Palliative Care in Pets with Cancer

[Daniel E.]

The online vet said I don't have to worry about future blood tests since dogs' bodies compensate well for any future anemia. (His last blood test was in May.). Like other vets have done, she suggests looking at his gums regularly to make sure they are salmon/pink rather than pale or white.

Her answer that was most helpful: Dogs with solid-mass kidney cancer (as opposed to blood-based hemangiosarcomas) do not generally have dramatic emergency situations, so I don't have to worry about the dog decompensating quickly/surprisingly in the middle of the night.

She says if I want to try a supplement, the one to try is the mushroom blend I'm Yunity. The research goes back and forth on its potential anti-tumor effects, but no other supplement is as well researched. Today I bought a bottle from Amazon so that I can easily get a refund if I like. (And since the dog is only 13 pounds, the dosage is less expensive.)

 

[Daniel E.]

Amazon product

The first part of "So Easy to Love, So Hard to Lose" helps readers who have a sick or aging pet. When we know the end is approaching, we must tend to the pet's needs and also our own. This is a highly emotional time and support is needed. More often than not, we have to exercise our ability and our responsibility to provide euthanasia. But doing so is so very hard - it goes against our long mission to keep the pet happy and healthy. Requesting euthanasia feels incompatible with loving a pet. This so one of the most difficult aspects of pet loss grief and it sets the stage for guilt.

After the loss of a pet, we grieve. Pet loss grief is different from any other type of grief. The grief is different because the bond is different.

This book takes the reader by the hand to travel through the emotional roller coaster of grief, to understand their journey and to guide them to a place where they understand what they are feeling, have paid tribute to their pet and can turn their grief back into love instead of allowing it to remain a festering sore. By reading the content and answering a series of carefully assembled questions, the reader finds support and their grief is alleviated, even though they feel that nothing will help.

 

[Daniel E.]

My favorite excerpts from a 2017 textbook on geriatric pet oncology (available from some university libraries):

 

[Daniel E.]

Regarding hemangiosarcoma in dogs:

Clinical Trial: Shine On Continuation (Phase 3)

Study for dogs to test eBAT prevention of cancer, seeking Golden Retrievers, Portuguese Water Dogs, and Boxers

vetmed.umn.edu

The first question we asked was, “Does the blood test accurately detect the presence of hemangiosarcoma in dogs?” The answer is an unqualified, “Yes.” Our results show that the test accurately identifies dogs in which hemangiosarcoma is present about 90% of the time.

The second question we asked was, “Can the blood test predict when treatment fails, and the disease comes back in a dog that is undergoing treatment?” So far, our results suggest the answer to this question is also, “Yes.” We expect to be able to confirm this answer through ongoing analysis of the available data.

The third question we asked was, “Can the blood test be used to detect the presence of hemangiosarcoma at the earliest stages in otherwise healthy dogs?” In other words, could we identify dogs at high risk of hemangiosarcoma that would benefit from prevention? Again, our results to date suggest that the answer to this question is, “Yes.”

 

[Daniel E.]

A quote in the 2017 textbook (the publisher of which provides free, downloadable appendixes):

 

[Daniel E.]

https://www.rover.com/blog/medical-marijuana-for-dogs/

“The entire veterinary medical community needs to take a hard look at this and realize that medical cannabis is here to stay in this country. We need to get involved in this discussion with pet owners to prevent animals from being harmed [by] pet owners using it without appropriate medical guidance.”

Claws & Effect: Cannabis Medicine for Pets | Project CBD

All beings with a backbone have an endocannabinoid system. Is cannabis a good option for your dog or cat?

www.projectcbd.org

Obviously whenever we’re talking about THC and pets, dosing becomes very important. At no point is the goal for the pet to get stoned. If that happens, then it means they’ve gotten too much. The aim is to give them enough cannabis to be effective, but not so much that they’re going to be negatively compromised. It is extremely uncommon to see an animal show negative signs when they have been properly dosed with cannabis as medicine. The worst effect would be drowsiness. If that’s that case, the owner may have to decrease the dose.

It’s not uncommon for a dog, or sometimes a cat, to show up at a veterinary hospital having eaten a cannabis-infused edible that belonged to the owner. The good news is that cannabis toxicity is nonfatal and does not cause long-term effects. However, those animals that get into their owner’s stash may require immediate medical care. I have seen and heard of a couple of cases where pets did not survive...

I prefer a liquid preparation, usually an oil. With liquids, it’s very easy to adjust the dosage. If you’re giving something like a pill or an edible, it can be difficult to figure out how to titrate the right amount. Furthermore, there’s every reason to believe that CBD and THC are going to be partially absorbed directly into the bloodstream through the tissues of the mouth, sublingually. If we put a liquid in an animal’s mouth, some of the medication will be absorbed directly and has a chance to be more effective...

If at all possible talk to a veterinarian. Cannabis is medicine and its dosing should be carefully calculated. It’s important to know the concentration of THC and CBD in milligrams for one’s pet. Once you have that information, you can look for a product that suits your pet’s needs. When in doubt, err on the side of under-dosing because you can always slowly increase the dose and monitor the effect. And make sure the medicine is free of mold, pesticides, and other contaminants.

 

[Daniel E.]

Me-oww! Managing Chronic Feline Pain

Buprenorphine is a partial mu opioid agonist. It binds to mu receptors but has only partial clinical effects, making it appropriate for mild to moderate pain, but not severe pain. However, there is good evidence, at least in cats, that analgesic dosages are much higher than described in earlier studies...

The pH of buprenorphine is very similar to that of the saliva of cats. This makes the drug effective when the injectable formulation is delivered oral transmucosal (OTM) in the cat, therefore increasing the ability to send the medication home with the painful feline patient. Chronic daily use is recommended only for severe or neoplastic pain.

 

[Daniel E.]

Since some vets believe that "sugar feeds cancer":

Convincing Patients That You Can't 'Starve' Cancer

The notion that you can starve a tumor is one of the most pervasive misconceptions among cancer patients.

www.medscape.com

 

[Daniel E.]

A quote in the 2017 textbook (the publisher of which provides free, downloadable appendixes):

More evidence of an insular industry that may be failing at palliative care:

Dying like a dog: the convergence of concepts of a good death in human and veterinary medicine - Medicine, Health Care and Philosophy

Standard views of good death in human and veterinary medicine considerably differ from one another. Whereas the good death ideal in palliative medicine emphasizes the positive aspects of non-induced dying, veterinarians typically promote a quick and painless killing with the aim to end...

link.springer.com

Whereas the good death ideal in palliative medicine emphasizes the positive aspects of non-induced dying, veterinarians typically promote a quick and painless killing with the aim to end suffering...We will argue that the discourses on good human and animal deaths are not distinct, but that they interact and influence each other...

The advances regarding veterinary diagnostics and therapy entail that even in the event of an unfavorable prognosis, there may be alternatives to immediate euthanasia. This requires a fundamental decision by the patient’s caregiver, similar to the one in human medicine, i.e., whether further treatment should follow a more aggressive strategy, focusing its efforts on the prolongation of the patient’s life, or a palliative route, preserving the patient’s best possible quality of life. The two strategies are not mutually exclusive, of course, as even an aggressive care-treatment plan must always assess and respect quality of life, but they represent two nonetheless very different routes (Bishop et al. 2016, p. 347).

Even in case of a non-curable cancer diagnosis and provided that veterinarian and owner have genuine interests in choosing what is best for the patient regardless of financial or other costs, several options may be available, therefore: from instant euthanasia at the veterinarian’s practice over palliative treatment until the animal’s ‘natural’ death up to the aggressive treatment of the tumor at an oncology clinic with the purpose of maximum life-prolongation. Thus, notions of what a good animal death actually entails become more and more relevant.

Unfortunately, veterinary ethical literature on the concept of good death is scarce. Furthermore, the multitude of aspects shaping the ethical discourse of animal death and the morality of killing are not apprehended in veterinary medicine, nor do veterinarians seem to be aware of the many philosophical assumptions they make in positioning themselves (Persson et al. 2020)...

Instead of assuming that there can only be one ethically right direction of convergence, veterinarians are advised to engage in a conversation...

Lisa Moses admonishes that veterinarians “have barely begun to have widespread public discussions about what end-of-life care for animals should ideally be and whether we want to avoid the pitfalls of human health care at the end of life” (Moses 2019, p. 389)...

 

[Daniel E.]

For palliative care for most pet cancers, corticosteroids like prednisone seem to be the most popular option for maintaining health and quality of life, even without obvious pain.

Besides being anti-inflammatory and potentially anti-tumor, steroids can increase energy/exercise levels and increase weight/appetite and hydration/drinking. My 12-pound dog takes 2 mg of the corticosteroid Medrol each morning.

At least for humans (with or without cancer), a healthy diet is more important than supplements. And the same must be true for dogs and cats, who are more likely to suffer cachexia (as they age much faster than humans anyway). Dietary adjustments may also help reduce any negative health consequences from steroid side effects like higher blood pressure or being more susceptible to infection. My dog on Medrol recently got an abscess, which is being treated with two weeks of clindamycin.

Since my dog's appetite is still very strong, Royal Canin's Mature Consult is the prescription dog food I am using now (which I supplement with yogurt, berries, apples, eggs, salmon, chicken livers, peanut butter, etc). It is for senior dogs, and the cost is comparable to most premium dog foods:

Dog Veterinary Products

We have a huge selection of formulas to provide your dog with a healthy veterinary diet to combat issues including obesity, urinary S/O and much more.

www.royalcanin.com

For gut health and potentially overall health, this is the probiotic and prebiotic supplement I give my dogs:

Proviable®-Forte Chewable Tablets For Dogs - Proviable®

Our most advanced formula for dogs. Helps support healthy intestinal balance. Contains 10 billion CFU's per tablet. Available exclusively from vets.

www.proviable.com

Ingredients per Tablet:

Ascorbic acid, dried Bifidobacterium bifidum fermentation product, dried Enterococcus faecium fermentation product, dried Streptococcus thermophilus fermentation product, dried Lactobacillus acidophilus fermentation product, dried Lactobacillus bulgaricus fermentation product, dried Lactobacillus casei fermentation product, dried Lactobacillus plantarum fermentation product, gum arabic, hydrogenated vegetable oil, maltodextrins, microcrystalline cellulose, natural flavor, silicon dioxide

I have gotten Proviable-Forte from my vet's office in the past, especially for treating diarrhea. It is also recommended by a vet oncologist on YouTube (who seems to be the happiest oncologist on the planet):

 

[Daniel E.]

Regarding hemangiosarcoma / hemoabdomen:

Dogs Don't Get Heart Attacks, But They Do Get This

Hemoabdomen cases seem to come out of nowhere

www.vin.com

The thing about hemoabdomen cases that makes them so frightening for pet owners is that they seem to come out of nowhere, and they hit like a random, unforeseen lightning strike on an otherwise sunny day - like a human heart attack. One moment their dog may be happily cavorting in the yard, and the next they’re lying on a gurney in a veterinary ER fighting for their lives....

The signs are typically a sudden onset of weakness and inability to get up. These can happen in any breed of dog, but the majority are in dogs that share a genome with German Shepherds. Golden Retrievers, sadly, probably take the number two spot. Any dog over eight years old that’s related to a German shepherd or Golden is potentially at risk for a spontaneous hemoabdomen, and this disease should be considered in any dog of this type who has a sudden episode of unexplained weakness. Check their gums, as they are often as white as a sheet during this event...

The survival rate for dogs with hemangiosarcoma after emergency surgery to stop the bleeding is, on average, about three months. That time span can be doubled with the help of powerful chemotherapy, which is an option that all owners should be offered. We tend to not be as aggressive with chemo for our pets as they are with people, so that can mean fewer side effects. For some folks, six months of good quality life is a blessing, while for many that is nowhere near enough to justify the medical high-wire act that must happen to even hope for a little survival. The word ‘cure’ is almost never uttered in the same sentence as the word ‘hemangiosarcoma.’

Many owners decide to not pursue surgery when we make the diagnosis of hemoabdomen, and I can’t blame them. They are usually looking at a 75% chance that their dog has a disease that will very likely kill them inside of 90 days. The alternative is a fast and painless euthanasia, or, in some special cases, a death at home. Despite all the drama of this disease, it is usually totally painless and I will honor requests to take pets home to die if the owners are educated about what may happen. For those that elect to pursue treatment (I would say about one-third to one-half of owners opt to treat), the goal is to take them to surgery as soon as they are stabilized. This means blood transfusions and other methods to try and make them the best anesthesia candidate we can, quickly.

 

[Daniel E.]

From 2013:

Vet recommends medical marijuana for pets in pain

LOS ANGELES — Until she introduced "magic cheese" to her sick and aging bulldog, Laura Bugni-Daniel watched him suffer for two years. He'd spend his days lying down or throwing up.

www.capecodtimes.com

Pot eased his Siberian husky's pain during her final weeks, after she had surgery to remove tumors. Not only did Nikita stop whimpering while using cannabis, but she started eating, gaining weight and meeting him at the door again.

It gave him six extra weeks with his dog before he had to euthanize her, he says. It wasn't a cure, but he thinks it freed her of pain and improved her last days...

Some other vets contacted said they share Kramer's view on pot, but they wouldn't talk on the record for fear of arrest or retaliation.

 

[Daniel E.]

A possible reason to consult with an oncologist even for palliative care is general practice vets may prefer to outsource anyway (which has been my experienc

Overspecialization - Wikipedia

en.wikipedia.org

Overspecialization detracts from physicians' ability to identify and treat problems in patients. One proposed solution is to use databases that streamline the obtaining of necessary information and knowledge, while teaching medicine to a depth that the human mind can handle

Another option may be seeing an emergency care vet, who may be more experienced with the latest pain medication options. Where I live, the only vet who specializes in pain medication works at the pet ER. ER vets do routine/wellness exams, charging less than most other specialists.

 

[Daniel E.]

Seven Things You Can Do to Enhance Your Dog’s Longevity – Spot Speaks

Act sooner rather than later when your dog isn’t feeling well. Compared to young and middle-aged dogs, seniors have less physical reserve and are more prone to becoming compromised following a spate of symptoms such as lethargy, not eating, vomiting, or diarrhea. Whereas a 24-hour “wait and watch” approach might be reasonable for the youngster with such symptoms, waiting this long with an older dog before contacting your veterinarian may have dire consequences.

 

[Daniel E.]

https://www.aaha.org/publications/newstat/articles/2021-012/fda-conditionally-approves-first-oral-tablet-to-treat-canine-lymphoma/

"The US Food and Drug Administration (FDA) gave conditional approval to an oral tablet developed to treat canine lymphoma."

https://www.aaha.org/publications/newstat/articles/2019-08/new-study-may-lead-to-a-cure-for-canine-lung-cancer/

"A lung cancer mutation in the dog that is identical to the mutation found in humans with never-smoker lung cancer"

 

[Daniel E.]

Another day, another new supplement...

An alternative to broccoli recommenced/marketed for pets with cancer:

"Eat Your Vegetables: A Review of Sulforaphane in Oncology"

Broccoli Seed & Sprout Extracts Supplement For Dogs | Avmaquin

Avmaquin™ is a tasty option to ensure your pet is receiving the necessary ingredients for sulforaphane production.

www.avmaquin.com

Personally, I will stick to the broccoli as my dogs love raw and cooked broccoli

 

[Daniel E.]

The Role of Glucocorticoids and NSAIDs in Cancer Treatment for Dogs and Cats

Glucocorticoids and NSAIDs can be potent primary or adjuvant treatments for a variety of cancers in veterinary medicine.

todaysveterinarypractice.com

"Although dogs and cats both initially respond to GCs [like prednisone], the response is transient."

"The treatment of nonhematologic cancers with GCs is more controversial. It appears that GCs, depending on the tumor type, may prevent tumor progression and metastasis, or may inhibit chemotherapy-induced cell apoptosis. These discrepant results are likely due to a multitude of factors, including different cell types of origin, varying GC receptor levels, the type of GC administered, and the dosage of GC administered."

"Metastasis is responsible for 90% of cancer deaths, but adequate treatments for metastatic disease have not been thoroughly evaluated, including GCs. In vitro evaluations suggest that GCs suppress cancer cell migration and invasion through induction of E-cadherin or downregulation of matrix metalloproteinases 2 and 9, RhoA (Ras homolog family member A), and interleukin (IL)-6.1 Induction of microRNA, specifically miR-708, decreases cancer cell migration, adhesion, and abdominal metastasis through inhibition of Rap1B. In addition, various studies have implied that GCs suppress angiogenesis through downregulation of proangiogenic factors (IL-8 and vascular endothelial growth factor [VEGF]), preventing additional blood and nutrients from reaching the growing tumor."

 

[Daniel E.]

The cheapest way to talk online to a board-certified vet oncologist (who is also a cancer researcher / assistant professor at Ohio State):

This veterinarian on JustAnswer helped me. Try it yourself!

Dr. Megan Brown, a veterinarian on JustAnswer, gave me an expert answer to my veterinary question. Check it out — it’s easier than an in-person visit and better than searching the web.

www.justanswer.com

From one of her previous responses regarding cancer:

"I have an old pup with cancer myself so I understand the challenges. Her time is coming and although I deal with this every day, it's even hard for me."

Dr. Brown is also available online by appointment at Vetster:

Dr. Megan Brown - Vet From Columbus, OH - Vetster Online Vets

 

[Daniel E.]

More responses at JustAnswer by other vets:

site:justanswer.com dog OR cat cancer - Google Search

 

[Daniel E.]

Glucocorticoids +/- NSAIDs: Why, Why Not, and Washout

"Even in healthy dogs, concurrent administration of NSAIDs with corticosteroids may be contraindicated, even if the NSAID is a COX-2 selective."