How to treat malignant mammary cancer on a $65 budget

I spent the last 2 weeks an hour away from home in a large metro area, externing at what we'll call Low Income Animal Hospital (LIAH). LIAH is run by the state VMA's charity branch. It's a non-profit hospital that employs about 3 full-time veterinarians to provide lower-cost care for low-income clients. All services come with a fee, but those fees are discounted to some degree based on how poor an individual client is.

My 2 weeks at LIAH were a huge learning opportunity. For one thing, I gained (re-gained?) some confidence that I will kind of know what I'm doing when I graduate in a month(!). We senior student externs are given pretty much free rein to see cases and formulate diagnostic and treatment plans.

LIAH is also a great opportunity to be reminded about what type of clientele many vets see out in the "real world" (i.e. not in the "silver tower" of a referral institute). The VTH and LIAH are pretty much polar opposites in terms of the financial ability of their clients. Those who visit the VTH (at least the specialty services) are pretty well self-selected to be willing to pay hundreds or often thousands of dollars for veterinary care. In contrast, the clients at LIAH are basically self-selected as very low-income, with common circumstances such as disability, unemployment, or foreclosure.

It's very sobering to have clients come in who have to choose between a rabies vaccine or a distemper-parvo vaccine for their dog, because they can't afford the $25 for both vaccines in addition to the $35 exam fee.

Or, like one of my patients on Thursday, the pet has a serious medical condition that could possibly be cured, if only it were in the budget. This particular patient was a 10 year old, un-spayed, female kitty named Patty.

Patty presented to LIAH with the complaint of "check lump on belly." The technician went into the appointment initially to record Patty's vitals and get a brief history from her owners, and when she came back to tell me about the case, it was clear we were dealing with badness.

Patty had a very large (about 1.5 inches across) mammary tumor in her caudal mammary chain, which had grown through the skin and was ulcerated and abscessed. Upon further examination, Patty also had about 20 other smaller tumors up and down her mammary tissue. Though these tumors had a characteristic feel to them (often described as feeling like BBs within the breast tissue), Patty's owners had been so distracted by the larger tumor (which, by the way, had been growing for about 4-5 months) that they didn't realize anything else was going on.

Unfortunately, about 90% of mammary tumors in female cats are malignant. Had Patty presented to the VTH's oncology department, we'd have recommended doing some thoracic rads to check for metastasis, sedating Patty for FNA of some of her masses and the lymph nodes that drained them, and, depending on the findings of the previous tests, scheduling a bilateral radical mastectomy.

And I still discussed those steps with Patty's owner. Just because someone doesn't have the money to pursue advanced treatment doesn't mean that you shouldn't give them every option. Is it an awkward conversation to have with clients that you are 99.5% sure cannot afford such a workup? Of course -- but you still have to bring it up. It's considered negligence to not offer the "gold standard" plan, because there are still that 0.5% of clients that will surprise you with what level of treatment they can and will pay for.

However, Patty's owners had scraped together $65 for that day's appointment. It was enough to cover the exam fee (about $35 after their discount), and maybe some meds to go home. My discussion with them moved almost immediately to a chat about palliative or hospice care, rather than delving into curative intent therapy. Patty needed antibiotics to try to treat her infected tumor (though such therapy may or may not be successful in controlling infection), and she needed pain meds because, let's face it, a giant infected tumor on your belly bleeding all over the place can't feel good. Unfortunately, even with the cheapest antibiotic selection and a lower dose of pain meds than I wanted to use, we were still $8 over Patty's owners' budget.

So the technician and I each kicked in $4, and sent Patty on her way for what will hopefully be a more comfortable few days at home before Patty's owners are ready to euthanize her. During our discussion, Patty's female owner also revealed that she herself is in Stage 4 ovarian cancer -- so Patty's owners know all too well what lies in store for Patty, and I think they feel some relief that they will be able to give her a peaceful passing when she is no longer able to be comfortable.

It's a case that will stick with me.