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

How to Make Decisions About Dog Cancer Treatments

Updated: February 28th, 2020

Summary

Overwhelmed and anxious, and unsure how to make decisions about dog cancer treatments? Read this article to find out how to “think like an entrepreneur” and calculate the risk.

How to Break Analysis Paralysis and Make a Confident Decision

With hundreds of thousands of readers of The Dog Cancer Survival Guide over the years, we’ve gotten a fair number of emails and comments. And the most-asked questions are how to make decisions about dog cancer treatments. They usually go something like this: “How should I choose between X and Y treatments?”

As Dr. Dressler reminds us, the most important question to answer first is a different one. The first question to answer is what is your general approach to cancer? Are you a Type A, who will do anything, no matter what? Or a Type C, who only wants to focus on comfort and palliative care? Or are you somewhere in between, a Type B, who wants to optimize longevity but not at the expense of life quality?

Even when we know the answer to that question, though, we can never know “for sure” which option will be best for our dog.

We want things to be simple. We want it to be like getting on a highway. Do I want to go North, or South? If I want to go north, I get on THIS ramp, and if I want to go south, I get on the other one!

But cancer decisions are almost never that straightforward. Nothing is sure.

And without that surety, many of us fall into a state called “analysis paralysis.”

We overthink it. We look for the right and best answer, and when we can’t find it, we get paralyzed with indecision.

And more information doesn’t help! In fact, the more facts we’re given, the more we feel overwhelmed.

To unbind your mind, sort your thoughts, and organize your options, I suggest using a simple tool that any entrepreneur or business person in your life uses every day.

In fact, you might use it yourself, even if you don’t realize it. It’s called risk analysis.

Hard Decisions are Not Easy

So, let’s say you’ve been given two treatment options by your veterinarian, and you’re trying to decide which to go with. Ironically, vets often aren’t much help when they don’t see a clear “winner” between two options. They usually leave it in our hands to make the choice. (This is also true, I’ll point out, of human physicians, who don’t like to make decisions on our behalf, either.)

Here’s a question we often see: should you use a conventional injectable chemo agent, which requires a vet visit, or Palladia, which can be given at home by mouth?

Or maybe you’re being asked to decide whether to amputate.

Or whether to do a second surgery.

Or to start a rescue protocol.

Or what diet to feed your dog.

Or whether it’s time for hospice care, or one more round of treatment.

Or whether you should skip chemotherapy in favor of herbal therapies that don’t have hard numbers associated with them.

Whatever the scenario you are contemplating, a relatively simple risk analysis will help you.

Here’s what to do.

Basic Risk Analysis for Making Confident Dog Cancer Decisions

Risk analysis is a way to look at the potential benefits AND potential risks of a situation so you can make the best decision possible, given what you know at this time.

For any decision you’re making, lay out the possible gains and the possible risks. Then see which one “outweighs” the other.

If you stand to gain more than you risk, do it.

If you stand to lose more than you gain, don’t do it.

Let’s go through risk analysis step by step with a concrete example.

Let’s say your vet says your dog is a good candidate for limb amputation. Here’s how I’d calculate the risks and benefits.

First Step: Outline The Scenario

In the first step, really take some time to outline the scenario or scenarios you are considering, in writing. Be complete in your description, including details like timing, cost, emotional resources it might take.

For example, here’s a sample scenario for a limb amputation:

“Rover will get the surgery, which will take several hours and involve anesthesia. He will have to stay overnight for observation and will probably come home the next day. Once home, he will have to wear a cone, will be groggy and exhausted for a couple of days, and may still need help getting outside to relieve himself during that time. He will be on pain meds and anti-nausea meds and won’t get the stitches out for a while. He will have to go back to the hospital if there is an infection or complication. Once he can stand, he will have to teach himself how to walk again, and even how to go potty. This could take as little as 24 hours, or longer. The vet thinks it will be at least a month before Rover is fully recovered.”

Second Step: List ALL the Possible Gains

List, in writing, what your dog could gain from the scenario if it works out.

Be as comprehensive as you can. Your dog has his own loves and joys – how are those affected? Be as specific as possible.

There are tangible things you can put on your list. Does your dog get to stop taking a medication that makes her constipated? Does she get to reduce her tumor burden? Live longer? Avoid a second surgery?

There are also intangible things you can add, too, like your own sense of relief at knowing your dog is out of severe, unrelenting pain.

Be realistic and honest, thorough and clear.

Here are just a few of the gains you could anticipate in this scenario:

  1. Your dog feels a LOT less pain. (Bone pain is considered the deepest, most upsetting and painful of body pains. A broken bone in humans can be so painful it can cause nausea – and there’s no reason to think the same isn’t true for dogs.)
  2. Your dog is no longer at risk for a fatal limb fracture.
  3. Your dog has a much better quality of life.
  4. Your dog can walk and run pain-free (once he recovers from the surgery).
  5. Your dog can fetch and play again.
  6. Your dog can go for long walks again.
  7. Your dog won’t need as many pain meds to get through the day.

Of course, some of these might not apply to every dog, and there might be other gains I’m not listing here. That’s why it’s so important to be thorough and really imagine the scenario as much as possible.

Step Three: What’s the Best-Case Scenario, and How Likely Is It?

Take a moment to describe the most wonderful outcome possible for your dog if you make this choice.

For example, in this sample case, your dog could sail through surgery with no complications, heal quickly and completely with minimal pain, and is able to start walking again on his own within a day or so of being able to get up and move. He is back on his feet and running and playing again in a matter of weeks, eating like a horse, and generally living a great life. In fact, he’s so playful, you notice that it’s been a long time since he moved so well – and realize he’s been in pain for a lot longer than you thought. You’re thrilled at his joy and play, and feel it was well worth it.

Now, attempt to answer this question: how likely is this best-case scenario to come true?

You won’t always be able to assign a number in this step. You might just be able to say “better than 50/50” or “very likely” or, sadly “not likely at all.”

Don’t be afraid to get a reality check from others about your best-case scenario. You can ask your veterinarian, for example, to tell you how likely he/she thinks that wonderful description is. There are also lots of forums and places online to go to for reality checks: if you are actually contemplating amputation, we highly recommend the folks at Tripawds.com as a resource.

Just for the purposes of this sample, I’m going to calculate the odds are better than 50% that this happens to your dog.

Step Four: List ALL the Possible Risks

Now list, in writing, all the risks you can think of associated with this scenario. With as much honesty, clarity, and detail as you used in step two, think about what you possibly stand to lose.

Money? Sleep? Time? Does your dog get worse? Feel worse, even if technically he’s “better”? Suffer?

List tangible AND intangible risks.

Here are some of the risks you could anticipate in this scenario:

  1. The surgery is relatively simple, but there could always be complications you can’t foresee.
  2. Anesthesia carries its own risks.
  3. Your dog won’t have that horrible bone pain anymore, but there will still be pain from the surgery itself for a few days.
  4. The wound will be ugly, and you will have to look at it. Even after it heals, you may still feel guilty looking at it.
  5. Your dog will have at least a few weeks of recovery.
  6. Your dog will have to be on pain meds and antibiotics after the surgery.
  7. Your dog will have to learn to walk on three legs, which will take more time.
  8. Your dog will have to learn to go potty without falling over.
  9. Amputation doesn’t address metastasis, so your dog might still need other treatments. (In osteosarcoma, 95% of dogs already have metastasis, either detected or undetected, at the time of diagnosis.)
  10. It will likely not “cure” your dog and remove the cancer completely. If your dog still dies from this cancer in a month or two, you might feel the surgery was not worth it if you have an unconscious goal of trying to “save his life.” By fully facing your underlying wish that the surgery will cure the cancer, you get a needed reality check.

We could add more to the list, I’m sure, depending upon the specific case. But this is a good start.

Step Five: What’s the Worst-Case Scenario, and How Likely Is It?

Take a moment to describe the worst possible outcome for your dog if you make this choice.

For example, in this sample case, your dog could have complications from surgery or anesthesia, and die during surgery.

That would be devastating.

But how likely is it?

Well, if you’ve got a good surgeon who has done many amputations, he or she will be able to tell you the numbers for surgical complications, because they’ll have them for their own practice.

But in general, the risk of dying from anesthesia accidents during surgery is on average 1.33%. (I took that number from chapter 12 of The Dog Cancer Survival Guide.) In other words, 1 in 173 dogs dies as a result of an anesthetic accident during surgery.

So, you are looking at a less than 2% chance of the worst-case scenario actually happening.

Step Six: Compare the Gains with the Risks

Next, you compare the gains with the risks. Just to get you in the right mindset, let’s jump out of cancer for a moment and take a look at a less emotionally-loaded example: booking an airline flight.

When you book a flight, you hope to get where you are going quickly. That’s your gain. It’s extremely likely that if you book that flight, you will in fact get where you are going, quicker than by another method of transportation until they perfect that teleportation thing.

On the other hand, there is a risk that the flight will crash and you will die. But that possibility is really, really, really really really unlikely. Teeny, tiny, teensy.

The gain of getting there quickly is well worth the minuscule risk of a plane crash.

Back to our dog cancer scenario. Look back at the sample lists and likelihoods and compare them. Are the gains worth the risks? Are you more likely to get the gain, than the risk?

In our amputation scenario, the gain is not guaranteed, but the best-case scenario has better than 50% odds of coming true. Meanwhile, the odds of the worst-case scenario coming true are maybe 2%. You might want better odds of a best-case scenario, but you still have to see that you stand to gain more than you risk.

Overall, for MOST cases, the gains of amputation outweigh the risks … which is why most people choose to amputate.

For most of us, the possibility of ending that relentless, I-can’t-even-sleep bone pain is well worth the relatively slight risk of dying on the table.

This is true for most people even when they are told that metastasis has probably already occurred. The pain relief from the surgery is so important to their dog’s life quality they do it, even though they know it’s only palliative.

End Analysis Paralysis with Risk Analysis

Here are the basic steps to take:

  1. Outline the scenario in detail.
  2. Make a list of ALL the gains you could get from this choice.
  3. Describe your best-case scenario, and lay odds on how likely it is to come true.
  4. Make a list of ALL the risks you are taking on with this choice.
  5. Describe your worst-case scenario, and lay odds on how likely it is to come true.
  6. Compare the relative gains to the relative risks.
    1. If you stand to gain more than you risk, do it.
    2. If you stand to lose more than you gain, don’t do it.

There’s your black-and-white answer to thorny questions.

If you stand to gain more than you risk, do it. If you stand to lose more than you gain, don’t.

What If It’s Too Risky?

Almost always, the risks don’t outweigh the gains when it comes to cancer treatments. Most people who read The Dog Cancer Survival Guide are looking at making low-risk, high-reward lifestyle changes, and they are choosing treatments that really do offer tangible benefits to their dogs. Most can see that they stand to gain more than they risk by committing to the treatments in the book.

But if that’s not you, and you can’t make the numbers work, then your analysis is telling you something: the plan you’re looking at is just too risky. See how you can reduce the risk. Look for as many ways as possible to reduce your risks and increase your gains.

If you still see too much risk, then maybe your analysis is revealing that you are near the end of your dog’s options. In that case, it may be time to read about hospice and euthanasia. Please see chapter 25 of the book for a compassionate and loving discussion of your options. You can also take a look at this article.

Be Well, and Remember Your Dog Loves You More Than You Could Bear,

Molly

Discover the Full Spectrum Approach to Dog Cancer

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