Understanding the Complexities of Chemotherapy in Pets: A Dialogue with Veterinary Oncologists

Ever wondered how pet owners and veterinarians perceive chemotherapy in pets differently? Join us as we dissect this emotionally charged topic with veterinary oncologists Abby Leonardi and Michael Childress. We chat about a fascinating study designed to understand these differing perspectives, and the revelations might surprise you. We delve into the heartening finding that pet owners are more prepared than expected to accept higher grade adverse events if it can enhance their pet's quality of life. 

At the heart of our conversation is the threefold benefits of chemotherapy for pets: a potential cure for cancer, prolonging life, and improving the quality of life. Abby and Michael also emphasize the significance of pet owners being informed about potential side effects and varying degrees of severity. We navigate this difficult and emotional topic with honesty and heart, reminding us of the resilience and optimism that are cornerstones of their work. So, tune in for an enlightening episode that will leave you with a nuanced understanding of the complex decisions pet owners and veterinarians face when considering chemotherapy for their furry friends.

Full article: https://doi.org/10.2460/javma.23.09.0496

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Transcript

Sarah Wright: 0:00

You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode we chat about how pet owners and veterinary oncologists differ in the perceptions of chemotherapy-related adverse events and cancer-bearing dogs, with Abby Leonardi and Michael Childress.

Lisa Fortier: 0:22

Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today we have Abby and Michael joining us. Abby and Michael, thank you so much for taking time out of your busy schedules to be here with us today.

Michael Childress: 0:36

You're welcome.

Abby Leonardi: 0:37

Thanks for having us.

Sarah Wright: 0:40

All right, let's dive right in, Michael. Chemotherapy is widely used to treat pets with cancer, and your study aims to assess differences in the ways that pet owners and veterinary oncologists perceive chemotherapy-related adverse events. Can you give our listeners a bit of background on this study?

Michael Childress: 0:58

Sure, this study was really born out of discussions that our group at Purdue would have around our morning rounds table or afternoon rounds table about how pet owners would often get very distressed about side effects, adverse events associated with chemotherapy that our group would not necessarily think was such a big deal. But it came to be clear to us that the way that pet owners and the way that veterinary oncologists or veterinary oncology residents perceive the side effects of chemotherapy could be very, very different and that those differences in perceptions could have important implications for the ways we communicate with one another. So this survey that we designed was really hoping to elicit. What are those important differences in the way that pet owners and veterinary oncologists perceive the side effects of chemotherapy and how they approach the cost-benefit calculus or the risk assessment portion of moving through chemotherapy?

Sarah Wright: 2:06

I was fortunate to have a few board-certified veterinary oncologists during my spinal rotating internship and I remember when they were talking to clients about chemotherapy being a potential treatment option, a lot of the clients would say, oh, I don't want my pet to be bald. And they'd explain to them you know, like it's a little different than in people. So I think this is a really important, good study to have in JAVMA. And then Abby, what were some of the important findings from this study?

Abby Leonardi: 2:31

I think some important takeaways from this study was it did seem like veterinary oncologists seemed to accept a higher grade adverse events than pet owners in this hypothetical setting of cure or extension of life. It was really interesting, though, that we did find that pet owners seemed to accept higher grade adverse events than veterinarians in the setting where only improved quality of life would be expected, so that was really interesting for us. The other thing that was interesting is it seemed like pet owners would accept higher risk of moderate to serious adverse events than veterinarians, which was completely surprising.

Lisa Fortier: 3:15

Yeah, I wouldn't have picked up on that either. You'd think they would always be. Oh, I don't want my animal to hurt. That's tough. It just tells you how much they love them and want them around for longer and any glimmer of hope. Abby, Michael talked a little bit a minute ago about how the study idea was born out of just sitting around talking about this. But what sparked your research interest in chemotherapy?

Abby Leonardi: 3:40

Yeah, in general, chemotherapy is such a widely used therapy modality for veterinary oncology but also human oncology. It's so so common to use and so it's very good to be very comfortable talking about gosh. What are the adverse events we might expect with that therapy? What risks should the owner be expecting with pursuing something like that? It is quite variable with how owners may perceive that adverse event, how they may tolerate it and how they then might continue therapy or go. Oh gosh, that was too much. I don't think I can keep doing it With that experience. It was interesting to me to see gosh. We don't really have a lot of evidence or research already looking at how that may differ between one owner to another. But also we don't have a lot of evidence quite yet to show how veterinarians may differ in that risk tolerance and that acceptance of adverse events. So definitely an area that needs more work and definitely something that was interesting to see how different people varied there.

Lisa Fortier: 4:46

Yeah, very much so, Michael. Then again, you talked a little bit about sitting around talking about this idea. But having the idea is one thing. It's another thing to be inspired to design the survey, get the survey, get up, get the survey out there, analyze it and then write the manuscript. What inspired you and what advice can you give to listeners who are in the same boat, where they have an idea but how do they really carry through to fruition and really to help our colleagues?

Michael Childress: 5:14

One thing that I've always been interested in is the concept of science communication and communication of medical information to the public, and how that information can be received and how that information intersects with an individual's personal values or motivations. For those of us that are steeped in scientific education, I think that our motivations are often very much based upon factual evidence, so we tend to make decisions based upon factual evidence in a lot of situations, at least if our emotions aren't running high, perhaps, but that may not be true of all of the animal owners that we encounter out in practice, and they make decisions perhaps based upon different values or different motivations than we do, and so our job as clinicians is really to take our factual information and learn about the animal owners' motivations and values and trying to find an intersection there, trying to find the best approach for an animal and how to treat that animal in light of the animal owners' motivations, in light of their values, in light of how they perceive the information that we're relaying to them.

Lisa Fortier: 6:34

Yeah, it doesn't matter really what we can do if we can't communicate it well. So thank you for this really valuable contribution to teaching about chemotherapy to our veterinarians. Abby, you talked a little bit earlier when you're talking about some of the most significant findings and I think you mentioned it again, but maybe just reiterate for our audience what was really surprising to you in this manuscript.

Abby Leonardi: 6:56

Yeah, in general, we were hypothesizing that veterinarians would accept higher grade adverse events than pet owners and it seemed to be in the hypothetical scenario of improved quality of life. Pet owners seem to actually accept higher grade adverse events than veterinarians. Even more interesting, I think, is that pet owners seem to have increased risk tolerance and accept increased risk of moderate to serious adverse events than veterinarians, and that was surprising and shows that potentially, pet owners risk tolerance might be higher than we give them credit for and maybe something that we can look further into.

Lisa Fortier: 7:41

Yeah, you're leading me into my next question. What do you think that is? What drives that? The desperation to keep their animals, that they don't, maybe the animals in chemo, in the hospital, and they don't really see the worst of the worst. What do you personally I know that's what you just said you need to look further into, but what do you personally think, michael maybe you next what do you think is driving that?

Abby Leonardi: 8:06

Yeah, I think some of it may stem from not having that scientific background, so they may not look at it as objectively as we do and maybe they're willing to accept more risk and be more tolerant of it, potentially because they don't have all of the information in their brain about gosh. What am I expecting with this treatment? What level of risk would be appropriate, given what type of benefit I might glean from that therapy? So maybe there's a little bit of a disconnect there, with full knowledge about what potentially they're going to, what they're going to derive from that treatment. But potentially there might be flavors of caregiver burden, potential stressors. They might look to their dog or cat kind of as an emotional support animal and maybe in that regard, them not being the patient themselves, they may be willing to accept more risk, with the potential that then they may have their pet for longer and get to spend more time with them. So definitely something that would be interesting to keep looking into.

Lisa Fortier: 9:13

Yeah, Fascinating, michael. What is your take on it?

Michael Childress: 9:20

Well, first I would say that I don't know that our survey was really designed to elicit the owner's motivations for pursuing chemotherapy in their individual animal. The survey was designed to elicit responses from the owners based upon hypothetical scenarios. I think I should just emphasize that point. But what might motivate an owner to take a greater chance to assume a greater risk of side effects of chemotherapy than, say, a veterinary oncologist would? I agree with what Abby was saying.

Michael Childress: 9:53

I think that it may stem from perhaps a difference in experience, and as veterinary oncologists veterinary oncology residents in Abby's case, when she was helping us conduct this study we have an experiential base that we can draw upon.

Michael Childress: 10:11

We know what to expect in terms of a therapy, we know what benefit it is likely to confer upon a patient, we know generally what the risk of side effects of a given therapy will be. So we can make that calculus to some degree, I think, without thinking about it too much, almost subconsciously, because owners don't have that experiential base and they do not necessarily make those calculations as quickly as we do. And so I think that really emphasizes the importance of communicating that information very clearly to pet owners before they make a decision to embark on a course of chemotherapy with their pet? What is the expected benefit to be conferred from a therapy and then what is the expected cost in terms of adverse events that might be caused by the therapy? I think it's important for owners to understand that. I think when they understand that, they will make informed decisions that hopefully align with reality, the reality of what can be achieved and what's likely to happen.

Lisa Fortier: 11:13

I know that wasn't what your survey was designed to do, so thank you for indulging me and going outside of the lines for a couple of minutes and sounds like another study in the way and we'll be happy to take it to Javma, because these are really important conversations to have.

Sarah Wright: 11:29

And Michael, is that a framed AJVR cover that I see behind you?

Michael Childress: 11:35

Yeah, it is Thanks from. I think that's almost 10 years ago, I think it was 2014. But yeah, our article made the cover of AJVR image from one of our articles. So good eye, very nice. That is not intentional that it was placed there. By the way, that was not a plan.

Sarah Wright: 11:53

I wasn't sure I was like maybe it's good background. So, yeah, that's awesome. Now we have a static cover now because it's online only open access, so but it's cool to look back at some of the older ones too and all the really cool covers. They're amazing. So thanks for indulging me. And then to our listeners just joining us. We're chatting with Abby and Michael about how perceptions of chemotherapy related adverse events and cancer varying patients differ between oncologists and pet owners. Michael, how did your advanced training prepare you to write this manuscript?

Michael Childress: 12:30

Well, I was board certified in oncology in 2010. So I've been doing this for a while. I get used to talking to pet owners every day. This is kind of my bread and butter. Even as an academician, I still spend a significant amount of my time talking to pet owners about chemotherapy, about what the expectations are of chemotherapy, about what chemotherapy can do and can't do to help their pets, so I had a pretty good clinical background. On the conceptual portion of this study, we got some assistance from some collaborators here at Purdue. Another oncologist, christopher Vulkerson, was a co-author on this manuscript and then a social scientist here at Purdue, cleve Shields, was very helpful at lending some perspective on survey design and how to elicit the type of information we really wanted to on this survey. It was definitely a group effort, but it was very much informed by the experiences of people like myself and Abby and Chris working day-to-day as oncologists and just understanding the typical concerns that pet owners bring to the clinic when they have a pet with cancer and they are considering pursuing treatment for that pet.

Sarah Wright: 13:51

We're currently preparing a survey for our authors and our readers, and there's a lot of work that goes into creating a survey. I had no idea until we started this process, so it's pretty incredible.

Michael Childress: 14:02

I agree. Yeah, it was a lot more work than I thought it would be.

Abby Leonardi: 14:05

That's just a very special skill.

Sarah Wright: 14:07

Yes, yes it is. I'm glad there's people that are good at it. Yeah, me too. And then the next set of questions is very important for our listeners Abby. What is one piece of information the veterinarian should know before discussing chemotherapy with a client?

Abby Leonardi: 14:27

I think in general it's really important to have a good idea of what the family member or the owner's goals might be for that treatment. What are they hopefully trying to get out of whatever options there are, like what is their baseline idea of what they're hoping to get? Knowing that baseline information can be helpful to go over the treatment options for that particular cancer type. What are we potentially going to get from each of those treatment options, and do those treatment options align with the owner's goals and what they then expect? Depending on their goals, you then can kind of see what kind of adverse event profile might we expect from that. Does that still align with their expectations and can we really make sure that we keep in mind those expectations so that we're all on the same page throughout treatment? I think is very important and overcommunication in general is very good to make sure everybody's on the same page.

Sarah Wright: 15:26

Yeah, it's definitely true in a variety of settings. Yeah, and then on the other side of the relationship, michael, what is one piece of information that the client should know about chemotherapy?

Michael Childress: 15:41

Sarah, you'll have to forgive me. I can't boil it down to one, so I'm going to give you two. I think there's a couple of things that clients should understand. One is that they need to understand what are the possible benefits that chemotherapy can confer to their pet, and when you boil it down, there's really only three ways that chemotherapy, or any cancer therapy, can benefit a patient. It can cure the cancer, it can cure the patient's cancer, it can extend the patient's life in the absence of cure, or it can improve the patient's quality of life, often in the absence of cure or extension of life. Although these are not necessarily all mutually exclusive, but those are really the only ways that the therapies that we offer can benefit a patient, and so clients need to come armed to that understanding, and they should be prepared to elicit from the veterinarian or veterinarian oncologist with whom they speak what is the likelihood of any of these outcomes, which of these outcomes is achievable with therapy and to what extent is it achievable?

Michael Childress: 16:45

The second thing I did say I'd have two. The second thing that they should understand is that all chemotherapy, all therapies for cancer, have side effects. The side effects of chemotherapy that we see in pet animals with cancer generally are not as severe as the side effects that are seen in human cancer patients, but they are of the same nature and they can sometimes be severe. And understanding how severe side effects might be in an individual patient is something that a veterinarian, oncologist or veterinarian has to assess, usually by a very detailed exam of the patient and a thorough diagnostic evaluation of the patient, because that information is going to modify that patient's risk of side effects. But in general side effects are going to be less severe in pet animals than are seen in human cancer patients.

Lisa Fortier: 17:37

Yeah, really good points. I really admire you, too, how you can retain your resilience after having these discussions day in and day out with clients who are scared. Cancer is a very frightening word, so I really admire both of you. That takes in a tremendous amount of grit and resilience. And, michael, where do you think your resilience came from?

Michael Childress: 18:07

I'm an optimist. Abby is one of my residents may not believe that, although she's probably seen both the optimistic and pessimistic sides of me, but I don't think you can be an oncologist without being an optimist. You learn to take pride and to take sustenance from small victories, realizing one of those three treatment outcomes either a cure of a patient or an extension of a patient's life or an improvement in a patient's quality of life. You view all of those as victories and you draw resilience and fortitude from that. Even if they're small victories, they can be very meaningful to pet owners and to patients, I think. And so I think that I draw a lot of resilience from words of thanks, words of gratitude I receive from pet owners and then seeing clinical improvements in patients, patients who may have come to me very ill at one point and several weeks later, after a successful course of chemotherapy, maybe feeling quite a bit better. I draw a lot of sustenance from that because there are certainly a number of failures to counterbalance those victories.

Lisa Fortier: 19:20

Yes, it's certainly not cancer. But I feel the same way as an editor. If I reject somebody's manuscript and yet we've given them really good feedback on how it can be improved or why it was rejected, they're always grateful. And just to thank you for your advice, thank you for your guidance, goes a long way, even when you're delivering not great news. Sure, yep, I agree. And Abby other than working with the doctor. Optimist, where do you think your resilience came from?

Abby Leonardi: 19:50

I feel like, definitely, optimism goes a long way.

Abby Leonardi: 19:54

You know, that's definitely something that is a driver for always finding the hope in any situation, but I feel like a lot of also what we do.

Abby Leonardi: 20:05

You know, knowing that you're able to improve quality of life or prolong life, to allow the family more time with them, is really really something that I think helps drive me in this profession.

Abby Leonardi: 20:17

You know, knowing that you got then that additional time they were able to spend that time and hopefully with a better quality of life than before still gives them something that you know, without it, gosh, they may not have. You know that that time and that time is so precious to have. You know, in these situations. So having that is really important and definitely there's there's some sad cases, but sometimes just you know, knowing that you were able to give the family more information, give them everything they possibly you know needed to know in that situation, sometimes provides closure and allows them then to go away from that situation knowing more about what happened, and maybe that can also help with emotional closure closure as well. So you know, I think that's a big driver of what I do too is just also you know how grateful some people can be. You know, sometimes they may not outwardly say you know I'm not going to say it, but when they do, gosh, that goes a long way, because then you know what you're doing is really making an impact.

Lisa Fortier: 21:23

Yeah, well, again, I admire both of you and thank you again for this really important contribution to JAVMA and to our practitioners to help have those difficult conversations and to understand from the other side of the table what might be going on. As we wind down a little bit, we ask a little more lighthearted question. So, Michael, we'll start with you. What is the oldest or the most interesting item in your desk drawer?

Michael Childress: 21:49

My desk drawer is largely filled with a bunch of junk, but I do still keep the little notebook that I made when I was an intern. This was a Kansas State University College of Veterinary Medicine 2004 to 2005. I kept a little you know cheat sheet notebook in my lab coat pocket all the time and had all of my notes on you know, important drug doses and important differentials for you know given problems and whatnot, and I've never thrown it away. You know it's just an important keepsake and every now and again I'll dig it out. I'll find it at the bottom of the drawer and I'll dig it out and I'll start flipping through it and just realize how far I've come. It's just important, I think, to sometimes take time to reflect on the path that got us to where we are, and that notebook is just a reminder of that.

Lisa Fortier: 22:45

Yeah, I've come a long way. Most oncologists say they either have a tape measure or the little caliper that they were given from some company or some mentor or something.

Michael Childress: 22:53

I've got a few of those too. They're cluttering up more nicely.

Lisa Fortier: 22:56

It's just not the most interesting one Right Abby for you. When you do a puzzle, do you start in the middle or do you do in the edges? And does this become a bone of contention if you're doing puzzles with other people? Do you let people do your puzzle with you, or are you like oh, this is my puzzle.

Abby Leonardi: 23:14

Oh yes, I'm definitely an edge person. I like to do all the borders and then work my way in, have a nice little scaffolding to work from. This works well with my husband because he also really likes the edges. So we team up, do all the edges and then work our way in. But our families his family in particular loves puzzles so frequently we'll do group puzzles, so definitely something that I definitely can share. I don't have to do it by myself.

Sarah Wright: 23:46

My family will definitely be doing a few puzzles as we head into the holiday weekend here, and so my fellow members. They just randomly will start putting together pieces that they think look like they go together, which drives me crazy, because I'm like, no, you have to be systematic about it, like your physical, like these are their steps to take so you don't miss anything. Yeah, so different strokes for different folks. Thank you so much, abby and Michael. We just really appreciate you being here today and for sharing your project too, and your study with JAPMA, absolutely yeah.

Michael Childress: 24:21

Thanks for having us, this was fun.

Sarah Wright: 24:23

And to our listeners. You can read Abby and Michael's manuscript in print JAVMA or on our journals' website. I'm Sarah Wright with Lisa Fortier. We want to thank each of you for joining us on this episode of the Veterinary Vertex podcast. We love sharing cutting edge veterinary research with you and we want to hear from you. Be sure to leave us a reading and review on Apple podcasts and our platform you listen to.