Hello, everyone. Thank you very much for attending this webinar on palliative care in veterinary oncology. So the learning outcomes for this webinar are to gain a better understanding of palliative care for our veterinary oncology patients.

Before we can do that, I wanted to review what the definition of palliative care actually is, because it's quite wide-ranging and sometimes can be a little bit deceiving with overlap between patients having definitive treatments, as well as palliative treatments for different types of cancer, which all have very different behaviours. With regards to the behaviour of these cancers, I'll go through the concept of local, regional and distant oncological disease, how it affects patients, how it affects our delivery of care and our options available to these patients, and palliative management of different. Types of cancer, which I will illustrate with a couple of case examples.

You'll be pleased to know that I won't go into any pharmacological detail about cancer pain pathways, because that is far too complex, but I will talk about general concepts of how to choose appropriate analgesics for appropriate patients. And there's a section in this webinar about interventional procedures, as well as general treatment options to palliate patients with cancer. The last part of the webinar will concentrate more on communication, and talking about order-driven care, and how we manage the order's needs, the patients' needs, our needs as vets, and particularly with a little bit of focus around older concepts of nutrition and dietary supplements in the care of patients with neoplasia.

So first of all, what is palliative care? The NHS defines palliative care as An illness that can't be cured, palliative care will keep you comfortable by managing your pain and distressing symptoms. Now, obviously, that can apply to many, many conditions in people and in animals, because Particularly as the profession develops and we have more treatment options, lots of animals are living with chronic conditions, for example, congestive heart failure.

A high blood pressure, renal disease, in our particular case, cancer, is becoming more common as pets get older, and others are much more willing to manage it. Whether that's palliatively or with more curative treatments. What's really important with palliative care in cancer patients is to take a holistic approach.

We have to consider the patient as an individual, as a whole animal, not just as regards to its tumour because it may have other conditions. And priority always is quality of life. Our patients, of course, are attached to their orders, so we have to consider the order values, which sometimes may conflict with our values as pets, and the communication is really important in managing those and achieving the best outcome for our patients.

In veterinary medicine, we tend to use palliative care for Patients where clients have chosen not to have definitive treatment, but actually, it is also in cancer patients for Patients that are not eligible for definitive treatment, as in, it wouldn't be possible to cure their tumours, and we are always going to be managing them palliatively regardless. So first of all, just a refresher on local and regional cancer. So localised cancers are cancers which are confined to one area of the body, and that may be as simple as a low-grade mast cell tumour on the skin, which can obviously be cured by a simple surgery.

A low grade plasma cytoma, for example, in the jaw can be removed by surgery. There are many, many examples of, small localised tumours that will never cause patients a problem. Owners can still get very upset about those, however, and will perceive that their animal has cancer, as in a quite significantly affected, even with a tiny mast cell tumour, for example.

Regional disease is cancer which has either spread to a regional lymph node or has infiltrated some tissues in the region of the local disease. And This may or may not be a problem for the patient. Also, it may be very difficult for us to assess how much of a problem for the patient it is.

If you have a look at the CT scan picture here, this dog, this was a collie dog, referred to me for a prostate tumour. Now, the dog really had very minimal symptoms. I think, if I remember correctly, had a UTI and the vet incidentally diagnosed quite a small, prostate carcinoma.

So he was referred for what? The owner and the vet perceived as definitive treatment. Unfortunately, when we did the CT scan to fully stage this dog, you can see that there's a big osteolytic lesion within his pelvic bone and also within the muscle, around the region of the prostate.

And that is a Regional disease, look for regional disease, which makes this patient much less eligible for curative treatment. I don't want to suggest that he was going to be cured anyway of a prostate tumour, but it's just an example of a dog who was normal. He was running around, he was very active.

The owners were absolutely shocked and horrified when they heard about this and saw the CT and On examination, I couldn't find any evidence this dog was in any pain, any discomfort at all. So was it affecting his quality of life? We don't know.

He needs palliative care, obviously, because he doesn't have an option for cure, and he, we need to make sure that his quality of life is managed. But I'll come on to that later, how we actually assess these things and make the right decisions for patients. So distant disease, this is disease which has spread, either it could be to lungs or to liver spleen, for example.

And often, again, this can cause alarm amongst vets, even oncologists, even especially orders when they hear that a tumour has spread, that can be very upsetting because people perceive tumours which have spread as being imminent for dying. Actually, many tumours that we deal with, the dogs can live and cats can live for many months and even years with metastatic disease, bearing in mind that these animals are often older and have comorbidities that may kill them before the tumour does. So, definitely for the major, for many tumours, sorry, not the majority, but many tumours.

Distant disease is actually not an issue either for quality of life, or depending on their age, significant risk of imminent death. Obviously, it depends. Some tumours are more aggressive.

Hemangiosarcoma, osteosarcoma, if they've metastasized, usually, that does mean that animal's life is significantly shortened. And they're certainly on the short-term palliative care pathway. But, for example, anal sar tumours, I've seen dogs live for years, soft tissue sarcomas, for example.

With disease that has spread and doesn't affect their quality of life in the slightest. So, considering all of these factors, and the patient as a whole, when we, look at their palliative care options. This is another patient example of mine.

So, this is Daisy. She's a Labrador. And she came to see me in 2022 because she had a nadal sac carcinoma diagnosed, and the other wanted to do everything.

So we were aiming for, what we would consider a curative treatment. She had surgery followed by radiation therapy. And Within the boundaries of our definitions of treatment that should have managed her disease the best we can, i.e.

Curative intent. A year later, however, the or notice she was struggling to get up. So she had we stayed during the CT reexamination, and it was found at the other referral centre.

She has this lytic bone lesion in the body of the vertebrae of T8. The referring centre, did a sample of this, and it was confirmed to be a metastasis of anal sac carcinoma, which is actually quite unusual in, with regard to the number of them that we see, it's uncommon that we see them metastasizing to the vertebral body, although it is reported. So, at this point, there's no curative options for Daisy.

Her disease has not spread anywhere else, which is interesting, but the owner wanted us to palliate her as best we can and very, be very, very aware of her quality of life. She's a very active dog, generally, and they were upset to see her not just in pain, struggling to get up, but she actually had developed neurological deficits by the time, she came to see us to talk about palliative options. So what did we do for Daisy?

Well, we offered analgesia, of course. So she had an oral analgesic combinations, which I'll talk about in more detail later. She had what's considered a standard of care in human palliative oncology and localised radiation.

Which was delivered once a week. She had a bisphosphonate. Sorry, radiation was only for 2 weeks, so it was two very short treatments, bisphosphonate, which is an IV infusion, and she had a really significant improvement.

And actually, the owner stopped giving her a lot of the pain relief over the next 4 months. 4 months later, she was a little bit painful. Again, the odour was quite astute, brought her in, and she had another dose of radiation.

This was in November, and I'm recording this at the end of January. So this 2 months down the line, she, was still being managed. So this is an example of a dog that has a disease, an oncological disease that can't be cured, but is being well managed palliatively.

How long we'll be able to manage that is open. So, obviously, we have already got 6 months for her, which is pretty good for a dog with a condition of her age. Chester, is another dog that I saw this year, last year, sorry.

He is a golden retriever, and he presented to the local vet for epistaxis, which was affecting his and the owner's quality of life, because obviously, breeding large dog isn't ideal to have in your house. The referring vet did the CT scan. And found this mass lesion destroying the crepior plate, which is almost certainly cancer.

It hasn't had an actual biopsy. Dogs otherwise completely normal, running around very happily, and I discussed the potential options for them. There is no cure for this.

There's no surgical cure for a tumour in this location, because we can't take margins. Radiation will not cure it. If the dog was 12, possibly it might control it for long enough that he died of something else, but he was relatively middle-aged.

So the dog is having palliative care. The owner didn't want to do some of the more involved options. So the dog is having just a COX-2 inhibitor drug and traamic acid.

And he's doing really, really well. He's a normal dog. The owner brings him in every now and again for assessment to have repeat prescriptions.

And he just carries on living with cancer, and this is becoming more and more prevalent in Our veterinary patients, as we know, you know, we all know people who are living with cancer and they might live 5, 1020 years with even metastatic disease. Obviously with our dogs we're not going to get that kind of longevity, but we can certainly, in his case, he's already got 6 months. He may well occasionally we see dogs with nasal tumours living with palliative management for, you know, a year, even longer, so.

Definitely worth treating these guys and discussing options with others because we can achieve very good quality of life with simple drug like transdynamic. That brings me on to cancer pain. It's a really tricky area because it's very difficult to assess pain in some of our veterinary patients, particularly cats and rabbits, for example.

It's also difficult to know if a particular cancer patient is suffering pain. We might see tumours in animals or in people where we would consider them to be painful, but the person might say, No, I don't feel pain. That could be because they have a higher pain threshold, and another person might feel pain.

It's all very individual, which is why treating cancer pain is incredibly difficult. The main things to consider, and this is certainly coming out in human cancer care now is. Mechanistic treatment as opposed to just, scattergun treatments.

So rather than just giving all the drugs we have in the pharmacy. Thinking about how is this cancer causing pain, is that low grade mast cell tumour in the skin causing pain? No, it's unlikely that it is, particularly if you remove it.

It's the nasal tuber causing pain. Possibly, it might be causing some discomfort, but it's more likely just causing discomfort because of the space occupying lesion. If there's significant body lysis, we generally assume that there is pain associated with that.

So, somatic pain is pain, which is associated with stimulation of nociceptors, which may be in the skin or the deep, skeletal tissues, muscle, for example. And that's generally when tumours are infiltrating. It, it doesn't tend to be so much with small localised skin tumours, but more, big, for example, hemangiosarcomas in the subcutis.

And Or big mass cell tumours that are actually taking up a lot of space. Then there's visceral pain, which we would all be familiar with ourselves with, dilation of intestine, for example, intestinal masses, stomach masses, any kind of, compression in the abdomens or large abdominal tumours, splenic distention, etc. And then there's neuropathic pain, which is probably the one we deal with the most in terms, of nerve stimulation, where tumours are causing altered sensation or release of, nerve growth factor and stimulating that pathway, which is quite an interesting new, Treatment potential in oncology.

So looking at our options, you know, we have the pharmacy, so that's always the first line, and particularly in general practise, that's where you're going to go for your palliative analgesics for cancer patients. However, it's worth thinking about these options. Bisphosphonates can be very useful for bone pain, so any bony metastasis, any primary bone tumours.

Definitely worth considering. They're not very expensive, they're very well tolerated. And they, there is evidence, importantly, there is actual evidence that they improve the quality of life in Patients with osteosarcoma.

Then we have the monoclonal antibodies to nerve growth factors like labrella. And the feline version. So these drugs interrupt pathways.

And obviously, we all know they're licenced for arthritis, there is some initial evidence in dogs and in people to show that they can also be beneficial in, other models of pain. For example, cystitis and In osteosarcoma. So whilst it isn't evidence-based or licenced, there is a potential there because NGF is involved in a lot of different pain pathways.

And then there's radiation. Which I am a bit biassed because I'm a radiation oncologist and I work at a radiation centre, so it's easily accessible. It is a very excellent pain relief for many, many types of tumours.

So anything superficial in the skin, subcutis muscle, anything infiltrating in the bone, for example, anal sac tumours, nasal tumours, it can shrink tumours down. And by doing so, It also has an intrinsic analgesic effect. So it's really important, to offer these options to owners and, and discuss how the pain is being caused by the tumour rather than just going blanket with the drugs.

Because, as we know, drugs all have Their own issues. They have side effects. They're expensive.

Many patients, particularly cats, can be difficult to tablet that can actually alter the human-animal, relationship and decrease quality of life for both. So, considering the type of pain the animal has, how severe the pain the animal has, what's the mechanism of pain, and then choosing a treatment pathways appropriately is The ideal standard of care for palliative management of cancer patients. So just on the right, some of the things I've already talked about, like the bisphosphonate radiation and NGF.

There are drugs at the top. Non-steroidals are always my go to first line for analgesia. CO2 specific ones, particularly, I would choose because they also may have some anti-cancer effects.

They're very good at controlling tumour associated inflammation. My second line and certainly most of the anaesthetists I talked to would choose paracetamol as a second line analgesic. The evidence for efficacy of.

Most of these drugs is quite poor, and it potentially They do not benefit a lot of patients. Certainly in humans, a minority of patients benefit from drugs like gabapentin and amantadine. With regards to management of pain.

So it's worth considering that when, you know, we might put every dog with spinal pain on gabapentin, but how many of them actually have less pain versus improved because of other treatments, such as KRS, steroids, non-steroidals, for example. And Tramadol is very poorly metabolised by dogs, and the active ingredients for analgesia is Poorly available. So actually, it doesn't have significant benefit for most patients, and these drugs can all cause sedation, which may in part be, a perception of owns that these animals are actually having analgesic benefit when actually it's more that they're just a bit calmer from having them.

One thing to mention here is neurological intervention. So sometimes actually cutting a nerve around a tumour can help, as long as it obviously doesn't affect the animal's ability. So worth talking to, a neurologist about specific tumours, for example, nerve sheath tumours in the limb, rhinotomy.

So we do this for, rhizotomy, sorry, we do this for, The word has escaped me tumours, no teeth tumours such as brachial plexus tumours, for example, and that can really improve quality of life to just get rid of pain for these animals in a palliative way. I wanted to talk about steroids because it's still one of the most common questions that we get. Should I put this patient on steroids?

Should I change this patient from a non-steroidal to steroids, for example, and The answer is they're uncommonly indicated to the majority of tumours that we see. Probably the most common tumours that we see are, sarcomas in the skin, mascle tumours, or skin tumours. Most of which would be better managed with a non-steroidal than a glucoseoid.

There are specific indications where steroids are indicated. For example, lymphoid neoplasia in the initial management, because the steroids will kill lymphoid cells. The longer term management, we don't have any idea of what benefit they have.

And if a dog is painful, then We should, try and do better analgesia because glucocoseos do not have great analgesic benefits. Brain and spinal tumours with edoema, they benefit from steroids because they reduce the edoema which is causing pain. Mast cell tumours, which have edoema around them, infiltrating muscle, for example, definitely worth using some steroids controllers in the first instance.

And occasionally they may improve an animal's well-being. So if you really have an animal and cats with nasal tumour spring to mind, being palliatively managed, they're often quite miserable, quite snotty. If a COX-2 inhibitor is not helping them, if they haven't improved with Metam or something similar, then actually trying a little course of steroids sometimes just picks them up in the short term.

And that's very much around the discussion with voters that this is short-term palliation. It's not going to have a significant durability for these types of tumours, but they can have benefit in the short term. So glucocorticoids, yes, they have utility.

It's about asking, you know, how is this tumour and its associated inflammation affecting this patient, and which is the better drug. So just to bear in mind that because an animal is under palliative care, so even if you have, for example, an osteosarcoma with metastatic disease, removing a painful tumour will still improve quality of life, even if that is only for weeks or months. And we might find that difficult as vets thinking that actually, we're doing a procedure on this animal, which is only going to live for, say, 4 to 6 weeks.

And Depends on the procedure, the recovery time, and the patient's ability to tolerate it. So, for example, surgical palliation, good surgical technique, good analgesia, you can get a patient amputated and out of the hospital in 24 hours, much, much happier than if that patient had been left with the osteosarcoma for 5 weeks, for example. Even if it has metastatic disease.

You know, this, this is an extreme example, because metastatic osteos may well kill a patient that quickly, but certainly there are other tumours where patients could live for a good few months, and that gives the owner time to get their head around that that euthanasia will be indicated that they're going to lose their companion very soon. And it gives that dog or cat, quality of life during the time it's being managed. Medical treatment also, I'm not going to go into any great detail about this, but you can give chemotherapy as a palliative treatment.

Arguably, any chemotherapy is palliative in our patients, even lymphomas will relapse even when we put them into remission. So it's an option. Targeted therapies such as kinase inhibitors can be given.

The aim is always to go with the lowest tolerated dose. And metronomic chemotherapy, for example, low dose chemotherapy, all of these well tolerated by patients, minimal side effects, avoiding harm and achieving some palliation for conditions that are affecting a patient's quality of life. I've talked about radiation already.

This is a picture of our new radiation machine that we got in 2023. It's an excellent analgesic. We don't know how it works, but we know it is.

People with painful tumours will report benefit within hours of having radiation. And I've certainly seen dogs that could barely walk and were miserable one week come in running around the following week after one dose. So, well, again, people are often reluctant to do it because they need an anaesthetic.

Anaesthesia is very safe in general. It's short, it's light. And if we can shrink or stabilise a tumour, provide analgesia, and improve quality of life, we don't keep them in for 4 and 6 weeks, having extensive side effects.

We just give a couple of treatments and to get these patients out back into the community, back to their orders and enjoying quality of life at home. So just a reminder side, this is just to remind me to say that all these treatments can be combined. We, in my practise as a specialist, we will see patients who come in and they might have, surgery, radiation, chemo, knowing that they're still only going to live for a few months, and owners are willing to do this as long as the patient is happy and have quality of life.

It's actually unusual that we do all of them. Often it's financially constrained or They just chooses the one that's likely to have the most benefit, but certainly combinations of treatment should always be discussed. And patients, for example, with less aggressive tumours like anal sacs, can be palliative and managed for many years with combinations of different, palliative treatment options.

So I'm just going to talk in a bit more detail about interventional procedures. It's something that obviously isn't, common in general practise. It's not even that common in specialist practise because it can be a bit difficult to get hold of the, stents and tubes and things in some patients.

So, we often see patients too late, we, the conversations haven't been had early enough. So I just want to flag those up as palliative options for oncological patients. So, stents are basically things that hold tubular structures open, so they can be placed, for example, even tracheal collapse, that's palliative management for common condition in small dogs.

For cancers, we use them to hold open blood vessels. For example, urethra, ureters, they can all be of benefit in tumours affecting those organs. Subs, subcutaneous bypass systems for urethral blockage, most commonly used for cats with urethral stones, but they could also be used for tumours.

Chemo embolization techniques is when we inject, what's the word, little bubbles into an organ. So, for example, for liver tumours, we can embolize them, cut, cut off the blood supply, and sometimes we can add chemo to those. And then there's plural pots, which are cystosomy tubes, which can be used to drain effusions that might be affecting, patient.

So this is a picture of a sub, so a subcutaneous bypass system for a ureter. And this was when we placed in a little dog, that had, TCC, so transitional carcinoma of the bladder that was infiltrating both the ureter openings and causing significant azotemia. And the dog was obviously unwell and miserable, and the owner wasn't ready to let them go and wanted to try something.

So we placed the sub and allowed that patient to relieve the azotemia. And the patient lived for another month or so. It wasn't an amazing time, but the procedure is minimally invasive.

It gave the order time to get their head around things, and the dog had quality of life that they may not have had otherwise because regardless of how early we have the the euthanasia conversation, unfortunately, some owners will not, proceed with that and will keep patients. Unwell, whereas by providing these palliative options, it does allow them to have a quality of life while they make that decision. This is an example of a plural pot.

So a plural pot is a tube, that goes in the thoracic cavity and sits in the pleura and drains effusions there. So it's effective in patients that have slow building up effusions that can be drained, for example, once every few weeks because it doesn't compromise their well-being. Patients with fast developing effusions, it's not.

Of any significant benefit unless it's a treatable underlying disease. So, for example, pyothorax, it's not a good example because it would block the pot. But in theory, you're treating a pyothorax, you could have a pot or a drain in there.

The animal's going to get better. That's fine. But if it's something building up that is not treatable, for example, mesothelioma tumour, and we don't have a good chemo option, and the patient has to be drained every day, that's not good quality of life and it upsets their electrolytes.

But for patients with slow developing effusions, it could really buy them a little bit of time. I had a little dog with a, what was an idiopathic effusion. It was probably related to an underlying tumour that we just couldn't find.

He had a port for about 6 months, and he just went to the vet and had it drained every 3 or 4 weeks when he got, a bit to sneak and tnick. And the owner was super happy with that, because they didn't have to go without any treatment pathways. They got to spend time with him.

He was comfortable. They knew that they could manage his breathing. And, you know, even though he was euthanized after about 6 months, they really genuinely appreciated having that pot placed for him.

And this is Dexter, who, sad to say, actually died a few days ago. He was a patient of ours for 2 years, and he presented with a large Heart-based mass, which was causing a pleural effusion back in 2022. We placed a poodle pot because we had to manage his pleural effusion to be able to anaesthetize him for treatment.

And he had radiation to shrink the tumour down. And that was very effective for him. He went from being a very miserable, skinny, tachyni dog to being fairly normal for about a year or just short of a year.

And then he represented with ascites. So we Re CTed him to find out what was going on. Had the tumour progressed, has the metastatic, for example, and it turned out that he actually had pulmonary hypertension due to The tumour causes some compression of his pulmonary artery.

So we placed a stent, in the spring of 2023, and his ascites resolved. And he was living very normally up until the end of 2023, but sadly, he has now passed away. However, I believe his order will still keep his Instagram account open, if anybody wants to have a look at his adventures.

So this is pictures of his stent being placed. You can see the tumour there obstructing the blood vessel. And, interestingly, the tumour hadn't grown.

It had just changed position. So the radiation had controlled it from the first treatment that you had the year previously. The stent is placed, and you can see that the tumour is now not obstructing the vessel anymore.

So the pulmonary hypertension improved and the site is improved, as you can see here. So this is stolen from his Instagram account. And, the picture on the left is with his ascites.

He honestly looked like he was 9 months pregnant. And the picture on the right is a normal looking dog, a few weeks before he sadly died. The last part of the webinar will focus around communication and how we can manage these conversations with orders in terms of achieving the best treatment pathways and options for our patients, .

So, owners are very keen to palliate or treat the animal's cancer quite often, and they will look on the internet, and they will come up with treatment options that have been suggested by other people, by support groups, and common ones that I see, you probably see as well, are CBD oil, probably number one, turmeric. Mushroom extracts, immune support, things, and homoeopathy. And there are homoeopathic vets out there that will give treatments for cancer.

I've certainly seen patients even with brain tumours coming in on You know, 8 different homoeopathic remedies. So owners are very keen in many cases to pursue these things, and they generally will go for the more easily available ones. So the turmeric and the CBD oil seem to be most popular, but a lot of owners will investigate other ones too.

So talking about these things is better. And in humans, there's this concept of goals of care in palliative medicine. So we use the owner's goals and their goals for the pet to design our palliation.

And we change that depending on the owner. We may have two dogs with the same disease or two cats with the same condition, but the owners may have very different perceptions of what is palliation for them. And as a vet or oncologist, or general practitioner, it doesn't matter.

We should never make assumptions about what the owner might want to proceed with or might not, because they, they surprise us. The most important thing is communication, having those conversations with owners. And being able to assess their goals for the animal.

Ideally, we would have a more established method of, standardising goals of care, but at the moment, the research on that is quite limited, and we don't have anything standardised. In humans, so the Macmillan Cancer Association charity on the left have this, kind of way of assessing quality of life. So they look at a human cancer patient and say, do you have, how are all these things?

You know, do you have, how's your health? How's your work? How do you feel?

How's your environment? How are you emotionally, and all of these things that affects us as people. And actually, that applies to our pets as well.

Our pets do have emotions. They do have well-being associated with their emotions. They do have quality of environment, and they should have all the same things that we should have as people in terms of freedom from pain, ability to express normal behaviour, access to good sleep, having social interactions with other animals, for example, and, you know, these are all very individualised things depending on what the animal's lifestyle was before they had cancer.

So, these are useful guides when having conversations with orders to ask, you know, how are all these things with your pet, or for guiding orders when quality of life is not good, or euthanasia might be indicated or recommended, sometimes asking that question. How well does he sleep? And the owner was, well, actually, he's been pacing around all night.

Well, that's not a good quality of life. He can't breathe because of his nasal tumour. Well, that's not a good quality of life.

Can we do anything to alleviate those things, or should we be talking about euthanasia rather than palliative care? You know, is the patient eating? Well, if they're not eating, that's not associated with a good quality of life.

Could we do anything? Could we place a feeding tube, for example. Depending on what the animal's treatment is and how likely it is to live for any prolonged period of time.

These are all good questions to ask on us. There is a paper that you can access, have a read of, this is written by a radiation oncologist from Switzerland, who has written this paper on the principles for ethical decision making in veterinary oncology. It's more of general decision making, but it equally applies to palliative care because A lot of tumours we're treating are being treated palliatively even.

What our intent is to do the best we can, and the patient might live for 1 or 2 years, that is still palliative treatment. So this is just a figure that I stole from that paper, which, which, displays the information I had on the previous slide. It's a different textual way.

Definitely worth a read for anybody who is interested in how we have these conversations and make these decisions for our animals with orders. So what is quality of life? How do we assess it?

And this is A difficult question because cats and dogs are very different, rabbits, etc. And how do we quantify many of the things, like I talked about earlier on in the webinar, how do we know if an animal is in pain when they can't tell us? How do we know how much pain or how significant it is?

And how do owners perceive behaviours, for example, You know, owners will say things like, I'll keep going with treatment until he stops eating, even though the animal might be in terrible pain. Or she doesn't cry out in pain while she's a cat, so she might not. These kind of perceptions that others have of how animals should express feelings the way that people do.

Questionnaires. There was a lot of work a few years ago, a few years ago, probably about 10 years ago now, on, health-related quality of, life for cancer patients. There were several papers published around that period of time.

So there are some tools out there. There are, quality of life questionnaires available that we can use. However, They seem to have fallen a little bit out of, favour, probably because of the difficulties we have interpreting the results and actually relying on owners to be able to give us useful information, about their pets' behaviour.

It's definitely something that's come back to my mind on writing this webinar, that actually, it's something we should be pushing forward more because It's all very well having our goals, goal-oriented care, but actually, if we had a more standardised way of identifying those goals that potentially could be very useful for clinical practise, particularly for us as specialists. So a few years ago, this was published, and this is a paper which showed that owners of dogs with cancer are much more likely to give their dogs specific diets as in home cooked diets, raw diets, vegetable-based diets, and also to give them nutritional supplements than they are to healthy dogs, which is a bit ironic when you think about the pathways, tumour development, that actually, there's a lot of confusion with orders around what is preventative and what is treatment of cancer. So a lot of others think that giving antioxidants, for example, after the dog has cancer will have some benefit to controlling the cancer, whereas actually what would have been more beneficial is to have that before the cancer developed.

That may have delayed or stopped it. Anyway, it's just useful to know that we need to be working with others on both sides of this, that actually, if, if people want to use those things in dogs, giving vegetables to dogs earlier in their life is probably preferable to trying to change their diet when they already have terminal disease. It's not a surprise, because if you Google veterinary cancer diet, this is what you find, endless YouTube videos of people cooking, all sorts of things.

Some of which are more useful than others, but actually, Not necessarily evidence-based. There's very, very little evidence around nutrition for cancer patients. The main things we advise as, veterinary oncologists is that patients eat something that they like.

It should be a well-balanced diet. They may still live for many months or even years with their cancer. It should be palatable.

It should be high in protein, carbohydrates with easily available energy. And We need to consider a few specific factors for our cancer patients. That is homemade diets.

Lots of owners like to cook, for example, chicken for their dogs that may be nutritionally deficient. It's not too bad if the patient's only likely to live for a few weeks. It's not the end of the world if they're just eating chicken.

But for a dog with a mast cell tumour or soft tissue sarcoma, no, they need a proper diet. Raw diets, obviously, we all have our opinions on those. Mine is that if our animal is immunosuppressed specifically by chemotherapy, we need to be really careful because there's much more potential for the animal to develop sepsis.

And Immunosuppression from cancer potentially also gives them a higher risk. We don't have evidence for that, but personally, that's the advice I give owners, is that I would prefer they didn't feed raw when their patient is immunosuppressed. And if they do, to be very, very careful and mindful of it.

And there's no evidence at all that any types of vitamin or well-being supplementation has any effect on cancers. And one of the most important things to remember is not to have sudden changes in diet. So, lots of others will have a cancer diagnosis for their dog and then suddenly start feeding it a completely different food or lots of treats, which then can make the animal sick with something else, for example, pancreatitis.

So encouraging, well-balanced, palatable, Dog foods, complete diets is my advice for any patient with cancer, and even in the palliative situation, it's better to have something they recognise they're familiar with than changing things. There is this prescription diet for cancer patients. It's not, particularly exciting.

It is basically what I said, a fully balanced, high energy, palatable diet, suitable for older animals, and it can also be used for other chronic conditions. Briefly, just to talk about CBD oil, some of you might be aware, that there is some evidence for it being useful in the management of dogs with osteoarthritis, that those dogs may get some analgesic effects for it. And that's to do with modulation of inflammatory and anti-inflammatory cytokines.

There is minimal evidence that it kills cancer cells. There is some evidence from cell studies, or in vitro evidence, but the studies are quite limited and underpowered, and I wouldn't want to ever recommend that an owner uses it for a patient in terms of managing its cancer. The .

Owners are quite keen on it. My feeling is it shouldn't really cause harm as long as they get it from an appropriate area. And it's frustrating that we're not actually allowed to prescribe it, because that would allow better regulation of how it's used rather than owners just buying on the internet.

But at the moment, because there's a lack of evidence that BMD doesn't allow us to actually prescribe it. So it's more a, Accepting the owners give it, rather than being able to recommend it for any, Particular use. These kind of things are all very popular, and very expensive.

So owners can go on the internet and buy things with all sorts of barks and roots and vitamins and things added. The Generally, again, don't have any evidence to support their use. I try to discourage owners from using them because they eat into their budgets for actual treatment.

And, it's very difficult for us as vets to know if any of these things are toxic, you know, going having to trail through literature that doesn't exist to find out if, such and such a route is appropriate to give to a dog. It is not ideal because it puts us in a difficult position of whether we recommended or didn't discourage the use of something, but others will use them, and I'd rather they told me they were using them than not. So, Keeping those conversations open is useful.

Something that's really worth mentioning is that I know that people in general practise do not have a lot of time. People don't have long consult slots, for example, and Potentially not the experience of managing some of the more complex metastatic cancers. There's a perception that referral to a specialist will result in an extensive treatment pathway, a big bill, the owner might not want it, the vet might not want it.

But actually, it's not the case. A discussion with a specialist is very useful. There's never an obligation to take on treatment.

We always give them the option. If the other wants to go back to the general practitioner to have management, we are happy to do that, to give a treatment plan for you to implement. And a lot of palliative options can be easily managed and rewardingly managed in general practise.

So, if you find that you want your owner to have a conversation with a specialist, then it's definitely worth referring for that. And you can always take the care back for orders that choose palliative options that are administrable in general practise. As the last mention, there are plenty of guidelines out there now on hospice care for pets, which is done at home.

It's not an actual hospice with animals lying around ill, useful reads from the American Associations of Animal Well-being. Questions to ask. It's all very similar to the conversations we've talked about before on quality of life and goal-oriented care.

But making sure that all that all areas have been covered for managing decisions to do palliative care, where the owners have chosen hospice management for patients that are quite unwell, the impact of any potential treatments, and also things like financial, legal, religious concerns that we've all been Exposed to at some point, whether we, you know, think an animal is legally being harmed by the type of care chosen by the owner. So these are really useful things to have a read of, and to help you in decision making. And it kind of struck a chord with me on looking at this figure.

You know, the consideration of emotional aspects about animals, that animals do have dignity and That, that should be allowed to have dignity in life and death. They do have a will to live, but they also know when it's time to die, and they do feel stressed. So considering all of those things and trying to engage the owner in realising those things as well is really important for their management.

Euthanasia, sadly, is the endpoint for most of our patients. Whether that's 1 month or 2 years after, after, diagnosis and palliation. I open that conversation early, often at the time of the diagnosis, because many clients actually don't know what euthanasia involves.

They're worried, they're scared. They don't know what to expect. They don't want to do it.

They might have religious objections, concerns about if it's the right thing to do. They might have had a bad experience with previous animal, but actually opening the conversation, asking them of their experience, what they want for their pets. Can help to make the palliative care journey much smoother, when that is accepted and planned.

And most donors are actually happy to have that conversation opened early. And again, there is guidance, through the American Veterinary Medical Association for euthanasia, and keeping euthanasia peaceful and As pleasant as it can be for others and our pets. So, in summary, we should take a holistic approach to the palliative management of our patients, clients, and keeping quality of life at the front of our decision making.

We should aim for goal-oriented care, managing expectations of our owners, and definitely, you know, help to have those conversations around owner interventions. Offer them all the potential. Pathways, palliative pathways.

And make sure that euthanasia is included in those conversations from an early point. And quality of life again, we can't say it anymore. Palliative care can go on for a long period of time or a short period of time, as long as the animal has a good quality of life.

Thank you very much for listening. I hope that was useful, and if anybody has any questions, my team and I can be contacted on the address here oncology at Southfields.co.uk.