Episode 7: Dr. Lori Cesario: Canine cancer - early detection, body mapping & treatment

About Dr. Lori Cesario: Dr. Lori Cesario is a Board-Certified Veterinary Oncologist who is dedicated to providing families with high quality information about dog cancer. Dr. Cesario runs the Canine Cancer Academy (https://www.caninecanceracademy.com/)

Laura and Dr. Cesario talk about what to do if you find a lump on your dog (and how frequently you should evaluate your dog to make sure everything is normal). By establishing a baseline, you’ll be able to more easily notice when something abnormal appears.

The best way to make sure you are monitoring and recording your dog’s lumps and bumps is to use a body map of your dog. Dr. Cesario explains what a body map is, and how using one is helpful for both you and your vet.

Laura asks about warts (which appear outside the skin as opposed to cancerous masses) - Dr. Cesario explains that the most important thing for your dog is to get a diagnosis for any sort of lump, whether it looks like a skin tag, a bug bite, or a wart. Fortunately, diagnosing a lump on your dog’s skin is often pretty quick.

After taking the first step of getting a diagnosis, you can then take the next steps, whether it’s treating the mass or continuing to monitor it.

Laura and Dr. Cesario discuss how treating skin tumors can work (and how an incomplete surgery can leave dangerous, cancerous cells behind). When you treat your dog for cancer, it has to be a comprehensive treatment so that the cancer doesn’t re-emerge. That’s why getting the diagnosis right in the first place is so critical to your dog’s health.

They talk about treatment options, including Dr. Cesario’s thoughts on holistic treatment. Treatment can vary for each dog’s situation, so treatment options really depend on the dog. Treating cancer often comes down to balancing health with quality of life for the dog.

Dr. Cesario gives some general cost estimates for treating canine cancer, listing cost based on the type treatment. She also goes over how much the treatment options can extend your dogs life (and how variable and unpredictable that time estimate can be).

Transcript

INTRO

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Laura Reeves [0:54] Welcome to the Good Dog Pod! I am your host, Laura Reeves. We have a guest today. This is not a topic that you can make fun, but it is a very important topic and it is a very accomplished guest that I am having join us: Dr. Lori Cesario runs the Canine Cancer Academy in southern California. And we are talking specifically Cancer 101. We’re going to talk about lumps and bumps, early detection. We’re going to find out what a body map is, which I think is pretty cool. And we’re going to talk about some treatment options! Thank you for joining us, Lori.

Dr. Lori Cesario [1:33] Happy to be here!

Laura Reeves [1:34] So talk to us a little bit about Cancer 101. Many of us have seen lumps on our dogs—little lumps, big lumps, sometimes they’re dangerous, sometimes they aren’t. So let’s talk about this type of skin tumor problem.

Dr. Lori Cesario [1:50] So, it’s very common for dogs at one point or another in their lifetime to develop a skin mass. Certainly, like you mentioned, some are no big deal and others we are going to want to treat. The first step is noticing that a mass has popped up. In some dogs that’s going to be easier than others, because certainly if your dog is a Weimaraner with a really nice, short coat, they’re going to stick out pretty easily. But if your dog has a really big, dense coat, it’s going to be harder to notice those small lumps and bumps.

Laura Reeves [2:33] Talk to us about (and maybe it goes with the body map) how frequently and in what way do you examine your companion dog to know about changes in its skin or lumps, that kind of thing? We do breast exams, right? So what do we do for our dogs?

Dr. Lori Cesario [2:54] Good question. I mean, there isn’t necessarily a set recommendation, but I think of course nobody wants to be thinking about cancer all the time, but maybe if you can just get in the habit of giving your dog a good front to back dog massage, especially if your dog has a thick coat… Get in there, feel from his head to his neck, even the throat area, arms, chest, back, stomach, legs. And then you’ll really just get a good feel for what is baseline and notice if something changes. I know all of the general practitioners talk about how important it is to brush your dog’s teeth. Of course nobody likes to do that. But another good thing about brushing your dog’s teeth is you’ll look at the teeth and the gums, and you’ll notice if there’s a little lump or bump that pops up in the mouth as well.

Laura Reeves [3:57] Excellent.

Dr. Lori Cesario [3:58] Even like a weekly or monthly basis, when your dog is just laying down, give him a good front to back dog massage. He’ll find it very relaxing, I’m sure.

Laura Reeves [4:08] Right? I tend to do this when I have my dogs up to be groomed. I put my dogs on the grooming table to be groomed and when I do their toenails and brush them through or what have you, then I’m also checking for lumps and bumps. 

Dr. Lori Cesario [4:23] Exactly.

Laura Reeves [4:24] If this doesn’t feel right, that kind of stuff. 

Dr. Lori Cesario [4:28] And you’d be surprised at how many of my clients come in and they tell me, “The groomer found this.” Groomers find a lot of the skin masses that are presented to me. 

Laura Reeves [4:41] Absolutely. 

Dr. Lori Cesario [4:42] Like you mentioned in the beginning, the body map: If you do find a lump or a bump (or maybe your dog is ten and he has five or ten lumps and bumps), the best way to keep track or to make sure that you’re monitoring them appropriately is to maybe find a body map online, or ask your vet. Basically, a body map is like a chalk outline of a person. It’s basically like that but for a dog. It’s a dog laying on its back and laying on its side. And you just want to roughly point out where your dog’s lumps and bumps are, as well as the date and the diagnosis. So that’s a big piece of the puzzle that we’ll talk about. And the size. You don’t just want to say where they are. The size is important because it’s something that we always monitor. It’s fine to estimate, but what is even better is if you could buy these cheap $3 calibers from Home Depot or Lowe’s (and you can look this up online, too) and you can actually measure yourself. They’re very inexpensive, and then you have a better idea.

Laura Reeves [5:53] So you can actually measure the specific tumor? 

Dr. Lori Cesario [5:56] Yeah, exactly.

Laura Reeves [5:57] Wow. 

Dr. Lori Cesario [5:57] So instead of saying, “Well, it’s sort of like a golf ball,” you can measure it and say, “It’s three centimeters.” And that’s very helpful, just to keep track. 

Laura Reeves [6:07] So another one I think is important (and I know this is not necessarily on topic but falls into the skin mass category and I think we should at least touch on it and rule it in or out) is warts. You see these sometimes in dogs that pop up that are different than, say, under-the-skin subcutaneous lumps. Sometimes you see outside-the-skin lumps. Can we talk a little bit about those? 

Dr. Lori Cesario [6:35] Yeah. In the same line as a mass under the skin (a subcutaneous mass) versus a wart, I think that brings up a good point—just that the most important thing, if you do want to give your dog the best outcome, is always to get the diagnosis. Skin tumors that are cancerous, especially something like a mass cell tumor, can honestly look like anything. It can look like a little wart, or it can look like a skin tag, or it can look like a little bug bite, even with the inflammation around it. It can look like subcutaneous mass, so like a fatty lymphoma. Because these things can look like anything, it’s always good to get a diagnosis. The nice thing is that in most cases, you can get a diagnosis pretty quickly and easily with just a little needle aspiration. A lot of people think of a needle being poked into their dog’s skin and it’s very scary, because they don’t want their dog to be hurt or stressed, but I can assure you that if you have one of the veterinary technicians just kind of scratching your dog’s head and loving them and the vet just quickly pokes, pokes, pokes into the mass, they’re not even going to know that it’s happening. Most of the time, you can get a diagnosis pretty quickly. Especially if it’s a fatty lymphoma, it literally just looks like oil on the glass slide and you can have your diagnosis very, very quickly. I think getting a diagnosis is always really, really important because that’s step one. Then we know: Okay, is this just the lymphoma? Do we not have to worry about this, unless it’s in an uncomfortable location or getting bigger? Or is it something that we have to address? 

Sometimes, if a dog has a skin mass and the owner is up for doing surgery, there are occasions where somebody might say, “If you’re interested in surgery, let’s just take it off and find out what it is later.” The reason why I don’t love that approach is two reasons. Number one: depending on the type of tumor it is (and when I say tumor, I just mean it can either be benign—which just means it’s not going to spread anywhere—or malignant—which means it might spread elsewhere in the body), when you look at a skin tumor, basically what you want to picture is the tumor that you can see, but there are also cancer cells infiltrating the skin around the tumor that you can’t see. 

Laura Reeves [9:17] Okay, so like that iceberg analogy. 

Dr. Lori Cesario [9:20] Oh, exactly! If we’re dealing with a benign tumor, then you can get away with taking the tumor, plus maybe one centimeter of skin around the tumor and that thing shouldn’t come back. But if you’re dealing with a soft tissue sarcoma, usually you have to remove the tumor plus three centimeters of skin around the tumor plus a deep plane of tissue. So that’s a very different procedure. If you’re just being conservative, you’re going to leave cancer cells behind and—number one—that has the potential to put your dog through a second procedure that sucks for them. 

Laura Reeves [10:04] Right, and it was unnecessary. 

Dr. Lori Cesario [10:06] Unnecessary, costs more money. And maybe what’s even worse is that in some cases, if the first surgery is incomplete and leaves cancer cells behind, it does raise the possibility that a second tumor might come back and that second tumor might be more aggressive.

Laura Reeves [10:24] Interesting. 

Dr. Lori Cesario [10:26] Yeah. Maybe if the first tumor wasn’t going to spread throughout the body, that second tumor might, and we just hate when that happens. 

Laura Reeves [10:34] That is fascinating to me, that you take one out and it comes back because you didn’t get enough margins. And it’s a more aggressive type of cancer. Interesting. 

Dr. Lori Cesario [10:47] Yeah, that can happen with mass cell tumors specifically, some tissue sarcomas. It’s mostly because the tumor cells that are most aggressive are the ones that are going to travel furthest away from the original tumor. When you do an incomplete surgery, those are the ones that are going to be left behind. 

Laura Reeves [11:05] That’s really a fascinating thing. I would never have thought about it that way. 

Dr. Lori Cesario [11:10] Yeah, you always want to just get it right the first time and plan as well as possible.

Laura Reeves [11:15] So do the diagnosis! 

Dr. Lori Cesario [11:17] Always diagnosis first, yeah. The other thing, of course, is if cancer spreads, we often find that the dog feels completely normal. It’s not really something that, at this point in time, we can pick up in a blood test. So if we know that a dog has cancer—if that tumor on its skin is cancerous—then before surgery, we’re going to say, “Okay, let’s take some chest X-rays and make sure that the lungs are clean and that there’s no cancer there.” What we hate to happen is we do surgery, we remove the skin mass and say, “Oh, it’s cancer. We better take chest X-rays,” and then we find that there’s cancer in the lungs and then that surgery actually didn’t help the dog. We just like to do things in an appropriate stepwise fashion. It’s most fair for the pocketbook and for the dog. 

Laura Reeves [12:09] Well, and I think that it can be so scary for people.

Dr. Lori Cesario [12:13] Oh, of course. 

Laura Reeves [12:16] We say this. The Big C is scary to us; it’s scary for our dogs, too. It can be an automatic, “Get it off!” 

Dr. Lori Cesario [12:25] I definitely appreciate that, yeah. 

Laura Reeves [12:30] But I think that people definitely need to hear that. Get the diagnosis. Don’t take it off and then look at it. Find out what it is first.

Dr. Lori Cesario [12:36] Exactly. And the other thing is there are some types of cancer where surgery isn’t the only option. So for mass cell tumors: If you know there’s a mass cell tumor, if you know that surgery is not going to completely remove the tumor, then maybe you’ll say, “Okay, maybe I just want to treat with prednisone. That’s more affordable for me. I don’t want to put my dog through surgery.” Maybe then you’ll have the information you need to make the choice that’s more appropriate for you. 

Laura Reeves [13:13] And I think we’ve said this a couple of times: Education is the answer to everything! So the more you know!

Dr. Lori Cesario [13:20] Knowledge is power. 

Laura Reeves [13:23] Absolutely. The more you know, the better you do. I think that you make a really, really important point there: finding out the information about what the tumor is before you go into an actual surgery. With the body map and the early detection and all of these things, are there any ways that we can—you mentioned prednisone—do you have any recommendations about things like holistic treatments, anything along those lines? 

Dr. Lori Cesario [13:53] For specific types of cancers? 

Laura Reeves [13:56] We’re going with the skin tumors, so I thought, okay, let’s think about that.

Dr. Lori Cesario [14:01] I’m definitely not a holistic expert. I was trained in western medicine, oncology. Whenever somebody comes to me for treatment options, I definitely give them all of the options that I know about. Sometimes it’s surgery. Sometimes it’s chemotherapy. Sometimes it’s radiation. Sometimes it’s a combination. Sometimes it’s steroids. There are lots of cancers where low dose oral chemotherapy can be helpful, and that’s palatable to lots of people because it shouldn’t cause any side effects, it only involves them coming in once every four to six weeks for a blood test and to make sure it’s still working. As far as holistic options, the main one that we use holistic options for, is hemangiosarcoma. Because even though we still recommend chemo (either injectable or oral), there is some evidence that immunity, which is a mushroom called Coriolus versicolor and Yunnan Baiyao which is a Chinese herb and also propranolol, which is a heart medication, that might also help dogs that have that tumor. Usually, we talk about surgery plus chemo plus, as I call those things, the supplemental medications—either for people who don’t want the first line or want to do those medications with chemotherapy. 

Laura Reeves [15:33] Okay. And I think Cancer 101, again, is so hard for us. So many of us anthropomorphize our dogs. They’re really our children. We want to do everything we can for them, just as if they were part of our actual human family. I think that the ability of veterinarians has advanced the knowledge, the science. You know more, you do more. You know better, you do better. Can you, under the umbrella of this 101 concept in treatment, can we talk about (as you mentioned) oral and injectable chemotherapy? Those are within the last ten years? 

Dr. Lori Cesario [16:18] We’re definitely doing more oral within the last ten years, because they’ve gotten these tyrosine kinase inhibitors,  Palladia during that time, and we’re finding out originally, Palladia was only developed for use in mass cell tumors and now we’re finding out that it’s useful for all sorts of carcinomas and other types of cancer. Palladia has become our new best friend in oncology. 

Laura Reeves [16:44] Interesting. 

Dr. Lori Cesario [16:46] I think that some people might think of going to an oncologist and being treated with chemotherapy is this very aggressive type of thing. But the big picture in veterinary oncology is that, yes, we want our patients to live longer, but we don’t want to compromise quality of life. 

Laura Reeves [17:09] That balancing act.

Dr. Lori Cesario [17:11] Exactly. Some cancers do have a gold standard treatment, a “best.” But that “best” is not going to be the same for all dogs, so what we typically try and do is we get as much information as possible about a dog’s cancer and how it’s affecting their body and their overall health and also the goals of the client and family. And then we piece together treatment options that we feel are most appropriate for them. It’s not like, “This is your option, and there’s no other option.” We try and figure out the best fit for a family and their dog. And we start with that. If it’s working—great—we keep going. Otherwise, we just modify the plan. 

Laura Reeves [18:04] Lori, I think one of the things that we need to consider as pet owners (and part of this best fit for your family in terms of a treatment plan for the dog) is also going to be cost. If you can give us… I’m not asking for an invoice. What is the best idea that you can offer people about insurance, about paying for this, about general cost estimates?

Dr. Lori Cesario [18:21] Yeah, very good point. As far as finding the best fit for people, normally I will lay everything out on the board and I’ll say, “These are your options.” It’s like: Option one, this is how frequently you’d have to come for treatment, this is how long your dog might live with the treatment, and this is the cost. And I’ll do them for every one. Sometimes option one is eliminated because of cost but maybe option four is eliminated because they don’t feel like that gives them enough time with their dog. Based on finances, priorities, logistics—that usually helps people narrow down what feels best for them. As far as cost goes, certainly if people have a good insurance, that definitely helps. 

Laura Reeves [19:21] Trupanion! (Sorry.) 

Dr. Lori Cesario [19:23] Because honestly having a dog with cancer is stressful enough. When the financial aspect is, for the most part, taken out of the picture as a stressor, it just is a huge relief. Obviously, always recommend good insurance. Other things that people can do are apply for something like CareCredit. CareCredit, it’s sort of like you say, “Treatments are going to cost $5,000.” So you borrow $5,000. And hopefully there’s six or twelve months interest free to pay the money back. I work at a specialty hospital. Typically most surgeries are going to be $4,500-ish. But I also practice in California, so California’s a little bit more expensive. As far as chemotherapy goes, I try to give people options that are also different budget options. That can be anything from low-dose oral chemotherapy that might, with the re-checks and the blood work and the chemotherapy, be $400 a month (and again, that’s California so California’s going to be more expensive) to anywhere to maybe $6,000 for a protocol for chemotherapy. Or maybe even more than that. It just honestly depends on what we’re treating and where in the country we’re treating it, and for how long.

Laura Reeves [20:47] I think it’s always important to remember regional differences.

Dr. Lori Cesario [20:50] Of course. 

Laura Reeves [20:52] I’m in southern Oregon and with my veterinary care, I am very blessed. Very good quality for the value. 

Dr. Lori Cesario [21:01] Some places will have discounts, like if you’re military or senior or working dog or something like that. Some people will do GoFundMe fundraisers and all of those things as well. Certainly there are a lot of cancer funds out there that will help defray the cost of treatment. I know even like tripawds.com I believe—they’ll pay for a certain portion of an amputation, if your dog has osteosarcoma. Some things like that are also very helpful. 

Laura Reeves [21:32] The only thing we haven’t touched on that you’ve mentioned in your laying out “It’s going to cost this much money and you’re going to get this much extra time.” Can you give us a ballpark? Can you extend the dog’s life a year? Six years? A minute? 

Dr. Lori Cesario [21:47] It’s all very variable based on the type of cancer and how progressive it is and also what treatment is elected. Sometimes we do have the opportunity to extend it for years, and then maybe the cancer never comes back. That’s always the goal. But other times maybe it’s six to twelve months. It really just depends. The goal is that during that time, their quality of life will be good. The anticipation is never that they would feel like crap for those six or twelve months, because then that’s not appropriate and we’re really doing something wrong. It is really variable and, of course, cancer is unpredictable and we can never know what’s really going to happen. 

Laura Reeves [22:30] Mother Nature is a wicked mistress. We say it on many levels and in many ways. 

Dr. Lori Cesario [22:36] Yeah, but we definitely do our best. And we do focus on quality of life, because we certainly want them to feel as good as possible. 

Laura Reeves [22:44] Absolutely! Because it is about them—not about us. I think sometimes we get a little wrapped up in that piece, too. Alright, well Lori, thank you so very much. I very much appreciate your time. I look forward to talking to you some more. We’ve got a couple more conversations upcoming, everybody. Watch this space! There will be more to come of Dr. Cesario. 

Dr. Lori Cesario [23:06] Thank you for having me! Glad to be here!