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Saturday, August 20, 2011

Difficult Decision

A few days ago I saw a 10 year old husky for a routine check-up and vaccines.  She is unspayed and has been overall healthy for most of her life.  During the exam I noticed a firm, irregular mass in her mammary chain, and with a second look I found a smaller mass nearby.  I called and talked to the owners, and they had not noticed these swellings, and were surprised when I pointed them out.  We had also seen this dog in May for unrelated issues and had not noticed the masses then either.  So in a 2-3 month period these lumps had developed.

In an older female dog who had never been spayed the most likely possibility is mammary gland cancer.  This form of cancer can potentially be as bad and as malignant as breast cancer in humans.  We took some chest x-rays to make sure there were no obvious metastases in the lungs, and when those were clear I talked to the owners about a partial mastectomy.  In cases like this it's important to move quickly, removing the masses as soon as possible to minimize the likelihood of them spreading.  Leave them too long and you're almost assured of metastasis.  There are sometimes benign masses as well as other types of cancer, but there is no way to tell for certainty without removing them and sending them for a pathologist review.

Today she came in to have the surgery done.  We did our normal preanesthetic evaluation, blood tests, and so on, and considered her generally healthy.  We placed her catheter, induced her, and began doing the surgical shave and prep of the site.  As we were shaving we noticed another small mass under the skin on the same site but several centimeters away from the largest mass.  Further shaving showed an fourth mass close to the newest one but on the other side of the abdomen, so in a completely different mammary chain.  This concerned me greatly, as we had masses developing in very separate locations from the largest lesion.  I had checked all of the mammary regions earlier in the week, so it surprised me to find more masses, even if they were small.  Did I miss them because they were small and she has thick fur?  Did they start to grow in a few days time?  Unfortunately I couldn't say for sure.

I called the owner before we went to surgery and presented them with the new information.  I discussed the options, neither of which were good.  The primary reason for doing the surgery was to remove the masses before there was further spread.  We didn't know how quickly it was spreading, as the lumps I found could have started growing two months ago or in the last couple of weeks.  Since there were new lumps in different locations, there was already spread.  However, we could proceed with the surgery and do a more radical procedure, basically a double mastectomy.  This is a radical, extensive, and painful surgery, and one not to be undertaken lightly.  The odds were good that spread in the bloodstream was already happening, but there was no way to tell for certain.  So should we do a more complicated surgery and roll the dice, hoping for the best?  Or should we realize that metastasis may already be happening, it was too late to prevent it, and save her a painful and potentially long recovery?

This was a very difficult decision for the owner.  Honestly, I was on the fence myself, though leaning towards not doing the surgery as I was worried that it wouldn't help her in the long run.  But my job is to give the client enough information for them to make an informed decision.  I can never make the decision for them.  And if it was my own dog I would have had an equally hard time making up my mind.

In the end the owner decided to forgo the surgery and observe her, giving her the best quality of life they can.  I can't say that this was the wrong decision.  Sometimes in medicine there is not a straightforward choice, only difficult ones.

8 comments:

  1. That's got to be a difficult position to be in. It sounds like you handled it smartly and gracefully, and I'm sure the owners were appreciative. I would have made the same decision they came to.

    I've said it before, & I say it again - thank you for sharing these stories!

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  2. really love the case studies Chris. Its a tough one to call on this. Question - could a blood test have indicated cancer in this case?, would a pathology sample from the largest lump not have been a good idea - it would have confirmed one way or the other if cancer was present?

    Obviously not being a vet, I don't know the answer to these questions but I would be interested to know the answer. They would be questions I would need to know the answers to if the dog were mine.

    I know vets can be reluctant to answer a client's question "if the pet were yours what would you do?", because as you say its a very personal thing. However as a pet owner I really appreciate when the vet gives their own point of view - backing it up with the reasons on the understanding that it is just that a - a personal view. When my dog was really ill, I appreciated this type of discussion with my dog's vet and really valued the possibility of discussing options and possible outcomes (not for cost as I would have done anything to save my dog but because I wanted what was best for him in terms of quality of life, ability, given age, to come through treatment or cope with procedure etc.

    Love the site - keep up the good work.

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  3. We saw a similar case in California about 5 years ago--older (11 years old I think) unspayed Husky female who presented to the GP with for a regular checkup and was diagnosed with multiple small mammary tumors and recommended immediate surgery. It was just before Christmas and the owners didn't have a lot of money due to the holiday, so they put it off till after the new year...

    She presented to our emergency clinic in mid-January with massive, bloody chewed/scratched-up tumors the size of baseballs up and down the entire mammary chain on either side. There was no way our surgeons were touching her; she was a mess (bloodwork was awful and chest rads weren't great either).

    They ended up euthanizing, but not until after the owner asked if she would have been better off spaying the dog as a puppy. Um...yes? Obviously?

    These tumors move so fast sometimes, it can be so sad--just another reason to spay and spay early!

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  4. Anonymous: Unfortunately there is no "blood test for cancer". In human medicine there are certain markers for a few specific types of cancer that can be detected, but we don't have this in veterinary medicine. We can get an idea of organ function with testing, but that's not specific to cancer. Yes, we could have done a biopsy and had a firmer answer. However, experience has shown me (and most vets) that a lump of this size and shape at this location in an old, unspayed female is almost always cancer of some sort. In cases like this the best option is to remove the mass as soon as possible, rather than waiting several days to a week for a biopsy result to come back.

    Orli: I've also seen those large, necrotic mammary tumors, and did warn these owners that this may happen with their dog. If these particular masses are growing rapidly, we may have a similar situation here.

    And yes, this is yet ANOTHER reason to spay your dogs when they are young!!!

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  5. sorry if this is a stupid question but would this definitely not have happened if the dog had been spayed as a puppy?

    I think I am right in saying that ideally puppies should be spayed/neutered circa 6 months? when is the latest they can be spayed (in their health interest)?

    I know vets do say spaying and neutering is a very good idea but I think owners think the real reason for this (even though the owner is being told its for the dog's health) being said to them is to cut down on irresponsible owners who allow their dogs to reproduce and the puppies end up in shelters at best and in the bottom of the river at worst.

    why aren't there more detailed information leaflets on dogs for owners (with graphic pictures if necessary) to show them all the terrible things that can happen if their dog is not spayed or neutered. I think, as an owner, if people knew that this happens and had a better understanding that they would get their pets neutered/spayed - for the dog's sake.

    interesting that there are no specific markers for cancer in dogs - is there research going on in this - it would be very useful.

    thanks for this great site.

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  6. what would be best practice to reduce this happening to breeding bitches - spay after third litter?

    is there a high incidence of this type of cancer in former breeding bitches that have not been spayed?

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  7. Early spaying definitely helps prevent MANY problems. Look at my post earlier in the month about the pyometra case...completely preventable with spaying. Mammary cancer statistics related to spaying are: if spayed before the first heat cycle, less than a 1% chance of ever developing this kind of cancer; spay between the 1st and 2nd heat cycles, it jumps to a 10% chance; spay after the 2nd heat and it increases to a 25% chance; never spay and it's higher than that. There is never a "too old to spay", as cancer and pyometra can happen at any age.

    When I have someone reluctant to spay their dog, I always go through these risks and emphasize the life-threatening aspects. The handouts at our clinics also do discuss these risks.

    I don't know of specific statistics regarding breeding bitches, but would recommend spaying as soon as possible.

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  8. wow impressive stats to hammer home the "please spay your dog" message - in dogs' own interest.
    Tks Chris

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