// One of the many times we would write all of Piri's medicine and supplements for doctors and specialists. //
It must've been late 2015. I can't remember exactly when but I noticed something odd in Piri's mouth. I noticed it when I was using PetzLife gel on his teeth to remove the harsh tartar build up. At first I thought it was his tongue scrunched up inside his mouth because he hated having the PetzLife gel applied on his teeth. I didn't think much of it, to be honest.
Then in December, Yangkyu saw Piri yawn and noticed that it was a round lump. This got me so frantic and we made an appointment to see our primary vet right away.
At the time, Piri had a lot of other medical issues -- he had kidney disease, a low grade heart murmur, he was old (16 years old at the time) and so surgery to remove the lump (and some teeth, too) was a hard choice to make. Dogs with kidney disease cannot filter out anesthesia well and so the risk is that they may not wake up.
We had four options --
1. Just leave the lump and hope that it will pop on its own and drain out that way. Oral cancer is rare and so we could hope that was the case with Piri.
2. Move forward with surgery with our primary vet.
3. Move forward with surgery with a specialist who would have more tools and resources available to them in case they were needed.
4. Move forward with surgery with either our primary vet or specialist after completing a consultation session with a cardiologist to get the green light to see if his heart withstand the surgery.
Based on Piri's blood work at the time, his kidney levels were not bad, making surgery more viable for him.
We struggled a lot with deciding because we in the past we had our share of doctors and their treatment plans that didn't mesh well with us. We left clinics and hospitals feeling worried, unsure, talked down to or not given thorough explanations at all but left huge dents in our wallets. We have developed such a good rapport with our primary vet and my heart wanted to just move forward with surgery with them. They knew Piri, his quirks and dislikes, and they all loved him. My primary vet was more than willing to do the surgery herself, but she did let us know that a specialists would have more resources on their hands. She knew of a good practice in Leesburg, a good 40 minutes away from where we lived, and would refer us. And in the end that is what we decided.
// Piri and Yangkyu walking into SouthPaws Veterinary Surgical Specialists located in Fairfax, VA. CVCA has one of is many offices located here. January 27, 2016//
// Waiting for our consultation session with Dr. Sara Bordelon. January 27, 2016//
Our primary vet also referred us to a cardiologist as well and that's who we went to see first in late January. Dr. Sara Bordelon at the CVCA Cardiac Care for Pets located inside SouthPaws was great and did a thorough examination of his heart. Piri definitely did have a low grade heart murmur, but it wasn't life threatening and he didn't need treatment right away. His blood pressure was a bit high, but everything else looked great. She gave the green light to go through surgery and said that his heart is strong enough to withstand it. I am not sure if it helped, but I still tell Yangkyu that perhaps having Piri on CoEnzyme Q10 supplements helped his heart. It is a supplement that we relied heavily on.
// After our consultation session, we came out to the front desk to find this message. //
// After our consultation session with Dr. Stiles at the Animal Dentistry and Oral Surgery inside the Life Centre located in Leesburg, VA. February 18, 2016. //
Next we had our consultation session with Dr. Curtis Stiles at the Animal Dentistry and Oral Surgery at the Life Centre in Leesburg in mid-February. Yangkyu and I still talk about how amazing and flawless our experience was with Dr. Stiles and his staff. One of the biggest things that worry me is poor communication and balls being dropped. I was afraid that somewhere, someone was going to not get the right information on Piri. Not only was our consultation session with Dr. Stiles reassuring (with him explaining all the medicine Piri will receive and its counter reverse medicine that will help wake Piri up if things went wrong or if Piri doesn't end up doing well under anesthesia), but his staff was on top of everything and nothing went under their nose or over their head. They also scheduled Piri's surgery on the day when an anesthesia specialist with years of experience working with senior dogs would be in their office so that they can have an extra set of hands and expertise for Piri should he need it. During surgery they called four times to let us know how Piri was doing pre-surgery, after going under anesthesia, after surgery and during recovery. I have never felt so calm leaving Piri to go under surgery (he's had two -- his disastrous neuter surgery and another for his paw).
// Piri at Town & Country Animal Hospital in Fairfax, VA, walking out like a champ after getting his pre-op blood work the day before his big surgery. March 1, 2016. //
Our primary vet conducted a final pre-op blood work a day before his surgery which was promptly faxed over to the Dr. Stiles' team, which they confirmed receipt with us.
// Piri just days before his surgery. His lump grew significantly since when we first found it inside his mouth in December, 2015. //
// Morning of his surgery. Dropping him off. March 2, 2016. //
// Before Piri was taken back to prep for his surgery at the Animal Dentistry and Oral Surgery. March 2, 2016 //
Piri's surgery was on March 2, and he did great. He had dental cleaning done, had three teeth removed and also the lump inside his mouth, which Dr. Stiles said looked cancerous. We were given our post-surgery in-home care instructions and it took about a day for him to get back into his regular schedule. We struggled to get him to take his pain killers when we first got home, but he finally did inside a small piece of sausage. He slept comfortably and his meals for the next few weeks included boiled rice, chicken and vegetables. He ate voraciously. He recovered without any issues. Like I always have said. My comeback kid did it one more time at the age of 16, just days before his 17th birthday.
// Picking Piri up after surgery after he got the clear after his recovery session. March 2, 2016. //
// Post surgery, recovering at home. March 3, 2016. //
// 10 days after surgery. March 12, 2016 //
Then we got the answer we were dreading -- his lump was cancerous. It was oral melanoma, an aggressive type of cancer. It will be like this for the next several months until he passed. Lots of celebrating followed by lots of crying. It truly was a roller coaster ride.
// Piri leaving for his consultation session with the oncologist. There would be a few more times where I wouldn't be able to go with him during this visits because I had guest dogs. I would feel terribly guilty for not being there for him. March 28, 2016 //
We were immediately back to talking with our primary vet who referred us to Dr. Elsa Beck at the Hope Center in Vienna, VA. My experience with Dr. Beck isn't a good one or a bad one. I never really had issues with Dr. Beck, but sometimes her staff came off awfully cold and indifferent or confusing and incompetent (messing up schedules, discharge papers, phone messages, medication refills). We weren't given proper explanation but always given a hefty bill. Yangkyu and I would always say that cost didn't matter. We don't have issues with hefty bills if we were properly explained what we were actually paying for and not feeling like we were being burdens when we asked for an explanation. It would be these things that ultimately would sway us to not go to the Hope Center for any type of medical treatment should we get another dog in the future.
After an hour-long consultation session at the end of March, one where I was allowed to call in because I had guest dogs staying with us, we learned more about his cancer and were given treatment options.
Piri's oral melanoma was aggressive and the invasion was deep in his mouth and bone. Re-growth rate would be fast, mostly likely within 1-2 months. Chances of it metastasizing was also high, likely to his lymph nodes and lungs.
Our treatment options included:
1. More surgery - as the lump grows back, continue to remove it
The cons of this was that Piri was old and his kidneys were not in good shape. Continued surgery would prove to be too hard for him.
The cons again being that his kidneys would be shot as he would have to go under continuous anesthesia for radiation treatments. This was completely ruled out as a viable treatment option for Piri.
3. Chemo (growth inhibitors - Palladia)
The cons would be that he would likely have side effects which would include stomach upset that can come in the form of vomiting and diarrhea and give him ulcers. We would later find out that it would be much more than this -- that his immune system would be compromised and severely weakened, he would be more susceptible to infections, which he couldn't fight off well and he would develop other illnesses.
4. Vaccine - There were two kinds. The first was called the melanoma vaccine, which was released in 2007, for the prevention of spread of melanoma to the lungs and lymph nodes in dogs with stage 2 and stage 3 melanoma. The vaccine consists of human DNA gene which is supposed to trigger the dog's immune system to mount an immune response to ultimately fight against the dog's tumor. You can read more about it here. It is administered four times every two weeks followed by 6 month booster shots. They are terribly expensive (I believe the cost differs depending on where you live, but ours was $660 per shot). Piri got through the first four rounds and passed before his first booster shot was due.
There was a second kind of vaccine that is still in its testing phases and was developed in Argentina. Dr. Beck didn't get too much into it but it was also an option for us should we want to be part of the clinical testing phase.
After our consultation session, we were given a private moment to decide what we thought would be the best course of treatment for Piri. How much were we willing to let Piri's body go through harsh treatments and how much would we be able to pay. Two were our two major factors in deciding.
In the end we opted for chemotherapy and the melanoma vaccine.
// Piri after he took his first dose of chemo. He wouldn't start struggling with it until a few days later. March 28, 2016 //
// Shopping at Pet Value. March 28, 2016 //
// We always tried new treats and toppers to help with his appetite. March 28, 2016 //
Piri's chemo came in the form of a pill called Palladia. It was taken every Monday, Wednesday and Friday. I still look back to this day and feel terrible for putting him through it. At the time, I wanted to try everything. I didn't want to think of the what if's. But after seeing how hard it was for Piri (although I have read that for some dogs they don't have side effects or it isn't hard on them), I am not sure if I would have decided on this if I were given a second do-over. But again, I can only say this because I had experienced it.
Administering his chemo pill was a task in itself. It's highly dangerous to touch with the human hand (later I would think back and wonder how I could've fed this to Piri when it was so harmful to touch).
// Just a regular day for Piri. Resting on his bed with the humidifier in the background. We had that on for him in hopes that it would help his breathing. He had developed a weird peeping noise he would let out from his nose. He picked it up when we were in Key West. I wonder now if this was when he sniffed something, which made me catch aspiration pneumonia. May 13, 2016 //
This was our chemo administration process:
1. We had two wee wee pads, one under another, that covered Piri partly like a bib while the rest of the pad rested on a flat hard ground surface. I didn't want to do it while he was on a soft surface like his bed in case the pill rolled off.
2. I warmed up a piece of spam (or sausage or slice of ham or skin of a roasted chicken) and set it on a paper plate (or something else that was disposable). Piri wasn't taking Pill Pockets anymore and so I needed something I knew for sure he would eat. Palladia dissolves when it comes into contact with food. You cannot take it out of something and re-use it if your dog ends up spitting it back out. It is a one shot deal. I would later wonder if these terrible foods that are not healthy for a sick dog eventually worked against his chemo and helped in increasing his liver enzyme levels. I placed the paper plate on top of the wee wee pad.
3. I also had doubled bagged plastic bags opened and placed right next to the wee wee pads. This is our garbage bag to throw everything out once chemo was administered.
4. I wore two medical gloves and opened the plastic bag and zip lock bag where we stored Piri's Palladia.
5. Despite wearing gloves, I did not touch the pill and instead lightly tapped the bottle in an upside position for one pill to slide down on to the paper plate where the spam was, making sure they did not touch. If you want to be extra cautious, you can either have another paper plate on hand just for the Palladia.
6. I closed the cap back on the pill container and set it aside.
7. I then grabbed the pill and snuck it inside food which I know he would eat for sure.
8. Once he ate, I took my gloves off, placed it on top of the wee wee pads, along with the paper plates which were already there. I neatly fold up the wee wee pads with the gloves and paper plates wrapped inside and place it in the plastic garbage bags I had already set up so I wouldn't be fumbling to get it open.
9. I put away his Palladia and immediately dispose of the garbage outside.
// Yangkyu bringing Piri down to take his supporting medicine while he was on chemo. May 17, 2016 //
Piri was on chemo for three months (March to June) before he came down with urinary tract infection at the end of June, which took a month of antibiotics (3 different kinds - Baytril, Clavamox and Zeniquin) until he was finally better. But his blood work at the time also revealed high liver enzyme levels, which suggested pancreatitis. Our oncologist wasn't sure if his increased liver enzyme levels was because of his chemo treatments or if it was because of his kidney disease. Piri was taken off of chemo until his levels normalized. He would not go back on it again.
After finally getting out of the woods with his UTI and somehow finding some stability with getting his liver enzyme levels slightly down with a new diet that included a low fat diet (which in fact went again his cancer and kidney diet), I discovered the similar lump inside Piri's mouth on August 16, our anniversary date.
// Picking up Piri at the Hope Center after being there for better part of the day to get a fine needle aspirate done for the lump in his mouth. August 22, 2016 //
We took him in to see Dr. Beck who performed a fine needle aspirate which revealed that the lump was not cancerous and that it is likely a plugged duct. He was given steroids which was supposed to help the lump shrink. It did not.
We had a trip to New York coming up at the end of September and I was afraid the lump might get bigger and make Piri's eating harder. We decided to get a consultation to see if we should remove it before our New York trip, even though we were certain it wasn't cancerous.
We had called Dr. Stiles office to see if they would be able to perform the surgery again, but they had said that it would be better for a surgeon to remove it. We went to the Veterinary Surgical Center housed within the Hope Center and this proved to be one of our worst experiences in dealing with medical professionals during Piri's cancer treatment.
// Piri coming home after his second lump removal surgery in his mouth. September 3, 2016 //
When I made the call to set up a consultation session, we were set up with Dr. Justin Ganjei. I looked up his profile and called back, and without trying to sound like I didn't have faith in Dr. Ganjei, I asked if we could meet with someone who might have more experience especially with older dog with multiple underlying medical issues. The woman on the line went on a textbook style response, which sounded annoyed and condescending. In the end, she did not switch surgeons as requested and we moved forward with meeting with the original doctor who was assigned to us.
We met with Dr. Ganjei at the beginning of September and I didn't feel the kind of rapport I look for when I meet with doctors who I give my trust with Piri's care and well being. I had a sense that the lady on the phone told him about my hesitancy. He said things that made me feel uncomfortable, made me distrust him more (when he was actually trying to win my trust) and his treatment suggestion of removing part of Piri's jaw seemed pushy and inappropriate, especially when I suggested to him that he a patient at the oncology department. His demeanor made me feel like they didn't have a good working relationship with the Oncology department and everything just made me feel even more nervous. Just as a heads up, I told him that Piri might get bitey because he's been poked and prodded for a while now. After examining him in the back he came back almost boasting saying, "He was fine with me. I stuck my hand inside his mouth. He doesn't trust your other doctors?"
Piri's second lump removal surgery was scheduled the very next day.
He recovered well and a couple of days later during one of our me and Piri neck scratching session, I felt a lump in his throat.
Biopsy results also came back which revealed that his oral melanoma was back. The fine needle aspirate conducted at Dr. Beck's office was wrong. They did not get a correct sample that included cancerous cells. I would later read that fine needle aspirates were not always correct.
I was devastated.
I emailed Dr Ganjei and asked him if he had by any chance felt a lump in Piri's throat area when he was performing his surgery. He said he did not feel any extra lumps.
I called Dr. Beck's office about the new lump in his throat and they suggested we do a fine needle aspirate. It would be an all day affair again, where we would have to drop him off in the morning and pick him up late afternoon. At this point, I was just really angry and frustrated. I decided that I would no longer go down the traditional treatment route.
// ES Clear for cancer support. Piri began to take several herbal supplements. You can read more about it here. September 7, 2016//
// Aside from the supplements from NHV, Piri received two more from the holistic doctor - Rehmannia 8 for his kidneys and Maitake to boost his immune system. September 20, 2016 //
We had begun to give Piri NHV herbal supplements to help with his liver, kidney, pancreatitis and cancer and decided to look into a holistic vet.
On September 20th, we met with Dr. Pam Grasso at the Animal Medical Centers of Loudoun. There we received a thorough consultation session, we asked for blood work to be done, a fine needle aspirate done on his new lump in his throat and she gave two herbal supplements to help improve his immune system (Maitake mushroom extract) and help his kidney function (Rehmannia 8).
Piri's blood work this time came back with his liver enzyme levels at normal levels and slight improvement on his kidney levels. Fine needle aspirate results indicated that they didn't perform it properly and wasn't very conclusive but did reveal that it was cancerous.
// Piri getting to meet with Dr. Pam Grasso, holistic vet, at the Animal Medical Centers of Loudoun. September 20, 2016 //
At the end of September, we went on our New York trip.
Piri was doing well on all his herbal supplements. He had his moments when he wasn't feeling well, but he had moments when he looked great. Just 5 days before he passed, he was running like he was a teenager.
Then on early morning on October 14, Piri crossed the rainbow bridge. It happened so suddenly and quickly. He was rushed to the ER and it was determined that he had pneumonia but what really made him die in the end remained inconclusive and we never received a clear explanation from the ER doctor at the Hope Center. It was just "dogs don't die suddenly from pneumonia. Piri probably had something else going on that made him die."
When I look back to this journey with Piri, the first thing I think of is how awesome he was. And the second thing I feel is, how bad I feel for putting him through strenuous situations.
It's something that I still grapple with because I try to think how I would be if I didn't put him through all those doctor visits and needles. I know my heart wouldn't be at peace either. I might have felt like I didn't do enough for him.
This is just a broad overview of the past year --- from when we first discovered the lump in his mouth to when he finally passed.
Piri was on 3 months of chemo (March to June) and his lump didn't come back until August. But there was also a new lump in his throat area in September, something that could've been present much earlier, but missed because it was hidden under his loose skin. Piri was then put on herbal supplements for a month before crossing the rainbow bridge.
Chemo is a harsh treatment. It works to kill cancer cells but while it's doing that, it kills everything else. I learned about herbal supplements late and the approach to managing cancer holistically. Perhaps it was too late for Piri and I wish if I were given a second chance, I would have started him on it much sooner. Even before he was sick. I like the idea of instead of killing everything to kill cancer cells, why not boost the immune system so that it can be strong enough to fight cancer cells. Why don't we complement that with a healthy diet that can combat cancer and keep the body healthy. I came across an amazing TED Talk video that I only wish I can seen earlier. It talks about the possibility of starving out cancer with eating the right foods.
This past year there were so many sleepless, tiring, defeating moments, but also one that was tremendously happy, uplifting and inspiring as well. I will get to those in another post, as well as the financial aspect of treating chemo.
Thank you for reading.
// November is Pet Cancer Awareness month