed with high grade terminal T cell high grade lymphoma, after having a tumour removed from his small intestine we are heartbroken as a family, the 8 days in ICU after he has never left my side was traumatic for him, five blood transfusions later the cost is already cost us $18,000 Not that money counts when this dog has potential saved my life, I feel for anyone going through this it’s soul destroying.

  4. Catherine on August 9, 2021 at 7:59 am

    My beloved spoodle Bella was first diagnosed with b-cell lymphoma in December 2018, it was a single fast growing tumour on her belly. The vet operated and removed the tumour but we were very lucky, the cancer had not spread. The vet prescribed prednisone which she took in small decreasing doses for around six months and when no further signs of the cancer occurred, he believed she may have been cured. Bella was vaccinated in November 2019 and while I will never know if it played a factor, I later read in an article from a veterinary oncologist that you should never vaccinate a dog after they have had cancer as it can cause the cancer to come back. Sadly in February 2020, the lymphoma returned and had spread to pretty much all the remaining lymph nodes. We did not have the money to be able to afford chemo so Bella returned to the prednisone tablets which we were told would probably give us about four months. I referred to Bella as my little miracle because once she was back on the prednisone she showed no sign of pain and would always demand to play fetch multiple times a day and to be walked once a day up until she got a nasty stomach bug in September 2020 when we were afraid we would loose her. Thankfully she recovered with antibiotics and love and care from both our family and our vet clinic, they really loved her. After the stomach bug she slowed down to one or two walks a week but still multiple games of fetch a day. The vets were amazed that she just kept going even with the tumours continuing to grow and on our last visit in March 2021 before she truly started to go downhill, he said to me “I honestly don’t know how she is still alive”. Sadly, in May 2021 Bella got an eye infection and was unable to see very well and a couple of weeks later over the course of a weekend could no longer keep her food down and we had to make the devastating decision to put her to sleep. From being told four months when the cancer came back we got to spend fifteen months with her.

  5. Sean on May 4, 2021 at 9:06 am

    The pred issue makes a lot of sense, unfortunately my girl (a 5 year old Bernese) seems to have had some airway issues when our vet saw her. They started her on pred while acknowledging it was not an optimal situation for the reasons listed above, however I think it was reasonable given her respiratory distress.

    We are hopeful of seeing an oncologist with the results of an aspirate hopefully within a week, maximum maybe two. My question is will that short period of steroid truly have such an impact on her response to chemotherapy? I agree with my vet that it was the lesser of two evils given her respiratory distress, but I feel awful that this was a corner we were backed into and it might impact her future care.

    • Molly Jacobson on May 5, 2021 at 6:28 pm

      Hi Sean, hopefully all will work out, but in reality you will never, ever know the answer to your question. There is literally no way to know how things would have turned out if we’d been able to make a different choice. It’s one of the hardest problems in coping with dog cancer. There are so many choices, and there is almost NEVER a clear-cut choice that is 100% better to do. 🙁 Even if it does impact her chemo, you will have no way of knowing that for certain. So while I understand why you’re thinking about this and worrying about it, if you can, try to set it aside as a concern. Every single choice we make in cancer is about choosing the better of two evils, seeing how it goes, and then choosing again, tweaking as we go. The path is never, ever straight. There is no highway, just paths through a dark wood that we can only see with a weak flashlight beam. It sucks. 🙁 Whenever I find myself thinking “oh no, what if this was the wrong choice,” I try to remember that I’ll never know the answer, so I should think about something else. Not saying it’s easy. It’s just the only rational thing to do. <3

  6. Jessica on March 17, 2021 at 4:26 pm

    Thank you for this wonderful explanation. It really has helped me to understand a lot more of what to expect with my pup. We just got a diagnosis about a month ago of low grade t cell lymphoma, after noticing her lymph nodes were all enlarged. We were relieved to hear that her prognosis was not terrible, that She should be able to live comfortably for a year or so before symptoms worsened and chemo would be needed. But our relief was short lived, in the last couple of weeks she’s developed edema in her hind legs (which she can’t feel due to arthritis and nerve damage in her spine), making it hard for her to get around. And now, the last few days we’ve noticed swelling in her lips, as well as excessive panting and what sounds like some difficulty breathing comfortably, I’m assuming because her lymph nodes are still huge. Our city has no specialists to help us and travel is not possible right now for us… Our vet is trying his hardest to find us some answers but in the meantime we’re left feeling helpless. I’m extremely tempted to start prednisone, even at a low dose, just to lessen some of her discomfort. She’ll be 9 soon, and Her body is falling apart. I don’t expect her to live longer than a year or so, even without considering the lymphoma. Any helpful words would be so greatly appreciated!

  7. Pola vonfaulkenberg on January 5, 2021 at 7:07 am

    Great advice- just found out my 9 yr old GSD has lymphoma in his neck- vet said very aggressive- suggested to go on prednisone if not getting chemo-I just don’t want him to go through any pain – with no guarantee how long he will live if has chemo. He is breathing really hard,salivating, and would not eat this morning – I don’t know what to do.I love him so much but don’t want him to not live like he normally did.

    • Molly Jacobson on January 11, 2021 at 9:48 am

      Prednisone is amazing for quality of life. If you aren’t doing chemo, I would consider your vet’s suggestion. Here’s our “everything pred” article to help you understand that choice, but keep in mind that lymphoma is super aggressive and acts fast, AND also responds quickly when you start treating. https://dogcancerblog.com/pred

  8. Daniel Hsieh on February 10, 2020 at 1:21 am

    Hi, Dr. Sue. I came across your article too late. I noticed my 12-year old beagle’s lymphoma suddenly becomes hardened and larger around December 2019. I took him to the lcoal vet. The doc gave us two options: steroid or chemo. We were literaly walking in blind and picked the steroid option. My dog has been on steroid for about 2 weeks now since Jan 23, 2020. The beagle suddenly eats a lot and drinks a lot of water but at the same time, we noticed the lymphoma shrinks a bit but only for about 1 week and then gets larger again. In this week, he started to snore loudly while sleeping. He also pants a lot. Do you recommend my dog abrutly stop taking steroid and switch to chemo therapy? I have conerns if I suddenly let my dog stop taking steroid and swtich to chemo durgs However, if I keep feeding my dog with steroid, I fear the chemo therapy will be tarnished in the future. I am facing a tough dilemma now.

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