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Lexie's Smile

Cancer is one of those words that all humans fear to hear spoken.  It is a disease that is not only frequently fatal but it is seen as being painful to treat and to try to cure.

In human medicine, quality of life matters less than length of life.  Human physicians fearful of lawsuits frequently put length of time over quality of time left.  Because of this, radiation and chemotherapy protocols are often painful and filled with weird side effects.  Some chemotherapy protocols that kill one type of cancer can stir another type of cancer out of a quiescent state and then that cancer needs to be killed with another protocol.

We currently have a little more leeway in veterinary medicine.  I know veterinary oncologists (cancer doctors) that follow the human trend and go all out to give the animal the most time on earth and I also know veterinary oncologists that are more quality of life people.  It's not the amount of time but what you do with it mentaly.  I am not an oncologist but I have found a few chemotherapy protocols that I am very comfortable with that give a good length of life with no or very minimal side effects.  The animals tolerate it well and the clients are usually very happy with their pets quality of life.  But in the end, the cancer always wins.

Lexie came to me with her teenage owner as a young adult dog.  She was out of puppyhood but not quite an adult yet.  Her young owner was the same.  Miss Frei was 16 but she carried herself in a way that demanded the respect that adults sometimes don't deserve.  Lexie was Ms. Frei''s dog and she made the appointments and paid her dog's bills.  She was thoughtful and asked intelligent questions.  Lexie was shy and really didn't want to be touched but she listened to Ms. Frei 's commands and tried to be as well behaved as a young dog can be.

About six months after I met them for the first time, Ms. Frei brought Lexie in because of a bump she noticed on her front leg.  Ms. Frei rode horses and Lexie frequently went to the barn with her.  She and I both assumed that the bump was probably the bite of stable flies or maybe an allergic reaction to something else from the barn.  I prescribed both antihistamines and antibiotics for Lexie and recommended no more trips to the barn for the next few weeks.  We called two weeks later to check on Lexie and Ms. Frei said that there were actually a string of bumps now going up the leg.  I was concerned that this could be some parasite or other more serious problem from the barn and recommended that we sedate Lexie and take a punch biopsy of one of the larger nodules to send in for a biopsy.  Ms. Frei agreed and we stopped her medicine for a few days and then did the procedure.

The sample was sent to our normal lab and I got back a very good result.  It was a reactive lymph node.  So we were on the right track initially with the antibiotics.  I changed to two different antibiotics and hoped for the best.  Which did not happen.  After two more weeks, there were more nodules spreading up Lexie's leg.  Feeling like the lab missed something, I called them and requested that they send the slides of the tissue and any remaining tissue to the veterinary school in Gainesville.  Then I faxed the vet school's path lab a report of the progression of Lexie's disease and the places where she's been so maybe they could diagnose it more effectively.

It took almost two weeks but they did give me an accurate diagnosis, it just wasn't what I was expecting.  Lexie had a cutaneous form of lymphoma.  It is a lymphatic cancer but in Lexie's case it was localized to the skin and not her lymph nodes, liver, spleen or other internal organs.

By convention, any lymphoma residing outside the main lymph nodes is at stage 5 and is not a good prognosis.  I spoke with an oncologist and she said that amputation may be an option or that we might try chemotherapy with one of two protocols that I was familiar with.  I ran the options past Ms. Frei and she felt that the chemo would be the better option if it wasn't too expensive.  I explained that the chemo I was thinking of required her to come to the office frequently with Lexie but that we could fit it in with her school schedule and that it really wasn't very expensive because Lexie was only 35 pounds.

My main concern was that Lexie was still very shy.  She would cringe and smile whenever she was handled and the chemo required that we give her an intravenous injection once weekly for 4 weeks then once monthly for who knows how long.  If the chemo agent came out of the vein it could cause redness and pain at the injection site and the layer of skin may "burn" and peel off.  So I really needed Lexie to hold still.  Fortunately, Lexie was very trainable.  I kept treats in my pocket and told her to sit and shake or give paw.  Then I would give her a treat.  We shaved her leg and again gave her a treat for holding still.  We put the catheter in and I injected the chemo agent, with a treat on the floor in her sight.  As I put the band-aid on her leg, the tech gave Lexie the last treat.  By the third visit Lexie would sit willingly and give paw, all the while smiling.  She knew the routine at this point and knew that after the poke came the last treat.  The owner was pleased with the progression of the treatment.  She had to give Lexie tablets at home after the chemo but they had no significant side effects either.  Lexie's cancer went into remission and stayed that way through months of monthly injections. 

Ms. Frei eventually had to go to college and couldn't take Lexie with her.  Ms. Frei was very attentive towards Lexie but she knew her parents would not be as attentive.  She was very apprehensive about leaving Lexie in her family.  I spoke to an oncologist to see if there were any treatments options that may better fit into Ms. Frei's parents schedule.  She said that we could try an oral drug that only needs to be given once monthly instead of the protocol that we were using to keep her in remission.  Ms. Frei was pleased with that option and we prescribed a different medication for her parents to give Lexie. 

The months went by and it seemed to be working well.  Lexie continued to be in remission when we did follow up calls to the parents.  They were looking for bumps on the leg as a sign that the cancer was returning and since they weren't seeing any, they thought all was going well.  When Ms. Frei came home for Break, however, she noticed that Lexie had lost weight, wasn't eating well and seemed sluggish.  We did bloodwork and it was evident that the new chemotherapy was causing liver damage.  We had to stop the convenient once monthly pill.  To accomodate the Frei's schedule, we worked out a more flexable schedule for the monthly injections. Some times it was six weeks, sometimes four weeks but Lexie was back on our schedule as a regular visitor.  Eventually we tried to purposely lengthen the times in between injections and got Lexie out to once every eight weeks.

I spoke to an oncologist again and asked if what I was doing was ok or not and she really wasn't sure.  She felt that if Lexie remained in remission then it was ok.  She also said that with grade 5 lymphomas like Lexies, we really didn't know how changes in injection schedules would affect it.  At this point, Lexie had been in remission for over two years and that was much longer than she would have predicted in the beginning.

By the time Lexie was five years old, she had been on chemo for almost four years.  Over the years I looked forward to Lexie's visits.  She would come in excited and smiling and seemed as happy to see us as we were to see her.  At times the whole hospital would come out and greet Lexie and she seemed to relish the attention.

Ms. Frei had been coming home regularly and had been more involved in questioning her parents about Lexie's habits when speaking to them on the phone so we were able to get minor problems under control before they became big problems.  One day her mother brought Lexie in because she felt there was something wrong and she knew her daughter would be upset if she passed it off as nothing.

We had been doing regular complete blood counts on Lexie because of the chemotherapy and never had encountered any problems.  Since the episode with her liver a couple of years earlier, everything had always been normal.  Things were not normal anymore.  Either the chemo or the cancer had finally gotten to her.  It really didn't matter which it was, the end result was the same.  I told Mom that I needed to tell her daughter personally and called her at school.  I told her that we could change her diet and give her medication to perk up her appetite but that we would need to stop the chemo and see what would happen.  She agreed.  I called regularly to check up on her and she seemed to be holding her own according to both Ms. Frei and her mother.

When the call came from Ms. Frei that Lexie was finally at the end of her life and needed to be euthanized, I almost felt like it was one of my own that I was having to say good-bye to.  She came in very weak, not smiling, not giving paw, not our Lexie anymore.  Trying to remain emotionless, I euthanized her and then I cried more than the family did because they had come to terms with it and I had not.  I could not imagine not seeing Lexie's smile or calling to ask about her.

I still wonder what the family thought as I cried over their dog's passing but I guess over the years I came to think of Lexie as one of my own and it hurt like losing one of my own.  Even now, years later, the memory of her is strong and I miss her smile.

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