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The Daily Vet by petMD

The Daily Vet is a blog featuring veterinarians from all walks of life. Every week they will tackle entertaining, interesting, and sometimes difficult topics in the world of animal medicine – all in the hopes that their unique insights and personal experiences will help you to understand your pets.

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The Internet can be a dangerous place for owners of pets with cancer. The sheer amount of virtual information available immediately at one’s fingertips is astonishing; bordering on overwhelming.

 

As an example, a quick search of the phrase “canine cancer” in a popular search engine returns over 3,240,000 hits. "Canine lymphoma" yields over 1,050,000 hits, while "feline lymphoma" reveals a mere 565,000 hits. How can an owner sift through all those pages and discern the "good from the bad" when it comes to learning more about their pet’s diagnosis?

 

When a diagnosis of cancer is made, owners are often placed in the difficult position of having to make decisions regarding diagnostic tests and treatments for their pet, frequently with limited information. This can lead to a feeling of helplessness and depression, or even defensiveness at times. I think it’s natural to turn to the Internet as a source of information, self-comfort, and self-education.

 

What I’m not so sure of is when exactly did entering phrases or words into a search engine begin qualifying as "research?" Having endured many years of rigorous academic training, when I think of actively researching a topic, it conjures up images of pouring over textbooks and critically reviewing clinical studies. To me, it means learning objective facts and studying information for accuracy of content, not clicking on random websites and reading unsubstantiated opinions backed typically by emotion rather than truth.

 

It is not unusual for owners to come to their first appointment armed with notes, printouts, suggestions, and/or questions they have garnered from searching their pets’ diagnoses on the Internet. My visceral reaction is typically one of tempered insult. I’m the one who endured many years of education and training and have several years of experience working as a clinical medical oncologist, yet I often joke in some cases that the (in)famous "Dr. Google," who never went to vet school, once again has managed to usurp my recommendations. It’s challenging for me to remember that the intentions behind my clients’ questions or suggestions are typically pure. Owners simply lack the medical knowledge to review the Internet information accurately, but they really only want the best care and best treatment options for their pets.

 

I’ve discussed before how I understand that a diagnosis of cancer can be emotionally provoking for owners, and a common frustration many will express is their complete lack of control over the situation. Owners cannot alter progression of the disease once it occurs, they are simply told, "Here are the facts and here are the recommendations."

 

An example would be an owner focusing on nutrition and diet after a diagnosis is obtained. What food their pet ingests is one of the few things pet owners can control in an otherwise uncontrollable situation. It is also one of the most Internet-searched topics owners will discuss with me during an appointment. Unfortunately, the lack of evidence-based information supporting nutrition as playing a role in the outcome for animals with cancer makes it difficult to make solid recommendations.

 

This isn’t to say I can't relate to the need to try to learn as much as possible about a diagnosis, and I’m aware of how daunting terminology related to science and health and medicine can be for individuals not trained specifically within those subjects. The vocabulary is unfamiliar, anxiety provoking, and even uncomfortable for some. Equally as challenging on my end is determining how to present complicated diagnoses and treatment options in terms the average non-medically inclined individual can understand. Despite my best efforts, even with the most medically educated clientele, I know the emotional aspects surrounding a diagnosis can create barriers to truly understanding the technicalities.

 

Following initial consults, I provide owners with an in-depth written summary of all the points discussed during the appointment. I believe this is something unique to the veterinary profession. Think about the last time your human MD counterpart provided you with a written summary of any aspect of your visit. Even with the information literally in hand, it’s not uncommon for owners to specifically ask for websites they could use to better understand all the topics I’ve discussed. I’m not sure I will ever understand the need to turn to non-validated sources of information when it comes to learning about health and disease, but I do understand my obligation to being able to point people in the right direction.

 

Therefore, I generally recommend websites directly affiliated with veterinary schools, professional veterinary organizations, and websites run by respected and prominent veterinarians and advocate such pages as resources for owners seeking additional information. I also have no problem discussing the pros of seeing another medical oncologist for a second opinion when appropriate.

 

I think one of the main reasons I enjoy being able to write weekly articles for petMD is because I feel it is my small way of contributing factual information about veterinary oncology on the Internet. Though I’m still frequently challenged by owners about something they read on a website or through an online forum, I try to maintain patience when these topics come up.

 

I take comfort in knowing there are good resources for pet owners, and that I play an active role in keeping truthful information available to a large-scale audience, one week at a time.

 

Dr. Joanne Intile

 

Image: Chad Kawalec Studio / via Shutterstock

Comments  15

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  • Dont discount the owners.
    02/27/2013 10:10am

    While the frustration is understandable, I believe that there are legitimate things that even the most seasoned vets can learn by listening to research their clients bring to them. Especially with general practitioners, while they are very knowledgeable about a wide assortment of veterinary concerns, they may not be as up to date with recent treatments for specific diseases. I have a dog who was diagnosed with Addison's disease. Because I knew nothing about it, yes, I did a lot of research on the internet and came across a group with several thousand members, all current or former owners of Addison dogs. They taught me to advocate for my dog to be on the lowest effective dose of her medications. It seems most vets are essentially overdosing the dogs on very potent and very expensive medications. By taking the research this group had collected over the years as well as articles from some of the leading vets in the field, I convinced my vet to try it. My dog is now thriving on a third of the percorten and a fifth of the prednisone that she will need for the rest of her life, and my vet is amazed at how well it is working. I had to stand up to her initially to prove to her we both wanted what was best for my dog, and since then we have become partners in her care. When I bring ideas to her, we actually discuss them, and she doesn't dismiss me as I have had several vets do in the past. Sometimes she convinces me of her point, sometimes I convince her of mine, but I know that no matter what we trust each other to do what is right.

  • 03/03/2013 04:24pm

    Interesting... “most” vets…. “essentially overdosing”… “very potent” medication. Please explain, in great detail. It seems the experts you failed to address/consult are those who have actually done research in the use of desoxycorticosterone pivalate and have extensive knowledge and data to make claims – as opposed to the lay people who spout unsubstantiated pseudoscience on the web (you know, kind of like the garbage the above article is addressing). There is a recognized protocol for use of desoxy in terms of both dosing and timing; it has been established and proven. And, as with ALL endocrinopathies, frequent monitoring and repeated blood panels are essential to finding the ideal balance and managing the patient correctly. Reducing the dosing of desoxy often times yields less consistency in maintenance of essential electrolyte levels and resultant instability and poor health of the patient. In many unresolved cases, it was found that those patients doing poorly actually needed more frequent dosing of desoxycorticosterone pivalate to maintain their electrolyte balance and level of energy.
    And, what your “experts” failed to inform you is that multiple studies have proven the safety and efficacy of desoxycorticosterone pivalate, even in dogs not requiring such (aka – non-addisonian dogs) due to a protective process known as atrial natriuretic peptide secretion. The only reason you and your web experts are looking for decreased dosing regimens is to spend less money on your animal companions with a life threatening disease. Shame on you; and shame on your vet for not doing the “research” herself and standing by the facts. Otherwise, please explain what effects excessive desoxycorticosterone pivalate has on your dog.

  • 03/03/2013 09:32pm

    Yes, you are right, my monthly cost for medication has decreased from $40/mo to a third of that, and that is for a medium size dog, but it took extensive testing, sometimes once a week, to get to that point, and I was more than willing to pay that price. Her electrolytes are now balanced, going only slightly above mid range at the end of the month. When she was on the dose they were giving her, her potassium was consistently on the low end of Normal, or even below normal range. If the potassium drops to low, it will cause cardiac issues, and potentially even cardiac arrest. The whole point of the medication is to balance the potassium and sodium levels in dogs who are no longer able to balance it themselves. By her third shot, it took almost 3 months before her levels were mid-range again, instead of bordering on the extremes. The vet wanted me to give prednisone at 5mg daily for the rest of her life, because that is what they normally did. She is doing well at 1mg EOD, and even that is giving her stomach problems, but she will be on it for the rest of her life. I cant even begin to think what 5mg would be doing to her. While none of the members of the group are vets, there are vets who have done extensive research about low-dose percorten, and whom vets can contact if they have any concerns. My dogs health and safety is vital to me, but yes, if I can get her well balanced and HEALTHY on a lower dosage, that does NOT make me a bad owner. Shame on you for being so close minded and judgemental that you would accuse me without knowing the facts. If you would like the information from the vet who has done the research, I would be more than happy to provide it so you can contact her directly and verify this information, if the database of information of hundreds of dogs isn't evidence enough.

  • 03/04/2013 05:13am

    Oh dear, how many dogs do you have in your practice with Addison's disease ? Have you not kept up to date with current research and have you done any of your own ? This is a link to the most up to date reserach on dosing of percorten: http://onlinelibrary.wiley.com/doi/10.1111/avj.12019/abstract
    You might also find it useful to look at the live data we have on our support group which clearly subtsantiates this research as more and more dogs are doing so much better with a lower dose of percorten.

    http://pets.groups.yahoo.com/group/AddisonDogs_/

    I would be happy to send you an invitation to the group to join us - we already have severaL vets on board alongside 5700 members worldwide. We, the members do not claim to be vets, we simply ask the questions and point people in the right direction to get the best treatment and advice for their dogs. When you say that someone would want to give lower dose to simply save money is naive in the least. Addison's is a lifelong commitment and at the prices many vets charge, we know of dogs being euthanised because their owners could not afford it. We also know that some vets put a big markup on the price of percorten. However, the most important reason for finding the LED is to help the dog to feel at its best all of the time with balanced electrolytes all the time. You would not give a diabetic dog more insulin than it needed would you ?


    Just to add, I had a dog with Addison's that lived for 12 years very well on florinef. He was also put on 5 mg pred daily and had I not found a support group on the Internet which told me he probably didn't need pred in addition to florinef, he would have been kept on pred all of his life which could well have been cut short by over use of pred. Luckily I have briliant vets that were open to listening as Addison's was new to them and when I took articles in to show them they listened to me and we always had a very good discussion about it. They allowed me to be a partner in my dogs treatment and care.

    I now have a dog with mamy isues inlcuding kidney disease which was diagnosed 2.5 years ago. Her vet is an Intern Med Referral specialist and he is superb. He also though, has been prepared to discuss her treatment with me and when I have taken articles in to show him from an excellent kidney support group re diet etc, he has been open to suggestions and even on one occasion suggested I ask them about an issue. My dog is still here when no-one thought she would survive beyond a few months. I love my vets.

    In the 15 years I have been around Addison's disease I am continually dismayed by the numnber of vets we still see on a daily basis that do not know how best to manage it; with dogs being diagnosed with Typical Addison's when they have Atypical Addison's and indeed some dogs which have been misdiagnosed altogether.
    There may indeed be some things you read on the internet which are inaccurate - I have found them myself - but please do not tar all with the same brush. If you are not prepared to find out and put in place the up to date recommendations for the managemetn of Addison's then shame on you because you are doing your clients and their dogs a huge disservice.

  • 03/04/2013 04:29pm

    Thank you Dr. Joanne Intile for a good article. There is great info on the internet and there is terrible info as well. We do need to learn to sort through it and our Vets can help us do that.

    Today one of my expectations of my Vet is that I should be able to discuss my internet research with her. I have a wonderfully open minded, intelligent Vet who practices relationship centered care not paternalistic care.

    @Piet you sound like you are either Veterinary or Medically trained. But you are spouting unsubstantiated claims.

    I belong to that Addison Dogs group that happens to provide up to date Veterinary Peer reviewed information for its members. Addison Dogs owners are often at their wits end and we offer them suggestions, we keep a database of Vets experienced in treating Addison’s. We are the ones telling them to throw the “insert stupid supplement here” away. We encourage them to talk to their Vet, to get a second opinion, to see an IM specialist.

    We do actually consult the Internal Medicine Specialists who have done and do the research on Canine Addison’s. Until very recently no one had done research on using lower doses of desoxycorticosterone pivalate (Percorten V or DOCP). Dr Julia Bates DVM, DACVIM just published a retrospective study, “Lower Initial Dose Desoxycorticosterone Pivalate for Treatment of Canine Primary Hypoadrenocorticism” in the Australian Veterinary Journal.
    She was taught this “low dose protocol as a resident at Michigan State University. MSU began using low dose Percorten when there was a shortage of the drug and rather than switch dogs to Florinef they decided to lower the doses of Percorten quite drastically and continue to treat all the dogs. It worked and none of the dogs were any worse for the reduced doses. In fact once the Percorten shortage was over they continued to use the low dose protocol because it worked.

    Piet I have read all the studies you have talked about, none of them address using lower doses of desoxycorticosterone pivalate.

    I prefer not to use the term “overdosed” when I speak of a dog receiving too much percorten, I prefer the term “over treated”. Vets are in part following the product insert when they treat at 1mg/lb. But they are receiving more of a potent hormone than they need to properly manage their electrolytes. All one has to do is read the Percorten product insert to see that the dose is to be adjusted. Yet often Vets seem to fail to do this. I have seen more dogs than I care too end up in ER because of their over treatment with desoxycorticosterone pivalate, requiring IV’s with potassium supplements.
    The Novartis Canada Product insert states that most dogs settle out between .5mg/lb and 1ml/lb, the US product insert .75mg/lb to 1mg/lb. So even Novartis knows reduced doses work.

    Percorten is an expensive drug especially if you have a large dog. Markup on the drug is frequently over 100%. That can make it $300 a month or more to treat a large dog just for Percorten and add lytes testing on top of that, owners too often choose to euthanize rather than treat. That is not an insignificant amount of money every month.
    If you can tell an owner that their Addison Dog can do just as well on .45mg/lb or less and the cost drops in half at least and that that dose may continue to go down without any ill effects to the dog why would you choose not to do that?
    Why would you want to use more of a drug to treat a problem that was needed?

    Piet you stated “Reducing the dosing of desoxy often times yields less consistency in maintenance of essential electrolyte levels and resultant instability and poor health of the patient.” Can you please provide peer reviewed info to support that claim?
    I provided Peer Reviewed info to support low dose Percorten.

    Shame on you for suggesting it is only about the money. It is about our dogs living better, healthier lives.
    Low dose percorten will save lives of dogs who owners would otherwise choose to euthanize because of monthly percorten costs.

  • 02/28/2013 07:33am

    I think you bring up some good points and reiterate what it is I'm trying to say: It's important to have an honest discourse with your veterinarian about what your goals are and what you understand and don't understand and then find credible Internet resources that can be used (along with your vet) to make the best decisions about your pets healthcare. What I take issue with are websites that are filled with more "propaganda" like messages, or sweeping generalizations NOT based on factual evidence that owners take for gospel. Especially those that prey upon the owners who may be too emotional over a diagnosis of cancer to be more objective about things.

  • Interesting advice
    02/28/2013 04:18pm

    I agree - don't follow the advice you find online, such as the opinions expressed in this article!



  • 03/02/2013 07:29am

    Awesome Comment! I agree with you

  • 03/04/2013 09:37am

    It is close minded vets that give the rest a bad name. If someone wants to call me a bad owner for being willing to think for myself in what is best for my dogs instead of blindly following what one person tells me, then that is not someone I am willing to have take care of my dogs. It is a shame that they would feel so threatened by me begin a proactive owner that they would dismiss and berate an owner for trying to become more knowledgeable.

  • Internet Information
    02/28/2013 06:33pm

    I'm sure it's frustrating to provide a great deal of information to clients, only to have them go to Dr. So-And-So's website and get a bum steer.

    Luckily I have an amazing vet. He provides a great deal of information and patiently answers my emails that begin with, "Yes, I've been sitting up late and surfing the web..." Sometimes the answer is, "Can't hurt. Might help." and sometimes he gently lets me know that the information is bogus.

    He provides printouts of relevant information so I can digest the information at home... and look up words if necessary. :-)

    He also never hesitates to suggest a specialist which gives me even more confidence that I'm getting the straight scoop from him.

    I may find odd information on the Internet from time to time, but (and I hope he knows this) as far as I'm concerned, he's pretty much the final authority of good information.

  • Need more
    02/28/2013 11:23pm

    I think I look at it two ways. I want as much information after the diagnosis that I can get my hands on. After leaving my vet with a handful of papers and a grim prognosis all I could remember was "wa wa wa CANCER wa wa wa". Nothing else sunk in. With the paperwork I was able to read numerous articles from well respected vet school websites. It gave me peace of mind to read all about the exact cancer she had. The prognosis was the same but sitting calmly at home reading about it gave me a chance to really understand what we were dealing with. I truly believe it helped me ask the important questions and determine the plan of care. The web is a tool not the end all be all.
    Sweet Lilly sadly missed.....3-1-11

  • Wish I had Googled
    03/02/2013 07:31am

    Jena Gilliam Gonzalez Not always true....I wish I had consulted Dr. Google about which pet vaccines are necessary, how often, and the risks. Then later when my cat developed vaccine associated sarcoma had I consulted with Dr. Google I might have learned that a Board Certified Surgeon and Oncologist is recommended. Instead my vet chopped of her leg and threw it in the trash. She died 4 months later. Now I try to Educate guardians. Almost three years later we are still in litigation. www.vetnegligence-vaccines.com

  • Internet research helps!
    03/04/2013 08:18am

    With all due respect, not all vets (or human physicians) are as up to date and as skilled at providing a treatment plan as you. I work in human medical research where personalized medicine is quickly becoming widely accepted. Why should a human take more medication than is needed to achieve the desired response? Similarly, why should a dog be dosed with more medication than needed to achieve control of a condition? My dog has Addison's disease. Through the internet, I learned of recent, at that time unpublished, information that was crucial to halving the amount of DOCP my dog receives to control his condition. I have my dog insured. Cost is not an issue. His well being is. He does much better on the lower dose, has fewer side effects, and he has more energy.

    As for internet education, I am VERY conscious of the potential harms. There is nothing quite like having an MD or a Vet come to my office with a data analysis that he has used an internet calculator to perform. There is knowledge needed to properly apply statistical tests that you cannot garner from the internet. However, the awareness that those tests need to be done is quite useful and stimulates productive conversations.

    Similarly, patients and pet owners can productively use the internet to learn more about their and their pet's conditions. Keeping up with the literature is, at times almost impossible, for Ph.D.s, MDs, and DVMs. I have seen MDs learn from their patients. I have seen MDs who should learn from their patients. Not every MD and DVM is as up to date, or frankly as good a practitioner as you are. If internet research helps make a patient or pet owner more aware that their practitioner may be out of date is that really so bad?

  • Proper Internet research
    03/04/2013 06:08pm

    I am going to refer people to Dr. Nancy Kay's DVM,DACVIM blog post on how she suggests people do proper internet Research
    http://preview.tinyurl.com/cmhwxqq

    When owners are faced with a diagnosis such as Cancer or even Addison's for their pet they are scared, really scared. Research is a natural way to ease that fear, it gives you something to do and gives you a sense of control back.

    Dr. Joanne I am sorry that your gut reaction is one of "tempered insult"when an owner presents you with their research. For the most part I assure you that we as owners do not mean to insult you. In fact quite the opposite.
    AddisonDogs see owners everyday who ask us how to they talk to their Vet about the new info they have without insulting them. We feel it is about working with your Vet as a partner in their care.

    You write up a plan with info for your clients, that is awesome. More Vets should do this. Good information is power. It eases fears.

    The internet is not going away so finding a way to steer owners to sites that provide accurate up to date info not only helps you but it helps our pets.






  • Internet Info
    03/05/2013 11:08am

    It is interesting to note that a website www.digestaqure.com is advertising on this website for a "cure" for Addison's Disease. Prime example of something to be treated with skepticism. I share Dr Intile's disdain of website "information" and Urban Legends is one of my most used bookmarks. However, there are good sources of information on the web and as Dr Intile pointed out she has spent a great deal of time studying her specialty- but how much time can she spend talking with one patient? Pet owners want to know as much as possible about diseases threatening their beloved pets so I would suggest that vets use the internet to guide their patients/clients to good sources. When my dog was diagnosed with Addison's I had a vet who was very experienced with the disease and was a great partner in guiding me to the Addison forum where I realized there were a number of others in the same situation and that the disease could be dealt with. Because we travel a great deal, I also had to deal with a second vet who did not have a great deal of experience with Addisons and she found the same forum very helpful- discussing some of the issues she noted with a specialist in the field. Like any tool the internet can be used or abused-just don't ignore it( as Mr Hein would have us do).

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