Life with Dogs allows us to practice critical skills that can have broad application. For example, guiding important medical decisions on behalf of our dogs can assist us in being prepared when we need to engage in a similar process on behalf of our human loved ones – or ourselves.
Medical decision-making is a process that requires careful and thoughtful gathering and consideration of information in order to make the choice that is best (or least awful) for our unique situation. It is a process that requires relevant, evidenced-based information and a team of supportive, trusted others who can help us think clearly when our crisis-saturated critical thinking skills are understandably overwhelmed.
The following illustrates the process of medical decision-making for a dog. Originally published to the Kaibab Blog in August 2014, this two-part series has been revised and updated to provide a clear example of medical decision-making on behalf of a dog.
Part One: Choices about Surgery
About three weeks ago I found a very small lump on Sydney and literally was at the vet 15 minutes later. Syd is a lumpy girl but you can start to get a sense of lumps -- when to freak and when to chill, and this had a moderate freak feel. Biopsies followed and then a consult at WSU in Pullman, Washington, which happened on Monday.
Sydney appears to have a very low-grade soft tissue sarcoma -- these are CURABLE. However, the location makes things tricky.
In order to get clean margins, the professionals believe five ribs would have to be removed along with the tumor; that is Option One.
Option Two is to take as much as possible without taking ribs, and follow-up with a course of radiation -- but that would mean weeks in Pullman.
The odds for success are equal with the two options (very, very high) and so there was a hard decision to make about what to do.
At first, I wanted it surgically removed -- all of it, and the ribs, too! This is why it is best to think carefully about things, and consult with trusted friends/family who can assist with the decision-making process -- our first reactions can indeed simply be reactions.
The Big Surgery (aka Option One) would mean Syd's life would need to change -- after all, she would be missing ribs, which are protective and supportive. No more agility. No rough play with other dogs. No to a lot of Normal Life for Sydney.
The second option would be complicated -- how could we get Syd to radiation five days a week for at least three weeks when we live 250 miles away across two mountain passes???
Syd and I discussed it all on the drive back from Pullman (okay, I discussed and she listened) and by the time I got home, I had decided what I thought -- but I wanted to check my thinking out with others, including Dear Husband. The best ideas and plans do not happen inside of our own head -- they need to air out a bit.
Another thing I did that helped was to break down the decisions. I did not have to solve the radiation issue immediately. Decision #1 was which surgery should happen: "Sufficient unto the day are the troubles therein."
And so Syd will have the less big surgery, removing as much of the small mass as possible without taking the ribs that allow "normal life" for her. More pathology will be done, and that will guide the next step in the decision-making; I will also want to see evidence-based information about radiation protocols so the best decision can be made about that as well.
Decision-making is -- or should be -- a process involving the unique qualities, characteristics, and factors of an individual, a family, a situation. There is no “one size fits all" when it comes to medical decision-making because decisions get filtered through values, experiences, knowledge (or lack thereof), resources of all kinds, and so on. This is why we should always refrain from second-guessing another family's decision -- we are not the experts in anyone else's life.
Part Two: Post-surgery Choices
The oncologist wrote, "With the behavior of soft tissue sarcomas, regrowth locally is my biggest concern. Radiation therapy follow up is recommended."
Thank goodness oncologists are so careful and proactive!!!! YAY for them!
But a recommendation from a professional -- no matter how wonderful and smart -- is not necessarily the best or right choice for any particular individual. It is not disrespectful to ask questions and/or to come to a different conclusion. In so many of these cases, the absence of a crystal ball means there really is no one correct path.
I asked some questions, requested literature, consulted with informed others (including Sydney’s regular veterinarian), did some research of my own, and reflected about things -- every dog health issue is a chance to learn things you didn't really want to know. This is the final result, sent via email to Sydney’s medical team at the Teaching Hospital:
Thank you for sending the excellent articles. The following is my understanding and the decision that follows from this understanding -- I welcome your thoughts.
Sydney had a Soft Tissue Sarcoma (STS) removed from her thorax. STS tend to grow slowly and rarely spread. Sydney had both a CT scan and ultrasound, and neither revealed additional disease. The STS was removed and radiation is being recommended to provide additional curative support. The presenting question is whether additional treatment is warranted for Sydney. In other words, do the benefits of additional treatment outweigh the burdens?
Cost is not a factor in the decision-making process (Sydney is covered by health insurance). Distance is a moderate factor but is mediated by offers for Sydney to stay with friends in Pullman. Side effects, risks of treatment, and disruption of normal life constitute treatment burdens for Sydney.
In order to understand the treatment benefit it seems important to understand her present risk of recurrence in order to compare to any reduction in that rate if additional treatment were elected.
The following seem to be important in considering the risk of recurrence of Sydney's STS.
1. The margins. Per the histopathology report: "The neoplasm is within 3 mm of the peripheral margin (blue ink) of the section on slide 9-1...The neoplasm is >14 mm from all other examined surgical margins."
The closer margin is identified as concerning to oncology; this concern is appreciated and understood.
There seem to be two mediating factors, however, that could balance the concern. First, the pathologist used this language when describing the 3 mm margin: "The neoplasm is within 3 mm of the peripheral margin ...; however the neoplastic cells are surrounded by a mature dense fibrous capsule in this region (cystic structure noted grossly)." This seems to suggest that the mass was encapsulated.
Second, both the histopathology report and an article published by Dennis et al. (2011) identify that level of margin as "clean" or "complete." STS surgically excised with clean or complete margins have extremely low recurrence rates. Indeed, the pathologist identified the excision as "complete."
2. The Grade. The mass has been identified twice as a Grade 1 STS; this low grade further reduces the risk of recurrence
3. The Mitotic Index (MI). In the histopathology report of Sydney's STS, the pathologist noted, "Mitosis is rare (none noted in 10 examined 400X fields)." Low MI appears to be associated with better prognosis - Sydney's STS MI would appear to be approaching zero, which is quite low.
It seems to me that the available information suggests that the surgical excision of the STS was accomplished with clean margins and that risk of recurrence is extremely low. This very low risk could possibly be further reduced with additional treatment, but that treatment has its own risks, side effects, and disruption of normal life for Sydney.
Given the very low risk of recurrence, the burdens to Sydney of additional treatment, and the reality that a recurrence is unlikely to be life-threatening and can be treated, I think we will not do additional treatment for Sydney at this time.
Again, I invite your input/thoughts. And thank you for your excellent work and care of Sydney."
Let me say that before all this I had no idea was a Mitotic Index was and why it mattered, what the various grades really meant, how common soft tissues sarcomas are, and so on -- like I said, the health issues of a dog are certainly an (unwanted) invitation to learn!
But in order to truly make an informed decision, one has to be willing to learn things and dialog with others. The best choices for those we love are made with others, and not by others -- big difference.
Each one of us has an important role on our dogs' health care team and yes, it is emotionally and intellectually challenging but it is critical. Nobody else is the expert in our lives or the lives of our dogs -- that job is ours alone, and it is one that requires our best efforts. Sydney got mine -- that is what she deserved.
The Soft Tissue Sarcoma over Sydney’s ribs did not recur. Sydney died of
osteosarcoma in April 2017.