The Dog Cancer Survival Guide (36 page)

(Some readers may be tempted to skip this chapter altogether, but, even if you don’t have that kind of budget or you don’t think you’ll choose conventional treatments, I recommend reading this chapter as part of your research. There is some financial assistance available (see
chapter 24
), and even the most die-hard alternative medicine adherent will find useful information here.)

Even guardians who can afford multiple hospital visits and expensive conventional treatments may find the words chemotherapy, radiation and surgery emotionally loaded. If this is you, take Three Deep Breaths (
page 24
) before you continue, so that you don’t dismiss these options before you really consider them. It may also be helpful to know that, after discussing these three treatments, some conventional and natural methods for managing their side effects will be offered.

Vets and oncologists often consider surgery first, because, if a tumor can be completely removed from the dog’s body, the cancer may be cured. This can feel like a miracle, and it is. If a solitary tumor can be removed with surgery and has not yet spread locally or metastasized to other areas, surgery is a very hopeful option. But, as you’ll see below, no surgery is minor when you consider all the factors.

The best candidate for surgery is a single, minimally aggressive tumor with no metastasis and limited local invasion. Unfortunately, many dog cancers are not diagnosed until after a tumor has already metastasized extensively into the area neighboring the tumor. In these cases, surgery may be used to remove the primary tumor, followed by chemotherapy and/or radiation protocols to “clean up” any invisible cancer cells. Depending upon the type and behavior of the tumor, radiation may also be used before surgery to shrink the size of the tumor and make it easier to remove.

Also, surgery may be used if an aggressive or metastatic tumor is causing pain or difficulty with movement – for example, when a tumor is pressing on a joint, or blocking the airway. In this case, surgery may be used to reduce the tumor’s size (this is called debulking), even though cancer cells will still be left in the body. This is an example of palliative surgery, or surgery which is done with the intention of making the dog feel better, rather than curing him.

Sometimes, a tumor has not spread, but is impossible to reach, or is hopelessly entwined with vital structures. In these cases, the tumor is called inoperable or non-resectable, and other treatments must be considered.

Planning a surgery requires some investigation; just like you probably can’t randomly knock down a wall to make your house bigger your vet can’t just charge into an unplanned surgery. Investigation and planning may take anywhere from an hour to a few days, depending upon how much information your vet already has. Your vet may need to do a biopsy to determine what type of cancer is present, test lymph nodes for metastasis, or run other staging tests like blood work, urinalysis, ultrasounds, X-rays, CT scans, etc. Once your vet or oncologist knows what he’s dealing with, he can come up with a plan for the surgery itself.

In some cases, surgery may not turn out to be the best option – but this can usually only be revealed once the right tests are run.

In general, every surgery has three stages: preparation, the operation itself, and recovery.

Preparation:
You will likely need to withhold food, and possibly water, on the morning of the surgery. To prepare your dog for surgery, the vet and his staff bring him into a room that’s been kept scrupulously clean. All of the linens and tools have been sterilized, and everyone has scrubbed hands and forearms. With the recent emergence of drug-resistant germs, including Methicillin-resistant Staphylococcus aureus (MRSA), most vets now require that everyone in the operating room wear a face-mask. Drug-resistant germs can hang out in the nasal passages (without causing symptoms) and be passed to others through the air. Since medical personnel are exposed to many infectious agents, they have a higher risk of carrying these unseen germs. Masking the surgical team protects your dog from airborne infections.

The surgical area on your dog is shaved and disinfected, and the vet or oncologist measures and marks exactly where the scalpel will make the incision into the skin. Your vet administers anesthesia intravenously and through a tube down your dog’s throat, so that your dog remains asleep during the rest of the preparation and the actual surgery. Most of the time, anesthesia is maintained using a tube secured within your dog’s windpipe (an endotracheal tube). Your dog’s vital signs, such as breathing, blood pressure and heart rate, are monitored throughout surgery. Antibiotics and pain medications are administered directly into the blood by an intravenous port (called a catheter) or by injection directly into the body.

Surgery is inherently bloody, and it’s important to make sure the bleeding ends with the surgery. To see if your dog’s blood is clotting normally, a blood test, called a complete blood count (CBC), will be done before surgery (often before the dog goes into the operating room). The CBC will show if the blood cells, called platelets, are present in normal amounts.

Another blood test, called a coagulation panel or profile, can measure the levels of proteins that clot blood. Some vets do not routinely run coagulation panels. In that case, I recommend doing a simple test, called a bleeding test, to make sure that the blood is clotting normally, as it is difficult to know exactly how cancer affects an individual dog’s body. Bleeding tests take a little time, but they are inexpensive and can be run after anesthesia is started while the rest of the preparatory work is done. The procedure is very simple: a tiny cut is made inside the lip, or a toenail is cut short so the wound bleeds freely. As it bleeds, the vet times how long it takes to clot. The time can vary, depending upon the test used, but generally blood clots within a few minutes. Much longer than that indicates the blood doesn’t coagulate well, and the dog is at risk for excessive hemorrhaging and blood loss during or after the surgery.

If platelet levels are low and/or the bleeding test shows the blood is not clotting well, your vet will have transfusions and medications handy (or, rarely, postpone the surgery). Once your dog is fully prepared for surgery, the operation begins.

Operation:
The type, size, and location of the tumor will determine what type of scalpel or other tool is used to remove it.

Most curative surgery aims for what is called a
wide excision
, which is removal of the entire tumor, along with a fairly wide, two to three centimeters, if possible, margin of tissue that looks normal to the visible eye. This margin extends around the tumor in all directions, including into the muscle layer underneath. Hopefully, this wide margin prevents a local recurrence by removing tissue that could contain microscopic cancer cells.

If a tumor is benign, a
marginal excision
is often used. In this type of surgery, the margin around the tumor is narrow. This leaves as much normal flesh intact as possible. Marginal excisions may also be used for palliative surgeries, which are meant to ease suffering or reduce tumor burden, rather than cure.

Some surgeries are more radical, or extensive, than others. In the case of a very invasive tumor, your vet or oncologist may recommend removing an entire limb, an organ (such as the spleen), or an entire portion of the wall of the abdomen.

There are also newer techniques, which may be much less invasive. Endoscopy allows us to look deep into the body with a fiberoptic camera, without creating a large opening. This instrument can also conduct small surgeries, by using robotic arms to cut and suture the tissues. For eligible tumors, endoscopy can render larger surgeries unnecessary. Endoscopic surgery is often available at larger facilities.

Endoscopy is becoming more and more common in veterinary medicine, and with good reason. This technique allows us to look inside organs and body cavities through a very small hole, which means the resulting scar is smaller and the recovery time is faster.

We can look inside the abdomen (laparoscopy), the chest cavity (thoracoscopy) and the bladder (cystoscopy) to get a biopsy, evaluate other organs for spread, and even remove tumors.

For example, laparoscopy enables a surgeon to biopsy a liver mass, determine if it can be removed, and evaluate the rest of the liver for metastasis. If the mass looks resectable, he can convert to a traditional abdominal surgical procedure to remove the mass. If the mass does not look resectable, or if there are other suspicious masses, he can take biopsies immediately, avoiding a large and/or unnecessary surgery.

Sometimes an entire tumor can be removed via endoscopy – for example, my surgical colleague routinely removes single lung tumors via thoracoscopy.

You may need to find a board-certified surgeon in order to take advantage of endoscopy. It may be worth checking with your vet or oncologist to see if this is an option for your dog.

Sometimes lymph nodes in the region of a tumor are suspected for spread, and are therefore removed during the surgery. There is some disagreement among oncologists about whether to do this as a default course of action. While it may initially seem logical to take out a node that seems involved in the cancer, it’s not always so simple. For example, if the lymph node is biopsied and found to be cancerous, this might indicate that the cancer is metastasizing or has already metastasized. Removing that one node will not address the metastasis, and could even reduce the ability of the immune system to manage the cancer. On the other hand, if an enlarged lymph node is causing pain or interfering with normal functioning, it may be wise to remove it entirely.

After excision of the tumor and/or lymph nodes, the vet or oncologist will clean the wound and stop the bleeding. Veins and arteries may need to be sutured back together or cauterized (burned) to stop the bleeding. Muscles and other tissues may need to be sutured, as will the skin over the top of the wound.

Recovery:
After the wound is sutured, a bandage may be needed to prevent infections or to provide pressure during healing. If the area must be kept still, a brace or other device may be put on your dog to keep her from moving. Then, the anesthesia is stopped, and she begins to wake up. Depending upon how extensive or intensive the surgery was, your vet may keep her for a few hours, or even overnight, to monitor her condition and administer injectable painkillers or other medications. For extensive surgeries, a few nights may be required.

If you’ve ever had anesthesia, you may remember feeling a little odd after you woke up. Dogs can also be a little unsteady on their feet or seem disoriented or woozy. Your dog may seem lethargic, sleep a lot, or may pant, in the hour or two immediately after surgery.

Otherwise, most dogs feel much better within three to four days, and most surgical wounds heal within ten to fourteen days.