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!