Consultation Prep

Keeping calm is not my strong suit. Hearing the “C” word when our veterinarian confirmed Lager’s cancer diagnosis weighed heavy on my mind, but the uncertainty of what would follow was even more difficult for me to handle. Securing a consultation appointment with the oncologist of our choice was the easy part. Waiting for that day to arrive, however, was torture. Time could not pass quickly enough to reach that date and get more information. To help keep anxiety and fear in check, I focussed my efforts on preparing for the first appointment:

1. Oncology appointment
   • When scheduling the oncology appointment I asked the following questions:
     • What will be covered during a consultation appointment?
     • Do I need to bring anything with me to the appointment?
     • What’s the best method of transferring notes and pathology results to you from Lager’s primary veterinarian?
     • Does Lager need to fast for this appointment?
   • There is no cancellation list for the doctor we chose, so I called on a daily basis, joking with the front desk staff that they would get to know me more than they’d like! The staff was understanding and my persistence paid off…I was able to catch two cancellations and move Lager’s appointment up twice during the torturous waiting period.
2. Research
   • I educated myself on the basics of Lager’s diagnosis, making sure to remind myself that each case is different and to be mindful that I don’t let what I read completely freak me out while waiting for Lager’s appointment with the oncologist. Researching enlightened me on oral papillary squamous cell carcinoma, treatment options, and presented new terminology that I needed to familiarize myself with prior to the consultation.
3. Notebook
   • When I’m nervous, I do listen, but nothing (and I mean nothing) will sink in. I knew discussing Lager’s diagnoses, tests, prognosis, possible surgery, etc would be upsetting …making it difficult for me to process the information at that time, and to correctly relay the important details to Brian. If I can’t precisely remember and process the information the oncologist is delivering, it will be near impossible for me to take the steps needed to get the best care for Lager.
   • I prefer to write my notes rather than type them.
     • As an old-school retired teacher, I am a firm believer that despite modern technology, whenever possible – handwritten notes enable you to remember and comprehend the information more efficiently.
     • Eye contact is important to me – especially post-Covid when one or both people may be wearing a mask. Personally, it is easier for me to maintain eye contact with someone while writing on paper versus typing on my phone.
     • I’m the Queen of Typos (as I’m sure most of you already know from my prior posts – and most likely this one!) .. I’m not the best speller to say the least, but I can decipher my handwritten misspellings much easier than the “creative” auto-correct choices my phone or iPad makes for me
     • No worry about getting a low battery alert on my phone…there will be plenty more to worry about, so taking one issue off my list is a win!
   • Although some people I know have recorded their consultations, I am not comfortable with doing so
4. List of questions specific to Lager’s diagnosis
   • What stage and subtype is Lager’s oral papillary squamous cell carcinoma?
   • What is the typical percentage of chance this type of cancer has metastasize? What additional tests (if any) will be performed to rule out the spreading of this cancer to other areas?
   • What are the treatment options you recommend and how does Lager’s stage/subtype impact his options?
   • What are the potential downsides, including common side effects that I can likely expect, as well as rare but more serious complications?
   • When would he begin treatment?
   • What is the cost of the treatments? Follow up appointments?
   • What is the prognosis with the different treatment options?
   • What is the recovery time of treatment/surgery?What oral surgeon do you recommend to perform any surgery needed to remove the mass and any other areas that it may have invaded?
   • Is Lager currently in pain?
   • Is he allowed to have soft toys before and after his surgery?
   • What supplements, dietary changes, lifestyle changes, etc can I do to further support Lager
   • Will Lager have any short or long term restrictions before/during/after surgery and/or treatment?
   • Should I cease all vaccinations for Lager at this time?
   • If I have further questions what is the best email address or phone number to call to clarify points or to further discuss information presented in this appointment?
5. Show support for Lager
   • I ordered an oral cancer awareness ribbon paracord bracelet (created by Ford’s Cord & More)

Oncology Consultation Appointment

October 4, 2022

Lager sported his oral cancer awareness bandana (highlighted later in this post) and I put on the hat that Margarita wore when we went to her oncology consultation.

Arriving to Lager’s appointment…

Being a good boy in the waiting area…Lager wore his cancer awareness collar, oral cancer awareness bandana, and oral cancer awareness charm for his consultation (all gifted to him and highlighted later in this post)

Lager’s oncologist is Dr. Olivier Campbell (coincidently the same last name as our primary veterinarian, but no relation). Dr. Olivier Campbell was so patient and kind – he took time to answer all my questions and explain everything (he even drew pictures to provide a visual and help me to better understand). Here is what I learned at the consultation:

• Lager’s cancer is a subtype (called papillary) of oral squamous cell carcinoma (this is good!). There are no particular “stages” with this type of cancer.
• Oral squamous cell carcinoma is locally invasive and potentially locally destructive with a very low potential for metastasis – this is considered a low-grade malignancy.
• This tumor type tends to invade the adjacent tissues, including the underlying bone in approximately 77% of cases. They can also occasionally metastasize to the regional lymph nodes and to the lungs. Tumors of the mandible (lower jaw) generally have a better prognosis than maxillary tumors (upper jaw).
• Oral papillary squamous cell carcinoma has a lower chance of metastasizing, but it is still possible
  • if it does metastasize, it will tend to travel to the lymph nodes, lungs, and stomach. Ultrasound, x-ray, and aspirate sample will rule this out.
• Surgery is the first line of defense against this type of cancer.
  • Surgeries of the jaw are usually well tolerated in dogs.
  • If a tumor is incompletely excised, radiation therapy can be considered to try to kill the remaining tumor cells in the area.
  • With local treatments, the reported median survival times range from 9 months to 3 years.
    • Lager’s prognosis cannot yet be determined until all tests are completed and mass removal is completed
• Although Lager is is not displaying any symptoms, he is most likely having some level of discomfort, so playing with toys are not recommended at this time
  • While waiting for his surgery, if Lager begins to display signs of discomfort, there are oral pain medications, non-steroidal anti-inflammatory drugs and injectable medications to help with bone pain.
• With this type of cancer, there are no supplements / dietary changes to add that have been proven effective as supportive additives.
• Vaccines should be ceased at this time but can be resumed once Lager is recovered from his surgery.
• Once surgery is complete, the oral surgeon will help us determine any restrictions moving forward

Tests completed at this visit:

• Cytology (mandibular nodes)
  • This test provides an answer in 80% of cases approximatively. Results are pending and should be obtained in 7-10 days.
• Thoracic Radiographs
  • No evidence of radiovisible metastasis, but the radiologist will review Lager’s radiographs to ensure that no significant change is present. An update will be provided at the same time as the cytology.
• Abdominal and Cervical Ultrasound:
  • Ultrasound of the cervical region reveals no enlarged lymph nodes and the mandibular salivary glands and thyroid/parathyroid regions are normal. There is no evidence of metastatic disease within the abdomen or at the cervical region.
    • Liver: No significant abnormalities.
    • Spleen: Prominent in size with normal in echotexture.
    • Kidneys: No significant abnormalities.
    • Adrenal Glands: There is a 0.7 x 0.9 cm, hyperechoic nodule at the cranial pole of the left adrenal gland most consistent with nodular hyperplasia. The remainder of the adrenal tissue is normal. A developing primary adrenal tumor is considered less likely. This may revisited in 2-3 months if symptoms arise, or if suggested by our veterinarian.
    • Urinary Bladder: No significant abnormalities.
    • Stomach: There is a large volume of echogenic ingesta within the lumen
    • Intestines: There is echogenic ingesta multifocally throughout the lumen.
    • Colon: No significant abnormalities.
    • Pancreas: No significant abnormalities.
    • Peritoneum: No significant abnormalities.
    • Mesentery: No significant abnormalities.
    • Lymph Nodes: No significant abnormalities.
    • Prostate Gland: No significant abnormalities

Visit Summary Notes from Dr. Olivier Campbell: Lager is an adorable dog. Unfortunately, he was recently diagnosed with an oral squamous cell carcinoma. In Lager’s case, the tumor subtype was most consistent with a papillary squamous cell carcinoma, which is thought to be potentially even less aggressive than other oral squamous cell carcinomas. On today’s visit, we discussed that we could characterize Lager’s health condition and the extent of his tumor with thoracic radiographs, cytology of the mandibular nodes +/- abdominal ultrasound, neck ultrasound to assess the retropharyngeal nodes. No evidence of spread of his tumor was observed upon imaging and the results of the cytology of the nodes are pending. The next step to consider to fight his disease would be to meet with a dentistry specialist to plan the surgical removal of the tumor +/- the lymph nodes if the tumor is detected in them. At home, please continue to monitor Lager as usual and contact a veterinarian if his condition deteriorates.

DockDogs World Championship

From 2015 to 2017 I was blessed to be Lager’s teammate in Dock Diving. It was a privilege to share the dock with him. We competed at the World Championship in 2015, 2016, and 2017. Right before the 2018 season began, Limoncello was diagnosed with Dilated Cardiomyopathy, and was not able to compete. I thought it would be best for Brian to take over as Lager’s handler since Limoncello’s diagnosis left Brian without a dock partner. Brian and Lager had a great run together before Lager had developed some insecurity on the dock beginning in 2019. Although they tried to work through it, Lager continued to hesitate on the dock. After we had Lager medically examined to be sure there were no underlying issues, we decided that change may be a good thing, and we once again switched back to me being Lager’s handler this year…I hadn’t realized just how much I had missed my teammate! Lager and I had an exciting season as we got back into the groove of competing together. Lager’s insecurity disappeared, and he earned himself an invitation in every discipline in which he competed!

In Lager’s best interest, we unfortunately will not be making the trip to Iowa this year. Although we are extremely disappointed that we won’t be competing at the World Championship with our dogs and that we will not see our friends, this is the best choice for our family, and most importantly, for Lager. We wish all competitors and DockDogs staff a safe trip, and are sending good vibes and positive energy your way. Don’t forget to soak in every single moment with your pups (and peeps!!) when you are there. Best of luck to all competitors… it’s your dog’s time to shine! Team Liver Killers will be looking for updates on social media and cheering you all on from New Jersey! We look forward to sharing the dock with you and your pups in 2023.

I Get By With a little A LOT Of Help From My Friends

Saying “thank you” is not sufficient to capture my gratitude for all of you. In fact, there really are no words that can fully express my appreciation for the overwhelming outpouring of love, prayers, positive vibes, phone calls, post comments, text messages, private messages on social media, and generous gifts. You all have provided support and strength as we embark on a new Journey through uncharted territory…and somehow the these acts of kindness always seem to arrive at just the right time. Brian and I both want you to know that you all have lifted our mood, enhanced our hope, and comforted our hearts. I will forever remember this compassion and thoughtfulness, and vow to to do my absolute best to pay it forward.

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^{Beautiful card that included a heartfelt written letter as well}

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These Superhero capes were gifted to Lager to provide him superpowers on his Journey. The red cape pictured on the left is new. The blue cape pictured on the right belonged to a friend’s dog. My friend explained that she was not only purchasing a new superhero cape for Lager, but also passing along the cape of her beloved dog who has been blessed with an extremely long life…and that she wanted to share that with Lager in hopes that the cape would grace him with many more years beyond his Journey.

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An amazing friend commissioned Ratjr Theos ( Portrait One ) to create this stunning digital painting of Lager.

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A box of gifts arrived for the whole pack! The whole family feels the stress during difficult times – we are so appreciative that the rest of our pack is being supported as well! This is the first time I have ever seen a Limoncello (LimonSMELLo) dog toy!

Eat Like a King

After a 5 hour day of being the bestest boy during all of his testing, Lager undoubtedly deserved a reward. We stopped at Burger King on the way home and Lager enjoyed a couple of fries and a few pieces of a plain cheeseburger.

Waiting With Hope

…And now we remain hopeful as wait for a scheduled surgery date, the final cytology results, and confirmation on the x-rays and ultrasounds. Overall Lager’s oncology visit was full of positives, and we are beyond grateful for that!