[00:00:02] Introduction: Welcome to All Cats Considered, a podcast from the Feline Veterinary Medical Association.
Here we interview professionals from across the veterinary world and take deep dives into the latest evidence-based research developments, studies and guidelines that improve feline health and wellbeing.
We are the home for veterinary professionals seeking to enhance the care of cats through high standards of practice, continuing education and evidence-based medicine. In each episode you'll hear interviews with a variety of experts in our field covering a wide range of topics and the latest developments in feline health. We'll share the key points you need to know to improve your patients care.
Let's dive in and listen to this week's experts.
[00:00:45] Gómez-Mejías: So welcome to another episode of Chattering with ICAT Care. I'm Yaiza Gómez-Mejías, iCatCare Veterinary Community Coordinator and today we are diving into feline oncology and oral chemotherapy.
Joining us are Mariana Lopes and Joanna Morris from the University of Glasgow and they have just published a clinical spotlight in the Journal of Feline Medicine and Surgery (JFMS) titled Oral chemotherapy agents in cats: clinical uses, administration and side effects.
In this article they review the most common malignancies we see in practice and provide a kind of roadmap for using oral drugs.
Thank you very much to both of you for your time. I really enjoyed reading your article and I found it's very useful and very granular errors, very realistic in terms of expectations and limitations around the use of these drugs. So, so let's start. Which are the most common situations in which vets should be thinking of oral chemotherapy and when should we not think about it at all?
[00:01:48] Lopes: I think it just depends a little bit on the goals, doesn't it? I think there's probably always going to be a situation where we could consider oral chemotherapy particularly, and that's the reason why we focused on oral chemotherapy on the article, is that sometimes not all patients will be able to have access to referral or even be close to a referral facility or will not be able to be referred for whatever reason.
I think that where the oral chemotherapy becomes useful is if we're trying to manage these patients into primary care practice where potentially the equipment or kind of the safety precautions will be a bit trickier with injectable chemotherapy. And in that sense, even if they're not getting the absolute best treatment that they could get if they were also able to receive injectable chemotherapy, the oral chemotherapy becomes very helpful because it's easier to administer, easier to source, easier storage as well.
I think there's lots of situations and lots of different diseases that we could consider oral chemotherapy and Lots of them will be very well treated and the treatment of choice would be oral chemotherapy. And we can think about things like low grade lymphoma in cats, for example. It's a very common disease we diagnose very frequently here in the hospital that can very, very well be managed and very successfully managed with just oral chemotherapy, for example. If we're thinking about more large cell high grade lymphoma, that's a bit different. Ideally we would want for kind of best treatment outcomes to include some injectable drugs.
But if that's not possible, you know, things like, you know, oral lomustine can also potentially achieve some, some efficacy in these patients. So I think there's. That was kind of the point of, of the, with of the review was just to say, you know, there's lots of different situations where it could do a lot of good for your patients just with oral drugs. It might not be the absolute best treatment out there, but it will still be better than nothing.
[00:03:43] Morris: Providing you have a cooperative cat that will take tablets.
[00:03:47] Lopes: Exactly.
[00:03:49] Gómez-Mejías: Is the cooperation ability the only factor you would look at or are there quality of life related factors that you would consider when deciding whether or not to start oral therapy, oral chemotherapy in primary care?
[00:04:05] Morris: Yeah, well, I think it really, I think the main determinant is the disease and what's known to get the best results. So if there's an evidence base to suggest that injectables or a mixture of injectables and tablets is a better treatment, then that's what we would want to do as our first line.
But if, as Mariana's explained, the injectable side of it is tricky, then we can adapt things and go more towards just using tablets on their own.
The main limitation with tablets, as we said, is cooperation from the cat. Some are much easier than others to administer oral chemotherapy. And also the tablet size can be problematic because most of the formulations are human drugs and made up for a bigger sized patient.
So that can be something quite tricky to make sure you've got the right tablet size for a cat.
[00:04:59] Lopes: Yeah, and sometimes. Yeah, no, sorry, just to add, sometimes we work a lot with our owners as well. And when we're making this decisions of what treatment are we going to go with? If it's a very spicy cat that, you know, for us to tablets in the clinic would be a big problem or even very stressful for the cat, we will just go back to the owner and say, is this something that you could administer? Like are you happy to administer tablets to your cat and if they say, yeah, no problem, do it all the time, then great. Provided that they are well informed of the precautions about administering chemotherapy at home and how to handle the tablets, gloves, and be careful with not having any children around the tablets and things like that. Provided the owner happy that sometimes is the best way forward is to just dispense the tablets and having them administer it
[00:05:48] Gómez-Mejías: back to the quality of life of the animal in terms of not just being cooperative or having the right temperament.
From a human point of view or, you know, from a human understanding point of view, is there anything we should bear in mind about, I guess, you know, depending on the stage of the cancer, and it may actually not make any sense, I may be entirely wrong. But can it be the case that the patient's got cancer is tolerant to, is not showing any resistance to being tableted, but still is not a very good idea to start that?
[00:06:24] Lopes: Oh, absolutely, absolutely. That is a big, big part of the decision making process is, is our patient well enough to receive this treatment? And I think that is probably the top one priority in any cancer treatment for cats and dogs, but for cats specifically as well, is quality of life. And that is the single most important thing, More important than qualifications of treatment is going to be how we're going to manage it. More than anything else is the quality of life. And really, if we think our patient has disease that is significantly impairing their quality of life, and we don't think the treatment is likely to improve that, yes, maybe the cat is nice, maybe it would be easy to administer, maybe it would be very easy to manage. But if we don't think the benefit would be there, even from the quality of life point of view, that would be a discussion we'll have with the owners and we'll very much say to them, you know, this is all the things we can do. But then the question is, should we be doing those things?
And that is a massive, massive part of the discussion before we start anything.
[00:07:24] Morris: So before we even decide on chemotherapy as an option, we've already done extensive investigations to find out the extent of the disease, to know whether it is something that's worth treating or whether it's too far gone. And the likelihood that the chemotherapy would make a difference is quite small. So we're only offering it to the cases that we think will benefit from the treatment.
[00:07:50] Gómez-Mejías: Thank you so much.
You described some of the drugs and derivatives as containing nitrogen mustard. Could you clarify for our audience what this actually means in terms of the drug's mechanism of action and reassure us that it has nothing to do with the condiments in our kitchen?
[00:08:10] Morris: Well, nitrogen mustard is a cytotoxic chemical. It's probably. I thought you were going to go along the lines of thinking about mustard gas which was used in like as a chemical weapon in the war and things. So it's more related to that than it is to mustard that you would put in your food. But it's obviously modified to make it much less toxic so that you can use it as a drug for chemotherapy rather than something that's going to kill an animal or something. I mean potentially, I guess if you overdosed it might be very harmful. But at the doses we're recommending it should be quite safe.
[00:08:49] Lopes: That is a very good question. I don't know why the name of the condiment is the same. I don't know where that came from.
[00:08:57] Gómez-Mejías: But what sort of group of drugs are we talking about and how do they.
[00:09:02] Morris: So they're alkylating agents and they act by inserting an alkyl group into the DNA in the cells and that causes cross linking of the DNA strands so that they can't separate and get transcribed and translated into protein. That's what happens with them.
[00:09:26] Gómez-Mejías: All right, thank you so much. And in the article you noted that for certain drugs we may see less toxicity cats compared to dogs with neutropenia frequently cited as the primary dose limiting factor in feline patients. Why do cats seem to tolerate these treatments differently and how should we monitor this feline specific risk?
[00:09:47] Lopes: So I think it has to do with obviously they're, they're different species and I think it all goes back to that classic sentence that we always say. Cats are not just small, small dogs. And whilst some drugs will be more toxic in cats, others will be, will be less. So I'm thinking, for example, one of the things we mentioned on the, on the article was for example how cyclophosphamide, which is very commonly associated with hemorrhagic cystitis in dogs, does not seem to have the same effect in cats. So for example, when we're treating a dog, cyclophosphamide, we will monitor the urine very carefully for microscopic hematuria, which is not as much as a concern in cats.
For example, other drug that wasn't mentioned in the paper just because it's not oral, but for example doxorubicin in dogs can cause cumulative cardiotoxicity. Again not as much something we see in cats, but for example temozolomide which can be used in dogs with a variety of tumors, the main ones being, for example, brain tumors. It's just not recommended in cats at all because there isn't a safe dose.
So the times it has been trials, it has proven to be very toxic. So I think it's just. And I think that we try to highlight that as much as possible in the paper, which is, it's very important to familiarize ourselves with the type of toxicity we might be, might be seeing with the patients that we're treating. Because inevitably, if some of that toxicity does occur, would have to manage it, you know, we'd have to treat our patients. And obviously we again, back to the whole quality of life aspect of things. We try as much as possible to not have our patients so sick that they need to be hospitalized for side effect management.
But unfortunately, very, very occasionally it does happen and it's, it's rare and it's not common, thankfully. But sometimes we'll have to, we'll have to be aware of it just so we can treat it effectively, so we can, and also we can avoid it in the future. Obviously, if we have a patient that has experienced toxicity with a drug and we're planning to use it again in the future, then we have to decide was a toxicity mild enough that we should do it again for the benefit that it's inducing to the disease, or was it so severe that we don't want our patient to experience the side effects again. And in that case, treatment changes will have to be implemented, such as reducing the dose, increasing the intervals, replacing the drug with a different drug. So all of those things are. Before just deciding, yes, let's do oral chemotherapy. Because I think sometimes there is this misconception that just because it's a tablet, it will be fine, it's okay. But it's not true. It's still chemotherapy. It should still be taken with caution. And I think, of course, you know, if we, if we need to treat our patient, we need to treat our patient. But it's important to be familiarized with the possible side effects and being prepared to manage them if they occur.
[00:12:35] Morris: And just on, on that with Kat, I think because they're slightly more aloof sometimes in their interaction with the household, sometimes side effects are actually just not noted. So you may think that the cat's not experiencing a lot of side effects, but it may be that it's just not being observed in the same way that a dog is in the household. Like people are very aware of when their dog's urine and feces change.
Whether they sneeze or their interaction changes. But sometimes because cats can keep themselves to themselves a little bit more, sometimes it's harder to, to appreciate with a cat is actually feeling unwell and things. So, you know, you have to rely a lot on the owner's observation and reporting back to you to know, to know whether it's actually undergoing side effects or not.
[00:13:21] Lopes: And we're not even talking about the outdoor cats that we'll just do everything outside. And sometimes we're asking, you know, hard things and they're like, hope, okay, couldn't tell you because I haven't seen anything. Sometimes that happens as well. So we kind of have to hope everything was okay. And, you know, obviously if they're bright and happy and eating, that's obviously a good sign. But sometimes there could be vomiting and diarrhea happening that we're just not, not aware of because it all happens outside.
[00:13:47] Gómez-Mejías: When it comes to blood parameters, blood tests, do you, have you got any general suggestions for a monitoring strategy when it comes breaking, for instance, to that neutropenia we talked about?
[00:14:02] Lopes: Yeah, absolutely. So, so every single patient before receiving chemotherapy will have at least a hematology plus, minus anything else if the drug has other organ specific toxicities. But hematology would be the, the baseline for everything. And then I guess it depends. So neutropenia, it is very much, it's kind of a, the most important thing. I guess this is not giving chemotherapy to a patient that's severely neutropenic. That would be quite, quite important just because we would put them at higher risk of sepsis and acquired infections and things like that. So that is the kind of the single most important thing. Then we also obviously look at, you know, anemia, thrombocytopenia, and things like that. Obviously all depends on baseline. So if a patient is anemic, but it's now less anemic than it was two weeks ago, that's good, that's fine. Anemia on its own is not a contraindication. It has a lot to do with how things are progressing over time. You know, if suddenly we've had a 20% PCV drop, maybe that wasn't the chemotherapy's fault, but maybe we should, we should go and look at why that's happening before we're just cracking on with the next dose.
Same with the platelet count. But yes, in neutropenia would be the most important thing then your cutoff, because I guess that's maybe what, what your question was at is where. What's the cutoff that is very, very variable. And I think it has a lot to do with how comfortable you are managing side effects if they were to occur. So if you're not very comfortable at all, or if you want to avoid them as much as possible, you could just use your normal reference range. So anything below the normal, you could just delay a little bit and then just give it once that's recovered. If you're more comfortable, you could accept a mild neutropenia. So for example, for cats, usually anything above 2 quite happy, provided they're clinically well, that's very important. So obviously if they're sick, they're not well, if they're not feeling great, we might prefer to delay. But if they're bright, happy, non pyrexic, that's also very important and only mildly neutropenic, then that should be okay. Obviously important to consider. Again, has the drop been very significant? Like, did our cat have a baseline neutrophil count of 10?
And now after one dose of chemotherapy, it's now two again, perhaps we might not want to be as bold as we were the first time around. Maybe we could try a little dose reduction and see if we don't run into problems. And then if you don't, then you could go for a full dose next time. It's all, it's kind of all very case by base and it's all very based on our overall clinical picture. We are not just looking at the bloods as an isolated piece of information. We're putting that into context with our patient, how well they are, how well they've been, also their disease. Lots of patients will have diseases that will affect their mythology values, particularly patients with lymphomas or leukemias. So that's also something to have into consideration. So for example, patients with leukemia, we will have to be a lot more permissive with their hematology values because if we're going to wait for them to have a normal neutrophil count, we could be waiting a very long time or ever.
So sometimes you just have to go ahead despite those low values. But yes, I think, I think it would be very nice if you could just have a blanket rule and say, do this, everything will be okay. Not quite as simple as that, but I think for safety, if you go with normal, normal range, I think you're usually safe.
But yeah, it's not, it's actually, you know, not just about the bloods really. Like if you have a patient with completely normal bloods, but they've been Having horrible diarrhea for five days. You're not going to say, let's go for the next dose. Obviously, again, it all comes back to the same thing, which is quality of life. Quality of life. The quality of life is not good. Let's hang fire. Let's give them some time to recover before we go again, because that is, again, that's the single most important thing. We want our patients to be happy at home just having a normal life. And if that's not the case, then we have to change something.
[00:17:50] Gómez-Mejías: Yeah, I was thinking of the cutoff, but I was thinking more of contextualizing care, given that one of the factors, one of the factors influencing the decision making around these drugs is contextualization.
Perhaps in some cases we will administer these drugs because we can't refer the patient. We always train to think how to reduce the cost. And blood tests are not cheap. So I was thinking of, you know, to monitor the neutropenia and, and the. Yeah, we'll get back to the anemia, because I had a question of that as well.
[00:18:23] Morris: Yeah, So I think the thing is, if, if money is a real issue, I. I don't think you can actually cut corners with the blood test because that is an integral part of doing it safely.
If the owners really do have financial issues, it may be better just to go for palliative care and not actually embark on the chemotherapy as the sort of best option, really.
I think they've got to be engaged enough and have enough finances to do it properly if they're going to. Otherwise, it's probably better to just advise something more palliative that doesn't require blood monitoring with blood samples.
[00:18:59] Lopes: Yeah, no, absolutely. Just don't think chemotherapy is the kind of thing that you can just do. Not on the cheap, necessarily, but without being careful and without monitoring. Because this is the thing is if you do it like that and imagine that we're accidentally giving chemotherapy to a patient that's secretly very neutropenic, actually we're going to make this patient very sick and actually that's going to increase the costs because you're going to then have to hospitalize your patient, etc. So actually, on the process of trying to save money, then you're going to end up on much higher bills for hospitalization and things like that. So I completely agree with Jo that there has to be a minimal, minimal finances to do it safely. And if that's not possible, then it's honest. It's best not to.
[00:19:41] Gómez-Mejías: Thank you so much for clarifying that and I'm making a clear distinction between palliative care and oral chemotherapy. And getting back to the, going back to the anemia you mentioned before, you started with this and I thought, oh, this is one of my questions.
When treating multiple myeloma with melphalan. Melphalan, I don't know how to pronounce it very well. We often face hematological adverse effects apparently. So how do you differentiate between the hematological disturbances caused by the disease itself versus those caused by the drug?
[00:20:15] Lopes: Oh, that's such a good question.
Yeah. Typical clinical conundrum, isn't it? So usually we try to combine the bloods with other markers of remission. So for example, for multiple myeloma cases, they often can present with hyperglobulinemia and they will have a very high globulin levels at presentation.
So let's say our patient was also, let's say our patient was also anemic at presentation and we started treatment and the hypergloblinemia and the anemia improved. Great, we're getting disease control. And let's say at some point during treatment we're becoming anemic again.
Then you're like, is this disease relapse? Is this now GI bleeding? Is this chemotherapy myelosuppression? Sorry, what's going on here? I think that's when contextualizing the other clinical information becomes very helpful because if your globulins are normal while your anemia is still is, is developing, you could probably like, probably not disease relapse because the globulins have not increased as well. Though potentially we're looking at a chronic myelosuppression. Or is this patient, has this patient been on steroids for a very long time? That could then lead towards more of a kind of ongoing GI bleeding type situation. So that is, I would say, a clinical challenge that we face pretty much every week.
And I think typically because again, we don't want to just do tests for the sake of doing tests. So, so sometimes we, we try to be as practical as we can and sometimes in this situation. So let's imagine our patients in remission and you feel like you can't afford to drop the steroids a little bit, like you're not going to risk relapse. You could just drop your steroids a little bit and potentially add some gastric protectants. And I know we don't want to add gastric protectants if we absolutely do not, do not have to, but that's often a good, a good test. If suddenly, by dropping my steroids and adding, for example, some of myprazole, my anemia is much better.
Like, great. That was probably a little bit of GI bleeding. Or by reducing the chemotherapy intensity, does my anemia get better as well? Okay, maybe we're kind of overtreating at this point. We can back off. However, if our patient is also just suddenly not doing so well, you know, maybe your globulins are coming up, then in that case, more likely to be relapse. So we just kind of have to, again, just take it all together. Sometimes it's hard, sometimes you don't know. And there's certainly been situations where we've gone back to, for example, repeating bone marrow samples and things like that. Yeah, and sometimes that happens. Like, we don't do that as a first line point of intervention because that's obviously more invasive and that's the cost. But eventually that would be a big piece of your final answer. So. Yeah, that's very good question and certainly a challenge.
[00:22:56] Morris: Yeah. So it is just a process of elimination, like Mariana says, and you sort of, you know, have to rule out each of the options and finalize which what we think the underlying cause is. And sometimes it's easier than other times.
[00:23:09] Gómez-Mejías: Thank you.
Yeah. I don't envy you. You know, having that challenge very often must be very stressful.
[00:23:21] Lopes: The magnitude of it also helps, doesn't it? Again, if you suddenly have a massive drop, like a 20% drop, and your patient has melena, you could be like, okay, probably GI bleeding.
[00:23:32] Morris: The speed at which it's been. So, I mean, all patients will go anaemic when they're on chemotherapy. But if it's just a very gradual kind of a few percent each week, you know, the most likely thing is it's chemotherapy induced. But if it's a very sudden precipitous drop, then start worrying that there's something else going on, like a bleed or whatever.
[00:23:54] Gómez-Mejías: No. Thank you again. And speaking of the gastrointestinal tract that you just mentioned, some of these drugs caused hyperexia as well, and nausea remains a possible side effect. Do you believe that Maropitant or mirtazapine should be administered preemptively for all the oral chemo cases, or should we wait for clinical signs?
[00:24:16] Lopes: Another great question.
So we dispense them to all our patients because usually side effects should, as much as possible, try to be managed from home, particularly if we're thinking that our patients are getting towards their kind of neutropenic nadir. You don't really want to have to see them again at the time they're the most vulnerable. Worst place for a neutropenic patient would be the hospital where there's sick animals everywhere and they could pick up something very, very easily.
So we try to keep them at home and manage them from home as much as possible. Obviously, if they're very, very unwell, they obviously come. But if it's just, you know, a little bit sick, a little bit having a little bit of diarrhea, these side effects can often be very well managed from home. So we do dispense Maropitant and probiotics to pretty much all of our patients and we very much empower our owners to give it. So we're just saying they're completely fine, bright, happy, eating, no vomiting, that's fine, you don't need to give anything.
However, if you notice anything like decreased appetite, a bit of lip smacking, maybe actually being sick and sometimes not even anything that, that obvious. Sometimes it could just them being a bit lethargic, a bit withdrawn, that can sometimes be a manifestation of nausea. So we very much say if you notice any of that, just go ahead and give, give that dose of cerenia and see and see how it goes. I don't know about giving it regardless.
[00:25:39] Morris: I don't think we tend to do that certainly unless at presentation, like with some of the GI lymphomas, maybe they're not eating that well anyway and the chemotherapy has the potential to make that worse. So in those sorts of cases, I guess we might start it right from day one. But that's because they've, they've already got some indication if they were eating quite happily. I don't think we would do it preemptively just because it's actually harder for the like with the more tablets and things the owner has to administer, the worse it is really for them.
Unless you've got a cat that's really obliging and will gobble up every tablet inside. But you know, if they're going to struggle a little bit with tablets, it's better that they get the important ones down, like the chemotherapy ones, and then don't have too many extras or optional tablets if they don't need them.
That's kind of how we do it. And then if they really aren't eating or whatever, then they need to come in for injectable appetite stimulants, anti nausea injections.
[00:26:38] Gómez-Mejías: Yeah.
[00:26:38] Lopes: And we keep, we keep very close communication with our owners. That's the other thing is they have our service email they know to get, they know how to get in touch. We're never too far away so it's very, very easy to get in touch with us. So we give them the supportive medications to give as they feel it's required. But then obviously if they have any questions or if the medication they already have at home is not working, we're very, very open to discussing it again with them dispensing something different. We're always available to see them if they need to be seen. It's very much a joint effort and I think it's very important that the owners feel included in the care of their pet and that goes a long way making sure the owners feel supported and they know that they're not alone if something bad happens, always at the end of the phone or the email.
So yeah, so I would agree. I think unless they were already not eating great at the beginning, I think we would just give the medication as a just in case type thing rather than just giving them the tablet straight away.
[00:27:37] Gómez-Mejías: Supporting caregivers is so important in everything we do and in these cases they are so challenging. I guess it's even more important. I was thinking of the caregiver guides that iCatCare published together with and it was published with one of the JFMS guidelines on the inappetent cats and we tried to include the that source in the, in the podcast notes as well.
I was thinking of compounding pharmacies as well.
Many feline drugs require compounding pharmacies to reformulate the human market tablets into cat appropriate sizes. But in the paper you mentioned concerns regarding variations and inconsistencies in the precision of these reformulations.
[00:28:22] Morris: So we don't really know how common that is. But then there have been a couple of publications where it's been reported. So it's always at the back of our mind sometimes. And if a cat seems to go particularly neutropenic, you know, after a dose or of reformulated tablets, you always of questioning was there slightly more drug in that tablet than there should have been, you know, because it, because it is difficult to be precise when they're reformulated.
[00:28:49] Gómez-Mejías: Right. So we should not systematically suspect of this, of these variations, but just suspect of them when the situation prompts us to yeah, yeah, yeah, right, yeah, yeah.
[00:29:02] Lopes: If we need to reformulate, we'll do it. Obviously this, there's nothing, you know, that we're systematically against but it's, it's, it's obviously not as easy to be so, so certain with the commercially available ones. And yeah, I do think there's occasional incidences where we thought we gave a very conservative dose and for some reason they. They suddenly became very neutropenic or just didn't do very well. And you're like, hmm, what's happened here? But then, but then again, every, every patient is an individual and you could give the exact same dose to two cats with the exact same weight and one is having a lovely time and the other one is not.
So that is also a big, big part of the, of the chat that we have with the owners, which is, you know, we always say we try to keep the side effects to an absolute minimum, but every patient is an individual and we'll just have to see how it goes. And if it's. And if it doesn't work, it doesn't work. At least we tried and we'll obviously support them through the side effects. And sometimes in that situation the owners want to stop, but there's really no guarantee how well a cat is going to tolerate the chemotherapy.
[00:30:07] Gómez-Mejías: Something that occurred to me, what you were talking about before this answer. You were talking about administering tablets at home and the nausea and maripitant. Do you use feeding tubes very often?
[00:30:22] Lopes: Not very often, no.
[00:30:24] Morris: Not for cats going home and having tablets at home. Obviously for hospitalized cats that aren't eating, we might, but I don't think we'd be sending cats home to have their medication at home with a feeding tube.
[00:30:39] Gómez-Mejías: I was just curious about that because there's a thing about feeding tubes of some vets being very reluctant to use them and some others being very keen.
[00:30:46] Lopes: So I actually think our feeling is more to do again, with the kind of quality of life aspect again, and it depends on the disease, doesn't it? So if it's a disease that you feel like will be very, very treatable and they're. For example. I think lymphoma is obviously the classic example, isn't it? Because the responses can be quite impressive and they can do very, very well. If they respond, they can do very well. So you can have a cat that's very sick with lymphoma, but then if they respond very well to the chemotherapy, they could regain normal appetite, normal activity and so forth.
But if it's a disease that you kind of maybe just hoping for stable disease, you're not really hoping for remission, your patient is already so inappetent that it needs a feeding tube.
Ethically, that's, I think, where I start to struggle, because is it really ethical to be giving chemotherapy to a patient that's unable to eat on its own.
I guess that that would be open for discussion, wouldn't it? But I think, like I said, we tend to be very quality of life orientated, very practical, very kind of working with the owners for their goals. And I would say our population of owners is very, very sensible. So we haven't really been in that situation very frequently. I think the only situation where I think would be fair enough would be if they're recovering from surgery still or, you know, something that we felt was very recoverable.
Again, a lymphoma patient would be the typical one is, you know, we can really make them much, much better with chemotherapy. That would be one thing, if not bit trickier.
[00:32:23] Gómez-Mejías: I like that word, recoverable. I think that's very helpful in the decision making about whether or not to place a feeding tube for this particular purpose. Yeah, yeah, yeah, yeah. I like it. Thank you so much. And just the last question before I let you go. In your article, you talk about Toceranib, which is very well known in canine medicine, but we don't talk about it that often in cats. So what are the main indications, pros and cons? General practitioners should weigh when deciding whether or not to use it off label in cats.
[00:33:00] Morris: So I guess it just depends on the type of diseases that we're using it for. In cats are usually sort of end stage or it's used in a bit more of a palliative way for like, you know, carcinomas that we've sort of failed with other treatments and we've got gross disease and things like that occasionally for mast cells, but you know, they have to be the sort of multiple mast cells or worse type mast cells in cats. So I guess I think when we're using it in our practice, it is more for cats that. That the prognosis is slightly guarded. It's more sort of end stage, you think, Mariana?
So they do seem to tolerate it quite well. So I don't think you should be shy of using it. You're a bit limited by the tablet size, but small cats get 10 milligrams, bigger cats get a 15 milligrams.
And you know, then maybe this is something that you can alter the frequency of blood sampling slightly to keep the costs down a little bit lower. Once you've established the first sort of month or so that they're tolerating it. Okay. You don't have to repeat the bloods quite so often, but apart from the effects on appetite I would say it does seem to be quite well tolerated.
[00:34:20] Lopes: Yeah, no, I would agree, I would agree with that. It's a, it's more of a, you know, it's, it's not like maximum tolerated dose chemotherapy and, and I guess unlike most chemotherapy protocols, it's, it's ongoing. So. So it's not.
Yeah, it's lifelong. So it's not the kind of protocol that you do for three months and then you stop. So that's why we tend to reserve it for situations where we have something to monitor. Like we wouldn't want to put a patient on a lifelong treatment that doesn't currently have any active disease. Because the concern is what if it doesn't need this treatment? Like, what if it wouldn't need it? So we're always more comfortable, happier to use it. If we have a patient that has, for example, an unresectable tumor or has metastatic disease or something that we can see the visible gross benefit that is it's shrinking or it's stable in size or the patient had clinical signs and it doesn't anymore bite, still having that burden of disease. So yeah, those would probably be the, the instances where we would use it the most in cats. But yeah, I fully agree. I think they most cats tolerate it very well and, and don't have some of those kind of annoying side effects that dogs can sometimes get with the protein losing nephropathy and they just don't seem to get it quite as much.
Which is good, is good because urine samples can also be a challenge for others to collect in cats sometimes. So the fact that we can say, you know, bring in a sample if you can, but if you can't is not drama is also quite helpful for them.
[00:35:54] Gómez-Mejías: Nice. Well, thank you so much.
It's been fascinating and it's been very helpful to get so many tips to help us with the clinical decision making as well.
[00:36:09] Lopes: Sorry, this is very, very important. Best tip. Best, best tip is get a good nursing team because we could not do any of this without our work. Absolutely. Superstar nurses that are very, very good at giving pills to the cats would not be able to do it nearly as much as we do without them.
[00:36:30] Gómez-Mejías: So, yeah, it's a topic where we need a lot of communication with the caregivers and nurses play a really, really important role there.
[00:36:39] Lopes: 100% could not do this without our nurses.
[00:36:42] Gómez-Mejías: No, definitely not.
So, hey, huge thank you to you both Mariana and Joanna for sharing your expertise and reminding that the ultimate goal of these treatments is to prioritize a good quality of life for our feline patients.
You can find the link to the full JFMS article in our Show Notes, and if you found today's episode helpful, please subscribe and leave us a review. And until next time, keep providing that excellent care to your feline patients. See you next month.
[00:37:14] Conclusion: Thank you for listening to this episode of All Cats Considered. We hope you enjoyed this interview. For more information on the topics discussed in this episode, please head over to catvets.com podcasts and explore the links in the Show Notes. Don't forget to subscribe to this podcast on your platform of choice so you won't miss any episodes as we release them. Have thoughts or ideas about the interview you heard today? Share them with us by leaving a comment on our Facebook page or shoot us an email at
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