Chapter 2
Searching for the Road to Remission:
Surviving the first month of treatment
In our experience, the first month of chemotherapy was the worst. We knew nothing about lymphoma and were frantically trying to save our dog’s life. VHUP knew a lot about chemotherapy, and about Berry’s condition. But VHUP knew little about how our dog would react to chemotherapy. This is the most fundamental point about treatment, one which we make several times in this book: canine oncologists can generalize about how most dogs will do, and about how some dogs will react to a particular drug. What they don’t know is what your dog will do: your dog is unique. As a result, we’ve included this narrative about Berry’s first month in chemotherapy to give you the hope and the determination to persevere through the first cycle of treatment.
We don’t think our experience in the first month was unusual -- other owners have reported the same feelings – confusion and failure -- and difficulties with chemotherapy drugs. The treatment process may seem chaotic and the outlook hopeless in the first month. But if you can gather your psychic resources and tough it out through these early days, your dog’s treatment may become much easier and the reward can be very significant, as it was for us.
Getting off on the Wrong Paw
On February 18, 2000, Berry’s treatment began with an initial injection of 10,000 IU "Elspar" (L’asparaginase) (see Chapter 7, "Understanding the Treatment Process II – Drugs and Drug Protocols", for information about all the drugs mentioned in this chapter). We also received a prescription for prednisone, two 20 mg tablets to be given to Berry each day for the next two weeks. Berry had no negative reaction to the Elspar. But, as we had been warned, the prednisone made him drink a lot. After a couple of accidents in the house, we figured out he needed to pee at least every 2-3 hours. We increased Berry’s food. On February 25, Berry was re-examined Dr. Bissett, who concluded "his lymph nodes are still large but the lymph nodes do feel smaller this week". A tiny change, "measured" by professional interpretation, but a hopeful sign nonetheless. That day, Berry received an intravenous drip of .8 mg of vincristine, and we were given Cytoxan (cyclophosphamide), the next drug in Berry’s protocol, to be administered at home between March 2 and March 5, 75 mg each day.
On February 25, we went home feeling relieved. Berry was entering his second week of chemotherapy and appeared to be improving, and we weren’t scheduled to come to VHUP the following week. Then, overnight, the site where the bone marrow aspirate had been drawn on February 18 erupted into an angry lump. Off we went to the VHUP Emergency Service where the abscess was lanced, and a lot of pus drained from the wound. Home we went with more drugs – antibiotics this time – and instructions to hot pack the incision three times a day.
The vincristine had no immediate effect, but on February 28, four days after it was administered, Berry began to vomit and pace constantly, as if unable to find a comfortable spot. We withheld food and water overnight, but he vomited repeatedly after food was reintroduced. He could not keep food or water down and eventually became dehydrated because we didn’t seek treatment soon enough. With Berry trembling from an electrolyte imbalance, Donald raced the six blocks to the VHUP Emergency Service. My visit to VHUP that night revealed an exhausted, depressed dog, an IV drip of electrolytes in his shaved paw. Berry’s sides, already shaved for the ultrasound two weeks earlier, had been further shaved as the Emergency Service hunted for a possible intestinal obstruction. His ribs were prominent. Both front feet were also shaved and bandaged from numerous tests and IVs. Berry was released from VHUP the evening of March 2 with instructions to reintroduce food slowly, but the following day, after hand feeding, he vomited again. Then, he refused both food and water.
Berry was to have begun his Cytoxan therapy on March 2, but we withheld the pills, terrified to introduce another chemotherapy drug. The instructions that accompanied the Cytoxan stressed that while taking the drug, a dog needed to be consuming lots of water to flush the drug residue from his system. If Berry wasn’t drinking, this was impossible. And what good would have been done, we reasoned, if the pills were vomited up? So we waited anxiously. Our local veterinarian thought the large dose of prednisone might be irritating Berry’s stomach, so we cut back on that as well even though rapid withdrawal of prednisone is not advisable. There seemed to be no "better" course of action.
Because Berry had not yet been admitted to the Oncology Service, we were receiving contradictory information about whether Berry’s vomiting was a drug side effect and how to treat it. Berry’s discharges on February 25 had alerted us that vincristine could cause gastrointestinal side effects like nausea, vomiting, and diahrrea. But the Emergency Service focused instead on the possibility of an intestinal obstruction – their usual line of business -- and was convinced that the timing was wrong for chemotherapy problems. Worried about further dehydration, we soaked Berry’s paws in Gatorade so that, in licking them, he would take in small amounts of liquid and electrolytes. On Saturday, March 4, we returned Berry to VHUP for more hydration – in this case, a subcutaneous injection of fluids to be slowly absorbed into his body.
We debated whether to discontinue treatment. We had had the best of intentions, but maybe we were being unrealistic. In the space of two weeks, Berry had been diagnosed with a terminal illness, and become exhausted, emaciated, and withdrawn. Even the Emergency Service paperwork said he was "depressed" – a word I had never heard a veterinarian apply to a dog. I asked Greg to be Berry’s advocate, charged with speaking for Berry’s best interests. DC and I resolved that Berry would not die at VHUP. If we decided to put Berry down, we would find a vet who would come to our house. But for the moment, we made Berry a special bed in the kitchen and waited for a change -- for the better or worse.
A Turn in the Road
On Sunday, March 5, Berry kept down his first food in days. He was too weak to walk around the block, but he acted like the old Berry, rolling in the leaves in Greg’s yard, happy to be outdoors, in the sun. We knew we had to keep trying and we realized we had to take much more active control of Berry’s care. That week, I had lengthy conversations with the VHUP Oncology Service, first with Dr. Karen Sorenmo, the Chief Oncologist, and later with Dr. Lisa Barber, the Oncology Specialist who would principally manage Berry’s case in the Oncology Service. Here was the expertise – and the compassion – that we and Berry needed. Dr. Barber could speak with authority about the subtleties of chemotherapy treatment, alternate drugs, and side effects. Reviewing recent events with Dr. Barber, it became clear that Berry’s crisis probably had been a delayed vincristine side effect – but one that could be managed. We agreed to continue the prednisone and start Berry – a week late -- on a reduced, but still therapeutic, dose of Cytoxan.
Berry was formally admitted to the Oncology Service on March 15. During a lengthy consultation, we learned an overwhelming amount about lymphoma, chemotherapy and management of side effects. Dr. Bissett confirmed that Berry’s lymph nodes "remain prominent, but are smaller than at the time of diagnosis . . . in addition, his spleen is significantly smaller". Follow-up blood work was done to determine the number and appearance of lymphocytes circulating in his blood, and we were promised the results the next day. Dr. Barber recommended that vincristine be tried again, at a reduced, but still effective dosage of .6 mg. Dr. Barber also prescribed metoclopramide, an anti-nausea medicine, to counteract the vincristine side effects. At home that weekend, we kept careful notes and administered the anti-nausea medicine at the first sign of Berry’s discomfort. On Monday, Dr. Barber called to say the lymphoma was reacting to the drug therapy: the percentage of cancer cells in Berry’s blood was down dramatically -- success!
Finding The Path to Remission
In this groping, uncertain way, Berry’s treatment had begun. Soon, Berry’s weekly sequential protocol of Elspar, vincristine, Cytoxan, and vincristine, each coupled with a daily dose of prednisone -- became routine. Every week, the oncologists at VHUP checked his external lymph nodes and spleen. The changes were gradual but positive: each week, the lymph nodes, spleen, or both, seemed a little smaller. Berry’s dosage of prednisone was cut in half and the frequent urination problem vanished. His Cytoxan was increased to a full 75 mg dosage without incident. Vincristine was increased to .63 mg in recognition of his weight gain. Berry’s blood counts continued to look good, allowing for each subsequent treatment. We had read that some dogs in chemotherapy lose interest in food, but Berry gained weight until he was a round ball of fur. We began to think Berry might survive long enough to spend the summer with us, but in May, Greg and I took him for a romp at the beach just in case.
At the completion of four cycles of drug therapy, on June 8, Berry was "restaged". This included a complete blood count (CBC), chemistry screen, urinalysis and bone marrow aspiration. Based on these test results, we decided to forego an abdominal ultrasound -- we did not want Berry shaved again unless the other test results proved ambiguous. Berry’s discharges that day classified his status as "Lymphosarcoma -- complete remission", meaning that there was no detectable level of cancer cells. This did not mean Berry was "cured" -- just that the cancer had been beaten back. Berry’s treatments were spread out to every other week. Berry seemed to gain energy as the prednisone dosage was reduced and again when the chemotherapy treatments were spread out.
We bonded ever more strongly with Berry during his treatment. Like the day he first demonstrated his "superior water entry" by leaping off a low dam abutment into a pond – feet tucked, tail aloft, ears flying – Berry surprised us with his spunk. And he lit up the waiting room and oncology treatment room at VHUP with his grin and wagging tail. He was a friend to every person (and nearly every dog) he met; an avid consumer of diverse foodstuffs, however humble; a founding member of our neighborhood dog park; my eager companion in pet therapy at the local nursing home; and the muse behind dogdoggiedog.com, his website created to help other VHUP clients. From March 2000 until September 2003, just before Berry went off to sleep The Big Sleep, Berry had a full and wonderful life, and we learned more and more about canine lymphoma.
We share that knowledge now with you.
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