How did you make the decision for Pred and chemo?

[FeebysOwner]

Things have been rough lately for Feeby (18+ yo) and me. Back in June, she was diagnosed with SCL, based on a PARR assay/FNA on her lymph nodes in her intestinal area. No thickening of her intestinal wall, and as of that time her only 'real' symptoms were lethargy and lack of appetite. (She had two previous ultrasounds, with enlarged lymph nodes appearing in the one done in December, but not the one done August 2021.)

She is being treated for hyperthyroidism and has CKD (Stage 2-3), along with arthritis. Her stool is always normal, and until a few days ago it was a rare event for her to vomit. Peeing has been pretty much consistent over the course of the past few years. Because her other conditions can cause lack of appetite, she has been on Mirataz for months, with good results for the most part.

The oncologist said she didn't see a need to rush right into Pred and chemo, due to her lack of symptoms, and even proposed a gradual phase in of the former, with a later determination to add chemo. She did want her tested for B-12 and Feeby is deficient, so has been getting weekly injections - today will be her 6th.

Since this past weekend, her eating has been down, and she will only eat a bite or two at a time - it doesn't seem to pick up much with Mirataz. Then, Feeby threw up 3 times on Sunday, and again once 26 hours later. She was vomit free until late last night about 20 minutes after eating some baby food meat. It was the first time she ate more at one time since a week ago, so I am thinking she threw up from eating too fast. I could hear her stomach 'gurgling' right before she threw up. Heard that a few times before but it never resulted in vomiting.

I contacted her regular vet and the oncologist on Tuesday. I have not heard back from the oncologist yet. The regular vet wanted to know what the oncologist thought before reacting to Feeby's recent changes. I think the regular vet would like to know if the oncologist thinks these changes are more likely due to the lymphoma than Feeby's other conditions. We are however going to add ondansetron to Feeby's meds for nausea.

I have 'promoted' steroids and chemo to other members on this site, but I have not yet been able to get myself over the hurdle to follow through on my own cat. Now that I am guessing this is where we might need to head, I can't even get the oncologist to talk to me. And I am not even sure if I can have the regular vet pursue this line of treatment without the aid of the oncologist. It doesn't help that the regular vet is the 3rd change for Feeby in the past 1 1/2 years - long story behind that one, but a point I need to make because maybe it is skewing my thoughts.

Did any of you have hesitations before proceeding with Pred and chemo? If so, what was the defining moment(s) to make you move forward? I am really struggling with this. I am happy to answer any questions. Thanks.

 

[daftcat75]

After having Krista's vet put her on the pred and pray program (pred and more pred when that didn't help), I was absolutely hesitant to put Betty on steroids. Especially because her only real symptom was a weekly hairball. She didn't vomit food making food trials exceedingly difficult. I think the breaking point was that after I worked with the IM specialist to get her an ultrasound and an endoscopy, the IM wanted to see her again and she had a hairball that morning. I got tired of arguing with the IM and I could no longer defend trying alternatives when it was clear they weren't working--or not enough anyway. Since starting the pred, Betty has not had a single hairball. We're finishing up the first pred taper stepdown and she could very well be at half the initial dose for the next two weeks (barring no surprises today and tomorrow.) I was initially hesitant to put her on steroids considering how young she is (five years old) and that she doesn't seem to have symptoms except the hairball. But those hairballs tore her up every week. It's been so nice for the both of us to not have to go through those. I've also been able to get her off the Mirataz since she started the pred.

I would certainly try the ondansetron first. For some reason, and maybe this is still part of Betty's IBD, I am not able to get Betty off ondansetron the last time we tried. But I don't see any side effects to be concerned with with that one. Betty eats well with ondansetron and not so well without it.

 

[artiemom]

I am so sorry you are going through this, especially with all the issues with your other kitties.. Poor Feeby.
Did the biopsy happen to mention what level the SCL was at? That may be your tipping point.

My guy, is at a level 2... I wish it was a level 1, but....
I did not have any hesitation at all with putting him on the Pred and Chlorambucil. I went forward with it, immedialy.. without any hesitation.

Realizing there is no cure; but the way to combat cancer is Chemo. It is used for humans. I guess because of my background in medicine, I did not hesitate.

It kind of sounds to me that your oncologist is not as accessible as you need. That is not a good thing. Have you thought of an Internal Medicine Vet? They can be the in-between person, between your Vet and the Oncologist. I know.. another Vet to take Feeby to... But, honestly, they are well versed in many diseases, and can be very helpful with handling chemo, pred and such. The Oncologist can be an occasional specialist-- for advice. The IMVet will probably be the one who is really following Feeby. She has so many issues.. it may be best for her.. And they can update you regular Vet about things.

I know, I am putting my nose where it does not belong.. I apologize. I feel for you. I really do.. ((Hugs))

 

[FeebysOwner]

artiemom - thank you! And no, you are not putting your nose in where it does not belong! I have followed your thread off and on and have really felt the need to go through it in more detail but am having trouble focusing now, which is definitely necessary to reap any benefits from it.

The summary report on the PARR assay that I was given does not indicate a level. I have asked for all the reports/data on all her test results and am not getting what I think is all of it, but they tell me it is all they have.

The IM that I had 'bowed out' when the SCL was diagnosed and handed it over entirely to the oncologist. I am left with my regular vet and the 'unreachable' oncologist.

I am looking for other options in terms of IMs and even oncologists. If that doesn't prove fruitful, I am going to ask my regular vet about moving forward with Pred and chemo. Feeby can't stay in the state she is in. If it isn't bothersome for her (and, it has to be), it is very bothersome for me. She is a shell of the cat she once was.

 

[Margot Lane]

It’s a real toughie and an agonizing moral struggle: my old guy has been on chemo and 5mg Pred for a year and going strong! His cancer is in remission but my vet says b/c of IBD to keep him on both for the rest of his life. I did try tapering, twice, with truly terrible and terrifying results. My vet, who is overwhelmed with cats who have this issue, says she has had better luck with cats that stay steady on a certain dose: in the past she encouraged finessing and tweaking the cats, but it never ended in a positive way. I think many here would say 5mg is pretty high, so, best to go through Daftcat’s excellent thread on the subject for good advice, esp. dietary advice. The pred takes awhile to kick in, but once it does, you will find happiness at the litter box: solid poops! Be prepared for a hungry cat! I am sure you have a baby scale but weighing Feeby often will prevent overfeeding!

 

[FeebysOwner]

The pred takes awhile to kick in, but once it does, you will find happiness at the litter box: solid poops! Be prepared for a hungry cat! I am sure you have a baby scale but weighing Feeby often will prevent overfeeding!

Thanks! Glad your cat is in remission! That is part of the issue - Feeby has no litter box issues, her poops are quite normal as they always have been. Once the tests confirmed SCL, the idea of IBD was off the table. Feeby gets weighed weekly and has been maintaining a steady weight so far - up to and including one vet she saw in late May that said she needed to lose weight.

It would seem that most cases are very different than Feeby's so far, but I will keep searching and taking anyone's advice that is willing to offer it.

 

[Margot Lane]

Diet is always such a huge factor, which is where I think it pays off to read Daftcat’s struggles. I think we’ve both learned the hard way that the less ingredients your wet catfood has, the better.

 

[FeebysOwner]

daftcat75 - thanks! I do think Feeby probably now needs some sort of anti-meds. But other than that, I don't see any kind of parallel between Betty and Feeby. Betty is perceived to have IBD, Feeby does not. I am glad what you are doing for Betty seems to be working, though.

 

[FeebysOwner]

Diet is always such a huge factor, which is where I think it pays off to read Daftcat’s struggles. I think we’ve both learned the hard way that the less ingredients your wet catfood has, the better.

At this stage, Feeby gets what she will eat. She has had it all, short of homemade food and raw feeding. She will only eat pates, and the 'smooshier' the better. Fancy Feast, Wellness, Weruva, Purina, Merrick, Blue Wilderness, Tiki Cat, Orijen, to name most of them.

 

[daftcat75]

I agree with FeebysOwner that Feeby and Betty are pretty far apart in their cases. And Betty is hardly a case study in a dietary approach to IBD. She loves her junky Hills I/D--and it's junky. Lots of carbs. That's not ideal for IBD or SCL. But that's what she wants to eat and she doesn't seem to show any food reactive symptoms--she doesn't vomit her food and she doesn't have poop issues. We have tried diet changes numerous times and ultimately, we come back to I/D because that's what she enjoys and eats enough of. If we're advocating for a diet change, it's going to have to be someone else's cat leading the way.

If Feeby isn't food reactive, if you don't already know problem foods of hers, then the best diet for her, given all her other struggles, is the one she'll eat. I do think you should try ondansetron. That works pretty quickly. So if her appetite doesn't get a boost in a few doses, you'll likely need to move on to the next thing. I think steroids and/or chemo can be helpful with SCL. But I wouldn't start either until you can find a specialist who is responsive and can help you through the dosage, dosing schedule, tapering etc, rather than just a set it and forget it write the prescription and never talk to you again vet like Krista's last vet.

 

[iPappy]

I didn't do chemo or radiation with Tag for a multitude of reasons (mainly, his liver issues, travel time, and the fact that CEL has a very poor success rate with either therapy) so I have no experience or suggestions on that. But I think it's so cool all you're doing for Feeby to keep her happy She's a lucky little girl! I wish I had something other to offer other than support.

 

[artiemom]

I will say that the very strong theory is: IBD morphs into SCL; more so if it has not been treated. Geoffrey's only symptom was vomiting. I had a suspicion of a chicken allergy, so I put him on a novel protein food.

I have been told that the duration of chemo (chlorambucil) and steroid is unknown; depending on the cat.
So I expect he will be on it for his lifetime.

Feeby has other issues.. I wish you luck, and pray that you can find a specialist. (IMVet) who is much more responsive. I really do. It is hard enough to go through; but, without having a supportive IMVet, I do not know how you could manage.
Your regular vet sounds good, but is probably overwhelmed at this point. IMVets, can be a bridge..
But you know all of this..

I agree with daftcat75 You should try Zofran, probably before trying Cerenia. The Cerenia does not seem to be helpful for Geoffrey--trial and error. I think the Zofran is much better for him.. but we cannot diagnose.

The chemo is easy enough to do: in a capsule.. I use gloves, wash hands after. It is stored in the refrigerator. There are a couple different ways of dosing.. Pulsed dosing seems to be very popular: larger doses given over a 2 week period, then 2 weeks off, and then back to chemo. The thought is to give larger doses, and then stop to give the body time to heal.

My guy is on Every other Day.. I am not arguing with the Vet about this. I am just doing it. I do not really see much issues with this, except for fur loss. Geoffrey has had more issues with the steroid. We switched from prednisolone (4 mg twice a day) to Budesonide (1 mg) once a day. This is agreeing with him so much more than the pred.

I wish I could help you more.. It is a tough decision. I think once you find a vet to bridge the gap, things will be easier.
((((Hugs)))).

 

[FeebysOwner]

artiemom - again thanks. So, I am not sure what constitutes IBD, in terms of symptoms. Feeby has never had stool issues, she has never been one to throw up (until this past weekend), other than the occasional hairball, which has since been resolved with daily brushings. As I said, even the ultrasounds showed no thickening of her intestinal wall. Just the enlarged lymph nodes seen on the last two of her 3 ultrasounds in the past year. She does have a thickened spleen which has remained 'static' throughout all 3. So, her lymphoma may have been caused by something other than IBD.

Nonetheless, I need to figure out why the IMVet bowed out when the SCL was diagnosed if it commonplace to have one alongside a 'regular' vet. And I need to find out what is going on with the oncologist. She did indicate that it wasn't her place to get involved with the day-to-day care of Feeby, so I don't know, maybe she thinks she's done her part?

 

[artiemom]

Wow. I cannot believe what you are going through! Absolutely ridiculous and they need to explain themselves. Unacceptable behavior!
I would think of reporting them!

The oncologist is the one who should be setting up the chemo, pred doses. Your regular vet is overwhelmed. Feebly is complicated. She needs an internal Med vet!
Absolutely ridiculous. The IMVet needs to be involved!! Dammit.

gets me so mad when there is incompetence and shuffling around.
You deserve an explanation from the IMVet—before you fire them.

Yes, try to find another, while dealing with this current one.
(((((Hugs)))))

and, do they know where the primary is? Lymph nodes or even spleen. Pretty much the same. But I bet the spleen is involved.
This would mean that it is not IBD or GI related.
If you try chemo, the spleen may even reduce in size.

 

[FeebysOwner]

It has been tough since I lost my primary vet of over 30 years, and another senior vet took over from him but was then 'let go' for unknown reasons (primary vet sold the practice 3 years ago, so I suspect there has been ongoing 'shake ups' with the new management). So, now I am on a third vet who hasn't even seen Feeby, but has been responsive. She only took over Feeby's care about a month ago.

The specialty group - another bad situation. Had one IM for the first ultrasound and she left the group shortly afterward. I was sorry to see her gone. Had another IM for the second ultrasound; she had no bedside manner and took offense to my numerous questions. When I went back for the 3rd ultrasound, I asked for another IM. She was wonderful and attentive, but then abruptly pulled out when the SCL was diagnosed. I thought the oncologist was also attentive, honest, and seemed easy to work with.

Then, boom, something changed. I don't know if it was because I did all the 'standard' testing through my primary vet's office, since they are closer, they don't require appts. for things like blood work, and to be honest they are cheaper. I told all of this to the oncologist, so maybe - for whatever reason - it wasn't to her liking. The last phone conversation I had with her was to share the B-12 test results and ask her opinion of what the primary said about B-12 injections. She told me it wasn't her place to 'tell another vet what to do'. Then, this past Tuesday I joint emailed her and the primary vet about the new 'events' going on with Feeby. The primary vet called me and wanted to know what the oncologist's thought were. So, I followed up with a phone call to the oncologist. When I left the phone message for her, I explained that the primary vet was interested in her opinion of everything. And here we are 4 days later with no response from her.

As far as I know, I would have to travel 2 1/2 hours to go to the next closest specialty group.

Btw, while they did an FNA on both the spleen and the lymph nodes, the PARR was only done on the lymph nodes. I gather from what I learned previously there weren't enough 'suspicious' cells from the spleen FNA to proceed to the PARR, unlike the lymph node FNA. Or perhaps it was deemed that only one PARR was necessary. Maybe it is because there were no other enlarged lymph nodes found elsewhere.

Sorry for the long vent session...

 

[artiemom]

Vent anytime. Even PM me.

 

[fionasmom]

I have no substantial advice to add, but did want to comment on the oncologist. When my dog had his melanoma experience, he was treated by an oncologist and surgeon at a specialty clinic. I did some follow up blood work and xrays at his regular vet as it was closer to home and he enjoyed going there. No one cared. The surgeon even told me that if it was more convenient it was fine.

 

[artiemom]

Yes, my regular vet has offered to do follow-up blood work, because it is easier than going into Boston. I have not mentioned it to the IMVet, as we are still able to easily get in there.

 

[FeebysOwner]

I have no substantial advice to add, but did want to comment on the oncologist. When my dog had his melanoma experience, he was treated by an oncologist and surgeon at a specialty clinic. I did some follow up blood work and xrays at his regular vet as it was closer to home and he enjoyed going there. No one cared. The surgeon even told me that if it was more convenient it was fine.

I am merely guessing as to what suddenly changed the oncologist's involvement. I just don't have any other possible explanation for what she is doing (or, rather not doing) now. It would seem logical most specialists would prefer not to necessarily be directly involved in the 'more mundane' things. Maybe she is a 'control freak'?

 

[FeebysOwner]

Update:
Took Feeby to 'new' primary vet for a mini-exam visit. She did speak with the MIA oncologist last week, but not much of what was discussed was shared with me. It must not have been good because the primary vet gave me a referral to another oncologist, so we are probably starting over again. She believes that Pred and chemo should be done concurrently, and she does not deal with chemo at all, so all of this is on hold until I can get an appt. with the 'new' oncologist.

I still don't have the reports I think I should have from the PARR assay done on Feeby's lymph nodes, but perhaps whatever is going on with that will come to light with a new oncologist getting involved. I have also reached out to Customer Relations for the specialty group that employs this MIA oncologist, but since they are located in the Tampa, I am not sure when I will hear from them given the damage from Hurricane Ian. I told them about the lack of communication as well as the suspected missing report results.

In the meantime, since nothing is being done about the lymphoma, I went ahead and had Feeby receive an injection of Solensia in case her self-isolation and lethargy have something to do with her arthritis. I am not happy about doing it since this pain med is so new and there aren't any studies about its use on CKD cats. But as the primary vet pointed out - given Feeby's age and illnesses - quality of life, not quantity, is what should be considered most important for Feeby now.