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Osteosarcoma: Beyond Amputation and Euthanasia

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Veterinary Practice News

Osteosarcoma: Beyond amputation and euthanasia

When amputation is not an option, please don’t go straight to euthanasia

By Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

March 12, 2019 1:00 pm

[1]
Osteosarcoma of the radius in an eight-year-old Labrador.

When a patient is diagnosed with osteosarcoma, we tend to focus on three options:
• the “gold standard,” i.e. amputation with or without chemotherapy;
• what many call palliative care, meaning pain medication and rest; or
• euthanasia.

But what if amputation is not an option? What if chemotherapy or radiation is out of the owner’s financial capabilities? Or a couple of medications are not enough to numb the pain? What if visible metastasis to the lungs is already present?

Bob Stein, DVM, pain management guru and founder of the Veterinary Anesthesia & Analgesia Support Group (www.vasg.org), recently shared another valid option.*

“With my suggested approach, we can often provide quality of life to even large-breed dogs for six to 12 months and sometimes more than 20.”

Let’s detail Dr. Stein’s protocol.

Pamidronate

Pamidronate, a bisphosphonate, is an injectable drug that is inexpensive and easy to administer (ref: TM Fan et al. JVIM 2007). It helps to reduce pain (in 30 to 50 percent of patients), inhibit bone osteolysis, and has potential cancer-suppression effects by impeding proliferation and inducing apoptosis. The drug has a wide safety margin and can even be used on patients with renal or liver insufficiency. While side effects such as esophagitis, allergic reactions, and gastritis have been described, Dr. Stein has not yet observed those adverse effects at his practice. Note: If pamidronate is backordered when you read this, use zoledronic acid instead.

NSAIDs

NSAIDs are a mainstay in pain management, but they are not particularly well suited to the management of bone cancer pain. Dr. Stein hopes NSAIDs can contribute, but consistently utilizes them for their antiangiogenic, cancer-suppressant properties. They also help with pain related to degenerative joint disease (DJD) in other limbs and discomfort related to weight shifting.

Tramadol

Tramadol has been shown multiple times to be unpredictable and, generally speaking, ineffective when managing canine pain, so we won’t dwell on it. When reaching for a reuptake inhibitor, Dr. Stein chooses amitriptyline or duloxetine as noted later in this column.

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Gabapentin

Several studies have been conducted to prove the effectiveness and safety of gabapentin. Like amitriptyline and duloxetine, gabapentin is better suited to bone cancer pain than NSAIDs. Initially used to treat seizures, gabapentin treats pain by blocking calcium channels. Patients with osteosarcoma receive a starting dose of 10 mg/kg three times daily, but Dr. Stein increases the dose as rapidly as tolerated to as high as 60 to 70 mg/kg three times daily. Due to gabapentin’s nonlinear pharmacokinetic profile, it is very difficult to overdose gabapentin, but you can see lethargy and sedation if you increase the dose too quickly.

Trazodone

Our patients are unaware they have a life-threatening disease. If their activity needs to be slowed down, prescribe trazodone. It doesn’t play well with tramadol (yet another reason not to use tramadol), but works well with gabapentin to provide safe and effective sedation. Use with caution, if at all, when utilizing a reuptake inhibitor like tramadol, amitriptyline, or duloxetine.

Cymbalta

Cymbalta (duloxetine), a serotonin reuptake inhibitor (SNRI), has been shown to provide pain control by increasing serotonin in synapses. Care must be taken to ensure there are no drug interactions with other medications, such as aspirin or over-the-counter supplements the patient may be on.

Amitriptyline

Amitriptyline, a tricyclic antidepressant, can be used to treat neuropathic pain via a broad variety of mechanisms. Unlike tramadol, amitriptyline can be effective when dosed twice daily. Doses as high as 3 to 4 mg/kg twice daily may be required for peak analgesic benefit.

Amantadine

Initially used as an antiviral medication, amantadine is a N-Methyl-D-aspartate (NMDA) receptor inhibitor. It can disrupt the nervous system response to prolonged pain signaling. Also showing evidence of chronic osteoarthritis pain alleviation, this drug can be used for relieving osteosarcoma-related pain.

Food

What we feed a cancer patient is more important than most pet owners realize. Food can either “feed” the cancer or help “starve” it, while boosting the immune system. Prescription diets for cancer patients offer:
• Low levels of carbohydrates (sugar is blamed with “feeding” cancer cells)
• High levels of protein, fat, and omega-3 fatty acids

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Weight control

Weight control is critical in cancer patients. Many veterinary professionals believe weight loss and cachexia are a classic consequence of cancer. Until the disease takes over, being overweight is a far greater risk. Quite often, the owner feels bad for their dog’s fate and tends to use food to offer comfort. Sadly, extra weight puts extra pressure on joints. In addition, adipose tissue releases cytokines that can exacerbate a multitude of inflammatory processes, including DJD, which can contribute to discomfort.
Weight maintenance or weight loss should be a critical part of the discussion regarding a cancer patient. Remember to include serial weight checks and follow-ups to tailor the food amount to your patient’s needs.

Supplements

Glucosamine, chondroitin, injectable supplements, and methylsulfonylmethane (MSM) have been recommended to help with arthritis present in joints unaffected by cancer.

Omegas

Not all omega-3 fatty acids are created equal. There is a lot of over-the-counter junk. Proper manufacturing and conservation are critical to prevent the supplement from becoming rancid. According to Dr. Stein, docosahexaenoic acid (DHA) supplementation can provide anti-angiogenesis properties. Calculate the dose of various supplements with a free calculator located at http://www.vasg.org.**

Harness

Using a harness, such as Help ’Em Up, can help owners lift or support dogs with osteosarcoma in a back leg. It can also alleviate extra strain on the back end when a front limb is affected. An effective harness also reduces the likelihood the client will be injured while assisting their dog.

Physical therapy

As osteosarcoma progresses, weight shifting can cause strain to the other limbs. Physical therapy and massage can lessen the impact of the increased load.

Acupuncture,  myofascial trigger point needle therapy

Needle therapy can be part of a multimodal program for pain control. Acupuncture has been shown to boost beta-endorphins, which are the body’s natural opioids. Acupuncture also can help reduce chemotherapy-related gastrointestinal side effects, such as vomiting, diarrhea, and nausea. Myofascial trigger point needle therapy can relieve the painful contracture knots that often form when muscles are overtaxed or injured.

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Others

Countless other modalities, including Reiki, have been recommended to help fight cancer, along with all kinds of nutritional supplements. Claims include cancer growth inhibition and overall support. We will leave it up to you to pick and choose what you believe in. Working with a veterinarian who is familiar with these modalities is recommended. Laser, however, is not recommended anytime cancer is suspected or proven.

When amputation is not an option, please don’t go straight to euthanasia. As Dr. Stein suggests, using some of the modalities mentioned here can significantly improve a patient’s quality of life, as well as their longevity.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his websites at http://www.DrPhilZeltzman.com and http://www.VeterinariansInParadise.com. AJ Debiasse, a technician in Stroudsburg, Pa., contributed to this article.

References
* VIP conference, April 2018, Cabo, Mexico (www.VeterinariansInParadise.com).
** http://vasg.org/drug_delivery_calculators.htm and bit.ly/2R7fDsL

Endnotes:

  1. [Image]: https://www.veterinarypracticenews.com/wp-content/uploads/2019/03/Osteosarcoma-.jpg

Source URL: https://www.veterinarypracticenews.com/osteosarcoma-beyond-amputation-euthanasia/

Spay-neuter considerations to maximize health

Feature photo by Bob Segal, Illinois

Care

When is it Ethical to Euthanize

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Authored by Bernard Rollin

Bernard Rollin does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Professor of Philosophy, Animal Sciences and Biomedical Sciences, Colorado State University

In the 1960s, I knew people who, before going on vacation, would take their dogs to a shelter to be euthanized. They reasoned that it was cheaper to have a dog euthanized – and buy a new one upon returning – than pay a kennel fee.

Two decades later, I was working at Colorado State’s veterinary hospital when a group of distraught bikers on Harley-Davidsons pulled up carrying a sick chihuahua. The dog was intractably ill, and required euthanasia to prevent further suffering. Afterwards, the hospital’s counselors felt compelled to find the bikers a motel room: their level of grief was so profound that the staff didn’t think it was safe for them to be riding their motorcycles.

These two stories illustrate the drastic change in how animals have been perceived. For thousands of years, humans have kept animals as pets. But only during the past 40 years have they come to be viewed as family.

While it’s certainly a positive development that animals are being treated humanely, one of the downsides to better treatment mirrors some of the problems the (human) health care system faces with end-of-life care.

As with humans, in many cases the lives of pets are needlessly prolonged, which can cause undue suffering for the animals and an increased financial burden for families.

The growth of veterinary medicine and ethics

In 1979, I began teaching veterinary medical ethics at Colorado State University’s veterinary school, the first such course ever taught anywhere in the world.

A year later, the veterinary school hired an oncologist to head up a new program on animal oncology. Soon, our clinic was applying human therapeutic modalities to animal cancer. The visionary head of the veterinary program also hired a number of counselors to help pet owners manage their grief – another first in veterinary circles.

I’d been under the impression that people would be reluctant to spend much money on animal treatments, so I was genuinely shocked when the following April, the Wall Street Journal reported individuals spending upwards of six figures on cancer treatments for their pets.

As a strong advocate for strengthening concern for animal welfare in society, I was delighted with this unprecedented turn of events. I soon learned that concern for treating the diseases of pets besides cancer had also spiked precipitously, evidenced by a significant increase in veterinary specialty practices.

One of the family

So what’s behind the shift in how pets are perceived and treated?

For one, surveys conducted over the last two decades indicate an increasing number of pet owners who profess to view their animals as “members of the family.” In some surveys, the number is as high as 95% of respondents, but in nearly all surveys the number is higher than 80%.

In addition, the breakdown of nuclear families and the uptick of divorce rates have contributed to singles forming tighter bonds with companion animals.

Such attitudes and trends are likely to engender profound changes in societal views of euthanasia. Whereas before, many owners didn’t think twice about putting down a pet, now many are hesitant to euthanize, often going to great lengths to keep sick animals alive.

Vets caught in the middle

However, veterinarians continue to experience extensive stress as they experience two opposite – but equally trying – dilemmas: ending an animal’s life too soon, or waiting too long.

n a paper that I published entitled Euthanasia and Moral Stress, I described the significant stress experienced by veterinarians, veterinary technicians and humane society workers. Many chose their profession out of a desire to improve the lot of animals; instead, they invariably ended up euthanizing large numbers of them, often for unethical reasons.

These ranged from “I got the dog to jog with me, and now it’s too old to run,” to “If I die, I want you to euthanize the animal because I know it can’t bear to live without me.”

In other cases, the animal is experiencing considerable suffering, but the owner is unwilling to let the animal go. With owners increasingly viewing pets as family members, this has become increasingly common, and many owners fear the guilt associated with killing an animal too soon.

Ironically this, too, can cause veterinarians undue trauma: they know the animal is suffering, but there’s nothing they can do about it unless the owner gives them permission.

The consequences are manifest. One recent study showed that one in six veterinarians has considered suicide. Another found an elevated risk of suicide in the field of veterinary medicine. Being asked to kill healthy animals for owner convenience doubtless is a major contribution.

How to manage the decision to euthanize

Here is my suggestion to anyone who is thinking about getting a pet: when you first acquire it, create a list of everything you can find that makes the animal happy (eating a treat, chasing a ball, etc). Put the list away until the animal is undergoing treatment for a terminal disease, such as cancer. At that point, return to the list: is the animal able to chase a ball? Does the animal get excited about receiving a treat?

If the animal has lost the ability to have positive experiences, it’s often easier to let go.

This strategy can be augmented by pointing out the differences between human and animal consciousness. As philosopher Martin Heidegger has pointed out, for humans much of life’s meaning is derived from balancing past experiences with future aspirations, such as wishing to see one’s children graduate or hoping to see Ireland again.

Animals, on the other hand, lack the linguistic tools to allow them to anticipate the future or create an internal narrative of the past. Instead, they live overwhelmingly in the present. So if a pet owner is reluctant to euthanize, I’ll often point out that the animal no longer experiences pleasant “nows.”

In the end, managing euthanasia represents a major complication of the augmented status of pets in society. Ideally, companion animal owners should maintain a good relationship with their general veterinary practitioner, who has often known the animal all of its life, and can serve as a partner in dialogue during the trying times when euthanasia emerges as a possible alternative to suffering.

Care, Health & Genetics

VACCINATION AGAINST CANINE CANCER STUDY

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Thank you Barbara Manson, Stoughton WI for bringing this to our attention!

Attention all Gordon Setter owners – our breed is included among those being recruited for this study. If interested, follow the link below to submit your information online.

Sally Gift, Mesa AZ

VACCINATION AGAINST CANINE CANCER STUDY

UW Veterinary Care’s Oncology Service is recruiting dogs for the Vaccination Against Canine Cancer Study (VACCS trial), the largest clinical trial conducted to date for canine cancer.

The goal of the VACCS trial is to evaluate a new vaccine strategy for the prevention, rather than treatment of dogs with cancer. Healthy dogs of certain breeds, 6 to 10 years old, will be randomized to receive either a series of vaccines similar to other routine vaccines that are given to dogs currently, or placebo vaccines. Dogs will live at home and be checked 2-3 times yearly for 5 years after enrollment. A financial incentive will be offered to defray the cost associated with diagnostics and treatment of any cancers that dogs develop, regardless of whether they are receiving vaccine or placebo.

In addition to potentially providing a new strategy for cancer prevention in dogs, if successful, this study could provide important justification for eventually looking at a similar approach in humans.

TO QUALIFY, DOGS MUST MEET THE FOLLOWING CRITERIA:

  • Owners must live within 150 miles of one of the participating trial sites
    • University of Wisconsin–Madison · Madison, Wisconsin
    • Colorado State University · Fort Collins, Colorado
    • University of California–Davis · Davis, California
  • Age: 6 to 10 years old
  • Weight: 12 pounds (5 kg) or more
  • No history of previous cancer
  • No significant other illness that could result in a life span of less than 5 years
  • No history of previous autoimmune disease
  • No current treatment with oral or injectable immunosuppressive medications such as prednisone, cyclosporine, mycophenolate, or tacrolimus

THIS TRIAL IS NOW BEGINNING THE PATIENT ENROLLMENT PROCESS.

If you believe your pet meets the study criteria and would like to receive more information, please click the button below to enter your contact details and preliminary information about your dog.

A member of the Oncology team will contact you within a week of your entry to collect further information and schedule an appointment.

Questions? To learn more about this study, please email us: vaccs@vetmed.wisc.edu.

DOGS MUST BE ONE OF THE FOLLOWING BREEDS:

  • Mixed Breed
  • Afghan Hound
  • Airedale Terrier
  • Alaskan Malamute
  • Basset Hound
  • Beagle
  • Bernese Mountain Dog
  • Borzoi
  • Boston Terrier
  • Boxer
  • Briard
  • Bullmastiff
  • Cocker Spaniel
  • Corgi
  • Deerhound
  • English Setter
  • Field Spanie
  • Flat-coated Retriever
  • French Bulldog
  • German Shepherd
  • German Shorthaired Pointer
  • Giant Schnauzer
  • Golden Retriever
  • Gordon Setter
  • Great Pyrenees
  • Irish Setter
  • Irish Water Spaniel
  • Irish Wolfhound
  • Italian Spinone
  • Keeshond
  • Labrador Retriever
  • Leonberger
  • Newfoundland
  • Norwegian Elkhound
  • Nova Scotia Duck Tolling Retriever
  • Old English Sheepdog
  • Petit Basset Griffon Vendeen
  • Rhodesian Ridgeback
  • Rottweiler
  • Saluki
  • Scottish Terrier
  • Shetland Sheepdog
  • Siberian Husky
  • Springer Spaniel
  • Staffordshire Bull Terrier
  • Standard Poodle
  • Tibetan Terrier
  • Viszla
  • Welsh Terrier
  • West Highland White Terrier