Canine Lymphoma - Diet Supplements
Q: Dr. Mike, I had written to you before about using the University of Wisconsin's chemotherapy protocol for my dog's lymphoma. Tomorrow I am going in for the third treatment. I plan to follow the treatments through to completion but I would like to get your opinion on using some supplemental nutritional things. I read one of your other letters about homeopathic remedies so I kind of have an idea of what you might say. I have been in touch with a DVM who specializes in these things. As I mentioned I do plan to continue traditional chemo treatments. It was recommended that I use a dietary supplement called Ambrotose. It is made by a company called Mannatech. It consists of 8 carbohydrates: Glucose, Galactose, Xylose, Fucose, Mannose, n- acetyl Glucossamine, Glactosamine, and Newramic Acid. It is supposed to help strengtben the immune system. Also it was recommended that I give my dog Carsinosin 30c which tiny cells from a cancer tumor given to help the body build an immunity to the cancer or to simple help the body fight off the return of the cancer. I would greatly appreciate your input on these things. Also is broccoli and carrots cancer fighting foods in dogs? Thank you, Venita B A: Venita- I think that most of the nutritional supplements are safe. There just isn't much information on whether they work well or not that is scientifically validated. So I don't see any reason not to try them, as long as that is known. Iams makes a dog food that is supposed to follow the nutritional recommendations of Dr. Oglive at Colorado State University, who has done some controlled studies on diet as it relates to lymphoma. Hill's also makes a prescription diet (n/d, I think) that follows the same recommendations. These may be worth looking into, as well. It is too early to be sure these diets have much effect, either but the same principle applies -- they aren't likely to cause harm. I will try to find information on the Carsinosin 30c but that sounds like a homeopathic product that is diluted 30 times from the original compound. (usually that is what 30C means). Most homeopaths recommend not using chemotherapy and trying to build up the body's response to diseases. In all honesty, as you surmised already, I just can't believe that this approach really works. But since I'm guess as to what the compound is, I'll try to do more research and get back with you. Mike Richards, DVM 4/8/99
Lymphoma Treatment with Wisconsin Protocol
A: Venita- Your question was in reference to treatment of lymphoma using the newer Wisconsin protocol or older protocols. Specifically, you were interested in the success rate of the treatments and potential for toxicity. The Wisconsin protocol appears to have a higher success rate than older protocols such as "COAP" or "COP" protocols. It is hard to give exact success rates due to variations in the way studies are done, but I think it is fair to say that reported success rates are around 80% for older protocols, using induction of remission as the definition of success. The Wisconsin protocol is reported to induce remission in 91% of dogs (from David Vail in Kirk's XII). It is a lot harder to compare the duration of effect because some studies report time to death with treatment, including the initial remission and the subsequent remissions after further treatment and other studies report only the time until the first remission is over. I think that the Wisconsin protocol is considered to be better for overall lifespan, too. I have searched for information on toxicity associated with the Wisconsin lymphoma protocol. As I was searching it occurred to me that the question isn't answered because pretty much all of the drugs used in chemotherapy are toxic. So all patients experience some degree of toxicity during treatment. The dosage of medications may need to be adjusted during the treatment and sometimes it is necessary to stop one medication in the protocol all together. With a success rate of 91% it seems safe to assume that serious toxic reactions resulting in treatment failure must occur less than 10% of the time and probably less than that since treatment failure doesn't necessary require that a toxic reaction occurred. While I was searching for information on the Wisconsin protocol it was pretty clear that it is the protocol that is currently favored among oncologists for the treatment of lymphoma. Mike Richards, DVM 3/18/99
Chemotherapy and Quality of Life
Q: Dr. Mike: They took out two lymph nodes from Visa on Saturday and also need a bone marrow test. Both the vet and surgeon are now very concerned since this lymph node under his chin was much larger than the week before and they see a change in his blood test also from the prior week. I was advised today, that I will not have the results of the biopsy on the lymph nodes untill the end of this week. I just feel like I am losing very valuable time waiting for test results. First one week for the blood work and now another week for the biopsy. I see such a difference in Visa in the past two weeks - he absolutely has no energy. I was not able to get an appoinment with the Animal Medical Center in New York until January 6th - do we have the time to wait? Also, since I am almost convienced that I am not going to hear good news at the end of this week, I would like to hear your thoughts about treating Visa with Chemo. The cost isn't a factor - I want to know what the quality of life is for a pet being treated with chemo. I DO NOT WANT HIM TO SUFFER!!!! Thank you. Jo G. A: Jo- Our most recent case of lymphoma was treated with chemotherapy about 5 weeks after we were very suspicious of the disease and still underwent remission quickly and has done well for a couple of months, at least. While it is best to start as soon as confirmation of the disease is made it is important to get confirmation due to the risks involved with chemotherapy. So far, the dogs in our practice who have had chemotherapy have done well or have done really poorly (no response after initial treatment). We haven't had much in between. The ones that have responded have not seemed to have been bothered too much by chemotherapy and the owners have all been pretty happy with the results as far as I know. Obviously the ones that didn't respond have been heartbreaking for their owners. If the diagnosis is confirmed give the AMC a call and see if they can fit you in sooner. Referral centers are often able to do that when there is a strong need. I will still hope for another cause for Visa's problem, for now. Mike Richards, DVM
Lymphoma - Sasha update
Q: Dear Dr Mike, As to Sasha, I went ahead with the Tagament and Aspirin and she greatly improved except for her temperature. I took her back for a recheck and was informed that she has a form of lymphoma cancer and she could live from 2 to 3 weeks or she could live 6 months. It has been a hard day but I will make sure she lives life to the fullest and when we can no longer manger her pain she will go peacefully in my arms. Thank you for your concern and maybe you could forward this to Dr Mike. Sadly, Kersti A: Kersti- I am sorry to hear about the diagnosis of lymphoma (I am assuming this is the problem based on the history and prognosis). If this is the case it is the most responsive of canine tumors to chemotherapy, although this usually results in a longer lifespan of one year to eighteen months, rather than a cure. Some dogs do live longer than that with therapy, though. For many people chemotherapy is not a reasonable option but I just wanted to let you know it may be a possible alternative. I hope that you are able to spend some good time with Sasha. It is a good time to spoil her a lot. Mike Richards, DVM
What is Lymphoma?
Q: Dr. Mike - First let me say how wonderfully informative your website is! You and your staff do a great job. My husband and I have three beagles and I have some questions regarding our youngest, Belle, who is 6 years old. She has had a history of ear infections since I can remember and last December she was showing the normal signs of having one (digging at ears & rubbing the side of her head on the carpet) however, we also noticed at that time that he right side of her face was a little "droopy" and she was walking crooked & running into things. My vet said that this could be due to a severe inner ear infection, gave us medication & told us to keep an eye on her & call for progress reports. The next week she became aggressive towards one of our other dogs (they've always been the best of friends) and also began to walk in circles, always to the right. My vet suggested that we take her to the vet hospital in our state, which we did. Two days before we took her, she began to vomit after eating and the day before she did not eat at all. The vet hospital performed a CT scan, spinal tap, lead tests and many other blood tests. The CT scan came back negative for brain mass, ruled out epilepsy, and showed her ear canals looked healthy. The lead test was negative and the fluid from the spinal tap did not have enough abnormal cells (I think this was the term used) for them to diagnose it as cancer. While she was down there, her eyes and nose began to twitch and she also began to tremble. They narrowed her condition down to two possible diagnosis: White Shaker Syndrome or Lymphoma Carcinoma. We were sent home with high doses of Prednisone to start with, 25 mg twice a day, and we are currently at 5 mg every other day. All of the Pred that she's been taking has caused her to have "man-made Cushing's disease", to quote my vet. We were told that if it was White Shaker Syndrome that Prednisone is usually a very effective treatment but if it is Lymphoma Carcinoma the Pred will temporarily destroy the cancer cells for a time but the symptoms will return along with the cancer. Not long after we brought her home, we noticed two "lumps" on the side of her neck which the vet indicated were the lymph nodes. He performed needle biopsy's which were benign and she was put on Baytril since he felt this could be due to infection. The lymph nodes did reduce significantly after the Baytril but are still present at this time.
My questions are: Do you have any additional information on Lymphoma Carcinoma and is there another name for this? I've not been able to find as much information on this disease as White Shaker Syndrome. Also, from her history are you able to give any additional input or ideas on her condition? I trust my vet whole-heartedly but would value another opinion. She and our other dogs bring such joy to our lives and the thought of loosing her at such a young age tears me apart. Thank you in advance for your advice. Theresa. A: Theresa- Lymphoma is the currently favored name for a condition that has been known as Lymphosarcoma, lymphoma, malignant lymphoma and maybe lymphoma carcinoma. Since I haven't seen that name, I am wondering if there is worry over lymphoma OR a carcinoma (a general term for several malignant cancers). Lymphoma is a cancer of the lymph system and it usually does cause enlargement of the lymph nodes. It is the most responsive tumor (I think) to chemotherapy in dogs. If it is not treated the average survival time tends to be about 1.5 to 2 months after diagnosis. If treated it is more like 1 to 1.5 years. Usually this tumor will show up on lymph node aspirates or lymph node biopsy so it is a good sign that it was not found. There are many other causes of enlarged lymph nodes since they react to infections and inflammatory processes. The length of time since initial symptoms were seen would seem to make it less likely that this was lymphoma. White shaker dog syndrome has been reported in non-white dogs, despite the name. Inner ear infections are difficult to diagnose with normal X-rays (I remember a study that showed that something like 40% of the time they were not possible to detect with X-rays). I do not know how much more accurate a CT scan is but I suspect it is better. It might be worth asking about that, though. The Baytril would help if an inner ear infection was present. Hypothyroidism has been reported to cause facial paralysis but I don't recall the other symptoms being associated with it. Peripheral vestibular syndrome can cause most of the signs you saw but it normally clears up in a few days to a few weeks. It sounds like a thorough exam and lab workup was done. I wish I could be more help but can't think of much else to do. Mike Richards, DVM
Is Chemo for Lymphoma Worth It?
Q: My 11 year old golden retriever was diagnosed with lymph cancer, based on aspiration of a lymph node. The Vet said that because of her age and the spread of the disease there wasn't much that could be done. She is on Prednisone and an antibiotic now. I have read that chemotherapy could help her, but have also been told that because of her age it would only delay things a short time and was not a cure. There is also concern that the chemotherapy would be hard on her. What is your advise? A: K- Lymphoma is the most responsive cancer to chemotherapy. Dogs seem to tolerate the chemotherapeutic protocols pretty well. The survival time for dogs treated with chemotherapy tends to be 9 months or so longer than untreated dogs, although there is absolutely no guarantee that a particular dog's cancer will respond well to it. The therapy is fairly expensive. There are few "cures". Those are the good and bad points of chemotherapy. Pet owners making the decision on whether or not to do chemotherapy have a difficult choice to make. For one group of people, the few extra months do not seem beneficial enough and they choose euthanasia when obvious discomfort sets in. For other folks every day is precious and they rarely regret the decision to try. For the group in between, trying to weigh cost, benefit in life span and comfort for their pet can be difficult. You just have to make a decision and then try not to second guess yourself too much. Prednisone alone seems to make dogs with lymphoma more comfortable and the effect lasts several weeks. It isn't nearly as effective as chemotherapy using combined protocols but many people chose this approach. Mike Richards, DVM
Making the Decision for Chemotherapeutic for Lymphoma
Q: Dear Dr. Mike, Our 8 year old German Wirehaired Pointer has just been diagnosed with lymphoma. Thus far she seems to feel well, and is both exercising and eating normally. The only outward evidence we see is that all the lymph glands are enlarged. This appeared quite suddenly about three weeks ago. A CBC run a few days ago showed a normal white cell count. The only anomalies were somewhat low platelet numbers and an elevated blood calcium level. One lymph gland was removed and sent to Iowa State University. Lymphoma was confirmed. Our vet offered two treatment options: 1) Giving Prednisone alone or 2) Administering vincristine once every other week for twelve weeks combined with daily doses of Cytoxan and Prednisone in dosages he has not yet specified. He reported that, in the aggregate, remission and survival rates with either option do not differ greatly. However, he suggested that, given the dog's vigor, the combination chemotherapy may be worthwhile. He spoke of perhaps gaining her an additional month or two to as much as six to eight months. We've been scouring veterinary web sites for relevant information so as to make the most informed decision possible yet this week. Unfortunately the research summaries we've found on the Internet are somewhat fragmentary. The reported results of various chemotherapy protocols do not seem readily comparable due to differences in sample size, severity of illness, etc. From what we've seen, at least in terms of median survival times, it does not appear that the more elaborate chemotherapies offer statistically significant improvement over administration of Prednisone alone. Our rural location makes it difficult to quickly access the original journal articles to verify this. Are you aware of any protocol that has shown significantly greater survival time than treatment with Prednisone alone? Our objective is to make the time she has left as painless and stress free as possible. Reported results of the more elaborate protocols don't seem to warrant the potential side effects or stress to the animal. Are we missing something here? We'd appreciate your thoughts on this. We are really in a quandary. Thanks. Jim A: Jim- There is not much question that the combined chemotherapeutic approaches to lymphoma work markedly better than prednisone alone. However, the hope for a "cure" is slim with either protocol. The mean survival times for prednisone therapy alone are somewhere in the neighborhood of 8 to 9 weeks (this is from memory but shouldn't be too far off). The mean survival times for combined protocols is between 12 and 18 months at the current time. The most commonly recommended protocol is the COAP protocol described in Kirk's Current Therapy X, I think. Most dogs tolerate chemotherapy fairly well. I think it is legitimate to question the merits of extending life for a relatively short period of time but that is a question that you have to answer for yourself. Everyone feels differently about the importance of those months. When chemotherapy works well, most owners are glad they tried it. When it doesn't work well (and it doesn't always) people question the decision. You have to make up your mind in advance which approach is best for you and your dog and then try hard not to second guess yourself too much. You should be able to get the most recent information on chemotherapy from ISU's oncologist or internal medicine specialists. This information constantly changes, usually for the better. Mike Richards, DVM
Second Opinionon Swollen Lymph Nodes
Q: Dr. Mike My 10 year old miniature schnauzer had swollen glands by her jaw so I took her to the vet, who aspirated the lumps and said it was consistent with the way he would expect cancer cells to look. He examined her and found swollen lymph glands under her jaw, at the tops of her front legs, and on the back of her legs. He gave me some prednisone (sp) to give her, but I would like to get a second opinion on his cancer diagnosis before I start the medication. Is there any way to know, if it is in fact cancer, how far along it is, and what her life expectancy would be on the medication? She is in great shape and doesn't act sick *at all*. She had a tick bite on her chin and I thought the swelling was from that, so that's the only reason I took her to the vet. A: We send the aspirates from lymph nodes we suspect to be cancerous to a clinical pathologist for review. If the pathologist agrees with our assessment and the clinical signs are consistent with lymphoma or other cancer we feel content that the diagnosis is correct. If some question remains, we remove a lymph node and send that. This allows the pathologist a better look at the architecture of the gland which can help determine if cancer is present. Lymphoma is often discovered pretty much the way you did - by accident. It does not seem to cause much pain or discomfort in the early stages. It therefore comes as a shock to many owners expecting a minor problem and going home coping with a diagnosis of malignant cancer. Prednisone therapy will usually allow a couple of months of comfortable time when used as the sole agent for lymphoma. If another cancer other than this has metastasized to the lymph nodes there would be no way to give you any sort of prediction without knowing the exact cancer involved. Combined chemotherapy is much more effective for lymphoma, giving reasonably comfortable lifespans of 12 to 18 months. There is a bigger expense and time commitment to the pet with this decision but for many people chemotherapy is an option to consider. This is the sort of situation in which some sort of second opinion - either from the pathologist or through examination by another vet -- is a good idea. Whenever a fatal illness is diagnosed and there is any question in your mind about the diagnosis, it is best to be certain. Mike Richards, DVM
Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...