How To Lose A Client In 6 Words

A pre-op view of Fame’s anal area. The large mass compressed the anus, which caused difficulty with defecation.

Photo by Dr. Phil Zeltzman

Fame, a 9-year-old Akita/shepherd mix, had difficulty defecating. Her referring vet noticed a large anal sac tumor. After a brief explanation of anal sac carcinoma, she told Fame’s owners: “You should put her to sleep.”

These six little words are the last thing the clients wanted to hear. They somehow ended up in my consultation room. Of course, as you can guess, I recommended surgery to excise the mass. Certainly, anal sac carcinoma is not a great disease, but we can definitely help these patients live a happy, comfortable life.

A “met check” was negative. In addition to anal sacculectomy, we placed 15 cisplatin-impregnated beads at the surgical site. They slowly release the chemo drug over four to six weeks, then are reabsorbed.

The owner just informed me that Fame is still alive 18 months after surgery. In fact, since surgery, she participated in an American Cancer Society “Bark for Life” event to celebrate her one-year and 18-month anniversaries.  And she hopefully will do the same this month--two years postop.

Around the one-year anniversary, the owner wrote the following incredible note:
“Fame and another dog led the cancer survivor dogs in the first lap at the relay. They walked while the theme from “Rocky” played. They both looked so proud to be walking together. I was so proud of Fame. She is a one-year cancer survivor. They gave her a 2009 survivor pin and bandana to wear. It truly brought me to tears walking her in that relay. I am so lucky to have her. I wanted to thank you so much.”

So what’s the point of this story? Clearly, this blog is not about me or my surgical skills. No, my question is, why did this colleague, an otherwise “good vet,” misinterpret these clients’ wishes? Why did she recommend euthanasia? Why did she ultimately lose these clients, who have now switched to another clinic? (Nothing I could have said would have changed their minds.)

Here are a couple of possibilities. Surely, there are many others.

1. The husband, if I remember correctly, was dressed in torn jeans and a not-so-clean T-shirt. Surely, we know better: We shouldn’t judge a book by its cover. Maybe the owner rushed to the clinic after helping a friend with his stalled car. Certainly, these clients weren’t filthy rich, but they were extremely nice and very willing to help their beloved dog.

2. Our colleague may think that adenocarcinoma of the apocrine gland of the anal sac is such a horrible disease, that euthanasia is the most humane option. Is it?

The prognosis depends in part on whether metastasis is present, on the size of the tumor and on hypercalcemia:

• Without metastasis, the average survival is 18 months, which I think is not that bad.

• With mets, the average survival is six months.

• If the tumor is larger than 4 inches in diameter, the median survival is 10 months.

• If hypercalcemia is present, median survival is eight months

So condemning this dog based on the impression that this is a deadly cancer is probably not the best recommendation in 2010. In fact, the numbers above can be argued with endlessly. The prognosis may be even better if we factor in IV chemo, locally implanted cisplatin beads or radiation therapy.

To avoid losing clients, I would humbly suggest that colleagues at least ask what they want to do, which may include referral to a specialist in complicated cases.

Is that a shocking suggestion?

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How To Lose A Client In 6 Words

Offering euthanasia to a patient as an option is not recommended, instead offering alternatives is more assuring.
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