Into the Light My Friend

Cody Hansen April 26, 2001 - January 22, 2013

My last day with my beloved Cody was as perfect as it could have been. The night before he had been in so much pain that he need an injection of morphine to go to sleep. We had slept soundly, together curled up on a mattress I placed on the floor. I woke up early with a sense of dread mixed with nervous anticipation; was it really going to be the day that I said good bye to him? When owners ask me how will they know when it is time, it always sounds a little trite to respond with "you will know," but most of the time if you allow yourself the opportunity to listen to your heart and read your pet's body language you do know when it is time. I knew I wanted to give him the gift of happiness and peace and a pain-free, anxiety-free passing. I knew I didn't want to end up at the emergency hospital in the middle of the night with him in a panic and me in tears with someone I didn't know. I had the opportunity to guide the situation. I reached out to people I felt might be able to help and was so grateful for the response. By noon I had a plan that I was comfortable and at ease with. That morning we took a walk in the open space by my house and Cody played fetch in his wheel chair. What a gift that wheel chair was because it allowed him to do the thing he loved best - chase the ball!

The cat gets in on the action

The other necessary thing do to that morning was pass a urinary catheter to empty his bladder. The night before I had pulled the urinary catheter that had been placed at the hospital because it might have been part of his discomfort. Passing a urinary catheter is a relatively easy thing to do, but does require sterile technique and expertise. Most owners with paralyzed dogs learn how to express their pet's bladder with external pressure and they get quite good at it. Repeated catheterizations are not ideal because the likelihood of a urinary tract infection is quite high. Basically there's no great solution for a dog that cannot urinate. There are surgical ports that can be placed that may or may not be appropriate considering the patient, owner, and circumstances. The reason the dogs cannot urinate is because the nerve that controls the relaxation of the bladder sphincters is damaged. Cody's was definitely not working properly.
We spent the morning playing fetch in the sun. My cat was happy to join us outside, and although did not appear interested in the ball, had a good time frolicking in the sun with Cody and me.

Playing ball in his wheel chair

Cody had an appointment to swim that afternoon, but before we went swimming I took him to the emergency and specialty hospital to get his bladder emptied again and say good-bye to his oncologist. Empty bladder, big hugs, tearful sighs and we were on our way.
Cody got to swim for an hour and a half. We played classical music and took pictures. My big beautiful pup was at ease in the water. He was suited up in a float coat and float rings around is neck and pelvis, so all he had to do was dog paddle, letting his back legs just hang. His concentration on the ball was so focused, so intense that not even a squirrel running through the room would have broken his stare. It was a delight to watch him in his element. I recall his very first swimming lesson when he was just a puppy. There was about 5 minutes of panic and adjustment, then we couldn't drag him out of the pool! Get near water and Cody would be diving in.
Then it was time to leave the pool. Again with the big hugs and tearful good-byes we made our way home.
Cody was put to sleep on the lawn that he had played ball on so many times. He was surrounded by loving family members. I held his head in my arms while he held onto his ball. I buried my face in his soft fur and whispered to him how much I loved him and that he was a good boy.
My grief will ease with time I know, but there are many things that trigger the memories. It is important to allow yourself to grieve for as long as it takes. My family and friends have been a wonderful support during this difficult time. His ashes and mementos are on a shelf with my other pets that have passed away. I hope that they are all playing together in that place where pet's souls go. I look forward to playing with them again.

This is the thank you card that I made to send to all the wonderful people who helped me and Cody.

3x5 Folded Card

View the entire collection of cards.

A Turn for the Worse

Cody's wheel chair was a godsend, but he was having trouble urinating in the cart. I would put him in it and he would posture to pee, but only little squirts of urine would come out. I figured that the pressure from the leg harness was occluding his urethra because when I took him out of the cart he urinated fairly well. So I set to work adjusting the cart; up, down, legs bigger, legs smaller... you name it that darn cart got taken apart and put back together multiple times per walk. No amount of trouble shooting seemed to make a difference. And, an email to the wheel chair company about the problem was, well...rather disappointing to say the least. "I'm sorry to hear that the dog is having a trouble using the bathroom." Gee thanks. Needless to say, I'm not impressed with the customer service at Walkin' Wheels.

He got his cart on Friday and could mostly walk on his own, he was just unable to get up by himself. By Sunday he was unable to walk; his back legs seemed to be totally paralyzed, and by Sunday night he was in a panic - dragging himself around the house, panting and very agitated. The trouble shooting began with taking him outside to pee - no luck, nothing, not a drop. Oh geesh. This meant I would have to pass a urinary catheter and empty his bladder that way. Sometimes you can manually express your pet's bladder with gentle pressure on the abdomen, but that wasn't gonna happen with my 80 lb dog with a super tense belly. No way. So it was off to the emergency room for a urinary catheterization. Yep, the bladder was huge when we looked at it with the ultrasound. My poor pup had probably not been fully emptying his bladder for about 2-3 days.

Now that Cody was definitely neurologic it was time to see the neurologist. I had set up an appointment for Tuesday, but because he couldn't urinate it was now an emergency. In this situation, if he didn't have cancer I would have assumed that he had herniated a disc. The symptoms and progression of symptoms were pretty classic for a herniated disc - progressive weakness progressing to paralysis. If this ever happens to your dog, get them to the emergency ASAP. The reason not to wait is that performing surgery in a timely manner can mean the difference between your dog walking again or being paralyzed for life.

Since my dog had cancer there was some question as to whether the problem was a herniated disc or perhaps spread of his osteosarcoma into his spine or spinal cord. The neurologist confirmed my suspicions. My options at this point were to consider some more imaging to see if we could find out exactly what was causing the spinal cord damage. We took radiographs, but they did not confirm anything. At least if there had been a bone tumor in the spine we might have seen it. Or if a disc had ruptured, the space between the vertebra where the disc is suppose to be might have been smaller (you can't see the disc itself on x-rays, because it is not dense enough). No answers yet. An MRI would have been the next step. I opted not to do an MRI. The reason was that it wasn't going to change the treatment plan. At this point with a herniated disc a pet owner needs to decide if they will proceed with an MRI with the plan being to go to surgery immediately after the MRI. Even if it wasn't the osteosarcoma effecting his spinal cord and is was just a herniated disc, the likelihood that Cody would walk again was dubious considering his concurrent cancer. He just didn't have that much time left. We went home. He with an indwelling urinary catheter, me with a heavy heart.

That night my poor dog suddenly became very painful after eating his dinner. Again, trouble shooting the situation, I figured his pain medications had worn off. He ate dinner, then refused his pill pockets (that's what I hide his pills in, and he loves them!). Situation critical! Finally I got all his medications into him with cheese! Just a quick comment here about owners and their quirks.... they love to tell vets the nitty-gritty details of what type of food they use to get medications into their dogs. We just smile and nod... So you can just smile and nod here...

It was a very traumatic night for both of us. My normally zen happy dog was suddenly sitting up with his front legs stiff, eyes wide, ears back and shaking. It just ripped my heart open to watch. After the medications started to kick in and after I did an acupuncture treatment he was able to calm down and sleep a little, but he still wasn't comfortable. A call to the ER yielded a recommendation to pull the urinary catheter in case it was making him uncomfortable. That didn't really help much. It took a trip to the ER, more medications and a shot of oxymorphone (a type of morphine) to get both of us to sleep (he got the shot, I was just emotionally and physically exhausted).

Seeing my dog in such pain made me realize that it was time to give up the battle. I did not want him to suffer in that kind of pain for a moment longer. I also did not want to wait for another crisis situation, where he would be in a panic and I would be distraught, to euthanize him. I decided that we would have a great last day doing all the things he loved doing and that he would go out as happy as possible.

Cody Gets a Sweet Ride

Cody in his new Walkin' Wheels

Yes they make wheel chairs for dogs! Because I'm in the business I forget that this fact is surprising to some people. A few days ago Cody started getting weaker in the back legs. I decided it would be a good idea to look into getting him a wheel chair. He was no longer able to get up by himself. I was having to lift up his hind end for him. Once he was up he was able to take a few steps, but then he was just falling down. I figured I would need something to save my back and Cody needed something so he could be mobile.
I should mention that I have been using a harness called the Help 'Em Up harness. This harness is really great for hoisting the rear end of your dog.

Cody in his Help 'Em Up harness

I really wanted to get the wheel chair quickly, so I asked my veterinary community for advice and was directed to Walkin' Wheels. Their web site is very easy to navigate and understand. They have created a good product that can be ordered on-line and delivered by next day air if necessary. It took one measurement and a breed description and viola I had a doggy cart on the way!
The cart is a beautiful thing! It has given Cody some freedom and the ability to chase his ball again!

The Fun Stuff!

It's all about quality of life, not quantity of life when it comes to pets. I'm trying to take Cody swimming as much as possible because it is something he really loves.

Cody with his swim coach

We are also spending lots of time just hanging out in the open space behind my house. My cat has taken to coming with us on walks also, so the three of us are just hanging out a lot these days.

Taking a walk with the cat

Emotional Rollercoaster

After our consultation with the oncologist, where I left with my head swimming with information about the various cancer treatments for osteosarcoma, I settled in to just trying to enjoy Christmas and time with my dog. Not a day went by though that I wasn't considering the options.

The decision making process went something like this:

I should take the most aggressive approach and help Cody beat this! We can deal with an amputation! We'll get a harness and even a doggy cart if we have to. I know good rehabilitation centers where we can get physical therapy. Cody won't miss his leg! I checked out Tripawds.com, a great web site and blog site for canine amputees. We can do this! The chemotherapy will stop the cancer in it's tracks! I gathered surgical estimates and thought about scheduling surgery for early January. His surgeon was going to be on vacation, so we would have to wait; bummer because the sooner the better. Oh wait... he has chest mets, and he is orthopedically challenged in the other 3 legs... maybe an amputation isn't a good idea.

This might be a good place to show some pictures of the hardware my dear pup is carrying around. Ya see Cody drew the short straw, so to speak. He got cancer in his "good" back leg (the left). He has no hip joint on the right because of a failed total hip replacement when he was a young dog. Since that time he has never really used his right hind leg much except to help with balance. Now with the left leg being bad, he has been forced to use the right leg, but it's not very functional

Ok, so amputation is out. That means palliative radiation and injectable chemotherapy. There! A decision. A plan. We can move forward. I scheduled appointments for chemotherapy and radiation for early January.

Throughout this process I had been talking to every veterinarian that I know about the options. Just to not leave any stones unturned I reached out to another expert. This veterinarian used to work at University of Florida doing stereotactic radiosurgery (SRS). He is now in my neighborhood and I have a good fortune of being able to refer cases to him. We discussed Cody's case and he felt that Cody might be a candidate for SRS. He would contact the head radiation oncologist at Colorado State and have her call me. Wow! I was thrilled. This procedure is as good as amputation, but it's radiation so Cody would get to keep his leg and we would kill the tumor!

At this point things got really complicated. I contacted Colorado State about a consultation. I probably used all available technologies that weekend to try to get Cody's records and radiographs to the proper people.  Fax, e-mail, text messages and phone calls! Saturday and Sunday went by.... 2 days are agonizing when you're trying to plan something like this. Monday morning (Jan. 7th) I spoke to the chief radiation oncologist. She hadn't seen Cody's radiographs yet.  She thought that SRS might give Cody about 6 months. Unfortunately they were overbooked and didn't have an opening until the 16th. Of course that is a really bad week for me to leave California because I have a work commitment that I cannot cancel. We discussed the option of driving him out and leaving him for treatment, then coming back to pick him up. Ok, I figured I could do that if this was really going to be the right thing for Cody. The price tag for SRS is approximately $5500. With that and the logistics I wanted to be super sure that this was a good treatment plan. The chief radiation oncologist called me back that evening with some bad news... she had the opportunity to look at Cody's radiographs and felt that with the metastases in the chest, Cody probably has about 2 months, and therefore didn't recommend I make the trip for SRS.

I was devastated. This meant returning to the palliative radiation + chemo plan. It felt like I was giving up. I cried for 3 days. It didn't help that Cody was sick from his first dose of chemotherapy. He stopped eating and started vomiting about 2-3 days after chemo. He bounced back and seemed really good after radiation. I decided not to continue with the injectable chemotherapy and try oral Palladia (an oral chemotherapy). However, now his neutrophil count is low, so we cannot start Palladia. When an animal is getting chemotherapy, the bone marrow is suppressed and doesn't make as many white blood cells as it normally would. The neutrophil is one of the several different types of white blood cells that fights infection. When the neutrophil count is low the animal is at risk for developing infections that can be life threatening. We have to wait until his neutrophil count comes back up before we can start Palladia.

Cody had more chest radiographs taken on Jan. 9th when he went for his first radiation treatment. Since we had been making big decisions based on his chest x-rays (not going to Colorado) we thought it might be worth checking to see what things looked like now since his last x-ray was early December. It had been a month and I again got my hopes up that if things didn't look worse that I might still consider going to Colorado. Well, unfortunately things looked worse. The nodules are bigger and easier to see and now Cody has some fluid accumulation around his lungs (pleural effusion).

Sometimes the decisions just get made for you in a sense. I'm resigned to the fact that my dog has osteosarcoma and it is a bad cancer and as far as I know there is nothing I can do at this point to cure my dog. Now I need to take some attitude lessons from my beloved dog. Live in the present and enjoy the little things! We are doing what we can to make Cody as pain-free as possible and doing all the fun things he loves to do!

Oncology Consultation

My happy Christmas Dog!

What's the next step after receiving the bad news that your best friend has cancer? Well after crying your eyes out, you gather your wits and schedule an appointment with an oncologist. I recommend this even if you don't think you will pursue any further treatment. Even if your general practitioner is the greatest on the planet I still think the additional information you will gain from a visit to the oncologist is invaluable. They went through 4 more years of special training to become experts in this field and are the most up to date on the latest treatments. They may also know of a study going on that your pet may be eligible for. They will also give you a prognosis in months. Which you may want to hear and it may help guide your decision making process. Personally I am not a huge fan of the "months to live" statement because all dogs are different and that can give one a false sense of hope or despair. But it does give one an idea of the effectiveness of the various treatments.

In the case of osteosarcoma the most aggressive approach to treatment is amputation of the effected limb and injectable chemotherapy. This will buy your dog 10-12 months.

If your dog is not a good candidate for amputation, you can consider a limb spare procedure depending on where the tumor is. There is a surgical procedure where they remove the tumor and replace it with a plate and/or bone graft. There is also a special type of radiation called stereotactic radiosurgery that will kill the tumor. This type of radiation is only done in a few places. Colorado State and University of Florida are two, there may be more in the USA that I am not aware of. A limb spare procedure plus injectable chemotherapy will buy your dog 10-12 months.

Just amputation without chemotherapy gains an average of 3 months.

Palliative radiation is a type of radiation that just relieves the pain, but doesn't kill the tumor. Palliative radiation plus injectable chemotherapy plus a bisphosphonate (a drug that helps build bone strength) may give your dog about 9 months.

All these projections are based on a dog WITHOUT evidence of metastases in the lungs. Unfortunately when there is gross evidence on x-rays that there are nodules in the lungs you can subtract about 3-4 months from all these estimates.

So what to do? With Christmas coming there is going to be a delay no matter what procedure we choose.  I need some time to digest the information and make a decision. Until we decide on the next step I am controlling Cody's pain with the following drugs: Tramadol (a pain killer related to morphine), Previcox (a non-steroidal anti-inflammatory), and Gabapentin (a seizure medication that is thought to help with neurologic pain). Cody has also been wearing a pain patch of Fentanyl since his biopsy procedure. Fentanyl is 100 times stronger than morphine. He seems pretty comfortable with the patch on, but I hope I can do something more to treat the pain.

Cancer Returns

It has been a while since I updated Cody's blog because, well... you know the saying "no news is good news!" He had been cruising along without problems until September, 2012. In September he started having intermittent non-weight bearing lameness of his left hind leg. It would get better with chiropractic adjustments and laser therapy and then he would stop using the leg again. I took radiographs (x-rays) of his left stifle (knee) and chest in September and didn't see anything of note on the x-rays. I even had the chest films looked at by a radiologist. I did not have the stifle film looked at, which I regret now because it turns out there was a suspicious area present, even in September. Note - if your veterinarian recommends having the radiographs reviewed by a radiologist say yes! They might catch something your general practitioner missed.
In early December I took more x-rays because the problem was becoming more frequent and not resolving with any treatment or after adding on more pain medications.
Well, bummer of all bummers, this set of radiographs showed a suspicious area on his femur AND if that weren't bad enough, his chest x-rays showed nodules that were not there in September. Knowing that those sort of patterns on radiographs usually mean osteosarcoma I dissolved into a sobbing puddle of mush and just hugged my dog like the world was ending. Of course I held out some hope that the problem would be a lesser evil like a fungal infection or less aggressive cancer.

The tumor is the area that looks "moth-eaten" at his distal femur.

Cody had a bone biopsy done on December 11, 2012. The results were chondroblastic osteosarcoma, low grade. It isn't much reassurance that the tumor is "low grade." An osteosarcoma is an aggressive bone cancer and usually by the time we (veterinarians) identify it on radiographs there already is microscopic spread to the lungs. Cody is already showing nodules (small masses) in his lungs. The thing is, in his case, we can't be sure just by the radiographs that the nodules are metastases from his osteosarcoma. They could be recurrence of his previous lung cancer or they could be metastases from his osteosarcoma. Could we biopsy them? Well, it would be difficult and require a CT scan and probably wouldn't really change anything we do at this point.

You can make out small round densities (lighter areas) that are the nodules.

One Year Post-Op

I have really good news to share. Cody is more than 1 year out from his diagnosis of lung cancer. Yay!

We have done radiographs and blood work at 4-6 months intervals and so far everything appears to be clear and cancer free. He still has trouble with his arthritis, but you wouldn't know it when you pull out the ball! He still chases it with gusto! The dog door gives him a little trouble these days too.

Diet and supplement update:
I started him on a commercial frozen raw diet mixed with a high quality dry food. The raw diet I am using is either Nature's Variety Instinct or Stella and Chewy's. I mix in just a bit of Wellness Core, Reduced Fat. I also steam veggies and add them when I have time. I found this diet to be easy for me to fit into our busy lifestyle and he seems to be thriving on it. His poops are very small - I'm taking that as a good sign that most of what is going in is being digested and utilized.

Current supplements & medications: Adequan injections, Royal Coat (fish oil & borage oil, by Ark Naturals), Lubrisyn (hyaluronic acid), Veterinary Immune Tabs (Ramaekers Nutrition), Vitalzym (enzymes), probiotics, Apocaps, Pain Plus (Resources), Dasuquin, Previcox, Heartgard Plus and Comfortis. Oh and occasionally Gas X!

6 Month Check Up

Wahoo! Last month we took chest x-rays and did blood work to see how Cody is doing. No obvious evidence of any cancer. Yay!
The anti-cancer regimen has morphed and changed over time. I am now cooking for Cody sporadically as time allows and I tend to keep it really simple. I'll boil chicken and steam veggies. Now and then I will throw a bunch of green stuff (parsley, kale, brussels sprouts, etc.) into the food processor and sprinkle it on the food. The consistent base of his diet is Wellness 95% canned meat, and Wellness Core, Reduced Fat kibble. I usually will mix some kibble in with the homemade diet, just to keep his tummy from getting upset. Because I travel a lot and sometimes he comes with me or sometimes I have someone else taking care of him I've opted to keep an easy feeding option like kibble and canned food on hand.

I've also recently changed his supplements. I've gone back to giving him the Veterinary Immune Tabs from Ramaekers Nutrition. In a previous post I mentioned that there was some concern over the anti-oxidant super oxide dismutase. I think that the amount is not very much, so I'm not going to worry about it. For the last few months I've been buying Transfer Factor and K9 Immunity separately. The Veterinary Immune Tabs contain both of these plus vitamins, minerals, amino acids, probiotics, some essential fatty acids, joint supplements, and tumeric. This supplement is costing me about $174 a bottle and it lasts Cody about 1 month (the recommended dose is 1 tablet per 20 lbs). That is my cost plus shipping. If you purchase this product through a veterinarian it will probably be about $200+ a bottle. You can also contact Ramaekers directly and order it directly from them which may save you a little money.
I am still adding in the Apocaps - Dr. Dressler's product. I've weaned Cody off of some of the other pain and joint supplements to see how he does. I've stopped the Dasuquin and Pain Plus, but have continued to give him Lubrisyn (an oral high molecular weight hyaluronic acid). He still gets Previcox, a NSAID, every other day. I make sure he is getting digestive enzymes and probiotics to help with digestion and keep his gut healthy. So far we haven't had any bad bouts of diarrhea in a while (probably because I haven't gone crazy with home cooking!).
Tonight he got a treat. I decided that buying a whole Rocky organic chicken would be the least expensive option for chicken. I roasted the chicken with broccoli and zucchini. The easy part is cooking it, now the fun will be deboning it all!!
Instructions: Pre-heat over to 400 degrees. Wash the chicken, pat dry. Put chicken in roasting pan, spread veggies (in this case broccoli and zucchini) around the edges and stuffed inside. I also kept the livers and neck and placed them in the roasting pan along with the vegetables. Add approximately 1/2 cup water. Cover and roast for approximately 1 & 1/2 hours or until the internal temperature of the chicken is 170 degrees. Remove skin and debone. Serve! Cody says thanks! Yummy!

Home Cooking - You Can Do It!

Oh good grief... the home cooked diet is the best option I know, I know...but honestly folks getting it down to a routine takes time. If you are struggling, don't worry I sympathize. I think there needs to be a support group for owners who make home cooked dog food (there probably is I just haven't done the internet search yet!).

I was at the store today asking the butcher about the meats they carry. Well you should have seen the look on his face when I told him the organic/natural, antibiotic free, chemical free, etc. etc. meat I wanted wasn't for me. For my dog please....and can you order some chicken necks too please? After I explained that my dog has cancer he stopped looking at me like I was totally crazy.  Turns out he had a Boxer a while back.

Today's batch was a master piece if I must say-so myself.  I did buy some shiitake mushrooms to add, but after Cody spit out the uncooked sample I gave him, I decided that at $12.99 a pound the shiitake mushrooms will be eaten by me, thank you very much.

The Dog Cancer Survival Guide is a good read folks

It has been three months since Cody's surgery. You would think that in three months I would have my act together and have Cody on an established anti-cancer regimen, but no....I'm still working the kinks out. And I don't even have all that personal family stuff like kids and a husband to deal with!! Personal life aside, it is hard to find enough time in the day to accomplish everything on one's to-do list.

I did have a phone consultation with Dr. Demian Dressler, the author of the Dog Cancer Survival Guide. I will share my notes with you from our conversation. First I would like to mention that one of the first comments Dr. Dressler made to me after he asked me if I had his book was "you've probably skimmed through some of it, but haven't actually read it yet, right?" Bingo! How does he know me so well? Then over the next hour and a half he basically proceded to give me the abridged version of the book. Well geesh, I could have just saved myself $300 bucks by reading the book! Not really. It was very worthwhile being able to speak directly with Dr. Dressler and ask him questions that related specifically to Cody. I would still recommend reading the book before setting up a consultation!

The gist of the conversation:
Get Cody on a home-made cooked cancer diet.
Minimize the amount of anti-oxidant supplements.
Supplement with omega 3 fatty acids only, do not add omega 6 fatty acids (they already get enough in the food).
Give Apocaps.
Give K-9 Immunity.
Give transfer factors.
Give probiotics and digestive enzymes.
Optional: give a trace mineral supplement (he recommended Beres Drops) and give modified citrus pectin.

The nitty-gritty: Diet
The Dog Cancer Survival Guide provides guide lines and a recipe for a home-cooked diet. There is a link to the diet on Dr. Dressler's blog: http://www.dogcancerblog.com/

The nitty-gritty: Anti-oxidants
You may have heard that taking antioxidants is good for you and your dog, right? Why? Well the theory is that antioxidants bind with free radicals preventing them from doing damage to cells in your body, thus causing cancer, heart disease, and general overall deterioration of the tissues of the body. All healthy people and pets should be taking antioxidants and enjoying the protective effects. People and dogs who are getting chemotherapy should not, in theory, take antioxidants. This is because when we give chemotherapeutic drugs we are creating free radicals in an effort to attack the cancer cells and kill them. Antioxidants theoretically block the action of the chemotherapy. Dr. Dressler has a good discussion on his blog (http://www.dogcancerblog.com/anti-oxidants-versus-pro-oxidants/) about antioxidants and pro-oxidants.  In summary he says: " Thus, before true clinical cancer actually develops, you want antioxidant effects, not pro-oxidant ones, in general. In contrast, after cancer clinically develops, one could choose pro-oxidants as the anti-cancer weapon. " There is a lot of debate over this subject so Dr. Dressler's approach is to at least try to separate supplements that are pro-oxidant, such as Apocaps, from supplements that have an antioxidant effect (K-9 Immunity). Hopefully we can get the best of both worlds with this approach? I don't think we really know yet.

I had Cody on a very good quality supplement called Veterinary Immune Tabs by Ramaekers Nutrition (http://ramaekersnutrition.com/vitpro.html). Dr. Dressler was concerned about the oxidant, superoxide dismutase (SOD) and recommended I discontinue the supplement.  For now I've stopped giving it, but I'm thinking the amount of SOD in this supplement is not very much and I may consider giving to Cody again. Especially if it works out economically.

To be continued with the nitty-gritty on Apocaps, K-9 Immunity, transfer factors, and omega 3s.

Support Groups

Cancer...the big 'C'... it conjures up all kinds of emotions and seems these days we are all touched by this scary disease in some way. A family member, a friend, your dog, your friend's mom....I'm willing to bet the degrees of separation between you and cancer is 1 or 2, certainly not 6.

There are people working on the question of why. There are people working on the question of when. There are people working on the questions of what. There are people working on the question of how. How do you deal with the diagnosis, the treatment, the emotional fall out? Well, there are resources and with the good 'ol internet most are just a few clicks away.

Recently a blogger reached out to me and asked me to post something about cancer support groups. Here is his post:

Support Groups Take Away the Loneliness

When you are facing difficult times, it helps to talk with people who understand what you are going through. Cancer, in particular, is a lonely road to travel that not everyone can relate to. Whether you are recently diagnosed or a survivor who has marked the 5-year milestone, support groups can help you travel this path and take away the feelings of isolation.

Tell someone you have cancer and they are sympathetic. They will tell you they’re sorry, they’ll say they’re praying for you. But they really don’t want to hear about how your bowel movements have been affected and how every stray hair now leaves you’re worried about the ones that remain.

Talk to another cancer patient, however, and you have someone who can relate and truly understand. They’ll share their experiences, assure you that what you’re going through is normal and help you find effective coping strategies. More than sympathy and prayers, you’ll get information that you can really use, and a friend who might even help you find some laughter in this difficult time.

The support groups can meet in person or they can be online. The method will depend on what works for you. Whether you are diagnosed with a common cancer such as breast cancer and chat online or going through a rare cancer like mesothelioma and meet in person, the therapeutic effect is the same: You won’t feel as alone anymore.

Support groups can also provide each other with valuable resources, referrals for doctors or tips on how to handle the debilitating exhaustion that sets in after treatments. Because these other people know exactly what you’re going through, they have a good idea of what you are looking for and can help you find it. They know which doctors have the best bedside manner and will share that information with you. They also know which clinics are using the most ground-breaking procedures for treatments and will guide you to that information, as well.

There is hope for anyone struggling with cancer. You don’t have to travel this road alone and you don’t have to isolate yourself to get away from the sympathetic glances that start to hurt as much as the diagnosis. As a survivor who lives in constant fear of a relapse, you can find comfort and relief in support groups. People in all stages of the process can find healing and help by sharing their stories and offering help to others. Find a support group today and get involved so you can say good-bye to the suffocating isolation.

By: David Haas

To Chemo or Not to Chemo

It has been about a month since Cody's surgery. He is doing well. The incision is healed and his hair is almost totally grown back in. No more evidence of grey in the muzzle! I'm not sure what I saw before.

I've slowly been gathering information about what types of things I can do to help prevent this cancer from coming back. I'm speaking to 3 veterinary oncologists and you might be able to guess how that is going! Three opinions!! Well not that differing actually. They all recommend metronomic chemotherapy. This web site has a very good explanation of the process and the theory behind metronomic therapy http://www.veterinarycancer.com/metronomic_chemotherapy.html

Basically it is low doses of chemotherapy given over an extended period of time. This therapy is thought to reduce the toxicity of the chemotherapeutic drug and also to inhibit angiogenesis. What the heck is angiogenesis??? Just like it sounds folks, production of new blood vessels. Cancer needs blood to grow. Shut down that pathway - no cancer. There's a great talk by William Li on angiogenesis: http://www.ted.com/talks/william_li.html. Check it out.

The recommended protocol for metronomic therapy is typically a non-steroidal anti-inflammatory (NSAID) plus a chemotherapeutic agent. Two of the three oncologists I've spoken to have recommended I keep Cody on Previcox (that is the NSAID I'm giving him for his arthritis) and add in Cytoxan (also known as cyclophosphamide). If a dog is not already on a NSAID the drug of choice is piroxicam which has been studied extensively for its benefits in treating transitional cell carcinomas in dogs. I am assuming (I haven't asked the oncologist yet) that they have found that all NSAIDs seem to have similar effects on cancer and that is why it doesn't make a difference which NSAID you use.

Now Cytoxan can be a little scary. The drug can cause a hemorrhagic sterile cystitis and/or bone marrow suppression. To prevent the cystitis you basically need to get your dog to drink a lot of water and urinate a lot. Not usually an issue with Labradors, thank goodness! To monitor for bone marrow suppression it is wise to have a CBC (complete blood count) performed every 1-2 weeks. Humans taking this drug are likely to lose their hair. This can happen in dogs, especially those that have continuous hair growth (Poodles).

I'm going to dig around a bit more and I'll let you know what I decide. I guess my biggest fear as a pet owner is that if I don't do the metronomic chemotherapy and the cancer comes back will I be kicking myself and wishing I'd done it. If the cancer doesn't come back well then I'll be singing the praises of all the holistic therapies I've chosen. If the cancer comes back even with doing all of the above well then I guess at that point you just have to let nature take its course.

Identification of the alien in Cody's chest

Well folks, the alien is out and the results are in! It is the best news we could have hoped for...at least for cancer. It is a "well differentiated papillary bronchogenic pulmonary adenocarcinoma, grade I, excision complete".  The terms "well differentiated," "papillary," "bronchogenic," and "pulmonary" are descriptive terms. Read as: a protruding tumor of mature cells of the lung that orginates from the bronchi. Adenocarcinoma is a cancer of an epithelium that originates in glandular tissue. Tumor grading is a system used to classify cancer cells in terms of how abnormal they look under a microscope and how quickly the tumor is likely to grow and spread. Grade I tumor cells look almost normal and are less likely to spread. A complete excision means that the entire tumor was removed and did not appear to extend beyond the margins of the tissue that was sent to the lab.

There was also no evidence of cancer in the lymph node that was removed and sent to the lab. Good.

Better news would have been something totally benign like a granuloma, or abscess. But at least we are dealing with a cancer that has a lower probability of having spread. The oncologists have told me that we should always expect there to be some microscopic cancer cells lingering and therefore they do recommend chemotherapy.

At this point I am holding off on chemotherapy. I feel fairly confident that we got all of the tumor and that if there are stray cells floating around that we can deal with them another way. I've decided to investigate alternative therapies.

How is the dog? Cody is great! Back to urinating and defecating normally. Happy and really started driving me crazy about 10 days post-op asking to play with his ball. His incision is healing well. We just got a new 3B cold laser at our practice, so I've been using it to treat the surgical scar. The photo is from 13 days post-op and day 1 of laser treatment.

The long scar is the incision where they went into the chest. The 2 smaller parallel scars is where the chest tube was located.

I also noted grey hairs in Cody's muzzle for the first time today. Coincidence? Or is the grey the body's response to the recent stress (both from the cancer itself and the surgery). Humm...

How much?

Cody is home safe and sound. Our first night home was a little rough. Since IV fluids are standard procedure during and after surgery I expected Cody to have to pee, but holy urination Batman! He peed and peed and peed and dribbled and peed some more. Stop reading if you get grossed out easily...

I just couldn't say no to my boy on his first night home, so I allowed him to sleep with me. Oh joy...we both woke up in a puddle of urine. Now that's love for ya! I was very tired, exhausted actually from helping out a family member who is in the hospital (that's another story) so I pretty much slept through the enlarging wet spot. I did wake us both up twice to change bedding and go outside. The good thing is that he seemed happy and pain free the entire night.

Today he has continued to need to urinate very frequently. I'm starting to wonder if he might have a urinary tract infection from the urinary catheter that was placed while he was in the hospital. It is not uncommon for a UTI to develop after catheterization. I'm also wondering if it is not being caused by the pain medication (Tramadol) that he is on. We'll see how he does tonight.

Because you might be curious about what I paid for his surgery I'll share. The final bill came to $4122.51. That was with some pretty good discounts. So if one is not in the veterinary field and doesn't qualify for professional discounts you might expect to pay almost $5000 for this surgery. Yikes! That is significant. Now, I live in a somewhat affluent area in California and I sought out a surgeon and hospital that has a reputation for "gold standard" of care, so that may have been a factor in the final cost. I just wanted to share this number because many people do not realize that the cost to care for your best friend can hit the five grand mark pretty quickly. I recommend pet insurance folks. It might make a huge difference for your animal friend who relies on you to protect and care for them. Nothing is more sad to me as a veterinarian than owners who choose to euthanize based on finances. It is just wrong in my opinion. And this is just my opinion as a private person. As a veterinarian I have to walk a finer line and try to counsel my clients as best I can to help them make a decision that they can live with. I live by the old saying that you can't put a price on love, or is it life? Well both! My buddy has been by my side for 10 years and I've made a commitment to him so what the heck. It's only money right? You can't take it with you!

Future topic: poop and diet again! And watch for a post with the results of the histopathology...
Thanks for reading.

Post Op Update

As far as lung tumors go Cody's was text book perfect - exactly what a surgeon would want to work with. Everything went well in surgery. Cody was a rockstar anesthesia patient; meaning all his vitals (temperature, blood pressure, heart rate, etc.) stayed within the parameters one would want while under anesthesia. His tumor was very well circumscribed (sort of encapsulated; think of a billiard ball) and very distal (at the far end of the lung); two factors that help with removal. The closer the tumor is to the hilus (think of the hilus as the "top" of the lungs - the place where everything starts branching) the harder it is to remove. Cody's tumor was in the right caudal lung lobe far away from the hilus. The surgeon removed the entire lung lobe. Lucky for Cody he's still got two lobes on the right side. All in all he really didn't loose much lung capacity.

The surgeon had a hard time finding the lymph node because it was small. This is a good thing. She did find it eventually, removed it and reported to me that it was about the size of a bean. This is promising. We're hoping that a small lymph node is consistent with no cancer in that lymph node. Cross your fingers.

The entire lobe plus lymph node have been sent to the laboratory. Now we wait on the results.

Cody had a chest tube in after surgery. The tube is placed into the chest cavity to help remove air that gets into the chest cavity during surgery. After closing up the chest all the air that got in while the chest was open needs to be removed to create negative pressure so that the lungs work properly. When there is air outside the lungs it prevents the lungs from expanding...or otherwise known in lay terms as a collapsed lung. The tube stays in place over night and air is sucked out of the chest periodically. When no more air comes out of the tube it is removed. Cody's tube was removed this afternoon. When I visited he had the tube out and was comfortable. He got a little excited and whiny when he saw me, so we didn't visit long. He needs his rest. He's got his octopus friend to keep him company and I'm comforted knowing he is in good hands. He may be able to go home tomorrow.

Thoracotomy

Tomorrow is the big day. Surgery - a thoracotomy.

Thoracotomy is an incision into the pleural space of the chest.^[1] It is performed by a surgeon, and, rarely, by emergency physicians, to gain access to the thoracic organs, most commonly the heart, the lungs, the esophagus or thoracic aorta, or for access to the anterior spine such as is necessary for access to tumors in the spine.

Thoracotomy is a major surgical maneuver—the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer—and as such requires general anesthesia withendotracheal tube insertion and mechanical ventilation.

Thoracotomies are thought to be one of the hardest surgical incisions to deal with post-op, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading toatelectasis or pneumonia.

Thank you again Wikipedia.

The surgery was supposed to be today, but it was rescheduled so that all the best nurses would be on the case. It is a big deal. Part of what makes it a big deal is that when you go into the chest you have to ventilate that patient because they can't breath on their own. This either requires a special machine or it requires a person manually squeezing a bag that looks a little like a black whoopee cushion. That person doing the breathing for the animal has to pay close attention to how much and how fast they are breathing for the animal. It is all about end title volume... or about how well you are able to oxygenate the patient. There is a measurement called the SPO2 which you can think of as the percentage of blood being oxygenated. The goal is to have that number at or higher than 97%. It kinda sucks to be the person ventilating the patient...no stress there, you're only breathing for the patient. Luckily there are machines that do the job quite well.

Another scary aspect of this surgery is the potential pain factor. The surgeon will be going in from the side. She'll have to spread the ribs apart and work down in a hole, so-to-speak. There will be excellent pain control before, during and after the surgery. He'll be on a Fentanyl drip. Fentanyl is 100 times more potent than morphine. Cody should be in la-la land and feelin' no pain.

The surgeon will remove the lung lobe and the entire mass will be submitted to the lab for analysis. There is still a remote chance it will be something benign, but probably not. Hopefully the surgeon will be able to remove the lymph nodes as well. Those will also be sent to the lab to look for evidence of spread of the cancer into those lymph nodes. If the cancer is in the nodes, then we most likely have a slam dunk decision about chemo - do it. If not in the lymph nodes, then I'll have to ponder it a bit... and of course get more advice from my oncologist friends.

Wish us well. Pray. Cross fingers and/or do whatever you do to send good vibes.
Thanks for your support.

Off to Surgery

Well, the decision has been made - we're going to surgery. A week from tonight. A week from tonight I'll be home worrying that he's ok. I've done my home work. I've found an excellent surgeon. We'll take out the alien and send it to the lab and find out without a doubt what exactly Cody has been growing.
I'm undecided about chemotherapy at this point. It will depend on the histopathology of the tumor. All my sources tell me that we assume that even after removing the tumor there are microscopic tumor cells floating around that we need to zap with chemo. We'll see.
We're pooped. Cody wore me out playing today. At least we got that going for us.

Diagnosis: The Big C.

Because I'm a veterinarian I can expedite some of the steps to getting a diagnosis of a problem, but just like any pet owner I can't necessarily expedite the emotional processing of the information.

The feelings come in waves from denial to acceptance to grieving. There's a feeling of something being stolen from me; a betrayal. This was not the plan. Cody was supposed to get stem cell therapy for his arthritis and live to be 16 years old. Now that is not possible because stem cell therapy is contraindicated in patients with cancer (can make the cancer grow).

On July 25th the radiologist performed a fine needle aspirate (FNA) of the mass. Since the tumor is big and is located right up against the body wall, this was a relatively easy procedure. Cody was heavily sedated and a large gauge needle was inserted into the tumor from the outside of his chest. Several small core samples were obtained and shipped off to the lab for histopathology.

I got the results on the 27th. The pathologist's diagnosis is papillary bronchogenic pulmonary adenocarcinoma. Well, this was the expected diagnosis because this type of tumor is the most common primary lung tumor in dogs. As I collect the cold hard facts from reliable sources the reality of the situation is sinking in. According the the numbers, the best case scenario is that Cody will be with me another 494 days, or approximately 16 & 1/2 months after surgery and chemotherapy.

There are a number of factors to consider that help to stage the cancer. Cody appears to be a T1 which means there is only the 1 solitary tumor. There's no evidence of metastasis either to other lung lobes or to lymph nodes (that was determined with the CT scan and an abdominal ultrasound). These tumors are also graded as well, moderately or poor differentiated. A T1, well differentiated tumor has the best prognosis.

I'm polling my co-workers and others in the business to find a surgeon. There is a surgeon about 45 minutes away who comes highly recommended. I will contact her this next week to talk about surgery. I'm fairly certain I will proceed with surgery. I'm not sure about chemotherapy. If I do nothing eventually the tumor will cause fluid to develop around Cody's lungs making it very hard for him to breath. It is hard to say when that might happen. These tumors grow slowly and according the the oncologist some dogs live another 1-2 years even without doing anything.

The CT scan

July 20, 2011

The tumor is the oval thing at 7 o'clock.