How to Make Decisions About Dog Cancer Treatments - Dog Cancer Blog

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

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How to Make Decisions About Dog Cancer Treatments

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. But even after you’ve figured out your general approach to cancer management – whether you are a Type A, B, or C – your original question will still demand an answer.

Since we can never know “for sure” which option will be best for our dog, many of us fall into a state called “analysis paralysis.”

In other words, we overthink it. We’re looking for the right and best answer, and when we can’t find it, we get paralyzed with indecision. The more facts we’re given, the more we feel overwhelmed. We feel, well, paralyzed. By analysis.

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. More on this in a minute.

Easy Decisions Are Easy

Now, sometimes we just KNOW what to do, almost like we have a good internal compass. If you’re like most people, you can drive a road you’ve never been on before, and still get to your destination, even if you don’t “know” how you’re going to do it.

But if you’re facing canine cancer, there might not be signs on the way to reassure you. And there is no equivalent to GPS. There just aren’t definite, well-traveled routes from where you are, to where you want to be.

So, when you don’t just “know” the right answer, it’s time to use 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 treatments.

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.

You probably use risk analysis a LOT without realizing it. I have a non-cancer story to help you understand this concept.

Last Saturday I woke up exhausted and cranky because I knew what kind of weekend I had ahead of me – the third in a row where I moved furniture and organized. I’ve been setting up a new home office area, and it’s turned out to be a Pandora’s Box.

Every time we clean something or move something, it breaks or reveals a new problem to solve. Since I can only do this work on days off, it’s taken up every minute of two weekends already. Last Saturday was the start of the third, and hopefully the last, exhausting weekend.

My husband also woke up cranky, but he’s an entrepreneur, so his mind is always looking for something he calls “leverage.” He looked ahead at the weekend of hard labor and sticky problem solving and thought “is this really worth it?”

That prompted him to do some risk calculation. Together, we took a look at what we stood to gain, and what we stood to lose, if we worked in the office.

We also came up with our best-case and worst-case scenarios and guessed at how likely each was to actually happen.

Then we measured what we stood to gain against what we stood to risk. If the gain was worth more than the risk, we would do it. If not, we wouldn’t.

Risk Scenario: Working in the Office

If we worked in the office, here’s what we stood to gain:

  1. It might be “done” before Monday, which meant we would FINALLY be done with the project.
  2. The other areas of the office that were holding excess office equipment would feel less cluttered.
  3. We could get back into the laundry area and finally get some laundry done later this week.
  4. We could get the rest of our home back in shape, after weeks of neglect. Later this week, we could clean.

Are you exhausted yet? Basically, every one of those items actually represents MORE housework 😊

The best-case scenario was that we would get the basics of the office set up and organized, but it would not be cleaned (because we wouldn’t have time to do a deep clean as well as the set up), and the rest of the house would still be a disaster, and the mountains of laundry would still be there.

How likely was this best-case scenario? Given how many difficulties we’d already run into – and how many things we thought would work hadn’t yet been tried – it wasn’t a sure thing.  We put the chances of the best-case scenario coming true at about 65%. Not terrible odds, but not a sure winner. (And frankly, the best-case scenario wasn’t that attractive!)

Next, we looked at risks. Here’s the list of what we risked if we worked in the office:

  1. Not actually getting the office “done” before Monday, due to even more problems cropping up than we anticipated, causing frustration and disappointment as well as delay.
  2. Not having time to clean the rest of the house. (Ummm, we’re kind of at emergency levels.)
  3. Not having time to do laundry. (Again, underwear emergency is imminent.)
  4. Having one of those stupid couple’s fights we can get into just because we’re tired and cranky and too many things have gone wrong and we both start acting like toddlers.
  5. Waking up on Monday completely exhausted from yet another weekend NOT off.
  6. Actually getting the cold/flu crud we know we’ve been exposed to in the last few days, by not resting and letting our immune system do its thing.
  7. Eating lots of takeout because we’re too exhausted to cook.
  8. Disappointing our dogs again by not taking them to the beach in the mornings.
  9. Dealing with dogs who tremble if furniture is moved out of place – for some reason they really hate it.
  10. Getting physically hurt if our already aching backs were tweaked once too often.
  11. Possible chiropractic bills from the overwork and tweaking of backs mentioned above.

There were more, but I think you get the point.

The worst-case scenario was that we would not get the office done, and would still have a dirty house and mountains of laundry … but ALSO be hurt emotionally and physically, in need of chiropractic adjustments, dealing with traumatized dogs and on the way to a cold. And we put the chances of this scenario coming true at better odds than we laid for the best-case: 75%!

James was convinced right away that we should not work in the office. The risks were far outweighing the possible (not guaranteed) benefit. The likelihood of our worst-case scenario coming true was higher than the likelihood of our best-case scenario.

I was skeptical, at first. Even though we risked all that, I still had an internal urge to GET IT DONE.

But reviewing those risks again made me realize the cold, hard facts: we just didn’t have the time, strength, or emotional resources to work for the third weekend in a row. We needed a break MORE than we needed the office done.

Without that simple risk analysis, I might have very well pushed ahead and tried to “get er done.” That’s the way I was raised, after all.

But I would have paid dearly for it.

Instead, I listened to my business-minded husband. We shoved all the clutter in the office and shut the door so we couldn’t see it. We did some laundry, and some basic housekeeping in the morning. We went grocery shopping in the afternoon, and took the entire day off on Sunday to rest, binge-watch Netflix, and walk our dogs.

And today, I feel rested, relatively rejuvenated, and yes, ready to move some furniture … NEXT weekend. In hindsight, it was the right decision, even though at the time it felt like I was “giving up.”

Applying this type of analysis to your decisions about dog cancer treatments is just as straightforward – although you’ll probably feel more emotional about it.

How to Use Risk Analysis with Dog Cancer

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 a 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.

Even people who are afraid of the even more likely risk that metastasis has already occurred, and the surgery won’t actually cure the cancer itself, usually decide to amputate, because they feel the quality of life increase is SO much more important than the fact that cancer will still be in the body. (Because the cancer will still be there even if you don’t amputate. Amputation in many cases is about symptom relief, not cure.)

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

About the Author: Molly Jacobson


Molly Jacobson is a writer and editor for Maui Media. As editor of The Dog Cancer Survival Guide and a lifelong dog lover, she is all too familiar with dog cancer.

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