In veterinary oncology it can be hard to know "when to say when."
I struggle the most with this concept when I have patient whose tumor grows and/or spreads despite multiple different treatment options I provide for them, yet they still feel well. If cancer progression occurs, and pets become sick, there really isn't going to be very much I can offer an owner to help. It's far more difficult to draw the line when their illness causes no effects.
Just this morning, I received a wonderful e-mail from an owner letting me know they decided not to pursue alternative treatment for their dog with a progressive form of oral cancer. The patient is a gorgeous and stoic Golden retriever who underwent an aggressive course of radiation therapy and chemotherapy between last summer and fall completely without incident or side effect.
His tumor was well controlled for about seven months, but we incidentally detected regrowth of the mass about two weeks ago. Knowing the dog was feeling great at home, I felt compelled to at least have his owners consider further treatment. We discussed a few different options, none of which were likely to be the proverbial "magic bullet." But I did have some things I could offer that could theoretically help slow things down for a few months. His owners carefully considered everything I talked about and ultimately decided that although their dog might enjoy coming in to see us from time to time, and acknowledged he was feeling absolutely fine right now, his final days should be spent chasing rabbits and squirrels around their backyard. Reading their e-mail brought me such a sense of happiness, and a tiny bit of relief. It was the relief that prompted me to consider this topic.
Just as in people, if the standard of care no longer controls disease, the patient should be given additional options to consider. My goals are different from a human oncologist though. It's not life at all costs for my patients; it's quality of life for as long as I reasonably think I can help them. For the vast majority of owners, I think we are all on the same page.
ost owners of pets with terminal cancers are accepting of the fact that their pets are likely to pass away from their disease. I rarely come across owners who wish to be extremely combative about their pets’ treatment plans, or who seem to deny the statistics I present. Sometimes I think I let those owners down — I'm not as comfortable being aggressive about treatments as they are hoping. More often, I find that owners fear they will not be able to detect pain or suffering in their pets and they will be unable to know when they should consider euthanasia. I try to assure them the anxiety surrounding their thoughts is far greater than what the actual experience is like.
It's difficult sometimes to consider what it's like to be on the "other side." When the standard of care treatments are no longer effective, and I give owners alternatives, what is it they actually hear?
o they pursue additional treatments because they will feel guilty if they don't do everything? Do they hope their dog or cat will be "the one that beats the odds?" Do they try just because they can? And I often stress over my inability to remain seemingly impartial. In other words, how much do I unknowingly influence owners?
Sometimes I wonder if I "give up" too soon. I wonder if I should suggest more options, or not be judgmental of colleagues who push boundaries I am uncomfortable with. During my residency I was instructed I would "have to decide what kind of oncologist I wanted to be." Though it was confusing at the time, having practiced this art for a few years now, I think I've come to appreciate what this means.
I know I need to be the kinds of oncologist who feels I’ve worked hard to help my patients live longer and healthier lives, but not without causing undo harm or risk for illness. I need to be the kind of oncologist who has the time to listen to owners and guide them through decisions without making choices for them, or making them feel guilty for not choosing other options.
It's no easy task to fulfill these goals on a daily basis, and I think I've learned to accept that as long as I feel I am accomplishing those goals frequently enough to sleep well at night, I'm probably doing okay. It's particularly difficult when your patients can't make decisions for themselves, and owners question, "Isn't there something else you can offer?"
The kind of oncologist I would like to be would be the one who remembers I'm a veterinarian first, an oncologist second, and one who adheres to our oath to "first do no harm." If I accomplish those simple goals, I think I'm doing a pretty good job. And truthfully, who could ask for anything more?
Dr. Joanne Intile
Image: Tyler Olsen / via Shutterstock