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Sunday, January 19, 2014

Why Didn't I Treat My Cat?

Okay, time to try and get through the emails I've received over the last few months.  I'll mix these in with new posts related to work and my life.  Here's one from Pam.

I was researching feline lymphoma this morning and found your blog entries about your 16 year old cat. I was curious why you did not do exploratory surgery or needle biopsies on the cat. I have an 11 year old cat who got diagnosed with small cell feline lymphoma about 1.5 years ago. He had done well with a chemo protocol. It has not been inexpensive, but since he continues to have such a good quality of life, we continue on as conservatively as possible.

Thanks for your insight and help.

I'm still tweaking my computer, re-installing software and files.  And for some reason when I pull up my blog page I can't see the search function.  The reason I mention this is because I can't search for the post to which Pam is referring.  So let me summarize.

A few years ago I had a cat who became sick.  He was vomiting, losing weight, and just not doing well.  I ran multiple blood tests, x-rays, and just about every test I had available and that made sense to run.  Everything kept coming up normal.  As he wasted away I had to weigh my options and chose euthanasia.  That was not an easy decision as he had been my friend since he was about three months old.

So on to Pam's question....It really came down to money, as well as whether or not I wanted to put him through everything.  Intestinal lymphoma was definitely on my list of possibilities but there were no obvious signs on exam or blood tests.  He never developed any masses, enlarged lymph nodes, or thickened intestines.  Any of these (especially the latter) can happen in this type of cancer and help direct the diagnosis.  It's also not uncommon to see high blood calcium levels or changes in the white blood cell count and percentages.  However, there were no abnormalities on exam or lab tests to give me a better idea.

It could still have been lymphoma.  If there is diffuse cancer in the wall of the intestine, a needle biopsy isn't going to be accurate.  Needle biopsies or aspirates are sometimes inaccurate, and you really need to make sure that the needle goes into the tumor.  Even with ultrasound guiding you, a needle into the abdomen will pass through intestines and may never actually hit a cancerous portion.  This is really a bad way to diagnose this kind of cancer.  The best way is a surgical biopsy, taking full-thickness samples from multiple locations.  However, that's an major surgery with an open abdomen, and he was in poor condition by that time.  He would have been a much higher anesthetic risk.

Let me take the time to bust a myth or two about veterinarians.  We do not get medical care for free for our pets.  Someone who owns their own practice might be able to simply not invoice out a major surgery, but they are still paying for the supplies, drugs, and salaries out of the practice's money, which in the end is their own money.  For someone like me who manages a practice rather than owning it the situation is even more different.  If I didn't charge for care of my own pets it would be essentially stealing time and products from the owner.  Yes, I do get discounts, but I still have to pay.  An abdominal surgery with intestinal biopsies may cost an average owner around $1500.  With my discounts I might pay around $1100.  Yes, a substantial reduction, but it's still a big chunk of change.  And that's where the other myth comes up....vets aren't wealthy (well, most aren't).  The average veterinary salary in the US is around $85,000 per year.  If that's a single income in the family (as in mine) it's firmly middle-class and not rich.  Considering that I'm still paying off my student loans almost 17 years after graduation, bills to pay, and two pre-teens to raise, I don't have bundles of money lying around.

Do the math in this case.  Let's say around $1000 for the surgery and we get a diagnosis of lymphoma.  It may be another couple of thousand for oncology consultation and chemotherapy, depending on how long it takes.  I don't have or use credit cards and even as a vet with personal and professional discounts I don't have $2000 to spend at the drop of a hat.

Then I had to weigh the likelihood of improvement.  He was 16, pretty old for a cat and at or beyond the life span for most feline patients I've seen in my career.  His was a good, long life without any serious hardships.  The diagnosis of lymphoma wasn't guaranteed, so I may have done surgery and biopsies and come up with nothing or something untreatable.  Pursing invasive diagnostics was a gamble and one I wasn't eager to take.  While lymphoma is often treatable and cats can live a few years past diagnosis, this isn't always the case.  At his age would I really be doing him a favor to give him another six months and then be right back at the same point?  After going through surgery and chemo?  If he was five or even 11 years old I may have made a different decision.  But 16 is far older and he may not have had much time left anyway.

I don't think there was an absolute right or wrong answer in my cat's case.  If one of my clients had wanted to do surgery and chemotherapy I would have completely supported their decision and followed through to the best of my ability.  This was a personal decision where I weighed the financial costs with the likelihood of recovery.  The scale tilted towards full recovery being less likely, so I decided to end his life peacefully.  This was my decision and even a few years later I don't regret it.

This ties in with another question vets are frequently asked...."What if it was your pet?"  But I'll talk about that tomorrow.