Three And A Spare

"See that bright white line? That's normal bone." I was showing Jake's x-ray to the Folsoms. "Then see here?" I pointed to an area of the humerus that was both wider and fuzzier looking, as if someone had smudged the picture there with a cheap eraser. "This is abnormal bone. I'm really sorry, but I'm afraid this looks like bone cancer."

Mr and Mrs Folsom said nothing for a moment while Jake, a slender 7 year old yellow Lab cross, wagged his tail and looked up at them.
Then Mr Folsom said in a flat, very controlled voice, "So he's done then. You're sure?"

"We should do a biopsy to be sure because the way this looks it could be something else, but I doubt it. I'm sorry, I know that this must be a terrible shock for you. However, if the biopsy confirms cancer that doesn't mean he's done. In that case I will recommend amputation and..."

Mr Folsom cut me off, "No way. We're not doing that. We can't let him suffer."

Mrs Folsom put her hand on his arm to shush him and turned to me, "We'll talk about it doctor. Let's get the biopsy first and then we'll see."

So this is what we did. Within a week we had the diagnosis confirmed - osteosarcoma, malignant bone cancer. We also did a series of tests to check for visible metastases, or spread of the cancer to other parts of the body. Finally some good news - these tests were negative. They wanted to come down to discuss the options in person with their teenage kids present.

After introductions, plus cookies for Jake, I began, "If Jake were my dog I would amputate. He is still young enough and healthy enough that he is a good candidate. Without amputation he is at a high risk of breaking that leg because the cancer has weakened the bone so much. If we do nothing his life expectancy at this point is about 6 to 8 weeks on average."

"Is that it? Just 6 to 8 weeks?" their daughter asked.

"Yes, that's the average, some shorter, some longer, but none very much longer. This is why I want you to think about amputation. That immediately gets rid of the pain and obviously eliminates the risk of a fracture. With surgery plus chemotherapy the average jumps to almost a year, with 20% of dogs living longer than two years. And a year is a really long time in a dog's life. Also, chemo is usually much gentler in dogs and has far fewer side effects than in people."

"But how's he going to manage on three legs?" Mr Folsom asked, his arms crossed, his expression clearly skeptical.

"That's the beauty of being a dog or cat. They do so well on three legs! You'd be amazed. In 28 years I honestly have never had anyone come back later and say that they regretted doing it. Obviously we have to make sure that his three remaining legs are in good shape, but otherwise it's just not a barrier."

"It's like he has three and a spare!" the daughter said. Mr Folsom was staring straight ahead.

Exactly. I couldn't have put it better myself. Three and a spare. It can be such a hard procedure to convince people to do, but it's one of the ones that brings the most obvious and immediate benefit to the patient. It's not just helpful for scenarios like Jake's, but also for some complicated fractures. I liken it to pulling a bad tooth. At that point the tooth is just a liability. It no longer provides benefit, only pain and risk.

Clearly this is not for every dog or cat with bone cancer. I don't want any of you who may have been through something like this and chose not to amputate to feel bad about your decision. The age of the pet can be a significant factor. For every year beyond middle age the decision becomes more complicated. And the bigger the dog, the faster they age. Also, as I mentioned, the other legs need to be healthy, and if it is cancer, it can't have spread. And finally, to be honest, I wish it didn't have to be about the money, but sometimes it does have to be. Surgery plus chemo runs into the thousands.

Incidentally, this general principle of being able to remove prominent parts of the body to benefit the patient goes for the eyes too. In some cases of glaucoma, which is high fluid pressure in the eyeball, the medications stop working and the eyeball painfully swells. At that point it is a liability, like a rotten tooth, or like a cancerous leg. People are sometimes aghast when we recommend removing the eye (a procedure called enucleation), but just like with amputation, once the owners get over the psychological hurdle, nobody ever regrets having the eye removed. Nobody.

This is one of the beautiful things about animals. They have very little in the way of body image hang-ups. They just do not seem to care how many teeth or eyes or legs they have. Terry Fox would be proud.

As I'm sure you guessed, three of the Folsoms ultimately out-voted the fourth and they opted for surgery, and Jake, being an above average dog in a lot of other ways, lived an above average length of time. He had 16 good months before we had to let him go.