Sep 15, 2010

Time for some therapy

Days 14 and 17, mostly - Sept 6th, 9th and beyond

Staple remover, stat.
Okay, not stat, per se, but it definitely was time to take the staples out on Monday, day 14 post-op. I have a staple remover (another artifact of my tech days) and did it myself. I planned to do it Saturday or Sunday, but I was a bit worried about the top where there was some irritation and it didn't look completely closed. The bottom was beautifully sealed and clean. Typically, they are taken out 10-14 days after surgery.

After noticing a little pink and bumpy irritation, I decided they may be doing more harm than good. (He's got a couple more layers of internal sutures anyway.) The staples definitely had irritated his skin in certain places, especially one area, near the middle, where I had been noticing a bit of yellow puss. It wasn't seeping from the suture so much as hanging around a bulbous skin protrusion just external to the suture. I had been warm compressing it for a couple of days, two or three times daily. It was getting better - shrinking - but still wasn't gone.

Over the next couple of days it kept healing. All of the other areas healed up nicely. On Wednesday, Sept 8th, there was still slight discharge around the middle part. The vet could look at it the next day though.

It's chemo time!
They say to start chemotherapy between weeks two and three post-amputation. I decided to set up an appointment with an oncologist at the UC Davis Small Animal Hospital, based on glowing recommendations from many vets and dog owners. Not only is the hospital state of the art, it also offers cheaper prices, a lot of personal attention, and opportunities to participate in clinical trials. At about 75 miles from home, the distance isn't so bad either.

Robyn (aka, Dabs) drove Cas, Rob, and I in her car, so once again, I got to ride in the back with Cas. We left at 9am and returned at 7pm. Long day. Also, a successful day, so no complaints here.

Let the shaking recommence
Although Castor was not pleased to be in another hospital, he seemed less terrified this time. It was probably a combination of lots of moral support and the size of the hospital diluting some of the scary smells. Less likely, he's getting more used to our visits. Regardless, I enjoyed his lack of teeth-chattering fear. (Shaking is sad but understandable. When the teeth get involved, it's heart wrenching.)

The exam and consult was long. Long but pleasantly thorough. A senior vet student took us back to an exam room and started by getting a rather comprehensive case history on Castor, not just on his osteosarcoma but everything from puppyhood on. She was friendly, accessible, focused, and clear. After she took his vitals (e.g., weight, temp, listened to heart and chest), the oncologist, Dr. O'Brien, came in to finish the exam and discuss his treatment plan. (Exercise: If Castor weighed 136 pounds pre-amp and 130 today, how much did his left leg weigh?)

On examining Cas, O'Brien said the, "he's in great shape," that I am, fortunately, so accustomed to hearing. His suture site looked mostly great too, aside from that bit of puss that wouldn't leave. He'll be enjoying a 10-day course of Clavamox now. (Weee...more antibiotics! [that's sarcasm tinged with gratitude.])

Our drug of choice
On to the chemo options. Basically, I could do none, do Carboplatin once every three weeks for six treatments, or participate in a clinical trial. The trial was monitoring dogs receiving either six doses of Carboplatin (as in my second option) or alternating doses of Carboplatin and Doxorubicin (Doxo) for a total of six treatments. Were Cas to participate, one of the two tracks would be randomly assigned to him. Unfortunately, there was no discount involved, and unfortunately the second, Doxo can have, usually after 6 doses, negative side-effects on the heart. Since Great Danes are already prone to having heart problems, he would have to have an ultra sound on his heart pre-treatment.

All in all, I left the conversation with nothing in the pros column for Doxo. In answer to my questioning, O'Brien said that there was no difference in survival rates between the two drugs noted in the current literature. Plus, Doxo is a bit trickier to administer. It requires an IV drip and can be very bad if it doesn't go directly into the vein. Worst case could lead to amputation. Of course, this has never happened there and is probably very rare. Still, another con for Doxorubicin.

Beyond that study, Jen had heard about a current clinical trial at Davis involving inhalant chemotherapy administered to post-amp osteosarcoma dogs. I asked O'Brien about it, but there were drawbacks to this study as well. On the good side, most of the treatment would be free. It is a purely experimental study using chemo administered as an inhalant, because osteosarcoma generally presents secondarily in the lungs. There were no previous data to look at though. Also, the doctor running the study is out of town until October. We all thought it best not to delay Castor's chemo.

So, I decided between the Carboplatin and the Carb/Doxo clinical trial. It seemed the only benefit to the trial was to be of service to the veterinary community. I definitely considered that when making my decision; however, given the heart concern and the potential added expense of the ultra sound, I opted to go with my original plan.

Honestly, by the time I went to the first oncologist, Dr. Cadille, I was pretty informed and tentatively set on a path for treatment - amputation and chemotherapy. I spent the week after Castor's (pretty sure) diagnosis reading a lot about osteosarcoma and speaking with Jen about surgical options. (Not to mention all the research that Dabs did, as well.) Still, I imagine that without that research, I would have felt sufficiently informed at the end of this Davis consult to make a confident decision on how to proceed.

Carboplatin, it is. So, now what?
After deciding on Carboplatin, we went into the side-effects. O'Brien reiterated the positive news that 85% of dogs experience no visible side-effects. The other 15% experience some nausea, vomiting, and/or diarrhea. Maybe 1% end up in the hospital. (For those of you who like anecdotal evidence, she'd only seen that at Davis twice, and they treat a lot of dogs.)

What's the difference? Why don't they lose all their hair and end up sick-as-hell, in bed until it's over? Well, she said, we treat dogs' cancer differently than humans. We worry more about quality of life, not wanting to sacrifice happy time for more time alive but feeling miserably. It makes sense, given the significantly smaller life spans of dogs than humans. The trade-off, I suppose, is that in humans we strive to eradicate the cancer. In dogs, perhaps, we just look to slow it down. Still, I think there is room for us, as humans, to give a little more weight to the quality of life issue when treating cancer in other humans. (There was an excellent New Yorker article, Letting Go, about this a few months ago.)

As for the potential, mostly gastrointestinal side-effects, they gave me Metronidazole (aka, flagyl) and Metoclopramide (aka, reglan) in case of diarrhea and vomiting, respectively. If he is to suffer these problems, it should happen around day three. If not, yay!

So, I am to monitor his mood, bowels, and desire to eat and let them know, at our next visit, if anything was out of the ordinary.

My dog is not average
That brings me to a topic I've already touched on, namely, median survival rates. Vets love to talk to me about this, it seems. (And it's not because they know I'm a mathematician. Rob inquired about the distribution of the data after O'Brien said, "median," and she backed away from the Land of Math very cautiously, perhaps so as not to arouse its predatory instincts by turning and running.) For completeness's sake, I'll say that O'Brien observed the survival rates of dogs with osteosarcoma after diagnosis as being:
  • 0-3 months without treatment; dog dies from pain, usually after breaking their bone
  • 3-6 months with amputation and no chemo; dog usually dies from lung cancer
  • 12 months with amputation and chemo
How do I interpret these numbers? Well, I assume my boy will have total remission. Period. If you want another anecdote, one that I find particularly useful, check out Nova the Great Dane. Her 19-month ampuversary was in June, and her lungs are still clear. You see, a median is just a certain type of average. A median survival rate of 12 months means that half of the dogs lived less than a year and half of them lived longer. It's that simple. There is no reason to assume Cas will fall on either side of that line, so I believe he'll follow after Nova. (Planting seeds of joy, remember?)

For instance, at the time of writing up one study of 35 dogs with osteosarcoma who were treated with Carboplatin and Doxo, 7 dogs were still free of lesions and 24 died from metastases. The median survival time of this study was 320 days. The longest surviving dog at that time, then still metastasis-free, was at 974 days post-amputation.

A median is a prophecy, not a prescription.

Will this tea and essence of flower cure my dog's cancer?
I only jest. Really, I had plenty of things to talk about besides the chemo drugs. I want to make sure I do everything possible to help my dog's battle be won. Of course, a teaching veterinarian at UC Davis will have different views than, say, the Great Dane Lady, but the more opinions, especially differing ones, the better, right?

I'll be honest; I am a skeptic. That's who I am, and I love that about myself. I want to believe that people have cured cancer with many things, even an alkaline diet, but (in the case of alkaline diet, anyway) I tend to believe it was something else entirely. I have not been presented with evidence that a person's (or dog's) alkalinity can be altered enough to affect cancer cells, nor that feeding them no carbohydrates will starve their cancer cells but keep the others healthy. I will try herbal, holistic, or alternative (take your pick) treatments, but I do expect some evidence, some data, some something to show it's viable. Something, in fact, more than testimonials on the internet. (Sorry, but I know the difference between science and anecdotes. Both great for different things.)

Over the past few weeks, I have read or been told about many different cancer-defeating weapons and some supplements and treatments that just support bone and overall health. For instance, among other things, people have recommended I try:
  • high-fat, high-protein, low-carb diet
  • alkaline diet
  • Essiac tea
  • Milk Thistle Dandelion (non-alcohol formula only for pets)
  • Yucca
  • Vitamin D
  • probiotics
  • accupuncture
  • physical therapy
So, I asked Dr. O'Brien, as well as others, their take on some of them. Her responses, to quickly paraphrase, were the diets are crap. Physical therapy is a great idea. Accupuncture may help with his pain, but everyone thought he wasn't actually in pain anymore. "His pain is gone now," the senior student said. (She was very sweet and helpful.) I stopped his Tramadol (pain med given post-surgery) a day prior, and I am stopping his Metacam (an NSAID) for the time being. I'll just be using it as needed, if I see limping, etc., which I don't anticipate.

Milk Thistle Dandelion (MTD)
is actually used by them sometimes (in a drug mixture) for liver support; however, Carboplatin isn't filtered through the liver (like Doxo) but through the kidneys (or "the kids," as I affectionately refer to them). So, while it wouldn't hurt and in some cases does help, his liver is functioning great and none of his drugs are liver-taxing. Thus, no MTD for Castor yet. Probiotics are fine too, unless he's having bad diarrhea, in which case some docs opt to not risk the "good gut bacteria" getting outside of their domain via the blood system. No one really knows if they're good elsewhere in the body.

For diet, most commonly you will see "high-fat, high-protein." The idea is that carbs feed cancer cells, so you want to try to starve them a bit. The problem? All cells feed on carbs. So, per Cadille and O'Brien, theoretically it makes sense, but practically, there's no data to support it helping in a fight against cancer. At all. However, independent of this topic, I had decided to switch Castor from Innova to Canine Caviar after finding out that Proctor & Gamble bought Innova. (P&G have been longtime animal experimenters, which I do not support.) Canine Caviar (CC) seems to be a great, whole food-type, "holistic" and independently run brand. There are other great brands for sure, but I chose this one.

I started Castor's transition to CC right after finding out about his tumor, and before knowing the facts, so I chose the high-fat, high-protein Venison and Split Pea formula, which really lives up to its name (caviar prices!). No vet I've asked has heard of Canine Caviar, but I was told the ingredients sound great. ("Really high fat and protein though.") O'Brien and others have said Innova is a great food too. After Castor's slight post-op picky-ness, I decided to continue feeding him half-Innova, half-CC for the time being. I may switch to something altogether different in the near future. Not sure yet, though. For now, they're both great foods, and he is tolerating the high-fat and protein in the CC.

Assuming he's getting a complete diet, which he is, Vitamin D is not necessary. In fact, I was told that it can cause problems if he gets too much. No Vitamin D - check.

As for Essiac Tea and Yucca, these are two of the go-to alternative medicine (or whatever you want to call it) cancer remedies. My mom tends to lead me down this path and she has had success using such options on many of her animals for many years, including her dog who died of osteosarcoma. (Yes, this is an anecdote, plus it's from my mom. How biased can I get, huh?) So far, I haven't been told negative things about either. I intend to investigate, at least yucca, further soon. I'm most likely try these two alternative options on Castor thus far. I picked up some Essiac but haven't used it yet. As for yucca, the Canine Caviar I'm feeding happens to contain it already.

Finally, as I hinted to earlier, the alkaline diet seems, from my reading and conversations with vets, to be bogus. The body regulates it alkalinity to be within certain bounds. That can't be overridden, nor would we be necessarily dandy-er if it could be. No evidence to support and lots of evidence to the contrary equals me think hogwash.

The take-home message for supplements and food was feed a complete diet, don't let him gain weight (cause he's perfect now), and be careful with antioxidant-type supplements. The thing is that they help prevent cellular breakdown, but that's exactly what we're going for now. We want to breakdown the cancer cells. So, lay off the antioxidants for a while!

I did set up an appointment with a physical therapist. The vet and student raved about her! It is great to at least consult with a pt for your pet's new tripawd life. There are lots of home stretching and strength training that can greatly benefit them. I plan to start Castor's therapy and work-out regime right after our consult. More on that later

Blood, x-rays, and drugs
We left Castor with them for the treatment. It would take a couple of hours. They have to take chest rads (x-rays) to get a baseline for future sets. He will have two more sets taken during his six treatments. This set came out as clear as the last, i.e., very. (YAYAYAYA!!!!)

He also had a blood panel done. His blood looks great. Better than most, she says. =) He will have to have a CBC (complete blood count) done 10-14 days after this treatment. It's done to monitor his white blood cells, making sure they don't drop too low (i.e., neutropenia).

The Carbolplatin was then administered into his vein (no need for an IV drip with this one, remember).

We picked him up about 4pm. He came running out, tail a-wag! He adjusted so quickly to life on three. Everyone was impressed by his resiliency.

They said he was a fantastic patient! (I am not surprised.) We picked up his scripts, paid the bill (ouch, but not super ouch), and set up another appointment for the 30th.

On the way out, we spoke with the physical therapist briefly. She said it sounded like we were doing well, except for one thing. Oh, the horror on her face when we mentioned the 12 stairs at home. "I would move," she said. Simple, direct. Okay, I guess we'll look into it. For now, with his Ruff Wear harness (How cute is he in it?!) and the Walkabout harness for his rear that we just ordered (by her recommendation), Rob and I pretty much carry him up and down. He floats along the steps carrying between 0 and 15% of his weight. Good enough for now. (My boy hops and flies!!)

Always Questioning
One more thing. (I promise.) As a former vet tech, I appreciate being able to have meaningful, informative discourse with vet professionals about my boy. I got that from my first trip to Davis, as well as my discussions with Dr. Cadille and Dr. Wright. (Thank you all!) I can't say enough about making sure, if you ever go through something as involved and important as this, that you understand what your doctors are telling you. They are there for you; in fact, you're paying them for that support. So, don't ever feel bad about asking more questions, even the same ones again!

There was once, that I can remember now, that I felt my question was not answered at all by O'Brien; it was a little far afield though, so I let it go. (I was curious as to the different mechanisms of the two drugs of choice for osteosarcoma. So, alas, I am still curious, but those answers can wait.) Other than that, I feel very informed and supported. I have had all of my (many many) questions answered. I even email O'Brien and Cadille to ask more questions as they arise. They always get back to me quickly.

I never agreed that, "there are no stupid questions." Sometimes questions do seem stupid to those you're asking. So what? Sometimes people get sick of answering your questions. True story. And? That's fine. What's most stupid is making decisions based on information you still have questions about. If your doctor doesn't answer you or gives you reasons to feel uncomfortable asking, find a better doctor. So, speak up. Ask your questions.

Any questions?


p.s. - Here is the report I mentioned above, if you're interested: Kent, M. S., Strom, A., London, C. A. and Seguin, B. (2004), Alternating Carboplatin and Doxorubicin as Adjunctive Chemotherapy to Amputation or Limb-Sparing Surgery in the Treatment of Appendicular Osteosarcoma in Dogs. Journal of Veterinary Internal Medicine, 18: 540–544. doi: 10.1111/j.1939-1676.2004.tb02582.x (Enjoy!)

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