My Worst Nightmare

Raven’s Journey with Lymphoma
Monday May 7th 2007
We flew back from Adelaide today after competing at the ANKC Agility Nationals. Raven has ended up as the Runner Up Masters Agility Champion and I am absolutely thrilled with our whole Nationals experience, she had more than proved she was amongst the best dogs in the country when it came to our favourite sport.
I had not been without some concern though the last couple of days. On Saturday or Friday morning I had spoken to a friend about some lumps on her neck, wondering if it was the lymph nodes. As there were no other enlarged nodes we put it down to her recent pyoderma on her tail which had been quite big and required her to be on a course of antibiotics which had finished just under a week ago. Nothing else about her told me she was ill. She still had her usual voracious appetite, was drinking well and toileting was normal.

By Sunday when I spoke to another vet about her, this was at lunchtime and she seemed a bit more tired than was normal for her, Penny told me all her lymph nodes were now enlarged (I could feel them myself with her help – her neck ones, chest ones, armpit ones and rear thigh ones were all enlarged). Raven had one more run to do that day – the finals Master Agility run and Penny advised me to make sure I saw a vet as soon after as I could. When we got on that start line I was just very grateful to be there and so proud of my little Raven with the shaved tail, it didn’t matter what we did, I just hoped she was ok. She ran well and she ran clean, but I knew she was not running at her usual speed, some things you can just feel. Regardless the smile and feeling that came from finishing that run is simply beyond description, but definitely a once in a life time feeling. We arrived at Perth Airport at 3pm on the dot and were out of there by 3.20 to go and collect her. We had a 6pm appointment with Brendon Kay at Applecross Vet, we drove straight there. It was a whirlwind visit, Brendon feeling the nodes and taking her temperature and asking that she be returned the next morning as they needed to do a biopsy of those nodes, his gut feeling right then and there was lymphoma. Of course this totally freaked me out immediately but I had no choice other than to bring her back the next day.

Tuesday May 8th 2007
I drove Raven into Applecross for around 8.30am and spoke to Brendon again just mentioning about the cracked molar at the back of her mouth and whether that should come out and what things they would do while she was under. He basically told me they would take two samples of the nodes for histopathology and draw blood to get the full work up. I also indicated to them that they should feel free to do a chest x ray as I had noticed that when I went to pick her up once she yelped slightly when I placed my hand under her ribcage to lift her. I also asked that her teeth be cleaned as well. At 2.30pm I went back and picked her up. Her x ray had shown nothing, and the blood tests would be back that afternoon but that we would not hear about the biopsy results till Friday. Raven had her neck partially shaved in the throat area and her right thigh at the back was shaved. She received three stitches in each where they had taken some samples. Other than being a little unsteady on her feet she was fine plus her teeth were nice and clean. Brendon’s gut instinct was still telling him strongly that it was Lymphoma. I went home and started to browse the internet reading as much as I could.
6.45pm that night Brendon rang back with the blood results, elevated white blood cell count and low red blood cell count was detected but all other levels normal. This is typical of Lymphoma and again there was nothing to do now except wait.
Cost so far: $740.00

Wednesday May 9th
I made concrete steps towards changing Raven over to a BARF diet, purchasing a variety of veges and some good quality chicken mince I made up a mash of the vegetables, cooked the chicken mince up and served Raven a dinner of vegetable mash, chicken mince, yogurt, omegamagic, sasha’s blend and a small amount of Advance Chicken kibble. I plan on reading up on this more and slowly changing her diet over. I had planned on doing this anyway when I got back from Adelaide because I wanted to see if I could lessen her allergies through her diet, this new medical challenge urged me on to get it done.

Thursday May 10th
Still no results and still no discernible changes in Raven’s condition, she still eats well, drinks well and toilets well, Is feeling her usual self, enough to bark at the birds and knocks at the door, still feels the need to boss Spryte and assert her position as top dog. Wants to go out the back yard and do stuff, except for that damn lymph nodes she looks to be as normal as ever!

Friday May 11th
This day will be forever etched into my memory and for no good reason. Steve Metcalfe of Applecross vet rang Tim at home (I was at work with my Mobile out waiting) and told him the news. High Grade Lymphoma aggressive. Steve said he would send all the paperwork and details over to Ken Wyatt at Murdoch Uni Vet’s Oncology department and that we should try and get her in as soon as possible, these tumours were aggressive, could double in size in a day and that without treatment she was looking at three weeks maximum. He said also that high grade lymphoma’s often responded better to treatment than low grade ones, with remission rate much higher although long term survival was shorter. Tim rang me at work and thanks to some understanding staff I came home straight away. During that journey Tim had rung Murdoch to try and get Raven in straight away. He got told by the nurse on reception that 3pm was the earliest and that treatment probably wouldn’t start till Monday. When I heard this I of course, freaked out asking if they realised that she has an aggressive form that needed treatment straight away and that she was basically dying at the moment. I rang Applecross asking to speak to Steve, turns out he had rung us from home. The nurse there was very receptive obviously to my underlying emotions and Steve rang me back quite quickly to clarify things for me. Getting into Murdoch at 3pm was absolutely fantastic he said and that it was good that they could get her in so soon. I spoke to him at length about things and he actually did make sense to me and explained things the best he could whilst still letting me know that Ken Wyatt is the best here and that he will be going through everything I need to know or want to know. I had several concerns, was it a B-cell or T-cell lymphoma (B-cell being the better one to have), what stage did he put her at, would she have to have bone marrow taken etc etc. He answered them all very patiently and made me feel that I was certainly asking the right things. So then we waited till it was time to go to Murdoch University Veterinary Hospital (MUVH).

2.30pm rolled around and we left then in case we had any traffic or any forms to fill in. They had Raven on their records from the dermatological consults so they didn’t need any more updates other than her current weight.

Just after 3pm Ken Wyatt came in along with 3 final year vet students and showed us to the Oncology consult room. First thing he asked for was a report on how I first noticed anything was wrong. I went through the above story with him. Explained that Penny the other vet friend at the Nationals had asked how many more runs she needed to do, at that stage it was the finals run. He even asked how she did! I guess more so he could hear that I felt our run was not our usual speedy manic runs, and that she had felt slow to me. He asked if I was good friends with Ann (a senior nurse at MUVH who also was at the Nationals) and that she’d had a word with him about Raven’s performance life. Our consult lasted over an hour during which he thoroughly checked her out, palpated her liver and spleen and declared that there were no abnormal enlargements of those organs. For that I was very relieved. He noted that one of the very excellent aspects in this case was the simple fact that Raven was not sick or symptomatic in any way which meant it had been caught early. He stated that even a month ago there would probably have been no discernable way of diagnosing the cancer and that it may have been there for between 1 and 2 years without any effects. Even testing blood a month ago would not have shown anything. He talked at length about the different types of lymphoma and their results with treatment and about how we go about determining how far the cancer had progressed and so on. There was much to take in and I only started to take notes when he started to talk about treatment options. He was in general very optimistic, he told us that most of his positive results eventuate from dogs that are presented to him still well and Raven is indeed healthy apart from the enlarged lymph nodes and slight tiredness. When he asked how Raven had gone at that last run I explained that she had done well with a 2nd place but certainly felt slower. He smiled and said that it was a good indicator of her ‘heart’ for life which bodes well for a good response to treatment.

He placed the numbers 1 to 5 on the whiteboard on a vertical line. He told us about 5 first. This is Prednisolone which is basically a palliative care protocol for dogs who already are sick and for whom recovery is not expected. We crossed this option off straight away. He then went to option number 2. This was called the CHOP protocol by him initially however he also said it was a modified version of the Madison Wisconsin protocol. The C stands for cyclophosphamide, the H stands for Doxorubicin (adriamycin or Doxorubicin Hydrochloride), the O stands for Oncovin or Vincristine and the P stands for Prednisone (the reason why it is modified is because we won’t be using the Prednisone). This protocol was the one they had used the most on these types of lymphomas and the one which they had experienced the most success rate with in terms of placing patients into remission. Initially the treatment went for 3 years it now goes for 19 weeks. It has a 1 in 6 cure rate and extended patients lives on average 17 months. He reminded us that the average number can be deceptive and to remember that half experience longer life expectancy and half experienced lesser life expectancy. The protocol involved 16 visits over 19 weeks. Once a week treatments for four weeks in a row then two weeks off. Approximate cost barring any complications (ie reactions to the drugs) around $5,500.

He then went into Option 3.This treatment was less expensive, did not have a cure rate and only involved 1 visit every 3 weeks and simply used the Adriamycin in high doses. Expected extension of life expectancy 6 to 12 months.

Option 4 was next, it was no set protocol, it used oral agents, once a month visits while you waited, and used Lomustin and Cyclophosphamide and basically you told him your budget and he would work out the most effective treatment with the funds you gave him.

Option 1 was left till the end. Ken said that it was the least used option and I never asked him why that was (the reasons could be two fold – cost plus prognosis of success for patients presenting as symptomatic) I will ask him next time though. The cost of this was somewhere between 5,000 and 10,000 dollars. The protocol starts off exactly the same as Option two for the first 8 weeks and then they take 160ml of the patients bone marrow. Next they give the patient a marrow destroying dose of the Cyclophosphamide that does destroy the rest of the marrow and therefore the cancer cells, then after a couple of blood transfusions the patients bone marrow is re-inserted and with a bit of luck the patient is cancer free. The cure rate for this is 2 in 6. And life extension expectancy is longer. It is a much bigger deal in terms of the patients recuperation and hospital visits and to me it sounds like a much more invasive protocol. But I like that cure rate! I believe that it is effected though by the marrow results initially to see if the marrow is clear. There would be no point in harvesting cancer ridden marrow and reinserting that back!

Tim and I don’t know which one to do yet (1 or 2). However she will start on Option 2 on Monday, as well as have a marrow test done to see if the cancer cells are present there yet. There is much to read and discuss and no doubt by Monday I will have another whole raft of questions for Ken. I am writing everything down, it helps me keep rational as well helps me feel like I am being proactive rather than passive in her treatment and care. If I think about it long term I get teary very easily but I think for now I will focus on her positive points for the treatment and enjoy every second of every day that I am with her. I’m wondering if I can somehow take her to work with me between treatment days. We will go to the trial on Sunday, Cypher and I will have a bash at a few courses and Raven will have fun barking her head off at him and revelling in the sympathy attention she will be accruing no doubt. She is healthy and happy within herself so I couldn’t deny her the opportunity.