Recently, there was an article that caught my attention in the New York Times. In A Tumor is No Clearer in Hindsight, Denise Grady wrote about whether Steve Jobs had made the right decision to wait 9 months to go to surgery after finding out he had a type of pancreatic cancer. The article goes on to discuss the dilemma of what to do when you find an incidental cancer. An incidental tumor, or “incidentaloma,” does not cause symptoms and is typically found during diagnostics for something else. In people, this is often the case when scans are done for back pain.
Should the incidentaloma be pursued and treated? One may argue that without the diagnostic scan for another issue, the tumor would never have been found. And what if the procedure to remove the tumor can cause complications, even if the complications are rare? On the other hand, maybe if the tumor is detected early, this may be a good time to remove it when it is small.
I routinely encounter dilemmas like this with my patients and their Guardians. Just a few weeks ago, this very scenario played out with Shannon. She is an adorable mixed breed dog – she looks like a cross between a Beagle and a Viszla. Shannon was already diagnosed with nasal carcinoma and was traveling to Animal Specialty Center from Virginia for CyberKnife RadioSurgery. Since my practice is in NY, the plan was to do her CT scan for radiation planning on Monday, and then treat her Wednesday through Friday of the same week. (There is typically a week between planning and radiation treatment.)
On her head and neck CT, the nasal tumor was not her only abnormality. There was also a mass in the region of the pituitary, consistent with what is called a pituitary macroadenoma. These are also treated with radiation, but to treat both would significantly increase the cost of the radiation. And since the plan was to treat her in two days, the radiation oncologist needed a decision from the pet Guardians that afternoon so she could prepare Shannon’s radiation plan, or we would have to put radiation off a week.
So on Monday, as Shannon was still recovering from anesthesia for her CT scan, the Guardians had to make a rather quick decision. I got a consult from our neurologist. He reviewed the options and the possible outcomes with and without treatment. Shannon was not displaying any neurologic symptoms. Her tumor was 0.85 cm, and guidelines are to treat with radiation when tumors are 1 cm or greater. No one knows how long her pituitary tumor had been there, or how quickly the tumor would grow. We do know that the average dog with an untreated nasal tumor only lives 3 months, and radiation can increase survival times to 12 to 18 months. Should they treat both, just the nasal tumor, or not treat at all? What would I do, I thought? What would you do?
We also found another mass on her CT, an oral tumor associated with the lower jaw tucked back by her molars. The radiologist said the appearance on CT was consistent with a benign oral tumor called an epulis, but I told Shannon’s dad (that’s what I call the Guardians) we need a biopsy to know for sure. Again, do we hold off on CyberKnife? Or proceed?
Ultimately Shannon’s family decided to go ahead with CyberKnife RadioSurgery for only the nasal tumor, and we biopsied the oral mass during the first anesthesia. The biopsy confirmed an oral epulis. Like the pituitary tumor, Shannon’s guardians are going to carefully monitor this. Shannon finished her radiation uneventfully, and she and Dad headed back to Virginia that Friday.
Like human medicine, we wrestle with the dilemma of incidental tumors and whether it is ever safe to just watch them. Do we need to treat them right away, or can we just observe them?
To learn more about the common dog tumors and treatment options, including full spectrum approaches, check out the Dog Cancer Survival Guide.
Sue Ettinger, DVM. Dip. ACVIM (Oncology). Dr. Sue is a boarded veterinary medical cancer specialist. As a Diplomate of the American College of Veterinary Internal Medicine (Oncology), she is one of approximately 400 board-certified veterinary specialists in medical oncology in North America. She is a book author, radio co-host, and an advocate of early cancer detection and raising cancer awareness. Along with Dr. Demian Dressler, Dr. Sue is the co-author of The Dog Cancer Survival Guide: Full Spectrum Treatments to Optimize Your Dog’s Life Quality and Longevity.