Download Grooming and the Cancer Patient SuperZoo lecture abstracts July

Grooming and the Cancer Patient
SuperZoo lecture abstracts July 2015
Sue Ettinger, DVM, Diplomate ACVIM (Oncology)
Dr Sue Cancer Vet®
Cancer is not a death sentence is dogs and cats. Chemotherapy is well tolerated in the majority of
pets undergoing treatment. With treatment, many pets are not only living longer, but living well.
Many clients have questions about grooming, boarding, and pet day care for their pets with cancer
or pets undergoing chemotherapy.
 Importance of Oncology
 Human animal bond: Pet is a family member, Owners often want same standard of care
 Cancer is leading cause of death in pets
• 1 in 3 dogs of any age will get cancer
• 50% of dogs over 10 years old will be affected by some tumor
• Cancer is the number one cause of canine death
 Treating a Cancer Patient
♦ Some people want to treat, others don’t
♦ Talking about treatment
♦ Visceral fear of cancer
♦ Need to approach with knowledge, compassion, and a positive attitude
 Some cancers are curable, many others can be managed with a good quality of life
• Cancer is not a death sentence
• Treating cancer like a chronic disease
 How are cancers treated? What are common side effects? And when is it ideal to go to the
groomer during these therapies?
 Treatment modalities
 Surgery
• Grooming
♦ Wait until the wound is healed and sutures removed – typically 10 to 14 days
♦ Delayed wound healing – MCT, Cushing’s, near joints or areas of movement
 Radiation
• Types
♦ Daily fractionation: Generally for microscopic disease, Curative intent
♦ Stereotactic radiosurgery: Macroscopic/bulky disease, Curative intent
♦ Coarse fractionation: Generally palliative, Big, bulky, non-resectable disease
• Radiation side effects
♦ Acute: rapidly dividing tissues,
 Skin – hair loss, redness, inflammation
 mucous membranes (nose, mouth)
 Gastrointestinal (GI)
♦ Late Slowly dividing tissue, Bone, nervous tissue, secondary tumors
• Grooming: Wait 2 to 4 weeks

Chemotherapy
• Conventional Chemotherapy: Conventional chemo is given at high dosages, known
as maximum tolerated dose, or MTD. The goal is to kill the rapidly dividing cancer
cells. But some normal cells that also turnover often can be temporarily damaged by
MTD chemo. Most commonly, it is the GI tract cells and the white blood cells that are
temporarily damaged. As a result there is a break period to allow these cell
populations to recover. MTD is typically given weekly to every 3 weeks.
♦ Chemotherapy side effects: Chemotherapy drugs attack rapidly dividing cells. All
rapidly dividing cells are potentially sensitive to chemotherapy. The normal
tissues that typically are most sensitive to chemotherapy are the bone marrow
(which makes red and white blood cells and platelets), hair follicles (causing
hair loss, aka alopecia), and the gastrointestinal lining. This is often referred to
as “BAG”
 Bone marrow suppression – most commonly results in a low white blood
cells (WBC) count (called the nadir), typically 7 days after chemo
administration
 Some exceptions: carbo in dogs, carbo in cats, Lomustine in cats
 Alopecia (hair loss) due to damaging the rapidly dividing hair follicle – Hair
loss is not likely to occur in most breeds. Shaved areas tend to grow back
more slowly (catheters on legs, abdominal ultrasounds). Certain breeds,
such as poodles, cocker spaniels, and terriers, that are groomed often, may
lose some hair because of their rapid hair growth rate. Cats often lose their
whiskers. The good news is that hair and whiskers will re-grow once the
treatments have finished. Occasionally, hair will grow back a different
texture or color. Also pets do not care about this cosmetic side effect, and it
does not impact the quality of life.
 Gastrointestinal (GI) – vomiting, diarrhea, decreased appetite, nausea –
typically 1 to 5 days after chemotherapy
• Is chemotherapy toxic?
♦ The overall toxicity rate is very low in veterinary chemotherapy patients. In my
experience, only 15-20% experience side effects. The primary goal is to provide
the best quality of life possible for as long as possible. As I say, live longer, live
well.
♦ Although less likely to occur, side effects vary from slight decrease in energy and
appetite to lethargy, anorexia, diarrhea and vomiting, fever, or mild hair loss.
Typically, these side effects are medically manageable.
♦ In my experience, there is less than a 5% chance that a pet will need
hospitalization for medical stabilization with fluids and IV antibiotics.
♦ In addition, depending on the severity of side effects are noted, the drug type or
dosage may be adjusted to minimize the chance of side effects recurring. I also
typically will add prophylactic medications to prevent side effects like nausea,
vomiting or diarrhea.
♦ When a chemotherapy drug is used that is known to have a high potential for
bone marrow suppression, a complete blood count (CBC) is often checked after
the treatment to see if the WBC are low. Antibiotics may be prescribed as a
preventive measure. Subsequent doses of chemotherapy are adjusted based on
the results of the CBC.
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Grooming
♦ I recommend avoiding grooming for 1st week after chemo
 most likely to have GI side effects
 especially if first time receiving a chemo drug
♦ And not near nadir when may have low WBC and be susceptible for infections
 Day 7 for most drugs, in most patients
Metronomic chemotherapy is low dose oral, or pulse, chemotherapy given on a
continuous treatment schedule. Since it is given daily or every other day, the
chemotherapy is given at lower doses then typical MTD chemotherapy, often with
reduced toxicity profile.
Instead of killing the cancer cells directly, metronomic chemotherapy targets and
inhibits tumor blood vessels growth, called angiogenesis. So you will hear that this
type of chemo is “anti-angiogenic”. Tumor blood vessel cells are more active than
normal blood vessel cells and are the targets of this type of low dose oral chemo.
There is also evidence that some low dose chemo drugs like cyclophosphamide have
effect on tumor immunology. It alters a subset of immune system cells in the Tlymphocyte family (regulatory T-Cells).
Protocols and drugs used vary
Side effects
♦ In general metronomic protocols are well tolerated, and most side effects are
mild (mild decreased appetite, vomiting, diarrhea).
♦ Although uncommon, cyclophosphamide (CYC) can cause an inflammation to the
bladder, called sterile hemorrhaging cystitis. The symptoms are similar to a UTI
(urinary tract infection) – increased straining, peeing small amounts more
frequently, sometimes bloody. CYC should be discontinued.
♦ If any of the side effects are severe, I tell my clients to stop the chemo, give
prescribed nausea/vomiting and/or diarrhea medications, and contact my team
Grooming: Low white blood cells counts are uncommon but possible. Once my
patient is about a month into treatment, has normal blood work and is doing well,
grooming is okay in my opinion.
 What precautions are needed for handling chemo patients?
 Is it safe to be around pets undergoing chemotherapy? Yes, it is safe to be around
chemotherapy patients after treatment. Being around family members – human and other
pets in the home - is an important part of a pet's life. Enjoying normal activities with petsincluding petting, hugging, and grooming - are all safe. However, the excretions (urine,
feces, vomit) from pets receiving chemotherapy can be hazardous. It is therefore important
to minimize our exposure to chemotherapy, and common sense precautions should be
taken when around chemotherapy patients.
 Cleaning up after a chemotherapy pet:
 The primary concern is for people mixing and handling chemo (the oncology
team), with less risk to those handing urine and feces. In the urine and feces are
metabolites, which are chemo that has been broken down by the patient’s body.
These metabolites are far less active than the original drug. So use common
sense precautions and follow good basic hygiene.
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Wear gloves for handling of feces, urine or vomit (i.e. if they have an accident
in the house/apartment, cleaning the litter box) for at least 72 hours after
treatment
Soiled bedding should be washed separately and go through 2 wash cycles
before being used again.
Use detergent to clean floors, carpets, or countertops. Wear gloves when
cleaning.
Accidental exposure: Wash skin thoroughly. If your skin becomes irritated,
contact your physician.
 Ideally I would avoid grooming for the week after chemo, but these are still
good guidelines for pets being boarded or on chronic oral chemo
 Make sure staff is aware that this pet is on chemotherapy
 If you or a staff member is pregnant, trying to become pregnant, are breast-
feeding, are immunosuppressed, or are taking immunosuppressive
medication:
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Please avoid contact with chemo drugs.
Avoid contact with the pet and your pet's waste for a minimum of 72 hours after
chemotherapy has been given.
Talk to your physician.
 Should pets undergoing chemotherapy treatment be vaccinated?
 While undergoing cancer therapy it is possible that a pet’s immune system is compromised
either due to cancer itself or by chemotherapy. The concerns are they may not develop the
desired immune response or may be at increased risk of getting sick from the vaccine (more
a risk with a modified-live vaccine).
 I typically do not recommend vaccinating pets during chemotherapy. I recommend waiting
for a scheduled break in the chemotherapy before resuming vaccinations, so this will vary
with the pet, the cancer and the chemotherapy protocol. Since rabies is a public health
concern, I do recommend that a pet is current on rabies vaccination.
 For some vaccines, we can check titers to see if the pet actually needs a booster (Parvo,
Distemper)
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