Cat with Cancer; Advice Requested

jellobiafraFebruary 18, 2013

My 15-year-old cat was diagnosed with cancer Friday. The vet strongly believes it is lymphoma that has metastasized to the liver. Without a biopsy, he can’t be sure of the disease’s origin or spread. The cat has lost some weight but is otherwise fine in appearance and behavior. She goes through all her daily rituals with my wife and me, wagging her tail and purring the entire time. While I certainly don’t know if she’s masking pain, by all appearances she is enjoying each day. The vet believes this to be true.

Our options are limited. Do nothing and she’ll slowly die over the next couple of months. Give prednisone, and we’ll perhaps buy an extra month. Or chemotherapy. And here is where my wife and I are struggling. …

For cats, chemo is given in very low doses, intended only to send the disease into remission; not eradicate. So its side effects are usually mild. The vet said she would have a day of sleepiness, poor appetite and maybe diarrhea or vomiting, after which she would be back to normal. She would go once a week for eight weeks, for anywhere from a few minutes to an hour, depending on the medication needed. If the treatment is successful, the vet projects eight to 12 months of life the way she is now. If not, she would still likely gain an extra couple of months. Of course, we could stop at any time if she reacted poorly.

The catch is, chemo can’t be properly prescribed -- or prescribed at all -- without a biopsy. The vet estimates a 75 to 80 percent rate of the cat surviving the biopsy, followed by a five-to-seven-day recovery. There’s a slim chance that, during the biopsy, we could see that the cancer hasn’t reached the liver and is thus much more treatable via chemo.

We’ve wrestled with this for days, trying to separate our desire to see the animal have as many good days as possible with what is in the best interest of the animal. We don’t want her to live a single day that’s not worth living, but we truly don’t know what is best. In effect, we’d be betting two months of her life on a 3-to-1 shot for eight to 12 more.

So I’ve reached out to you all here. Not necessarily for advice, but for any perspective an unconnected observer may provide. Anything that may help us decide what is best for the cat. I look at her 50 times a day and feel helpless, like I should do something -- anything. But I don’t know what to do. Your kind words would be appreciated.

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I'm sorry you have to deal with this dilemma.

My experience is with a 10 year old dog who was diagnosed with the likelihood of cancer during a routine physical. Even though the tumor wasn't biopsied, an xray & scan revealed that the tumor had already developed in multiple areas of the liver.

I chose to avoid chemo or surgery and, instead, keep my handsome boy as comfortable as possible during whatever time he had left . With the metastasis (that is, spread to the liver & who knows where else) the prospects of extending his life to any significant degree with such procedures were extremely slim.

Overall, he lived for only 11 weeks after that chance finding of elevated liver enzymes during his annual physical. I was glad I didn't put him through additional procedures.

    Bookmark   February 18, 2013 at 8:50PM
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The following is a rough discussion of the 'formula' for making tough decisions about chemo I offer my clients after I diagnose cancer (or some other serious, potentially fatal illness) in one of their pets.

You have to first ask... can you afford this? Many of us can not, and that pretty makes up the mind for most of us right there. This sort of question rarely comes up in the human world of cancer, as we find the cost of treatment rarely a consideration in making the decision to let ourselves die. Though it sounds cruel in the veterinary world, cost is a very real consideration. And sometimes it gives us an easy way out (though easy way out is not always a bad thing since treating cancer' or other serious illnesses is certainly not ALWAYS the right thing to do).

If you cannot afford treatment, then Quality of Life (QOL) is only real issue from then on. If there is still good QOL (and you will know this better than your veterinarian often- IF you are being honest with yourself), then you also need to be prepared to do aggressive palliative treatment for pain and nausea, or euthanize, when the time comes. Personally I think if the QOL is at all in question, it is time to euthanize, or regret, guilt and animal suffering will often result. This is where we as pet owners and also veterinarians tend to mess up. I find euthanasia BEFORE a poor QOL situation exists leaves a pet owner far less unhappy in the long run. But this question is not an easy one for many of us to get our heads around and it is an impossible one to really resolve here.

If you CAN afford to go ahead with treatment, and there is any hope at all, then the decisions are: still do nothing, treat, or euthanasia. The first decision, doing neither, is a rather selfish and cruel decision if there are any QOL questions as I already discussed above (but of course this can be argued and am certainly not necessarily 'right', so take that comment with a grain of salt if you want... however, it is based upon over 27 years of helping thousands of owners make these difficult decisions, as well as having dealt with death of dozens of my own pets over the years). I never recommend clients just let their pets die at home as this is never in the pets best interest. If a pet has an excellent QOL, then that is a different situation, but as soon as QOL is in question, and there has been the decision NOT to do chemo or treat, euthanasia is probably the only reasonable decision, or an owner may later feel a lot of guilt about the delay afterwords. Sadly the guilt most owners feel is from doing the opposite- humane euthanasia when a pet is suffering is never a reason to feel guilty. This is where being a pet is way better than being a human.. .their lives can be ended mercifully and avoid all the uncomfortable and miserable dying that many of us humans sadly have to go through because we cannot come to terms with ending our own lives properly.

If you know you can afford treatment and have decided that QOL currently is good... THEN the question about HOPE has to be answered... realistically is there any? SHOULD treatment be attempted, just because it can? Many veterinarians may recommend chemo because chemo can be done, but avoid the questions of whether it SHOULD be done. If there is little to no hope, then no way! But to know the answer to the question of hope, as you mentioned already, you need to know exactly what you are dealing with (sadly this is not always possible- some cancers are mysteries). I personally would need to know this answer in my own pets, so, unless my own pet was actually in the process of dying, or a biopsy would most likely end in death, I would at least proceed and find out what is going on and get an accurate prognosis... without this, the rest is all a big guess (and regret can sometimes creep in down the road).

So lets say now you know you CAN afford treatment, and you have learned the prognosis is 'decent', The next decision is the hardest. SHOULD we still do chemo knowing what we know? What about how hard chemo is on our pets? As you also mentioned above, chemo in pets is different than it is in people. In people we are usually trying to cure or at least get as many years out of us as possible. This means trying 'really hard' (and so the chemo also tends to be 'really hard' since chemo usually has so many serious side effects). This is where we end up treating our pets more humanely than we do ourselves. Chemo 'at all costs' (in other words, pain, loss of hair, ability to digest, walk, etc. are 'ignored or shelved temporarily) and our human lives during chemo can be horrible. Chemo 'at all costs' is rarely performed on pets. The goal is never to get them to live another 10-20 years, or rarely to cure them (though that sure would be nice).... it is QOL (quality of life)- remission ideally, or at least managing pain and discomfort (instead of causing more). In most cases, in my opinion, the actual chemo drugs do not worsen most pets QOL and in fact usually improves it.

However... that is not the only QOL issue when considering chemo- all the traveling to and from the hospital, doing tests, time away from home, etc. is, too me, more stressful on our pets than is the actual chemo itself. Very scared, timid or anxious pets do not enjoy this process, and this is also a QOL issue. It is this issue, actually, that I think I would have to deal with more when making a decision on whether to do chemo on my own pets. I think I would be reluctant to do chemo on my own unless I could either do it myself, or my pet was the type that was not anxious away from home and loved all people (most veterinary employees are pretty likable from a pet's point of view, but not all pets are the type that like strangers -some are literally terrified).
So If you can afford chemo, AND it is a half decent prognosis AND your pet is one that does not mind being away from home a lot and having strangers handle them, THEN I would probably go for it.
Which ever decision is made, to either 'go for it' or euthanize then and there, proceed as soon as possible or, again, regret will end up nagging you for a long time to come. I see many clients hesitate at this point often and the pet suffers from this hesitation. As the veterinarian, the decision is way more easy for me but that is simply the luxury of lessened emotional involvement ... for my own pets, however, it suddenly becomes more difficult so I can certainly sympathize... though my experiences as a veterinarian have helped me to make informed decisions quickly. Much less regret that way!

Now if you made the decision to 'go for it', you have to stay very aware of all aspects of what is going on since at any point, 'going for it' may not be working out any more. If that occurs, and the likelihood of remission or improvement is not good, the decision should probably be to euthanize very soon (right away is best). Do not agonize any more about it. Both you, as well as your pet, will be miserable otherwise.

This rough 'formula' works for many of my clients (and me), but of course there is no fool-proof formula for tough situations or questions for every single situation or all people or pets... .

    Bookmark   February 19, 2013 at 4:12AM
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I am so very sorry you are having to make the hardest decision of your life, when my rottie was diagnosed with cancer I decided I wouldnt put her through all the chemo & surgery when they couldnt give me any hope that she would be alright. I did what I thought was right for her and I have no regrets over my decision. My thoughts & prayers are with you and your precious kitty.

    Bookmark   February 19, 2013 at 9:11AM
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spedigrees z4VT

First of all I'm so very sorry about your kitty. It is never easy when our long time companions are diagnosed with a terminal illness.

I have had a number of older animals (cats, dogs, and horses) who have had inoperable cancers, and I kept them comfortable as long as possible. My vets suggested supportive therapies, such as sub-cutaneous fluids, which I implemented with good results. Your cat will tell you when he is uncomfortable and is not enjoying his life anymore. If he eats, sleeps comfortably, and likes to be petted, he is enjoying life.

I do not believe in chemotherapy and wouldn't have this "treatment" myself, much less inflict it on one of my beloved pets. It is a lucrative business, which is why the industry pushes it, but its efficacy is questionable. Chemo shrinks tumors initially, but in most cases does not prolong life. The side effects are not worth it, plus it knocks down immunity and kills the patient's chance of a remission. I cared for a mare with inoperable uterine cancer who surprised the doctors by rallying and going into remission for a year, when her chances of survival for even a month were negligable. Chemo, even at small doses, probably would have prevented any remission. I had a vet tell me once that she administered chemo to some of her patients upon request, but felt she was doing it for the owner's benefit and not for any health benefit for the animal.

Nor would I have a painful biopsy done. Once my pets reach their senior years, I treat them as I would want to be treated. In other words I take every measure to make their lives more comfortable, and I avoid any measure that would cause them pain, like invasive tests or painful treatments.

Enjoy your time with kitty. Each day is a gift. If he appears to be enjoying even parts of his life, he wants to stay with you for now.

    Bookmark   February 19, 2013 at 2:31PM
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First, I want to say how sorry I am that your cat, and you are dealing with this. We are in the process of treating our 8 1/2 (just about 9) year old cat for nasal lymphoma, so I can share our experience with you if it's of any help.

Our cat is over halfway through a 25 week (modified Wisconsin) chemo protocol for nasal lymphoma. So far, she is doing well with her treatments. No side-effects that we can tell--in fact, she would eat constantly if we let her, as she is on Prednisalone in addition to the chemo.

Our own vet, who doesn't sugarcoat results, or laying out all the options, told us without hesitation upon receiving the Dx, that our best, best course of action, was Cyberknife radiation (more precise along with fewer treatment days than regular radiation). Second would be chemo, third, Prednisone to keep her comfortable, but really, our best bet would be to do the Cyberknife. This is not something he does, only two veterinary centers in the US do it (one in Colorado, and one in Yonkers, at the Animal Specialty Center).

The oncology vet at ASC ran blood-work, did a CT scan, and an abdominal U/S prior to beginning treatments in order to determine if she was a good candidate for Cyberknife radiation. Prior to running the tests, the vet actually suggested that we take our cat elsewhere (she recommended places to take her) to have regular radiation performed, as Cyberknife was not necessary in this situation. For various reasons, we opted to go with Cyberknife.

Our cat's blood test results were all normal, her liver enzymes all good. No metastases in the abdomen, and the tumor had not invaded further than the sinus cavity. Her liver and spleen were slightly enlarged, which could be from having cancer, but could also be age-related, or just her genetic make-up. We were not, and have not been given any prognosis, but the radiation oncologist felt our cat was a good candidate for radiation, so we proceeded from there.

The Cyberknife, chemo, tests, etc., are expensive. We have VPI pet insurance which has covered some, but certainly nowhere near all of the bills. We are far from rich, but had some money saved for emergencies, which allowed us to go ahead with treating her. As she is relatively young, we felt we should at least try.

Following radiation, they began chemo (she received her first treatment before we brought her home after her third/last radiation). The oncology vet is very hands-on, and tweaks the chemo drugs if/when warranted (she lowered the dose slightly of one of the drugs after our cat had slightly low WBC the week after receiving that drug). Initially the chemo treatments are done weekly, until ~ week 10 or 11. We have progressed to every other week for treatments as of late last month. This will continue for another two months (6 months total for the chemo).

So far, they are very happy with our cat's progress (apparently she is considered to be in remission, the next hurdle will be one month out after completing the chemo treatments, and so on....).

I know every situation is different. We battled fibrosarcoma with our 15 year old cat 10 years ago. She had major surgery early that year, followed by chemo (I forget how often--every three weeks???) and we lost her that November. I don't know if I'd have put her through the surgery knowing the outcome, but we did what we thought was right at the time.

I wish you the best as you make this difficult decision. Good luck.

    Bookmark   February 19, 2013 at 4:13PM
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I'm so sorry.

Although we know that we're likely to outlive our pets, it doesn't seem like we're *ever* prepared for it.

My inclination would be to ask the vet why he/she feels sure that the cancer is in the liver;
if there's a good, understandable reason (liver feels enlarged, etc), I'd have her euthanized.

The temptation is to rationalize keeping them with us, citing the "good days", but animals don't live through a bad day in hopes of a good day.

They live in the present, & if they're having miserable days & you know they're never going to be restored to health, I think it's time to be kind & give them a gentle way out.

I think it's better to let them go a little too early than a little too late.

Again, I am sorry, & I wish you and your beloved kitty the best.

    Bookmark   February 19, 2013 at 4:25PM
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Thank you for that great explanation of your process. It was very helpful. My cat is about 10 yrs old with mild kidney problems that have been stable for some time. She is doing great now but there will eventually come a time when, from the kidneys or something else, I need to make this decision.

I am all about quality of life, with pets and people. I don't want to die a miserable death and I don't want my sweet kitty to ever suffer. I hope we are both around a long time.

    Bookmark   February 20, 2013 at 1:37PM
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With all due respect- the OP wrote that the cat was enjoying each day. Euthanasia is not the decision he is contemplating right now - that day will come but no need to rush to that, at this moment in time.

And that would be my advice to the OP (since he asked): be in the moment. Be with your kitty right now, loving her, enjoy the days that are left. Since you asked, I dont know that that the price you pay is worth the benefit. Not only in terms of financial cost, but the time she spends recovering from the chemo and stressed from being uprooted and taken to the vet is precious time that you and she are not able to enjoy together. Is it worth it? If it was a sure thing, that you knew she'd have x no. of months or years more to live, that would be one thing. But the odds frankly aren't that great. I can't imagine liver cancer is all that different in cats as it is in humans - and for humans, it really is considered one of the most lethal forms.

I would suggest getting a second - heck, even a third opinion. Your vet should be OK with you doing that . You just want to know without a shadow of a doubt what's going on, and also it may be that another vet is better than your regular vet for these kinds of end of life situations. When Grimalkin, one of my old girls died at 16 of feline leukemia the first vet was a real @ss - the second was WONDERFUL, she understood that she was there to help ME, the human as much as my cat, and she was so kind and giving of her time to help me make my decisions.

    Bookmark   February 20, 2013 at 1:46PM
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PS- just read some of the other post including lzdrr's formula. I have a slighly different POV, based on being a regular for several years on the Feline Diabetes Message Board (FABULOUS online community BTW - highly reocmmended!)

I don't know how many cats died in the time I was there, how many I said goodbye to, how many owners I consoled - but the one common denominator throughout all of them was that the owners let's say 97% of the time had regrets. Second guessing seems to be part of the grief process, no matter what course of action you take, or not take. Some who euthanized regretted it, thinking they were jumping the gun. Some whose cats died of their own accord regretted that the cat was alone or that they did not act sooner. I think bottom line is - just be kind to yourself - know that a certain amount of second-guessing is part of the process, and remind yourself that whatever you do is done out of love.

All the best to you OP and give your kitty a scratch behind the ears for me.

    Bookmark   February 20, 2013 at 2:08PM
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Well said. I think you are right on. Why is it so hard to do?

    Bookmark   February 20, 2013 at 8:32PM
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Judy Steinberg

I think i maybe new to posting here or did so under a did user name. So sorry about your cat. I have a similiar problem with my 9 yr pom. Took him in for something else and was diag with fibrosacoma of front leg. His has enlarged liver and spleen, hx of cronic pancreatist, elevated trig really high and now boderline cushiing. Only would be rad 3x wk for 3 at cost of 3500-6000. travel 300 mile daily. Maybe give 1 1/2 yrs. Ampt leg not a real good choice due issue with back legs. So I believe My option will be comfort and leting him peacefully as soon as he indicates. But I do unstant what the vet is try to say. Try to make your decision and live or do it or you will be miserable. Every time I look at Dexter I cry and wonder when or should I do more. I pray for you and you decision your pet

    Bookmark   February 22, 2013 at 3:25PM
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So sorry you're having to make this choice. It's never easy. We were in your shoes a few years ago. Our 16 year old was diagnosed with melanoma. The vet told us we could opt for treatments and surgery but he wouldn't recommend it at her age. He suggested we bring her home and lover her for the time she had left. He told us what we could expect, and that she had about a year left. That was in Oct. That was what we did. The next Oct her appetite declined. Within a few days she was sleeping all day. She was compfortable, so we made her a cozy bed, and in the night she peacefully left us. We were happy that we made the right decision for our girl.

    Bookmark   February 23, 2013 at 4:07PM
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Thank you to all who responded. Your advice helped provide perspective.

This was one of the most difficult decisions I’ve ever had to make. Ultimately, my wife and I decided to treat the Bandit with prednisone and a holistic supplement. The chemo would have necessitated a biopsy that had a 20 to 25 percent risk of fatality. And then the chemo itself would have been eight weeks long. The treatment’s effects are mild and typically last only a day, but the Bandit hates going to the vet. The hangover lasts a week, and it includes listlessness, fear of being picked up and diminished appetite. Essentially, it would have been a very risky biopsy and eight weeks of trauma to get to the good side, which was two (but most likely six) to 12 months of symptom-free life. I felt that if the biopsy didn’t get her, eight weeks of trauma and refusing to eat very likely could have. The most difficult thing is knowing that you CAN do something but AREN’T.

Please keep the Bandit in your prayers. We’re hoping for the miracle of a few extra months, so she can enjoy the warm weather of spring and a few more opportunities to live through all of her favorite daily routines.

Thank you again.

    Bookmark   February 25, 2013 at 6:44PM
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Our prayers are with you.

    Bookmark   February 25, 2013 at 7:24PM
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Ditto. I hope she is as comfortable and as happy as possible during whatever time she has.

    Bookmark   February 25, 2013 at 7:28PM
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I hope her time far exceeds what you may think.

    Bookmark   February 26, 2013 at 2:20AM
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My thoughts & prayers are with Bandit & your family. Bandit is a very good looking kitty.

    Bookmark   February 26, 2013 at 11:30AM
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spedigrees z4VT

I think you made the right decision. I hope that Bandit will live to enjoy the spring and summer. He may well be with you longer than you expect. Please keep us updated.

Bandit is, indeed, a very handsome cat. Despite his illness, he is a very lucky kitty to have a wonderful home with caring owners.

    Bookmark   February 26, 2013 at 11:44AM
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The fact that you CAN do something doesn't mean it's what you should do. I agree with your choice and would do the same. I believe the extra time you may have gained from extensive treatment would only be for your benefit, not hers.

A biopsy of the liver is very scary. Several years ago I had to euthanize my dog 2 days after her biopsy. She started bleeding and it wouldn't stop, even after additional surgery. Tests came back 24 hrs later showing she had no liver function.
You're very fortunate that you have a vet that has given you all the information you needed to make this decision. I so hope she beats the odds and is with you for much longer.

    Bookmark   February 28, 2013 at 5:48PM
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How can I be SURE that my cat has small cell lymphoma? My vet who is very good said she saw indications of this in an ultrasound, near his pancreas in his upper abdomen ( but not IN the pancreas). There is still a chance it is extreme IBD and the only way to tell is a biopsy. My vet feels that an endoscopy with the help of ultrasound is unlikely to get a good sample...we'd have to open him up. And she doesn't think we should put him through it. He's 11 and recovering from IBD like symptoms of diarrhea and vomiting, My vet's "gut" is telling her that it is a lymphoma and wants to add Leukeren to his prednisolone and just monitor via ultrasound. I don't want to put him through unnecessary pain or risk either. He is my heart. But I want a definitive answer. And I don't really feel I have one....other than my vet's gut feeling. In addition the vet has only had this ultrasound machine for a few weeks and is just getting comfortable with it. She is top in her am so confused - I'm thinking of sneaking behind her back and getting another ultrasound by somebody who does nothing but ultrasounds. What should I do??!

    Bookmark   January 23, 2014 at 1:14AM
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My understanding is that surgical biopsy is the ONLY way to get a definitive diagnosis of abdominal lymphoma. Another ultrasound by another vet is still only going to give you a "best guess" diagnosis, and it's going to drain your pocketbook of funds that you could be using for other aspects of the diagnosis and treatment/management of your cat. OTOH, is a definitive diagnosis going to change how you manage your cat going forward? Would aggressive cancer treatment, if cancer is confirmed, provide a good prognosis? If not, then don't put him through a biopsy.

Scroll up and read lzddr's post above. It will help you put all of the issues related to your situation into perspective and help you make a decision in your cat's best interest.


    Bookmark   January 23, 2014 at 12:27PM
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