Easy-Peasy Thyroid Cancer

I had to change blogs in mid-blog stream. Something came up that was too offensive not to blog about. This was a blog that was published by the Huffington Post by Cindy Finch, called The 6 Injustices of Cancer. (http://www.huffingtonpost.com/cindy-finch-msw-licsw/the-six-injustices-of-can_b_6573648.html) I am reluctant to include the link because it will mean more traffic and better metrics for an article that I don’t think deserves it.

Why six injustices? I have no idea. They are not even the six that I would have chosen if I had written a blog about the six injustices of cancer, but, as a thyroid cancer survivor and veterinary surgical oncologist, you peruse this kind of thing. It starts out with,

  1. When it’s over, it ain’t over
  2. Cancer now, may mean cancer later
  3. Your doctor may dismiss your concerns
  4. Cancer is humiliating

Ok, sure, although I don’t find this list particular groundbreaking or visionary, I can relate and half-smile my way through. Then comes #5:

  1. Some cancer patients get off really easy

Here are some quotes from provocative section #5: I’ve heard it a hundred times, “I’m a cancer survivor, too.” “Oh, really? What type of cancer did you have and what was your treatment?” “Oh, I had thyroid cancer and had to take a radioactive pill for 30 days then I was all better.” Blah blah blah, lots of crap on who has it bad and who has it even more bad, blah, blah blah “High on pain and often low on quality of life afterwards (if they live), these folks represent the worst among us.” (Clearly not talking about easy-peasy thyroid cancer here) “If you’re not one of these folks, perhaps you should be quiet and sit down and let someone else tell their war story.” (Clearly talking about thyroid cancer peeps here).

Let me just say that the thyroid cancer community is not amused. Currently, there are over 100 angry comments on the Huffington Post Site from thyroid cancer survivors pointing out the hypocrisy of this article and it’s making the rounds with the thyroid cancer survivors Facebook pages. I should say that Cindy Finch is sorry. She apologized. She is trying to make it right. She now sees the light and is going to write more poorly-written blogs about things she doesn’t know anything about, like thyroid cancer. I don’t really understand this because she says in her article that she has heard it “one-hundred times” so now that she has heard it two-hundred times, she sees it differently? I accept the apology, but the call for thyroid cancer survivors to share their thyroid cancer experiences with her is a bit too much for me, I don’t want this to be the person who tells my story.

This article unintentionally but accurately sums up the struggle of the thyroid cancer community. Most thyroid cancer survivors have struggled with the perception, both internally and externally, that thyroid cancer is easy cancer. The first thing that most people say when you tell that that you have thyroid cancer is, “That’s good cancer, right?” Yeah it is great cancer. Thyroid cancer does not measure up in the cancer hierarchy because it is not well-publicized or well-funded and what people do know about it is that it is cancer-lite.

The majority of people with thyroid cancer have a curable form of cancer. This is partly because most forms of thyroid cancer are slow moving and also because of science. Science has figured out that you can make iodine radioactive and that, because iodine is only taken up by thyroid cells (cancerous or otherwise), it will selectively kill thyroid cancer cells and spare normal cells. So let me just say that again, this is a form of cancer that has been cured by science. Thanks Science! Instead of celebrating this, thyroid cancer is dismissed for its curability. Also, after you have had your entire thyroid gland surgically removed (which is not actually as fun as it may sound and often more than one surgery is required), you have no thyroid hormone, which is a vital hormone for activities that people enjoy, such as being alive. Our friend, science has also found a way to replace thyroid hormone. That is also great news for thyroid cancer. Having said that, not all forms of thyroid cancer are a walk in the park, not all forms are curable, and not having a thyroid gland is a real challenge sometimes. Some people actually die from thyroid cancer. Surprising, but true. The people that are struggling with recurrence and metastatic disease from thyroid cancer deserve respect and support. Please do not marginalize them.

For the rest of the thyroid cancer survivors who apparently are not allowed to share their experience because it was too easy, they are silently struggling with fatigue and the small possibility of recurrence. When you have no thyroid gland, you look completely normal, but you just feel off or fatigued sometimes. You will again be dismissed if you dare to bring this up and told that this is just aging, or that you need to suck it up when you are tired (just got told this last week when I brought up the difficulties I was having with early mornings, thank you very much). The thyroid cancer survivors are constantly on defense about their cancer and they are also, as a group, really tired. I’m sorry we are not survivor-y enough for you. As a group, I don’t think that we are trying to prove anything or compete for cancer-pity dominance, we are just trying to get our thyroid levels in order, raise awareness, and get people to check their necks.

There are only two types of people that have had cancer. Dead people and alive people. Not all people with cancer live to blog and whine about it. A lot of people with cancer die. The dead people are silenced by death and the cancer-lite people are silenced by not suffering enough. What about the injustice of being dead? This did not even make the list of the six injustices of cancer. If it was possible to blog from the afterlife, I suspect that the grave-bloggers would tell this author that she actually has a lot more in common with the thyroid cancer survivors, considering she is alive and all.

I am a veterinary surgical oncologist at the University of Florida. I think about and work with cancer every day. I am also in the privileged position of learning from my physician colleagues at the human hospital. Because of this, I am very aware of the fact that I am incredibly lucky for everything that I have in my life and for having a cancer that is most often curable. The human experience that I learn from often has some tragic combination of bad genes, bad luck, bad disease, bad financial or social situations, bad or no health insurance, fear, and ignorance, which conspire and in many cases, cause death. But can’t I just feel lucky and happy without feeling guilty or invalidated? Why do we always feel the need to compare our scars? Things that all cancer survivors (and even people who have had cancer scares for that matter) have in common is that we thought about dying and we realized that sooner or later, we are all going to die. Maybe we should just focus on our fragile common ground.

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Conference Fatigue Syndrome

First of all, I need to apologize that I missed my blog post last week. I hear that is a bad move on the social media front, and I am sorry to my tens of followers. I was getting ready to be a speaker at the North American Veterinary Conference (NAVC) and I ran out of time. I just got back from six days in Orlando at the North American Veterinary Conference with 16 000 of my friends. It was full on. This is the biggest veterinary conference in the world. The main focus is on general practitioners and I have not attended this full conference before. This year, I was invited to give seven talks and the way they were scheduled, I was doing something every day, so I was in for the long haul. It was a scene.

When I first got there, I was emotional and overwhelmed by the feeling of being bonded to thousands of other people by our love for animals and the fact that we have devoted our lives to taking care of them. I also found something else that brings us together even more than animals. That is the love of free shit. Veterinarians love free swag. On day one, I found myself in a massive line that required stanchions and ropes for crowd control. I was waiting for a free teddy bear from Build-a-Bear that Vetfolio was giving away. I don’t even have children, yet somehow I had to be a part of it. I needed a bear. It was bizarre and unsettling to see so many professionals carrying around their teddy bears for the entire conference. A little bit of comfort at a massive conference center. Another line-up developed the next day with similar fury at the free T-shirt making station. Free, ugly, yellow T-shirts that everyone not only lined up for, but immediately donned. In one of my talks, about 1/3 of the audience was wearing a free yellow Tshirt. I did not partake in this. I draw the line at free stuffed animals. Then there is the free swag in the exhibit halls. I saw veterinarians with large boxes of something (kitty litter?) that were so big that they came with a little plastic trolley so you could continue to pick up more free shit and then you could put everything on your kitty litter box and your trolley. How are they going to get this all home? Everyone slowly cruises the flashy exhibit hall, trying to find the best swag and trying to grab it fast, without having to make eye contact or engage in the obligatory sales conversation. Nothing is for free. Actually, maybe some things are, because every time I went back to my hotel room, there was a present waiting for me. It was lovely. Chocolates, a travel mug, a useless car fan, a window decal and a “survival kit” (with Purrel, Advil, Band-aids, Kleenex, skin cream etc – I would have respected them more if they had thrown a condom in for good measure). It actually got to the point that the few times I returned to my room and there was not a present waiting for me on the freshly made bed, I was deeply disappointed and confused.

At the opening ceremony, there were speeches and the people from the NAVC were dressed fancy. Like black-tie fancy. It was a peculiar mix of people from a fashion perspective. (BTW, I would like to take this opportunity to offer my services as a stylist to anyone at the NAVC who would like a hand in this regard.) Intermixed with the speeches and sponsors were some circus openers and dry ice, and then, to top it all off, comedian Jim Gaffigan to entertain us. Jim Gaffigan was hilarious! I have to hand it to him. Last year, I came to NAVC for one night and the opening ceremony comedian (I get the feeling that the order of events doesn’t change too much every year) was Kevin Nealy. Kevin Nealy phoned it in. He did the minimum for his tens of thousands of dollars and he appeared most unhappy to be entertaining a ballroom full of incongruously dressed veterinarians. He might have made me chuckle, but I can’t remember. Jim Gaffigan made me laugh out loud and he gave us a show that would have been fit for a TV special. It was awesome! I didn’t go to the Monday night rock show (38 Special – wow) or the Tuesday night lecture (Ebola dog stuff). Mostly because of exhaustion and intense networking opportunities.

I didn’t know about the intense networking. I guess I am naïve. I didn’t realize that the tweeting would get so crazy at a conference. Or that I would get to Tweet up with my virtual friends on Twitter. I didn’t know that people said Tweet up. It was very cool to meet my virtual friends in real life. Real human beings were sprouting from my phone! I also taught a friend how to tweet. His first tweet was nearly a disaster as he used Siri to advertise his talk on Anal Sacs. Siri did not hear anal sacs. Enough said. I also didn’t realize that people would buy copies of Lucky Dog. I brought some copies with me just in case and sold them all randomly. Learned after the fact that this is illegal in the land of NAVC and it actually has a name. It’s called Suitcasing (that is a verb!) and it is naughty. (Sorry!) I am not sure how you get punished if you get caught. Maybe you have to stay in the Gaylord Palms resort for a few extra days and you never get to go outside.

I never got to go outside anyway. I had a few brief moments outside, on the bus from one massive hotel conference center to the other massive hotel conference center and my attempts to go for a run. I couldn’t seem to get more than 5km out of the hairpin trails outside the hotel and was told that it was unsafe to go “off property” (off compound). During my second run I ended up on the golf course by mistake and was reprimanded by some very impatient and angry golfers. The next morning, I went on the conference Fun Run. Hoping for safety in numbers. We actually ran on the same trails where my golfer friends were getting their knickers in a knot. The fun run brought out another characteristic that veterinarians share. We are a wee bit competitive. It was like a real race, with numbers and a finish line and medals. The whole deal. I met a woman who was running and she told me that she wasn’t carrying her cell phone for the 5K race because it was “too much weight”. Really?

The whole experience was wonderful and exhausting. It is going to take days to recover. I think that I have conference fatigue syndrome (CFS). The only cure is my own bed, my own dog and going for a long run on my own.

Can We? Should We?

I know that most blogs that are being written this week are about the horrific events in Paris yesterday. It seems strange to write about anything else, but I am going to write about veterinary medicine. This is partly because I don’t feel like I have a lot to contribute as a veterinarian, other than to offer my condolences. It is also because although I am enjoying social media, I seem to have a major block when it comes to adding to the conversation when something particularly joyful or awful happens in the world. If it is trending, I clam up. I can’t seem to get into the social media frenzy of grief porn. I want to get on board and tweet #JeSuisCharlie, but I can’t/don’t/won’t do it. #JeSuisSad.

So on to a topic that seems much less important when the world is literally going to shit right now, cancer surgery in animals. I am speaking at the North American Veterinary Conference next week in Orlando (#NAVC, #LuckyDog, #Orlando) and I have been charged with a talk that is entitled (not by me, I might add): “How I answer the question ‘Could We’ versus ‘Should We’?” Grammatical errors aside, the title is provocative. And by provocative, I mean that I do not love this title. It puts me on edge. Maybe I am being oversensitive because I am just really really tired of hearing people say, “Just because we can, doesn’t mean we should” when they are talking about my career and my passion. In my experience, people that say this have very little experience with the subject. This line of thinking definitely strikes a nerve with me, so it is ironic that I was handed this title as a starting point for my talk. The question itself implies that sometimes, in veterinary surgical oncology, we do procedures that we shouldn’t do, which in turn implies that we are not working in the best interest of our patients. This is where the striking a nerve part comes in.

Part of the reason for the bad reputation that veterinary surgical oncology has earned is that the procedures are, by nature aggressive. There is no getting around that. This is because most cancers are also aggressive. A lot of surgeries in this field (human and veterinary) are aimed at removing all of the visible and microscopic cancer cells. This means removing the tumor and then 2-3 centimeters of tissue surrounding the tumor. This usually results in a large defect. Sometimes it means removal of a body part. Luckily for my patients, there are a lot of dispensable body parts. Also, they are not fazed by a dramatic change in appearance caused by cancer surgery. Some people call this disfiguring, which I also think is offensive. First of all, the cancer is disfiguring. Secondly, animals don’t care what they look like. They care about comfort and function, but that is about it. Humans care what they look like and what their pets look like. I would feel sad myself if something happened to Rumble to drastically change his appearance because I believe that he is the world’s cutest dog. You have to let go of that when your dog has cancer. Again luckily, our pets don’t care what we look like either.

So the first question is, “Can we”? This is relatively easy to answer. Veterinary surgical oncology has advanced tremendously in the past 25 years and I am sometimes overwhelmed to be a part of the development of this amazing subspecialty. A lot of procedures that were not considered feasible or technically possible (and even called barbaric and unethical) in the past are performed routinely today. We are also able to perform advanced imaging, such as CT and MRI routinely to help us plan surgery. (This actually also helps with the “should we” part as well as the “Can we” part.) Along with surgical oncology, veterinary critical care and anesthesia has also advanced in parallel and allowed us to do bigger surgeries successfully. This means that we can manage blood loss and control pain, as well as providing 24-hour advanced nursing care to our patients post operatively. If the patient will be comfortable and functional post operatively, and the owners can afford surgery, the answer is often yes, we can.

“Should we” is the next question. I guess this is where it gets a little sticky for some people. This is how I work through this. If I think that surgery will offer my patient a high chance of cure or long-term tumor control, or if surgery will offer the patient improved comfort and quality of life, I will recommend surgery. Also, if the owner wants to treat and understands the potential risks, I think we should. Sometimes this risk will include either death or euthanasia on the operating table. It’s dramatic at times. Owners have to consider this risk when they are deciding. Then there are the two most common questions: “What if we do nothing” and “What would you do if it was your dog?” If the patient is suffering and will continue to suffer and go downhill with no therapy or palliative therapies, then I think that something has to be done. This something can be euthanasia, but if that is not happening, then we are obliged to do a procedure to help our patients to feel better, even if their their time is limited. This is why being a surgeon fits perfectly with my personality. I like big interventions that make a big difference (my mentor used to say, “Win Big, Lose Big”) rather than limping along with palliative care while our patients slowly fade away. This is the paradox of surgical oncology. The big interventions that seem too invasive, too big or too much to put an animal through are actually less to “go through” compared to doing nothing and letting an animal live with cancer pain.

As for the next common question, “What would I do if this was my dog?” That is the problem, it is not my dog. I think it is dangerous for anyone to chime in on this one. That is where the preachy, “Just because we can, doesn’t mean we should” can get on my nerves. Sometimes I do procedures on my patients that I might not do on my own pet. Further, I have no idea if I would do some procedures on my own pet until I am in that particular situation. Similarly, the question of whether or not it is “too much to put him through” is problematic. If you are at a specialty hospital with 24-hour care, you have to trust that they are going to treat pain aggressively and make the post operative recovery as easy as possible and that it won’t be too much. That is our responsibility to our patients.

So, I hope that clears this all up for you….This lecture is starting to take shape.
See you in Orlando!