We continue our discussion about cancer surgery with Stephen Withrow, a surgical oncologist at the Colorado State University Animal Cancer Center in Fort Collins. Dr. Withrow is double boarded in surgery and internal medicine (oncology). In the July installment, Dr. Withrow emphasized the importance of preoperative diagnostics (FNA, biopsy, imaging, etc.), establishing a relationship with a good pathologist and creating a solid team of like-minded people when dealing with cancer surgery. The godfather of cancer surgery kindly shared 10 more pearls to improve the care of your cancer patients. Last month we discussed 10 ways to deal with lumps and bumps. This month, we continue that discussion and discuss 10 more tips for dealing with lumps and dumps. 11 Blood Products Massive resections such as canine thyroidectomy or liver lobectomy may lead to severe hemorrhage. Such surgeries may not be as successful without blood products. Whole blood, packed red blood cells, platelet-rich plasma and fresh-frozen plasma have enabled us to provide far superior care. We can either treat a patient pre-emptively if we know there is a preoperative deficiency, or intra- or postoperatively if unexpected bleeding occurs during surgery. 12 Become Aware Both the veterinary community and pet owners have become aware that cancer is the leading cause of death in pets. And sadly, cancer is here to stay. Constant awareness and frequent physical exams will help earlier detection. Because we know what the devastating consequences of undetected cancer can be, we need to strive to educate our clients and detect the disease early. Treatment-wise, we used to apply the “big surgery for big cancers” principle. Now, in order to try to obtain clean margins and sometimes to achieve a cure, we also prefer “big surgery for small cancers.” 13 Raising the Bar With the advent of specialty practices and the training of generations of future board-certified surgeons, we have been able to raise the bar of the care we can offer to our cancer patients and the services we can suggest to our dedicated clients. In turn, with this knowledge shared in journals and at conferences, general practitioners can provide better care themselves or refer difficult cases to a specialist. 14 Changing Gloves If you have close margins or you accidentally contaminate your gloves or instruments by penetrating the capsule of a mass, it is wise to changes gloves, instruments and/or drapes. If you have generous margins however, this may not be necessary. 15 Be Comfortable To avoid the “peek and shriek” syndrome, it is important to have as much information about the tumor preoperatively as possible, and to know your limitations. It is sometimes unfortunate for the patient and the client to be in a situation where, for example, you open an abdomen, find (or “peek” at) a large hepatic or intestinal or adrenal mass, “shriek” and close the abdomen as is. At the very least, you should obtain a biopsy of the mass to further guide the client. 16 Use Staplers We now have a variety of sophisticated surgical staplers and tissue sealers that enable us to perform resections in a safer and quicker manner than when we were limited to ligating. We can now perform safe and fast lung lobectomies, splenectomies, nephrectomies and liver lobectomies. Similarly, vascular clips can make some surgeries, such as adrenalectomies, much smoother and faster. Both staplers and vascular clips come in single use and reusable versions. Depending on how often you practice advanced surgery, one type might make more financial sense. 17 Reconstruction Thoughts Thanks to the leadership of pioneers like Mike Pavletic, advanced reconstruction techniques, such as skin flaps, skin grafts and muscle flaps, have enabled us to offer much more invasive excisions followed by fairly cosmetic reconstruction. For example, we can resect a large portion of the thoracic wall over several ribs, and close the defect with a muscle flap in a way that will enable the patient to be functional and comfortable. 18 Communication As the complexity and the cost of the services provided increase, compassionate client communication has to improve in parallel. Prior to any fancy surgery, we must communicate clearly with our client, using simple words. Critical points to discuss include the anticipated outcome, the expected cost, the possible complications and risks, the postoperative care and the projected statistical survival. 19 The “Good Death” “I consider veterinarians to be very fortunate to have the privilege to provide euthanasia when a patient’s quality of life becomes unacceptable or when the hope for a cure is elusive,” Dr. Withrow says. “We have made tremendous progress in the attention we pay to a client’s need for support at this critical time, between condolence cards, footprints, locks of hair, grief support groups, separate grieving rooms, quiet time, etc. A pet’s euthanasia has now become a dignified event, where the whole family can be included.” 20 Be Holistic Because our cancer patients are often geriatric, we shouldn’t have tunnel vision; we cannot only focus on a lump. We need to remember the patient’s other health issues, such as liver disease, anemia, kidney disease or leucopenia, which should be taken into consideration during treatment design. For example, what do we do when a patient with liver and/or kidney disease needs piroxicam? What do we do when a patient with low red or white blood cell counts comes in for his next chemotherapy treatment? Cancer is one of the most treatable (and occasionally curable) of chronic diseases. It is likely that the better our clients take care of their pets, and the longer they live, the more we will deal with cancer patients. In 2011, we should not have a fatalistic approach. In most cases, we can significantly prolong a patient’s life span while providing a good quality of life. Dr. Phil Zeltzman is a mobile, board-certified surgeon near Allentown, Pa. His website is www.DrPhilZeltzman.com. He is the co-author of “Walk a Hound, Lose a Pound” (Purdue University Press).
