My Kingdom for a Curative Crystal Ball
There are many times in a given week I wish I owned a crystal ball. I really believe it would not only make my life easier, it would allow me to work more efficiently, save owners money, and create higher job satisfaction. Despite infinite utility in all aspects of my life, I promise I would only use it for work-related purposes. I really think it would come in handy several times a day.
The main time I wish I owned a crystal ball is when owners and colleagues ask me what I think a particular pet’s prognosis will be. As a knowledge-thirsty resident, I remember trying hard to memorize median survival times for all the different tumor types I would encounter.
The more I’ve worked out there in the “real world,” the more I’ve come to realize the numbers reported in most studies are absolutely meaningless. In other words, with experience I’ve come to realize so little of veterinary oncology can be described in black and white terms.
When a veterinary cancer study reports survival time, there is generally a huge bias built into that number because most animals do not die from their disease, but rather they are euthanized before succumbing to death. And the point at which owners decide to euthanize a pet is extremely variable. What one owner will tolerate, another would not, and because of this, survival times will likewise be variable.
As an example, the reported average survival time for dogs with lymphoma that do not undergo treatment is 30 days.
Many dogs with lymphoma are relatively asymptomatic when they are diagnosed, but at some point, all will start to show clinical signs related to their disease that will adversely affect their quality of life. For most dogs, signs begin within a few weeks of diagnosis. Although they are generally not severe at first, they are progressive in nature, and the point at which an owner makes the difficult decision to relieve their pet’s suffering will differ. Some will decide that a single missed meal is too much for them to bear, others will allow their pets to linger with their illness much longer, while others will allow their pets to pass naturally.
And, of course, some dogs are extremely ill at the time of their diagnosis and are euthanized immediately. The survival time for all of those dogs would simply be recorded as the number of days between date of diagnosis and death, which would obviously be completely different and unpredictable in each of the aforementioned cases.
Statistical manipulation can help account for some of the bias, but this typically means that the best I can offer distraught owners is an average. And the average doesn’t help me know what will happen to their particular pet. If I only had that crystal ball to show me how things would pan out, I just know I could be a better doctor (at least in the owners’ eyes).
The other time I wish I had a crystal ball are when pets come in without a diagnosis and I recommend several tests to help us achieve a definitive answer as to the cause of the clinical signs and the owners are limited as to what tests they will permit or can afford. It’s such a hard position to be placed in: to decide the one “best” test I think will give the proverbial “most bang for the buck” is so difficult. When it works in our favor, I’m thrilled, but when it doesn’t work it’s frustrating for all parties.
For example, sometimes I’m referred a case of a dog or cat with an elevated white blood cell count and concern that cancer is the underlying cause. Ideally, there are several tests needed to determine:
1) If cancer is the reason for the elevation in the blood count
2) What form of cancer is the cause
Many cancers can mimic one another clinically, and in some cases extensive testing is necessary to determine a final diagnosis. In this example, ideally we would do several different blood tests, bone marrow testing, and imaging tests (with tissue sampling) to determine the extensiveness of disease. Not every owner can afford all of this testing, or even if money is not an issue, they do not want to have their animal undergo such testing, and I’m asked to pick a single assay that will give the correct answer.
Obviously, if there were a single test that would give all the same answers as 5 or 6 tests could, I would easily recommend it before all others, but this simply isn’t the case. I will fully admit there is a great deal of anxiety induced within my mind when I’m asked to pick one test that will give a diagnosis, especially when owners have financial concerns.
If I had that crystal ball, I would just peek inside a few times a day, just to reassure myself I’m making the right choice or the right guess as to the right outcome, or to stave off a horrifically incorrect recommendation or prediction. I would even wear a scarf on my head and hoop earrings if I thought it could really happen.
I promise I wouldn’t use it to help fill out my March Madness brackets, or to peek at who will win the Kentucky Derby, or to figure out the next Mega Millions winning numbers. But since the ball seems a bit elusive to me for now, I promise to keep practicing medicine to the best of my abilities and making my best assumptions as to how things might pan out for my patients.
And I’ll have to simply rely on my magic wand for when I’m really off the mark.
Dr. Joanne Intile