So my name is Doctor Rachel Venable. I am a veterinary oncologist and I'm going to be doing the webinar tonight, talking about what oncologists wish general practitioners knew and did. So I really want this to be a, a, a nice kind of chat, even though webinar, and, you know, really going over some different things and how we can all work together.
All right, so here we go. All right, so there are my disclosures. Sorry, I'm leading the webinar tonight, so hopefully we won't have any technical issues.
We do have people in the background to help, but . I will be watching to see what you guys put in the chat box too, but I'll probably answer most of your questions there towards the end, but I will keep an eye on what's coming through in the chat box. And then here is my, company, so I actually started this on my own.
It's called Pet Cancer Care Consulting. I am passionate about increasing access to care to veterinarians. I love working and educating with veterinarians, and I think oncology is a real need for a lot of different practices just because of access and there's not a lot of us.
So there's some of my contact information and my website and I'll throw up this slide again at the end, but I would love to hear from you guys. All right. So now we'll go ahead and start rolling here in the webinar and, you know, sometimes I feel like between the primary practice and the specialist, it can sort of feel like a tug of war at times when it comes to clients.
Sometimes it's, you know, who does the full workup, you know, who, who does this testing or that, who's really in charge of the treatment and sometimes Whose client is it, right? I think we can all go back and forth and think of different moments where it's felt like this, but I really think that we can work together as a team and really maximize what we know and what we can do best and work together to get those, you know, the best outcome for our patients that we can. All right.
So when to worry and what to know. So this is what we're gonna talk about. We're gonna talk about how to diagnose cancer, you know, what to do once you have diagnosed it, you know, what are some different tests and things that you could do at the clinic?
What are maybe some pain points or things that I think, you know, you guys don't always know what some of these tests are, so I'm gonna highlight those tonight. So hopefully you'll feel better, . Better educated and knowing about some of these tests that I find pathologists just sort of briefly mention, and then we're gonna talk about different ways that we can all work together.
All right. Well, if you're listening or watching this webinar, my guess is you already know cancer is a big deal. It's huge for our pet population, especially dogs.
The number that gets thrown around a lot is that approximately 6 million dogs a year get cancer. We also hear about 50% of dogs over the age of 10 will get diagnosed with cancer. And there's been several studies looking at different age and breed, but a study that came out a couple years ago looked at over 3000 dogs, and they found on average they were usually over the age of 8 when they were diagnosed with cancer.
Actually, neutered dogs were older than intact dogs when they got cancer. They also found weight was inversely, compared at age compared to diagnosis. So what that's saying is basically big dogs get diagnosed with cancer at a younger age than little dogs.
They're usually older, same with pure breeds, those normally have a higher rate of cancer. You're compared to our mixed breeds. So when should you worry?
What, you know, when do we get concerned that maybe we should do more of a workup? Should cancer be on our radar? So I would say anytime you have an ulcerated mass, this is a picture of a dog with cutaneous squamous cell carcinoma.
I actually live out in the desert, so we have a lot of pit bulls and they also love to sunbathe, and so we see a lot of skin cancer. So anytime you see something ulcerated and open, especially some tumors like mast cell tumors, if they're ulcerated, that could be a sign that they're more aggressive. So definitely anything angry, bleeding like this, you want to investigate it.
Now, there are some benign tumors like an infindibular cyst that can actually ulcerate and look angry, but it's, it's technically benign. But again, if you see something like that, that would trigger me to, OK, we should look into this, let's not ignore this. Now how about this dog?
So this is an example of something, a mask that didn't go away for over a month. So if you can see on the inside of the leg there in that picture. This was something, it looks like a spider bite, bug bite that, you know, that's what the owner thought, but it didn't go away, so brought her into the vet and it was actually mass cell tumors, just a cluster of little mass cell tumors right there.
So again, if a tumor is on the body for over a month, I would investigate it. There's certainly lipomas and benign things that can stay that long, but anything that's not going away, we should just document to make sure we know what it is. This picture, we're looking at some dogs with a firm mass.
I think you can see my cursor up here. So there is a, a large swelling and if you notice too, this dog is already missing her mammary chain. So this is a dog with a history of mammary carcinoma, but also is already starting to get some regrowth along there.
So anything firm and fixed, especially dogs with history of cancer, but even if they didn't have a history. That's something that you want to investigate if there's a firm fixed mass. And then also non-healing skin lesions, that's something to keep in mind.
So this is a picture of a dog. This is actually cutaneous lymphoma. You know, cutaneous lymphoma can present in a few different ways and I've got a, a, you know, a handful of pictures throughout this lecture.
But I wanted to show you because in this case, this was a dog that she didn't respond to typical, you know, skin infection, allergies. She had been treated for several months before someone did a punch biopsy and actually diagnosed her with lymphoma. So if you are treating a dog for skin infection and it's not improving or resolving with your typical medications, I would reach for more advanced diagnostics like a biopsy or at least investigate it more, right?
Like you need to start worrying like maybe there's something more going on here. All right, so a lot of these, as I mentioned, they're masses that we should sample and and fine needle aspirate is really one of the least expensive, best tools in your tool kit that is in the vet clinic. It's really something that I think for outside of oncologists, it doesn't get utilized enough.
It's so simple, it's so fast, and you can get so much information. So I like to talk about how to do an aspirrate because I always get a lot of questions from this. I think probably because everyone's gotten some, you know, inconclusive or non-diagnostic samples before.
So to just break down how to do a proper fine needle aspirate. So first of all, you want about a 6 mil syringe because if you get much smaller than that, you won't have enough pressure to blow the cells out of the needle hub. As far as the needle goes, you want about a 22 to actually, you can get away with a 25.
I used to think those were too small, but a study came out which showed pathologists were able to diagnose from a 25 gauge needle as much as they were at 22, and there was actually less blood contamination. So often all start with a 25 gauge needle. And then if I don't get enough cells, I'll I'll move it up to like a 22, but I do like the 25s because you don't get as much of that blood contamination.
Now when you're aspirating a mass or a lymph node, we do what's called the woodpecker technique. So that's where you insert the needle into the mass and then you move it up and down and you move it all around, right? Cause we're literally talking about cells.
So you want to try to sample the entire swelling, you know, not just in one specific area, so all around it. Now, when you're moving that needle up and down and around, don't pull it all the way out because that's not aspirating, that's stabbing, right? We don't want to do that to the poor animals.
So keep it in there, move it around. We do it quickly, kind of like the woodpecker bird, and then you just pull it out and you blow those cells on a slide. I will use suction if my typical woodpecker with just the needle doesn't get anything or it's very small, cause when you add in suction, you can get more cells, but you get more blood contamination.
And if you're talking about aspirating the lymph node, often we can break those lymphocytes and your, the cells are all disruptive and the pathologist has a hard time reading it. So it's not very often that I actually use suction. Now when it comes to smearing the slide, you can either do parallel or perpendicular, but I recommend staying towards the middle of the slide.
So I actually do perpendicular anymore because I had a pathologist tell me a few years ago that all the commercial stainers they use don't stain about the bottom eight of the slide. And she thinks there's probably a ton of cells there and probably they don't always get the diagnosis. Like there could be more on our slides than they realized because they don't stain the bottom bit where a lot of those cells are getting pushed down.
So now I try to keep everything as much in the center as possible so that I know the pathologist is actually seen on my sample. You also want to be very gentle, you know, you don't smash the slides together. Literally what you can do is, you know, you have one slide at the bottom and then just set the other slide on top, and then just gently pull apart and you can even think in your mind, maybe gentle or light, so that you don't just accidentally smush everything underneath.
And then it's also really important to Check a couple slides in-house. And, and you're not doing this to try to diagnose whatever the, the mass or the lymph node was. That's why we send it out to the pathologist.
What I mean by checking in-house is you wanna make sure you've got a decent sample. You know, if you're sampling a lymph node, you wanna see you actually see lymphocytes and not salivary cells. Or, you know, if you're sampling a lump, if it just looks like blood and fat or just blood.
You know, if you don't think it's a lipoma, like if it's something hard, then what I'll tell the owner is, you know, I looked at a couple slides. I'm just seeing blood and fat. I think we may need to switch to a biopsy or I'll tell them, you know, I took a handful of sides.
I didn't look at all of them, maybe some of them have something on there, but there's a chance that we submit this, it'll come back non-diagnostic. And what I find is actually a handful of owners still want to submit those slides, and sometimes they do come back with an answer. Sometimes when they stain and look at all the slides, the pathologist does find something.
But then also I find for those clients that when I call back and say, you know, it's non-diagnostic, they're not upset because they knew that that was a real possibility. All right, the other important thing, if you have something of mass or swelling is to make sure you measure it. I can't stress that enough because there's so many of our tumors that the size of diagnosis is prognostic.
And as the oncologist, I normally don't see these until the tumors in a jar of formalin, so I have no idea what the original size was. So please measure and then document it in the records. And this is a picture here I have of a a mouth.
There's a lot of dental groups where I live. And this is often what they use and it's so nice because they just draw in, you know, the different things with the teeth, but if there's a tumor, they draw where that tumor is in the mouth and then how big it is. And so it's really easy for me to look through the records and know, OK, that's where it was, that's how big it was.
The other thing, you know, If it's something on the outside, you just have body maps. They're usually just an outline of a dog or cat, and you just again you draw in where the tumor is, measure it, and then if you sample, like if you know it's a fatty mass, if you sample it fat, you just write that. Because if the client's bringing to your attention, hey, the swelling, I've noticed it, it's not going away.
They want you to sample it. They want to know. And so if you do a body map, then you can use that in the future if the client isn't sure if it's a new lump or if it's growing or shrinking, you can always refer back to that.
And it's something that the clients want you to check it out, so it takes time. So you can certainly charge for this. So doing the aspir, the body map, but it's a real nice way to keep track, especially these old lumpy bumpy dogs.
All right, imaging. This is something I want to talk about because the oncologist and we see all these images and things that just some of the different ways that, you know, I can help you guys help me, right? And one of them is chest X-rays or just X-rays in general.
So most vet clinics, you guys can certainly do these. X-rays can tell us so much about cancer and what's going on in the body, but it is very important that if you're doing X-rays, you do correct positioning and technique. And anymore with digital X-rays.
There's really no excuse, you know, back in the day with flat film, you may only had a, you know, one or two shots to do that, but now it's just a matter of making sure our staff knows how to position these correctly and so that they're not all twisted and wobbly and you know, that we get what we need. The other thing that's important is that with digital. The software tries to calibrate between the chest, which is mostly air, and the abdomen, which is mostly soft tissue, and so it's, it's different.
So if you try to do like whole body X-rays, it tries to level it out and what it means is we lose detail. So like those whole body CAT X-rays, basically all you can really tell is that there's no giant mass, but if you're wanting fine detail, like if there's pulmonary mats. We can't tell that from a whole body X-ray because that detail just isn't there.
So I really don't feel like those whole body X-rays at most clinics, you're really saving people that much money when we have the digital X-rays now. Now with this X-ray, and I don't know if you guys can put a comment maybe in the chat box, but what do you guys think is wrong with this X-ray, and I'll, I'll just wait for a moment to see if anyone has opinion or I'll just go ahead and tell you guys. All right, well, oh, we've got one here.
So cranio ventral thoracic mass, so, so yes, I do think this dog potentially some of it, it's hard to tell too because this dog is so crunched up, that it's hard to see what's going on in there, so that's part of the problem. The other big issue is there's so much of the abdomen in here, that's part of what's making it so hard to read what exactly is going on in the chest here and so I always tell people, You know, this is not a chest X-ray. This is what we call a chapdomen, right?
So let's let's either get the abdomen or let's get the chest. All right, other imaging. So in primary practice, you guys can definitely do some of these other advanced imaging like ultrasound and CT.
You know, CT, the biggest thing is just the equipment. It's expensive. So whether or not your hospital has that, where I live, we actually have mobile CT which is really nice that they, basically this giant trailer.
Where they can come to any vet clinic and they do the scans there. So if you have access to something like that, I think it's really nice. Otherwise, ultrasound, you do need some extra training, CE courses, that kind of thing.
But I, I do think at primary practice, you guys can do ultrasounds for sure. Couple of things to keep in mind though. You can have a radiologist review.
I would 100% do it with CT scans. I don't know anyone that tries to read those on their own. There, there's just so much going on.
There's so many images. It's just, you know, better to just run the scan and send it out to the radiologist. And on ultrasound, you can do that as well.
And honestly, that's what they do in people. If you've ever had an ultrasound, there's an ultrasound technician that gets all the images and then they send that to the radiologist and they type up the report. So there's some different companies and groups out there that are doing that now in VetMed.
Or if you're doing it all in-house, just make sure you have a report cause it's tough when I go through records and I see abdominal ultrasound was normal. I don't know if that was really just kind of a fast scan ultrasound when we're making sure, you know, there's no obvious free fluid or giant mass or if that was really a detailed ultrasound where we are measuring the kidneys and intestinal thickness and double checking lymph nodes. So if you are doing like a full ultrasound in clinic, just make sure you have a detailed report to go with it.
All right, the other big thing with ultrasound that I and CT really, but that I think you really need to do is get pre-approval for fine needle aspirants and cytology, and the reason being is if we do this imaging and we find something like big lymph nodes, masses, whatever. It's a lot faster if we could just sample right when that pet's there because otherwise what happens is, you know, they end up having to reschedule for another time to do it. We may have to re-sedate the animal again or they come and see me, and then at that point, you know, we again, we have to sample, so it just Drags everything out and if we could just streamline it where we can get it done all at that one time when we're doing that imaging, it it just makes a lot more sense.
So for me, like I always put at the high end of the estimate, you know, and I always tell clients if there's something I think we can safely sample that would, you know, benefit, I, I would recommend it and I put that at the high end of the estimate. Now this picture here. This isn't something I would sample.
This looks like a large cavitated splenic mass, probably hemangiosarcoma, actually it was hemangiosarcoma. There's a couple solid areas in there, so if you were really good, you could maybe try, but for the most part, we don't want to put a needle in any of those because we feel like it's kind of a needle to a water balloon, right? It could pop and they could bleed.
But if it's otherwise a solid mass, so whether it's in the spleen or big lymph nodes or maybe even intestinal mass. If it's solid, if we don't think it's gonna, you know, pop, if it's not blood-filled, then generally we can get an answer. If it's cancer, I will say.
If it's not cancer, then usually we don't get an answer, but if it's cancer often from a fine needle as for we can get an answer. And it's rare that we see complications, cause normally these pets, apart from their cancer are otherwise healthy. They're not in liver failure, they're not in kidney failure, you know, their clotting times are OK.
So I, I would always check blood work in advance to make sure like their platelets are fine, they're not anemic. But if you think About it. If we can put a needle in the jugular vein and those pets don't have any complication, then likely we can put the same size needle into a solid mass in the abdomen, and they shouldn't have complication either.
So just something to remember and think about when you guys are doing that advanced imaging. All right, can you diagnose with imaging? I get this a lot.
So, the answer is yes and no, right? So technically, no. You need either cyto or histology to confirm, but you know, a mass in the triagon of the bladder were highly suspicious for bladder tumor, right?
Especially if it's like a, a Scottie dog or, you know, a Saint Bernard with a lytic proliferative bone lesion in the proximal humerus, probably osteo. But we can get into trouble. Where I see this mostly as an issue is cats with you know, chronic weight loss or vomiting or diarrhea.
They get an ultrasound, the intestinal wall is thickened and they're told it's lymphoma. And and the problem is we don't really know, right? It could be inflammatory bowel disease, could be small cell lymphoma, maybe large, but probably more small.
So it's just something to keep in mind that we are limited. It's kind of the same with if you start treatment. We can, often like in that cat situation they get put on prednisolone.
And I think it's OK as long as the owners understand that if things don't work, we don't really know what we're treating and so then it makes it really hard to know what to do next, or if they come see me, and they've already been on prednisone for a while, you know, we may not be able to sample anything cause it could interfere with the test results. You know, I would hate to do endoscopy on a cat that's been on Pred because likely those samples are gonna come back negative. So and and we won't know is that just because the cats on pred or do they not have lymphoma.
So anyway, it's OK if you have clients that just want to do prednisone, but they just really need to understand that they can't really go back or it makes it quite challenging if they do that. Other diagnostics to think about. So, par, I see this a lot on cytology reports and I don't know if you guys always know when to do this cause I, I find sometimes it's just a cut and paste, so it's not necessarily specific for that case.
So basically, par is only for lymphoma and leukemia and this is Something we want to use if we're not quite sure if it's lymphoma or leukemia. Basically, it does PCR to see if those lymphocytes are from a clonal population. And if they're clonal, that's the definition of cancer.
If they're not, then that makes us think, well, maybe this is more inflammatory, infectious, you know, we need to do more investigating. So you can do this on cytology, whether that's a lymph node organ or fluid, sometimes even biopsies, we can do this. But what's really nice about this test is it can be ran on the samples they're already at the lab, so the PET doesn't have to come back in to get more samples.
The other one out there is flow cytometry. So this is also a lymphoma, leukemia test. And this is when we already know the pet has lymphoma or leukemia or we're very highly suspicious, and we want more details, like we want to know is it B cell or T cell?
Or, you know, there's other prognostic markers that we can get from flow cytometry. Also, if we're wondering about acute leukemia. Versus stage 5 lymphoma.
You know, back in the day we used to do bone marrow aspirates and even then the pathologist had a hard time calling it. With this, we can just run a purple top tube and there's specific markers they're looking for that really change prognosis. It's CD 34, just if anyone wanted to know, but they look for that and that can really tell us, yes, this is going to behave very aggressive or no, you know, well, you know, it'll be more like stage 5 lymphoma, but not like acute leukemia.
Other diagnostics out there. So histologic, the special stains. You know, this is, I would recommend doing these special stains.
So this is like on your biopsies, right? When the pathologist truly doesn't know what it is, you know, what they mentioned like round cell tumor. You know, if it's lymphoma or a mass cell tumor, we're gonna Treat that very differently and the prognosis is often very different.
So I would run the special stains in that scenario. Again, every now and then I see where pathologists just mentioned we could do special stains, but the tumors they mentioned, it's not really going to change anything, like maybe it's different types of sarcoma, but it's, you know, like a myosarcoma versus a rabbit, you know, so again, I think it's really the point of this would be, is it going to change prognosis and is it going to change our treatment? The other one is the prognostic panels, really, we just have that from melanoma and mast cell tumor.
I don't run these all the time. I really just run these if I'm not sure how these tumors are gonna behave. So sometimes melanoma doesn't actually look that aggressive in the mouth.
And in those cases when I want to double check if I think it could be aggressive, I'll run the melanoma panel or like on the skin. Normally melanoma on the skin is benign, but every now and then we get some bad players and so if it's looking more aggressive, I'll run that prognostic panel to get a better sense of, OK, how aggressive do we truly think this could behave. Same with mast cell tumor, there's sort of this gray zone when the mitotic count is 5 to 7, because depending on the grading scheme, they might go that low or high, and there's different studies with showing a mitotic count of 5 is more aggressive versus other ones have shown not until 7.
So again, that's a time to maybe run those panels to get a better sense of how aggressive do we think this might be. Genetic sequencing, and this is a picture of what this looks like. This is a newer thing, it's a bit of the wild west in veterinary medicine, but we're getting more and more data and information on it.
They do it quite a bit in people anymore. You hear a lot on commercials like breast cancer or small cell lung cancer. They'll talk about the different genetic mutations and then specific targeted therapies.
That's where we're really trying to go with all this. So. Cancer actually starts at the level of the genome.
So if we know the different genetic mutations, the hope is we would know one diagnosis. It should help diagnose prognosis in certain situations and then ultimately treatment, which again, still learning about in dogs, but those are definitely tests that are out there and I, again, I'll see that sometimes mentioned on pathology reports. All right, when to biopsy?
This is another question I get a lot. And I would say generally speaking, if you've tried your fine needle aspirate and it's a tumor. And you know, it's something hard and all you're getting is blood or, you know, just it's not exfoliating.
You usually those are sarcomas, but that's a time that you could biopsy to try to figure out what it was. The other time to think about biopsy is if, you know, the grade would change what the client wants to do. So we don't grade all of our tumors, but mass cell tumors or some soft tissue sarcomas, mammary tumors.
You know, I've seen some clients where if it's a low grade and maybe we need to do a radical surgery, they're more apt to do that cause they're hoping for almost more of a cure situation versus if it's a high grade, I've had some clients that are like, well, if this could behave aggressive, then I want to be aggressive, you know, and do, so it sort of depends on the client and the situation, but those are situations where if it's going to be maybe a, a difficult Surgery, right? So like this one, this actually is a dog with an oral osteosarcoma. So this is going to be a tricky surgery, you know, treatment is going to be challenging.
It's not gonna be easy. So this would be one where when you're trying to maybe initially work this out and the client doesn't know what they wanna do, getting a biopsy could be helpful cause then they would know, OK, we're gonna have to do really advanced things to treat this in this situation. Now, remember when we're talking about biopsy, there's two different types.
There's excisional and there's incisional. So excisional is what we normally do. It's where you remove the whole tumor, so it's a treatment and we get a diagnosis.
So that's kind of a great 2 for 1. That's why we do it a lot. But really, this is when you wanna do when surgery is more simple.
So like this is actually a picture of an anal sac carcinoma being removed. So this is something where we could remove the whole mass, right, in its entirety versus an incisional biopsy. That is when you're just getting a piece of tissue.
So this is actually a picture of a dog with cutaneous lymphoma. So this one looks much more ulcerated, much more irregular. But in these dogs, there's nothing really to aspirate cause it's redness of the skin.
So you pretty much have to do like a punch biopsy, so you just get a little piece. Now, when we're talking about incisional. You wanna try to aim for the center of the mass, but there are some exceptions here.
So like in this picture, you can see from across the room, that tumor is necrotic in the middle. So don't biopsy that. You're just gonna get goo and the pathologist isn't gonna be able to tell you anything.
But you can't just get right off to the center and the reason you want to aim towards the center is because you don't wanna contaminate the normal tissue. And because otherwise that can make maybe the cancer spread a little bit or it's certainly going to make surgery more complicated and bigger. So just try to get your incisional sample where you're not going to contaminate any of the normal tissue but hopefully not get like a, a big necrotic area.
And this was a poor little dog with a giant mast cell tumor. All right, now, with excisional, this is what I mean by make sure the surgery was fairly easy, is that you want to get margins, right? Because we always talk about with tumors, especially like mass cell tumors or sarcomas, they put out tentacles beyond the tumor and so if you just shell out the tumor, you're leaving all these cells behind.
And the other big problem is the cells you're leaving behind are the more aggressive ones. They're the ones that have already started moving and migrating out from the original tumor. So these are going to be the more aggressive ones and now we've left them in the body.
So ideally you want to get a, you know, the standard is usually 2 to 3 centimeters around the mass and a fascial plane deep. Depending on the cancer, there are some variation, but that's a, you know, general rule of thumb. All right, the other thing when you're doing biopsy is you want to get the full histology report, because, you know, I know sometimes you can skip the comments and just get the bottom line.
The problem with that though is there's so much in those comments, you know, it tells us a little bit more of, you know, how, how much did the pathologists truly think that this was actually this cancer, or could it be something, you know, are they not really sure if it's cancer or not. Sometimes just how aggressive it is, a lot of times it could be in those comments. So I would make just your charge for histology include the full histology report.
Also, if you get that, you can get a better understanding of do we need to actually do those special stains or not, you know, again, cause sometimes pathologists. It can be hard to know, are they just noncommittal or they really not sure what this is, you know, I think we've all worked with some pathologists that don't bottom line anything. I see this mostly in cytology, but where they'll be like concern for lymphoma, probable lymphoma, and for some pathologists, that means they don't know, but other pathologists I've worked with, that's just what they call every lymphoma.
And so having those comments, knowing more about what they're seeing will just help us to know, OK, do you really think this is cancer? Do I need to do more testing or not? All right, so let's say we know what the cancer is, so what do we do now?
Well, you could refer, that is certainly reasonable. But maybe if you can't get in for a while or if the client's not quite sure, you guys can do staging at the clinic, and that really gives more information, even helps when they come to see me cause I have more information to talk to this client about their pet's cancer. And so staging is really to see where else could there be disease in the body.
Now I just want to show you guys this picture, because this was a dog that I treated, and if you can appreciate his eyes are this crazy copper reddish color, what do you guys think is is going on here? Any any anybody that really likes eyes in the in the crowd. Well, and you probably can't quite see it up close, but basically this dog, it was really bad hyema and hypopion, and this dog had a really bad lymphoma.
Actually had it in the bloodstream. His lymphocyte count was over 100,000. And when we started treating him with chemo, his eyes actually turned to dark brown like normal, but it was just crazy when he first came in, he had these real bright copper colored eyes.
All right, so if we're talking about staging, it's important to know where, you know, is the cancer going to go in the body. So that will help direct what testing you should do. So if it's something that spreads through the lymphatics, then you want to check the local lymph nodes.
Like in this picture, you can see that dog's mandibular lymph nodes are huge. It's actually causing swelling up in her face. So you want to sample local lymph nodes, even if they feel normal.
Mass cell tumor and melanoma, a couple of studies have shown that roughly about 20% when they palpate normally actually have spread there. So it is worth just trying to get a needle by needle aspirin in there if you can. And the other places, you know, X-rays or ultrasound, again, we're looking at big lymph nodes and the cancers that spread through the lymphatics, so your round cell tumors, so lymphoma, mast cell tumor, carcinomas will often spread through the lymphatics.
Sarcomas, it's quite rare. So if I have a dog with a soft tissue sarcoma or osteosarcoma, I won't generally aspirate the local lymph node unless it's really big and irregular. All right, hematologic spread or through the blood.
So this is another pathway that cancer can spread and when this is when we see it in the lungs, and this is that seed soil hypothesis where the capillaries in the lungs are so small that the cancer cells can't come through. And so this is actually a picture of a dog, . With really bad metastasis, right?
Snowstorm. I saw somebody say, so yes, this is a really bad exam, you know, you know, I guess a very advanced, I should say example. So sarcomas, they go through the blood.
Some carcinomas will go through, and so it is something to keep in mind like with bladder tumors, so that's a carcinoma usually. So you wanna check the local lymph node with ultrasound, but I have had a few dogs where ultrasound apart from the bladder tumor was fine, but then we did chest X-rays and they look like this, and that's because it had spread through a different pathway. So just cause the local lymph nodes are fine doesn't necessarily mean it hasn't gone anywhere else in the body.
Round cell tumors, fairly rare, it goes to the lungs. Now, lymphoma certainly can. We don't typically see this nodular pattern, like what we're seeing right now.
Mass tumor is extremely rare that it would go to the lungs. All right. So what about treatments?
So we know, you know, what the cancer is, maybe we staged it, we know where it is in the body. So what do we do to treat? Well, really depends on the type of cancer, where it's located, if there's a grade, cause certainly high grade, we're gonna treat very differently than low grade and stage, you know, again, is it all over the body or is it just right there?
So the four pillars of oncology are surgery, radiation, chemo, and immunotherapy. But something to keep in mind too is palliative care, especially in the primary setting, because I feel like a lot of times those clients that maybe don't want to see a specialists and things, they're really looking to you to help them keep their pet comfortable. And so that is something to keep in mind cause there's a lot of different things we can do.
I listed some things there, pain meds, antibiotics, you know, oral tumors like this crazy picture, you know, those can get really infected and it can be quite painful. So that's something to keep in mind of different ways that we can help try to keep these guys more comfortable. Prednisone.
So prednisone is certainly a treatment. It's quite a good drug and it's very cheap, right? I remember when I was a vet student, they used to always say better pred than dead.
I don't know if that's something that they still say anymore. That was a while back, but there are some It falls with Pred, right? It can interfere with diagnostics, like I said with that cat with small, you know, potential small cell GI lymphoma, you know, if you start him on prednisone, it can interfere as trying to actually confirm or get that diagnosis.
Surgical margins, this is mostly for mass cell tumors. So if you have a dog with a mast cell tumor, if you put him on Pred, most of them it will shrink down, but that tissue that was involved, it's already been bathed by those tumor cells. So generally when we shrink the mass.
The histology comes back with incomplete margins, generally speaking. And so if you're trying to shrink a tumor so that you can remove it because it's too big wherever it is in the body, that's OK. But I wouldn't just as a knee jerk reaction, every dog you diagnosed with a mast cell tumor, put him on prednisone, cause it can make it quite hard to know where to do surgery, you know, for that next person.
And the other problem too, especially for lymphoma, if you put them on prednisone, it can make chemotherapy less effective later. So that's just something to keep in mind. It can up regulate the P glycoprotein pump that then pumps out our chemo too fast.
Now, if you have a sickly. You don't really have much choice. You need to put them on prednisone.
But otherwise, if it, they're feeling pretty good, you know, I would make sure the owner really understands that there's a time clock that starts when you start that prednisone when it comes to lymphoma. That's really the only one that we've documented that. The other thing about treatment, you know, surgery.
So you guys are, again, the front line usually doing all the surgeries and things, but remember, the first surgery is the best chance for a cure. So again, it is best if you know what you're removing, right? Cause I know sometimes these dogs and cats, they get dentals and the owners want to a handful of things, so we remove these lumps and then later or maybe in surgery, we realize like, oh, this is not a lipoma.
So I do recommend doing aspirt so you have a better sense before you get in what you're, what's involved. So that way you can get good margins if it is something like a mass cell tumor or something more aggressive. Cause, you know, a second surgery, it, it's not always possible, especially depending on where it is on the body, and the reason I have a picture of a cat here is because the vaccine associated fibrosarcomas, there's multiple studies showing that if that first surgery isn't, if it's just Marginal, it's very small.
Those cats, not only does the tumor come back sooner, but they actually have a shorter survival time. So it literally shortens their life span. So it is something to think about, you know, that first surgery really is important, really is important that we get it big enough and that we know what we're doing.
Now chemotherapy, I know this is a tough one, and I have a lot of vets that come to me and say like as soon as I mentioned chemo to pet owners, they just shut down. They're just like, no, which I understand, right, because chemo in people is terrible, but it's important as much as we can to let him know that in animals it's very different. You know, I think there's more and more things online now, so that can kind of help owners.
They can see pictures like this one, you know, this dog, he was on chemo for over 6 months and he looks great, right? He may not appreciate how much I like to dress them up. I always think it's fun when they finish chemo that we celebrate by dressing them up.
You know, me and the owners, we love it. I don't know how much the pets do, but he certainly was a good sport and took some great pictures, but it is important just to, you know, try as best as we can to explain to owners that they actually have better quality of life cause that's really the goal in veterinary oncology because at this point we haven't found that if we push their bodies really hard with high doses or more drugs that they're gonna live longer, you know, at this point what we found is that we can usually provide more time. But we want to make sure we get that balance of good quality time because just their lifespan in general is so much shorter.
All right. So again, what are other treatment options? So referral is certainly another option, you know, and again with this talk, just trying to highlight how the specialist it should be another member of the team, something where we can all work together because we can't know everything about everything.
I mean, God knows I know nothing about ears. They, they were never my specialty, and whenever I see a pet that has an ear infection, I always send them back to their primary vet because I don't even own an otoscope. So it's something where, you know, we all have our different areas of knowledge, and I think we can do the best when we all, you know, use our areas work together and there's actually a couple of studies showing that pet owners like this.
So this is one where They looked at different pet owners. It was a survey and questionnaire, and basically what they found, and this is looking specifically at oncology, that pet owners, they really appreciated just the option of referral, even if they didn't take it, they liked when their vet offered that to them. In fact, they're actually a little bit concerned.
When the vet didn't want to refer, and I think sometimes maybe they took that as more internal like, well, does my vet think I wouldn't do everything? I don't know. But they did find that people didn't like that or if they were given a real pessimistic assessment, you know, like, oh it's, it's not worth it, or they won't last long, cause we do have to be careful about that because what's worth it is very different for different people.
I, I know. I'm sure you guys all have, I've seen it a lot where there's times where I'll talk to clients like hemangiosarcoma and I'll say, you know, we can add in different chemo and things and we're usually looking at extending, you know, maybe 3 to 6 months or so, and, and they just think that's great versus I've had other clients with less aggressive cancers where I'll say. You know, we add in this treatment, we could maybe get, you know, another 1824, you know, 2 years, and they're just like, man, I, I just don't know if it's worth it to do all that for that time.
So it's, it's different. It's different for everybody. So I think the important take home is just to, you know, give the information that you think is important because there are certainly are times where I, I, you know, we may not be able to do a whole lot, but I think it's always fair to at least give people that option of if they want to go see the specialist or, you know.
As long as their pet is feeling pretty good, maybe trying some of these different options again, as long as they know the right expectations with things. And then another study, this was a really large survey, it was almost 900 people, and again, they looked at client satisfaction, and they saw with primary care vets, they really liked that their vet was still involved and working with the specialist. Again, these were all oncology centered.
They want you guys to stay involved and then really for the oncologists, they just want to make sure we knew what we were talking about. So it was more that things worked and that our estimates were good. But the other thing that I think was great from this survey and this study, it was essentially people were 6 times more satisfied with their vet just from the option of a referral.
So again, You know, we may think it's a little thing and and may forget or or again maybe our own biases, we, we don't really mention it, but it's something, it's just a quick mention and I'm sure more clients than not don't always go to a specialist, but I think it's important just to remember to offer that to them because they do appear to really appreciate it. All right, so let's say now you have a client that did go to an oncologist. They're on chemo.
I find they often like to come back to you guys when there's side effects. So just something to keep in mind, I remember with like traditional chemo, our side effect acronym is BA, so that means bone marrow, so it means it affects the blood. Alopecia really hair loss shouldn't be an emergency, but Maybe there's some owners out there that it is, and then gastrointestinal, so stomach upset.
Now, if you do end up running blood work for pets that are on chemotherapy, like with an oncologist, cause again, I find they like to do this with you guys. I don't, probably cause you're closer or better hours, I don't know. But it doesn't matter where I worked.
There seems to always be a disconnect where if you guys run the blood work, somehow we don't get the results. I don't know why, like I said, I even do quite a bit of relief work anymore and it just seems to be anywhere. So what I'm saying is if you guys run the blood work, especially that one week.
CBC checking like if it's a new chemo drug. Just make sure you call the owner with the results because for some reason, it's like Murphy's law. We never seem to get it.
And it's usually days later, the client will reach out and be like, oh, I thought you guys were gonna call me with the blood and this and that. Cause if there is something abnormal, it, you really need to act on it right away. And that is, if the neutrophils are less than 1000, we need to put those pets on an antibiotic.
So if you see that, certainly call the oncologist or specialists, make sure, you know, they, you're all on the same page or that did we get the blood work? Cause again, like I said, I don't know why, but we don't seem to get it. But also if the pet is sick, especially if the neutrophils are low, then they need to be hospitalized and that's more of an emergency, so something to keep in mind again if you're running that lab work.
And then also supportive care. If they're getting treatment whether it's chemo, surgery, radiation, you know, again, clients like to come to you guys and there's a lot of different supportive meds you can help out with. Pain meds, you know, really just make sure you don't mix NSAIDs with steroids.
We know that's really bad. But appetite stimulants, really, I don't know of any that interfere with chemo or radiation or surgery, nausea medication, so like Cerenia, ondansetron. Diarrhea meds, and then again, antibiotics, you know, really most of these, it should be fine and you can always reach out to the specialist before prescribing, but most of these really should be fine and and shouldn't interfere.
Drugs that can interfere with chemo. Are other immunosuppressive drugs, so like cyclosporin or prednisone, if they're not on it, probably wanna double check before you start that, plum finacol, like a really strong antibiotics or some of the anti-fungals. So just double checking on some of that stuff.
Apaquil, the reason I put this on here, it's cause we get a lot of questions because the manufacturer does have the warning saying not to give this drug in dogs that have cancer. But there's been studies showing that it doesn't make cancer worse or dogs have a higher rate of it, and actually it's been looked at in a couple different studies to treat cancer, so I think it's probably fine to give, but what I always tell owners is, look, there's a warning label, so there is some concern, Could it make things worse, but because of these other studies and things, I think it's probably fine, but often what most people want to do is try to come off of it. But if the dog is just chewing themselves apart and like side a point, nothing else works, I really think that, you know, Apaquil is still a reasonable thing to keep trying, to put them back on.
So that, that's kind of my take on it, and I do mention to the owners because they might find that warning label. All right. And now I just wanted to tell my story a little bit and different treatments and how I can help you guys too.
It's basically, when I was in clinic, saw a real problem and it was just that there were so many pets that couldn't get in to see me, whether that was because I was too booked out or just the, the travel, the distance was too far, you know, sometimes different financial barriers, and I felt like they just had to be another way. To help all these people, and access to care is something I've always been passionate about. I grew up in a farm out in the middle of nowhere, and even to this day, my parents, it's still, it's several well, several hours, for them to get to their own specialists, little alone animals.
And so I thought, you know, there's gotta be something different and really thought about video chats and consulting cause we're doing that more and more in people. And so I thought that would be another way to try to help animals, especially with cancer, cause there's so much involved with that. So something else you guys can think about is teleconsulting, especially if you have a client that, you know, doesn't want the referral, whether they can't get in, or maybe it's too far away, all kinds of Reasons why people don't necessarily go, but teleconsulting is another option and honestly it's been around forever, been, has been around since the 90s.
So that is certainly a way for you to not feel like you have to know everything about everything, but reaching out to the You know, to a specialist to get more information to help you with these clients. So, you know, again, help you with different treatment options and increased client education. A lot of times satisfaction.
I find, especially with oncology patients, once they know more about the cancer and what they're facing, a lot of them really do calm down, and they feel a little bit more in control of the situation, whether they're doing aggressive treatments or just palliative care. So with what I do, you can access an oncologist anywhere and it's a nice continuity of care because I do work with you guys, so we can actually chat and if there's questions or things on exam you're finding or reading in the records, and so I actually do video chats, so I talk with the vet and the pet owner, or I can do detailed reports. Now, with the vet, you don't have to be on the video chat the whole time, but definitely like to have you guys involved because I can't.
Feel the pet and often I found, you know, the baby, the tumors regrown or lymph nodes have enlarged since the last visit. So it's just another way to help your clients, help guide therapy there at the clinic or a lot of times I can help them get into a local specialist sooner. Now, The video chat can't do in every state, so certainly reach out to me if you are interested, but it's just another option, another tool in your tool belt, and it can also help increase revenue and set you apart from other clinics if you're offering some other services.
Because one of the big things you can do in the clinic is actually pills. You don't have to have special equipment for this, not compared to IV which you really, you have to have quite a bit of special equipment. Then there's a lot of different drugs, so targeted therapies or even some of our traditional chemo that comes in pill forms.
There's a lot of different cancers that we're actually using to treat these. So mass cell tumors, bladder tumors, you know, if it's diffuse metastatic. Disease.
Now, generally speaking, IV treatment is better than the pills. There's some scenarios where that's different, but generally IV is better. So I don't want to get that confused here.
But it is just, again, for those clients who maybe can't get into the oncologist or it's too far away, or sometimes they just prefer you guys, they wanna stay with you. So here are some other things and I could certainly help walk you guys through using any of these drugs. And again, It's just nice cause it can help client satisfaction and revenue by just having more options in your clinic.
So if you're going to do pills, one thing to think about is, you know, how comfortable are you with managing and monitoring. So that's where teleconsulting, so whether you use them or whether you use me, cause I can help with ongoing protocols and care, but it is important to know side effects and safe handling, especially the owners cause they're gonna be giving these at home, and then monitoring response, that's huge. Like with any therapy, you wanna know why you're doing it and for how long.
And so a lot of times with cancer Malesions and things and then also remember palliative care. I mean that's huge, really just trying to keep the pet comfortable and also monitor quality of life. That's a big thing too, so that the client kind of understands what are the end goals here, you know, when do we consider our pets no longer good quality or when medically do we think they're suffering.
So to sum it all up, cancer is pretty common, you know, a couple of huge takeaways I would say measure tumors and aspirate tumors. Those are huge things that can tell us so much about cancer that are very simple and very cheap, you know, the different testing team approach, all the different options you have in the clinic. And again, here are my services and I would love to here, talk to you guys.
If you have any questions, certainly reach out to me. Then there's an email and website, and I think we have a couple questions here. So what about legal implications of teleconsulting without seeing the animal.
So with mine, and again it depends on the state, so it depends on what state you're in. Most states, it's OK because I'm working with the veterinarian, so I'm not going directly to the pet owner, so that is very different, or if the pet owner, if we don't do the video chat, if it's just the detailed report, that's Available in most states cause again that's more of like what Ben's been doing for years and there's a handful of different groups doing that too. So that is fine, but again with what I'm doing, there are some states you can reach directly out to the pet owner, but I prefer not to do that.
I like to work with the veterinarian so that you guys know what's going on and have been involved. So looking at some of the other questions here, so Has there been any risk studies with Calencia and the same, another one was with Labrella, so kind of those are the new monoclonal pain drugs. So as far as I know, no, there are no studies showing risk in the sense of cancer and these drugs, but there's also no studies looking at cancer and these drugs.
So, For the most part right now, oncologists were saying we do think it's safe. So if you're giving Labrella for a dog that has bad arthritis, we do think it should be safe even if they also have cancer, because it's a, a nerve growth factor inhibitor and we know that nerve growth factors can be involved with cancer. So if you're trying to inhibit that, then, you know, that, that should be OK as far as cancer goes, but You know, also at the same time they have not been studied together, so it's something where I usually tell people we think it's safe, but we don't, we don't totally know yet and as far as anything bad, nothing that I've heard of from a cancer perspective.
Is it any antibiotic that can benefit most of the patients? Thinking of weekend days and specialists not. So honestly, generally broad spectrum antibiotics, you know, I think we all like Clavamox or amoxiclab.
If it's a chemo thing, so let's say their white cell count is low, then I usually like antibiotics that aren't going to cause GI upset. So inrofloxacin is a big one that we'll all reach for because it doesn't cause that GI upset cause the thing you don't want to have happen. Is the dog that has no neutrophils, you give him Clavamox and now they have roaring diarrhea and vomiting, and then the bacteria translocates because the GI tract is so leaky and now you have a septic dog.
So that's what we're trying to prevent. So if it's, you know, a low white blood cell count, I usually reach for inrofloxacin. If it's something like an oral tumor and the pet's uncomfortable, like oral tumors, I like clindamycin, or if it's something on the leg that's opened up, then again kind of just your broad spectrum, you know, cephalexin or Clavamox, that kind of thing.
Another question. I was under the impression that only reason to stop Apaquil during chemo was due to its interference with other Jack inhibitors for certain cancers. Is that still true?
So Apaquil is a Jack stack inhibitor and so there have been, especially on the human side, some of those drugs can cause Cancer or, or maybe could potentially make cancer worse. And so that's the concern with Apaquil and what's on the label is they don't recommend once a pet's been diagnosed with cancer that they continue to be given this drug. But if they mentioned, people are actually looking at it to treat cancer.
They're actually looking at high doses of it for cutaneous lymphoma and some other ones, and some other studies have found that it doesn't appear to increase cancer. But I do still think you need to let owners know that there is that that warning label in case they want to come off. And then I see there's 10, I got a a thank you very much from the UK.
I'm impressed. This is very late at night for you, so thank you so much for listening tonight and then any other questions before we go? Can have just a few more.
I hope everyone is having a good evening and have plans on, you know, for me, I've got dinner plans after this. All right, so another one said thank you and happy turkey Day. So thank you guys, and yes, I hope you all have a great holiday that is coming up, the Thanksgiving here in the US and again, if you guys have any questions or whether it's about cancer or my services, feel free to reach out.
I would love to talk to you and thank you so much for being part of this webinar tonight.
