Is length the most important thing? (Day -160)

Quality vs Quantity of life in dogs

I’ve recently spent some time within some of the top oncology (cancer) referral vets within the UK and been in consults with people who have to be told that the biopsy says it is cancer. One of the most difficult questions that pet guardians will then ask is how long a loved pet has left – this is an awful question that has to be answered so carefully because we just do not know.

We try to use evidence based studies looking at different treatments when discussing the options – however these studies over use statistics to give averages. Unfortunately within veterinary research many studies only have a small amount of patients which is caused by the way the veterinary industry works. This means that when looking at a study with average life duration from start of treatment of 3 months that some dogs may have died at 1 week whilst others lived until 9 months or a year. I am personally starting to believe that statistics should be limited to use only in sample sizes over a defined minimum limit to improve reliability (I wrote about statistics here).

However what is missing from most of these studies is perhaps even more important and is the second question that most pet guardians ask. That is what the quality of life is like. It is something that may sound strange however it is much easier to quantify quantity of life (i.e. days) than it is quality (i.e. happiness) of a pet.

This is still something in it’s infancy within veterinary medicine – with humans we can explain that it will hurt now but it will mean that they are good later. The first time I saw this discussed was within surgery decision making in the AWSELVA journal in 2014 (J. Yeates & S. Corr) to evaluate treatment options based on the amount of painful time vs the amount of pain free time.

This is something that is difficult though as we need to define how we recognise the quality of life. For example if we consider movement as an indicator as recently there have been studies using accelerometers (step counters) to monitor the activity of an animal. A study just published used this to measure the physical activity in dogs receiving chemotherapy as an oncology treatment which may be acceptable.

However if we look at dogs with neurological problems that may have abnormal circling or pedalling movements then activity may not be the best quality of life. Here is where other techniques may come into play with things such as a seizure diary being kept to record frequency and duration of seizures to allow comparison of good time vs bad time.

Hopefully soon we will have better measures for the quality of life – and be able to apply these when making decisions that may impact animal welfare.

Beating cancer one pet at a time one year on…

Arriving to Fitzpatrick Referrals Oncology and Soft Tissue Hospital

A year ago today I was invited to the grand opening of the new Fitzpatrick Referrals Oncology and Soft Tissue hospital in Surrey. On that day I made myself a promise that I would be back to learn how to fight this devastating disease so in June this year I ended up sat in a room with 3 world experts discussing the care of a single patient. It’s not about just doing the advanced procedures or having the fancy toys to play with. It is about the four legged member of the family that gets to spend more time with its parents without being in pain or suffering.

Something that I really like with the way that Fitzpatrick Referrals is run is that it is based on a massive team approach. Especially with oncology this can be extremely important – the week started with tumour rounds via video link with the Fitzpatrick Referrals orthopaedics and neurology hospital. Having two rooms full of Veterinary specialists talking about a single patient allows delivery and development of the latest cutting edge ideas. Having an orthopaedics team supporting oncologists allows for world class treatment for advanced tumours that may also involve the bone or need advanced reconstruction so that the patient has the best outcome.

Chris Fitzpatrick Referrals Oncology and Soft Tissue prep area

There is little that can prepare you for entering such a facility, and I barely slept the night before I was so excited. After rounds I changed to scrubs and entered the prep-area where I’d stood 8 months ago wishing that I was here to see practice, and let it finally sink in that I was here. As it is such a new field it is not as busy as the Fitzpatrick Referrals Orthopaedics and Soft Tissue hospital however there was still a full surgery board. Something I like is that there is a specialist anaesthesiologist Dr Diego Castineiras, for me this is amazing as there are so many things to consider with anaesthesia that there is always a ton to learn. Something I saw for the first time here was flushing the esophagus after reflux to prevent it developing strictures later.

Moving from prep to the first surgery of the day I get to really see what surgical cancer treatment looks like – tumours are removed with large margins. Removed tissue is stained and sent to pathology to make sure all the margins are free of cancer cells. And finally the most scary part – the massive wounds left behind are reconstructed so that they heal using advanced techniques when necessary.

Before this the biggest surgical wound I had seen was a strip mammectomy where all 5 of the mammary glands on one side of the body are removed. This wound basically ran the entire length of the dog and we performed this surgery in stages cutting a bit and then suturing it up as we went. This worked in that case however here the patient had tumours in multiple sites so removing them all was not going be so simple, the wound was massive and a caudal epigastric axial pattern flap created to close it. Something I really liked here was the use of towel clamps to bring the wound edges together temporarily so that you can plan your closure before placing the sutures responsible for holding the shape together.

One of the things that had a really big impact for me however was that of cytology. We were in surgery when we found another lump on a dog. The question was whether it needed to be removed or not – we could save the owner money and the risk of another anaesthetic if we removed it now however we didn’t want to remove it if it didn’t need to be. Thanks to cytology however we did not need to guess, a simple FNA biopsy, a couple of glass slides, some diff-quick stain and a microscope told us the answer accurately. This was a Mast Cell Tumour and needed to be removed. Cytology is something that is covered quickly, so now after this experience of it used properly in practice I will be doing a lot more sticking needles into things and having a look to see what is there.

The use of chemotherapy is often better tolerated in animals than it is in humans, and this is where the medical oncologists get involved. It is a tool that can be used in many different situations and can work really well with great results however the use of chemo drugs is still difficult in general practice as there is always a danger to staff working with them. I was lucky to have Dr Kelvin Kow spend time to explain drug preparation and different protocols with me as it is an area that I’ve not covered in vet school. One of the most amazing things with chemo I think is its use to shrink non-operable tumours to a size where surgery becomes an option.

The passion behind medicine

It however is not all about curing a pet of cancer – sometimes that is not possible as we just don’t know enough yet. In this case it then becomes palliative where the goal is to give a loved pet the extra time with their guardians without pain. This can be with just medical treatment, however sometimes the problem is large tumours simply taking up the space other organs need to work correctly. In this case then removing the tumour whilst not curing the disease allows the dog to eat, urinate or pass faeces and so have a relatively normal life until the disease progresses. This is where it is the experience of a oncology team that allows this ethical decision to be made – is the recovery period of surgery (which is likely to be painful) significantly shorter than the “happy” extra time the dog will spend with their guardian?

The best thing however is that whilst there is a great team based at Fitzpatrick Referrals Oncology and Soft Tissue, it is also about the teaching of other vets, and vets of the future especially with the new Fitzpatrick Learning Academy laproscopy training center. To be able to see a surgical site the best way is to scrub in, and if it is really deep then it is the only way. I was lucky to be allowed to scrub and see some really cool palliative surgery with the removal of lymph nodes from around the aorta towards the pelvis where tumour cells had spread from the initial site around the anal glands.  This is something that will give the dog months more of life to share. The sharing of knowledge and answering of questions gives me hope that we will beat cancer, with hospitals like this being the beacon of hope in the veterinary profession.

FLA Training Center

Something that I am asked a lot when people see that I’ve seen practice at Fitzpatrick Referrals is if it is as good as on TV. The truth of the matter is that it is better! There is not enough time to cover everything on TV so the other thousand things that go into giving patients the best care in the world are not shown.

Helplessness against broken nature…

Vet student in surgery

The definition of inoperable changed for me today, I’ve always understood sometimes there will be challenging surgery, and sometimes most will not do anything as there was nothing developed yet. However I never believed that there would be anything that is impossible to operate on.

With every single patient I am prepared to give everything that I have got to try and do everything possible. So today was no different, I spent 45 minutes removing 3 litres of fluid from the abdomen by syringe. And then it was time to go to surgery which I had spent several hours preparing for in study to make sure I was on my game to assist with the surgery today.

It all went wrong trying to open the abdomen, first we thought the scissors were bad, but then we realised it was the tissue that surrounds the linea alba on the abdomen that was 10cm thick and hard. We found a way in though going around this – and this was where it all fell apart.

The only way I can think to describe it is like when frozen food melts on the way home and then when it is refrozen everything becomes one totally mixed up. Even the bladder was not visible and “melted” into the body wall… The doctor I was with had never seen anything like it, and I really hope that I never ever get to see anything like it again…

The most horrible feeling in the world is that of helplessness… And that is where I am right now.