Page 332 - Withrow and MacEwen's Small Animal Clinical Oncology, 6th Edition

310 PART III Therapeutic Modalities for the Cancer Patient

epigallocathecin gallate (EGCG, a flavone from green tea), and situation. Research in human medicine indicates that breaking
lycopene in dogs (carotenoids). 390–392 All of these nutraceuticals bad news, discussions of the prognosis, and end-of-life discussions
often are suboptimal because of many of these barriers and a lack
required dosing at very high concentrations, which may preclude
VetBooks.ir their clinical use. There is tremendous disconnect between what of specific training in communication. 401–404
The content, duration, and methods of communication train-
is available and what may be required, in addition to a lack of
clinical trial investigations to assess the efficacy and safety of these ing in veterinary curricula are highly diverse and variable. Many
compounds. Furthermore, metabolism of these compounds may practitioners have not received formal communication training and
be different in cats and dogs; therefore caution is advised. Dosages may feel unprepared to engage in difficult conversations. 405–407 The
over 150 mg/kg of EGCG in dogs caused hepatic necrosis, and the veterinary profession identified a skills gap between the content of
use of lipoic acid (an antioxidant thought to help salvage glutathi- the veterinary school curriculum and the actual skills required to be
one) has potential for toxicity and hepatic damage in cats when a successful veterinarian. 408 Using experiential techniques, defin-
used at dosages thought safe in dogs and humans. 393,394 ing key skills, and creating practice opportunities enhance effective
In conclusion, set nutritional requirements during neoplasia do communication. 409–412 In accreditation standards, the American
not exist in companion animals. In part this is due to the variety Veterinary Medical Association’s Council on Education recognizes
of neoplastic diseases involved and the danger of trying to extrapo- communication as a core clinical competency for success. 413
late data generated in human cancers. Many aspects remain to be Several aspects of cancer care make it a unique communica-
addressed, including nutritional interventions for anorexia/cachexia tion context. 414 The initial diagnosis frequently is made by the
during treatment and remission, and nutrition recommendations primary care veterinarian, who may refer the client and patient
based on specific disease processes. Therefore no one dietary rec- to a specialist. Therefore the first visit with the specialist often
ommendation can be made for cancer patients; rather each case occurs after the patient receives at least a tentative diagnosis, and
should be evaluated based on the patient’s body condition, the spe- the focus of the conversation is on confirming the diagnosis, treat-
cific neoplastic process, and the treatment protocol initiated by the ment and prognostic information, and decision making. In this
oncologist. The topics discussed are merely guidelines for interested setting tough conversations occur on the back of a newly formed
clients and clinicians – the most important factor in nutritional veterinarian-client-patient relationship. Cancer is an emotionally
intervention is to supply a complete and balanced ration that meets laden diagnosis, and clients often have high levels of uncertainty,
the patient’s energy requirements to prevent weight loss. anxiety, fear, frustration, and guilt, which heightens the stakes for
both parties. Fortunately today we can offer clients a menu of
sophisticated diagnostic and therapeutic options for treating their
SECTION C: RELATIONSHIP-CENTERED pet’s cancer. This also presents the challenge of navigating complex
APPROACH TO CANCER COMMUNICATION information sharing and the decision-making processes of making
the “right choice” for their pet without overwhelming clients. The
initial visit may require as much listening as talking to hear what
JANE R. SHAW is most important to clients to address these challenges.
Cancer communication is a process that occurs over time, start-
Recognition of the relationships that people develop with their ing with delivering the diagnosis (i.e., often delivering bad news);
companion animals brings an awareness of the impact of animal making decisions about treatment options; discussing the progno-
illness on pet caregivers and the veterinary team. 395,397 Increas- sis; assessing the QOL; transitioning to palliative, supportive, or
ing acknowledgment of pets as family members is associated with hospice care when required; and ending with preparing families
greater expectations by pet owners for the highest quality medical for euthanasia, dying, and/or natural death. These difficult con-
care for their companion animals, in addition to compassionate versations are spread throughout multiple visits over time; during
care and respectful communication for themselves. 395,396,398–400 this time, the relationship grows and a partnership develops, mak-
The human-animal bond is particularly stressed and fragile when ing it more comfortable to address end-of-life conversations when
an animal is sick, and even more so after a diagnosis of cancer. appropriate.
Appreciating the effect of animal companionship on the health and Another special consideration is that cancer conversations fre-
well-being of humans creates a new dimension in public health. quently are managed by a team of veterinarians, including the
Today, the responsibilities of veterinary professionals include the referring veterinarian and multiple specialists. Most pets with can-
emotional health and well-being of clients and their pets. 398 cer are treated with a combination of therapies involving differ-
Communication about the diagnosis, treatment, and prognosis ent types of expertise (i.e., medical oncology, surgical oncology, or
of cancer presents challenges both for veterinarians and for cli- radiation oncology) or different disciplines (i.e., cardiology, neu-
ents. From the veterinarian’s perspective, a number of factors may rology, or internal medicine). For example, the medical oncologist
contribute to discomfort with this conversation, including lack of may determine the diagnosis and conduct the clinical staging; a
training, insufficient time, practice culture, feeling responsible for surgical oncologist may remove the tumor; and a medical and/
the patient’s illness, perceptions of failure, unease with death and or radiation oncologist presents the efficacy of adjunct therapies
dying, lack of comfort with uncertainty, the effect on the veteri- after surgery. Each of these experts layers on information for the
narian-client-patient relationship, worry about the patient’s qual- client about potential treatment options and the effect on the pet’s
ity of life, concerns about the client’s emotional response, and the QOL and prognosis. Then a medical oncologist might discuss pal-
veterinarian’s own emotional response to the circumstances. 400,402 liative, supportive, or hospice care and facilitate end-of-life deci-
Some of these same reasons may account for clients’ anxiety dur- sions. Referring veterinarians are involved throughout, because
ing difficult conversations; these include self-blame, unease with they share the closest bond with the client, who often trusts their
death and dying, anticipatory grief, effect on the human-ani- opinions and seeks their guidance. This shared case management
mal bond, effect on the veterinarian-client-patient relationship, model underscores the importance of continuity of communica-
pet’s QOL, and concerns about their emotional response to the tion among all care providers. Given the team approach to cancer