All About Oncology Referral
By Chelsea Greenberg, DVM, MS, Diplomate ACVIM (oncology)
Timely diagnosis and treatment of cancer in the veterinary patient is required to improve both patient comfort and prognosis. Members of the cancer care team have responsibilities to each cancer patient that vary depending on the individual circumstances. The goals of cancer treatment are to extend both quality and length of life. More than 70% of cancers in companion animals are readily treatable. However, it takes careful planning to develop an appropriate, comprehensive, and realistic treatment regimen.
Members of the cancer team each have responsibilities to the veterinary cancer patient that may vary depending on the individual circumstances. The primary responsibility shared by all is clear communication to ensure the best possible patient care!
The cancer care team:
Owner/caregiver
Primary/family care veterinarian
Medical oncologist
Surgical oncologist
Radiation oncologist
Other services (radiologist, clinical or anatomic pathologist, mental health provider, etc.)
Caring for cancer patients encompasses more than just chemotherapy or making general treatment recommendations. Oncology options change frequently based on new information, and the prospect of a treatment plan combining oncologic surgery, radiotherapy, chemotherapy, or immunotherapy can be intimidating. Discussing cancer with the pet owner is another challenge because cancer is such an emotionally charged word. How will the client react to bad news? Will the client accept the treatment recommendations? How much information does the client need? Will there be treatment-related adverse effects to manage? Should treatment even be discussed?
These challenges are not trivial, and these questions represent valid concerns. Overcoming challenges can bring many rewards, which is one reason why many oncologists find fulfillment from their specialty. This comes from the ability to offer families quality time with their cancer patient, and often extend the time they have available. The idea that cancer is the worst diagnosis a pet can face is wrong.
Many other diagnoses are life-shortening, and significantly impact a pet’s (and owner’s) quality of life, including dilated cardiomyopathy, atopic dermatitis, osteoarthritis, inflammatory bowel disease, renal failure, diabetes mellitus, and Cushing’s disease. These conditions are not typically fatal in the short term. However, they all require ongoing diagnostic tests and medical management, along with a committed owner. This is the same with cancer – it's a chronic disease.
As we all know, pets are rarely cured of the above examples of chronic disease; however, some pets are cured of cancer. Even when an individual animal cannot be cured of cancer, we can almost always help them feel better with proper supportive care.
Which clients do I refer?
Clients who are interested in treatment for their pet’s cancer
Clients who may be interested in treatment
Clients who need more information before the treatment decision can be made
Who do I refer my cases to?
Typically, an oncology referral is sent to a medical oncologist unless it is known that radiation therapy or the services of an oncologic surgeon are required for first line therapy. The reason for an initial referral to a medical oncologist is that medical oncologists are trained in the coordination of the members of the cancer team. They can help answer the questions: what treatment should come first? Surgery? Radiation? Chemotherapy? Immunotherapy? Medical oncologists are credentialed through the American College of Veterinary Internal Medicine with an entirely different training program than small animal internal medicine, neurology, and cardiology (which are also credentialed through the ACVIM). Surgical oncologists are credentialed through the American College of Veterinary Surgery (ACVS) and radiation oncologists through the American College of Veterinary Radiology (ACVR) which are separate institutions from the ACVIM.
What do I refer?
Ask the oncology team in your area! Some oncologists see patients with an undiagnosed mass, and others require a histopathologic diagnosis before the appointment – and everything in-between. Having things ready beforehand can help streamline the referral appointment and minimize frustrations for all involved.
When do I refer?
This can depend on a few factors. First is the availability in your area. There are some locations that have few or no oncologists, and in other areas the available oncology teams have a lead time for new patients ranging from a few days to several weeks. The discussion of referral with the owner could come when you’ve confirmed the diagnosis, or even when you have a strong suspicion for cancer. It’s important to help pet owners understand that “cancer” encompasses hundreds of different types, with variations in histologic grade and clinical stage, creating thousands of possible presentations. So, there isn’t necessarily a one-size-fits-all approach. To get the most information for the client regarding treatment options for an individual cancer patient, it’s often best to refer as early as possible.
For some pet owners, the best time to refer may come later in the process. They might wait until after minimum database to learn about any other health issues their pet may have. Others may prefer to wait until after some staging information is available or prefer to wait until the histopathology results are in hand. There are some owners that want to jump straight to referral if a mass is identified during physical examination. There is no one-size-fits-all timing for oncology referral.
When the decision has been made to refer:
Before the oncology referral:
Share what information you have about the referral process with them. This may include potential costs. However, if you are not certain, it’s best to avoid guessing. Overestimating costs could discourage an owner from seeking treatment, and underestimating can generate frustration and anger. Generally, the more information they have about the upcoming referral appointment, the lower their level of anxiety when they arrive at the referral hospital. Clients are usually nervous about an appointment with a veterinary oncologist. It is also essential the client understands that you, the veterinarian who has cared for their pet for years, is an integral part of the cancer care team!
Common worries/questions include:
What are the best treatment options?
Cost of treatment?
Am I doing the right thing for my pet?
Will treatment cause pain, nausea, vomiting, hair loss (chemotherapy)?
What’s the prognosis?
Is a cure possible?
Do we have to do treatment if we visit the oncologist?
Is my pet a good candidate for treatment?
Making the Most of the Referral Process:
What to send to the oncologist before the pet’s appointment:
It is a great idea to send all information you have about the patient from at least 12 months before the cancer diagnosis, including information about concurrent diseases.
Items to send (if available):
Images and associated reports
Lab work
CBC
Chemistry
Urinalysis
Cytology
Histopathology
Special tests (ACTH stim, urine BRAF, etc.)
Surgery reports
Medical records (electronic or handwritten)
Records of dispensed medications and drug reactions
Any information that can be sent ahead of time is appreciated by the oncology team (and in some practices is required). Having patient records beforehand significantly shortens the client waiting time during referral. Because things sometimes get misplaced or misdirected, it’s a good idea to send hard copies of everything (or a USB drive with digital records and images), along with the client for their visit.
During oncology appointment:
Note: The steps described below are a general description of how an oncology practice operates. Some oncologists will have different procedures. If there are any questions, contact your local oncology team for information about how they work.
The evaluation of available medical records, imaging and previous test results is completed before entering the examination room and meeting the client.
Conversation with the client about pertinent history as well as a physical examination of the patient.
Conversation with clients about their values and goals for treatment. What would they like to achieve? Long term tumor control (definitive care/cure)? Short term tumor control (palliation)? Any specific concerns?
Discussion about treatment options and if additional staging/testing is appropriate before developing a treatment plan or formulating a prognosis.
After the referral:
A detailed letter is typically the primary form of communication from the specialist back to your practice. The recommendations/treatments will be written up in the pet’s medical record and sent to your hospital for you. Written records can be delayed a few days after initial appointment.
Once a plan of action is chosen by the owner and treatment is started, regular follow-up will be needed. This can include scheduled recheck examinations, bloodwork to monitor chemotherapy, or medication refills (chemotherapy or supportive care). Unscheduled visits may also be needed if anything unexpected happens. To ensure optimal care, clear and timely communication is necessary between all cancer team members.
Why should I refer?
Cancer is more readily treatable, and associated with a better quality of life, than many other common diagnoses like dilated cardiomyopathy, renal failure, etc.
Tailored information and individualized treatment options for your patient
Can be cost effective
Limit the number of surgeries needed for disease control
Individualized staging and monitoring
Improve patient outcomes with combination therapy
As with human cancer patients, combining surgery, radiotherapy, chemotherapy and immunotherapy leads to better outcomes
Curious about how Torigen may be able to help your pet patients? Contact us to learn more.