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Archive for July 18th, 2012

Dog Blog: Living with canine cancer (1)…

Posted by indigodream on 18 July, 2012

As I may have mentioned before, looking after Lou, who has cancer, has been an incredibly intense experience; losing Poppy in the middle of it hasn’t helped!

It’s also been a tremendous learning experience, one I’d rather not have had, but here we are –  so, for the future and for other dog owners, here’s my diary – listing what happened and what I learnt from it…

Lou enjoying a bit of sunshine at the beginning of March – little did we know then what was ahead of us…

Week Commencing 23rd April

I noticed over the weekend that Lou was snoring, especially when lying on her left side. This was a new thing, so I mentioned it the vet on Wednesday 25th April. Lou was not very co-operative when the vet was trying to look down her throat so we didn’t have a very meaningful consultation. The vet thought we should just keep an eye on her and, if the symptom persisted, we should do an endoscopy of her throat.

I learnt that:

  • It is very important to observe my dogs and to get new signs/symptoms checked out. I can make observations, but only the vet has the expertise to interpret what I’ve seen! We’re very lucky that I absolutely trust Lou’s vet (the senior partner) and feel that we are in partnership in maintaining Lou’s health.

Week Commencing 30th April

Lou’s symptoms persisted and were getting worse – more snoring when asleep and now she was breathing noisily when awake. I made an appointment to see the vet on the Monday evening – unfortunately we missed the appointment because of car breakdown. The breakdown also meant a forced march – me and the four hounds – to get help. The walk made Lou very ill with raspy excessive panting, urinary incontinence and general malaise. I saw a vet on Tuesday – she thought that Lou was suffering with exhaustion and joint pain. We thought about doing an endoscopy then, but decided to leave it a day to see how Lou recovered. On Wednesday morning Lou was much worse and was now having trouble swallowing as well as breathing problems. We admitted her for an emergency endoscopy – we got the worrying news that there was a “mass” at the back of her mouth – it was so big that they couldn’t get the scope any further down her throat. Our vet made an immediate referral to the internal medicine specialists at the Royal Veterinary College (RVC) Hospital in Potters Bar. I picked Lou up from our vets and took her to the RVC that evening – they admitted her for investigations – physical examination, blood tests and a CT scan.

Lou stayed in hospital for 2 nights – by Friday we knew that the mass was a large tumour on the right hand side of her soft palate (rather than something simple like an embedded chicken bone) but we had to wait for the biopsy results. The tumour was friable and very unlike the surrounding tissue – this was not a good sign! Part of the tumour broke off during the biospy – this gave Lou a bit of symptomatic relief.

At the time, Lou was still recovering from MRSA, so she was nursed in isolation – she was not well cared for – when we got her back the fur around her bottom and thighs was matted where she had leaked urine and some faeces but hadn’t been cleaned up – we were not impressed.

I learnt that:

  • I should be more decisive – I dithered, along with the vet, about whether/when to do an endoscopy – not that there was a clinically significant delay…..this time!
  • I took basic nursing care in hound hospital as a given, but I was wrong – I need to very explicit about what I expect from the vets and put it in writing.
  • I don’t like irrelevant phone calls – the specialist, Tom, was very sweet and rang me several times a day to reassure me and tell me what he was about to do – I just needed to know what he’d actually done and what the results were!
  • There is an uneasy relationship between specialists and generalists – the specialists tend not to believe anything they’re told by the local vet so repeat costly tests in order to satisfy themselves of the veracity of the results. This seems to be endemic/cultural (apart from Poppy’s excellent neurologist, Clare Rusbridge, who has none of these pretensions).
  • Annoyingly they only did a part CT instead of a whole body CT as agreed. It is a frustrating thing with specialists.

W/C 7th May

The Bank Holiday delayed the biopsy results but by Tuesday we knew that Lou had cancer – an unusual presentation of a lymphoma – not at all what the specialists were expecting. Lou’s case was referred to the RVC’s oncology team, who ordered more tests on the biopsy samples. By Thursday we knew that she had an “intermediate high grade B-cell lymphoma”.

Lou and Poppy getting to know each other – both were is their best health here!

“High Grade” means that the cells are very abnormal and is an indication of how aggressive the cancer is; a “B-cell lymphoma” is a cancer of the B-cells which are present throughout the lymphatic system and are responsible for manufacturing antibodies to fight infection.

We were devastated when we got the news – lymphoma seems to come from nowhere, develops quickly, and, untreated, generally kills dogs 4 – 6 weeks after diagnosis. However, unlike some canine cancers, lymphomas respond well to treatment (the cells are very sensitive to chemotherapy).

I learnt that:

  1. Lymphoma needs FAST action – they grow fast and kill quickly – we’re so lucky that we spotted Lou’s so early (hard to miss in her throat though!)
  2. Lymphoma is treatable, with a good chance of a meaningful remission
  3. This is a useful information site: http://www.caninelymphoma.net/ – from the descriptions given, Lou, of course, seems to have the rarest form – extranodal lymphoma
  4. Chemotherapy is not used to cure cancer in dogs – they cannot use doses high enough because the side-effects would be prohibitive – the aim is a meaningful remission

Week Commencing 14th May

Last week, the RVC oncologists gave us an appointment on Thursday 17th May – it was a very long week – Lou’s tumour was growing at an alarming rate. By the time we got to the oncologist her breathing was rasping and laboured; swallowing was very difficult and it was an effort to mince her food finely enough to tempt her appetite and keep her hydrated. Lymphoma dogs apparently lose weight rapidly – Lou had already lost over 3kg. By the time we got to the oncologist we felt that she only had days to live – we would have had to call it a day because we were so frightened that the tumour would suffocate her to death – we simply could not allow that to happen.

Knowing that we had an appointment with the oncologist, we asked our local vet earlier in the week whether he thought Lou was well enough for the rigours of cancer treatment. He thought that part of her long-standing malaise might have been caused by the cancer and that treatment would make a significant difference to her wellbeing. Our local vet was very pro- chemotherapy.

On Thursday morning, Lou was admitted for more tests and an ultrasound scan – we saw the oncologist for the results later that day.

The results confirmed that Lou had a very unusual form of lymphoma and, miraculously, it was isolated in her throat neck and was not active in any other lymph nodes or body organs e.g. spleen/liver. This meant that her chances of a meaningful remission was greater than with generalised disease. The oncologist recommended an intensive 8-week course of chemotherapy and referred us to a radiation oncologist for radiotherapy. We had given consent for the chemotherapy to be started immediately. The chemotherapy includes regular steroids – this meant that Lou would need to come off the anti-inflammatories that she was taking for her arthritis. I was very worried about this – the last time we withdrew her anti-inflammatories she was in screaming pain within 36 hours. We started her on an alternative painkiller (Gabapentin), that was, at the time, working well for Poppy – the vet also reassured us that the steroid would also act as an anti-inflammatory.

Lou’s chemotherapy regime involves a weekly injection of Vincristine with Cyclophosphamide and steroid tablets every other day.

What I learnt:

  1. Steroids are used to reduce the body’s immune reaction when it is flooded with cancer cells that have been killed by the cytotoxic drugs
  2. If Lou did not respond to treatment, or suffered from unacceptably severe side-effects, then we could call it a day at any time
  3. Chemotherapy injections are very expensive – as well as the drugs and administration, there is also the associated, essential, blood tests

Week Commencing 21st May

When this photo was taken we knew that Lou had a tumour in her mouth but hadn’t had the definitive diagnosis..

Lou responded well to chemotherapy – no vomiting or diarrhoea – the usual side-effects. The combination of steroids and gabapentin and tramadol (strong morphine-like painkiller) have been much more effective at controlling her arthritis pain than I expected. However she was very “up and down” – the local vet reckoned that this was being caused by spikes of fever caused by the massive release of pyrogens (fragments of dead cancer cells which trigger an immune response) – we couldn’t treat this with drugs, though the vet suggested a fan to cool her down. Predictably, Lou decided that she didn’t like the fan, so the intermittent fevers were just something she, and we, would have to live with. She was panting a lot – we found out later that this is a common side-effect of steroids.

We were amazed to find that Lou’s swallowing was back to pre-tumour normal and that her snoring had stopped by Monday – within days the chemotherapy had shrunk her tumour to a sub-clinical size. We quizzed the oncologist about it – we couldn’t believe it! She confirmed that it was a positive sign – around 10% of lymphomas do not respond to chemotherapy – if Lou’s tumour had not been sensitive to the drugs regime she would have been much worse.

When Lou had her second dose of Vincristine on Friday our local vet gave us the unwelcome news that chemotherapy would make Lou’s wee and poo quite toxic – we’d need to be very careful handling any accidents in the house and double bag the poo that we picked up when we were out and about. Fortunately the drugs/metabolites are apparently neutralised by soil so we didn’t worry too much about the garden.

What I learnt:

  • The right chemotherapy can work much faster than I expected
  • Oral steroids are much more effective at controlling arthritis than I expected
  • Lou needs a weekly blood test  (white blood cell count) 12 hours before her Vincristine injection – this means at least two vet visits per week – hard work for me and for Lou.
  • Chemotherapy makes dog wee and poo quite toxic – though they’re not that nice to start off with!!!
  • I’m glad that we gave Lou a chance at life
  • We are lucky to have the resources (financial, emotional and practical) to sustain Lou
  • Check the RVC’s bills, they double charged us for 3 items, it took weeks to resolve – this did not help ambient stress levels!

Week Commencing 28th May

Lou was still doing well, but Friday’s Vincristine injection seemed to knock her back for several hours after administration. The vet had said that normally you couldn’t tell a chemotherapy dog from any other dogs in the surgery , but it seems

By this stage, Lou has had lots of scans (hence the shaved bits!) and has started her chemotherapy but not her radiotherapy – she’s having a good day here…

that Lou is quite sensitive to treatment. There’s nothing obvious – she was just low and lethargic after the injection, but she seemed to recover within 24 hours.

I lose track of the time but it was around now that Poppy developed urinary incontinence – Lou was to join her a week or so later! It was understandable (and nothing to do with poor house-training) – Poppy was drinking excessively because of kidney disease; Lou was drinking excessively because of steroid treatment – It’s hard to measure their intake but I had to put two x 1 litre water bowls down if I needed to go out at all, and I was refilling them at least twice a day. Boots (the chemist!) do a useful range of absorbent bed pads, which were useful, but washing wet dog beds became something of a morning ritual. Luckily the incontinence was treatable using a drug called “Propalin” – this worked amazingly well and instead of having two old ladies constantly (and unconsciously) leaking urine we were down to the odd accident now and then.

Richard went to see the radiation oncologist, Jerome, this week – he made a convincing case for radiotherapy – we discussed it, asked some more questions, then booked Lou in for the first of a two week course of radiotherapy on 11th June (after the jubilee!).

What I learnt:

  • Sod’s law dictates that if a rare reaction is possible then Lou will probably get it – she certainly didn’t have the common effects! This was to become relevant after radiotherapy!
  • Lou’s cancer is so localised that radiotherapy might achieve a local cure so that the cancer would not recur in her throat
  • There is some evidence that radiotherapy combined with chemotherapy can give an extended remission – 12 to 18 months minimum for this type of lymphoma – of course that evidence comes from cats because it’s so rare in dogs!
  • Dog nappies are cheap/easy to buy on the internet – we’ve not had to use them yet but it’s good to have them

I’ll continue the story in the next post – it must sound like a tale of woe and hard work so far, but the good hours pay for the bad days – in the fullness of time the good days will pay for the bad hours! Every time there was a new situation/symptom we have learnt from it and used that experience to deal with the next new thing!

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