Should I use chemotherapy on my dog with transitional cell carcinoma (TCC) of the urinary bladder?

     This is a very good question and I will confess that as little as a few years ago I  was not a big fan of chemotherapy in dogs.  Likewise, though I discussed this option with families faced with having to treat TCC in their dogs, many would not consider the chemotherapy either because of personal experiences with chemotherapy or because their pets were doing so well following our Ultrasound Guided Endoscopic Laser Ablation (UGELAB) procedure that they did not feel any need to pursue chemotherapy.   Since the prognosis for a patient with TCC was so poor, in the beginning  of our developement of the UGEALB procedure,  we were happy to “knock the tumor for a loop” using the laser and to buy a little extra time without “heavy-duty” medicines.  Traditional surgery provides a median survival time of about 80-129 days for TCC patients.  UGELAB was providing a median survival time of approximately 380 days even when faced with obstructive tumors in the urethra that were considered inoperable before UGELAB.  We were delighted with these results and with repeated laser treatments some dogs were now living years instead of months. 

      Then  “the hammer fell”.   Dogs that had lived much longer than expected as a result of our laser procedure where now  dying not because of the  obstructive nature of transitional cell carcinoma but rather because we had kept them alive long enough to die of metastasis and/or extension into the body cavity around the bladder.    It became obvious that the only way to overcome this frustration was to consider chemotherapy.  Statistically, the longest median survival  time  studied was a combination of mitoxantrone and piroxicam.   Still considering quality of life for  my patients as a primary concern, I consulted with several board certified veterinary oncologists to learn about their experiences with this combination of drugs and what we might expect for our TCC patients.  Surprisingly, the oncologists I spoke with had all had good experiences in administering these drugs in combination without significant side effects.   We had already been using piroxicam for years with minimal side effects, most of which could be handled by adjusting doses or providing protective stomach preparations along with the piroxicam.   Faced with the certainty that our wonderful successes with endoscopic diode laser surgery would eventually be terminated by the development of metastasis,  it seems like a “no brainer”  to give the mitoxantrone and see how we made out.  We had nothing to lose and everything to gain. 

     The first few patients we treated with mitoxantrone could not have gone smoother.   The side effects were minimal and certainly justified considering that we were fighting a cancer that will eventually kill.    Two of our TCC  patients “parents”   reported that their furry kids actually  felt better for a few days after the chemo than they had felt before the treatment.   Difficult to explain,  but no complaints here.  I do not mean to imply that this chemotherapy regimen will not have any side effects.  Some dogs are a little quite for a few days or have a poor appetite.  One of our patients has continued to have a poor appetite long-term and he ( Charlie) insists on having his Mom cook for him but to me, if due to the chemo, this is a small price to pay for a longer and happy life.  Almost all dogs  will develop a very low white blood cell count at 10-14 days and this most be monitored so that the treatment can be adjusted as needed.  We have had no “horror stories” in this regard and every dog has had their blood counts return to normal.  While I am a VERY positive person and attack TCC with a “will win” attitude  we need to recognize that serious side effects are possible  including death.  Faced with the certainty of dying from TCC  my personal belief, given our experiences,  is that proceeding with chemotherapy after  palliative laser therapy (UGELAB) is simply the right thing to do in most cases.

   During initial consultations with clients trying to learn more about treating transitional cell carcinoma in dogs using diode laser through a cystoscope,  I always try to emphasize point out that I am a very positive person, unwilling to simply “roll over” for this bladder cancer.  We have had some wonderful results and a few heart aches, but overall we have met with what I consider to be tremendous successes.  Recognizing that my positive attitude might influence my perception  of what it is like to undergo the UGELAB treatment, I also feel it is important to understand the process from the perspective of the moms and dads and furry kids who have experienced the UGELAB procedure and , in some cases, the mitoxantrone/piroxicam treatment.  This TCC BLOG is a wonderful venue for an appropriate exchange of experiences at Ridgewood Veterinary Hospital.  I encourage those families to contribute to this blog and to help me create a realistic environment wherein others facing this deadly canine bladder cancer can decide on a treatment plan best suited to them and their pets.   Please join our conversation so we can all help,  when appropriate,   to create a longer, healthier, happy life  for these wonderful furry family members.   If you have  joined us in the battle against TCC at Ridgewood Veterinary Hospital please share your story with us.  If you elected to treat with mitoxantrone, what was this like for you and your dog?   If you are struggling to decide on an appropriate treatment for you dog, please post your questions.  Want to stay in touch with the conversation as it progresses?   Sign up for an RSS subscription at www. RidgewoodVet.com under the TCC BLOG link.      

     Let’s help each other  learn more about how to “just do the right thing” for our kids!!!

 Dean J. Cerf, D.V.M.

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42 Responses

  1. When my Scottie, Oliver, was first diagnosed with TCC in February 2009, he underwent traditional surgery to remove most of the tumor, but I understood that some tumor had to remain to avoid damage to the bladder itself. After surgery, chemotherapy was recommended to avoid spread of cancer cells. I immediately thought of human side effects to this treatment and my husband and I were loathe to put Oliver through this “torture” for unknown results although our oncologist assured us that dogs generally do well on chemo and that dosage can be adjusted if side effects develop. After considering our options (few), we agreed to have Oliver undergo treatment. Armed with anti-nausea and anti-diarrheal medication, we brought him home after the first treatment and we watched him very carefully. We saw no appreciable change in his energy, his appetite, or his overall personality and demeanor throughout the treatment period. As TCC goes, his tumor did regrow, and we were referred to Dr. Cerf who was able to provide Oliver with the laser surgery successfully in December, 2009. Throughout 2010, between our oncologist and a second surgery with Dr. Cerf, we have been able to maintain Oliver’s quality of life. This year, at Dr. Cerf’s recommendation, we will continue the chemotherapy treatments from time to time and we will continue to ask Dr. Cerf to keep a watchful eye on our “boy”. As it is, we have been fortunate to have Oliver and his fighting spirit for 12 years; something we would have never imagined back in 2009.

  2. After having a lot of concern and doubt about giving Molly, my best friend and champion agility dog, chemotherapy I am very happy to report that I couldn’t attribute any ill affects after 2 treatments with Mitoxantrone. We have treatment #3 scheduled in a few days. Molly is a 12 year young Bichon Frise.

    A little bit of our experience might help someone who has wrestled with these decisions as my wife and I have. We began this journey with a single agreed upon rule – we will not continue any procedures that do not help to sustain a “very good quality of life”. We will not have Molly suffer because we cannot let go!

    The first chemotherapy treatment was given in early December ’10. This was Molly’s second TCC procedure following the initial operation in late November. The initial operation went so well we agreed to start her chemotherapy treatment during the same follow-up operation AND clean her teeth AND perform a tooth extraction! Molly was ready to go home by 4:30pm. The 50+ mile drive to Long Island was clearly uncomfortable for Molly and for the entire next day Molly was lethargic and refused food and water. To insure Molly was hydrated I injected water into her mouth every few hours. The natural thing for me to blame for Molly’s discomfort was the chemotherapy. I couldn’t help but think this was going to be a big problem – not the operation. I began thinking this might be her last treatment. I am a bit impatient and did not compute the sum of everything Molly had just been through – especially the real culprit – the anesthesia! With hindsight I now recall Molly reacted the same way with anesthesia for a teeth cleaning several years ago.

    When Molly woke up on day #2 she was happy, active, very hungry and drinking fine on her own. We were able to resume our daily 2+ mile walks and she was happily getting her go-fer ball to play fetch.

    On December 27th Molly received her 2nd dose of Mitoxantrone and returned home that evening with “zero” negative affects on appetite or water intake – or anything else. My wife and I chatted that you wouldn’t think Molly had any treatment at all. The very next day – 28th we were out for a relatively long 2+ mile walk. Yes Molly was tired — a good tired …. she slept on her back with her 4 legs up in the air when we returned — just the way I like it! To me, her reaction after the 2nd dose proved to me the, relatively minor down day we had after the 1st dose was clearly the anesthesia from her operation and not the chemotherapy.

    While Molly is only one case, I am now a believer that dogs may have a very different reaction to chemotherapy than us humans.

    I should add some of the other facts of Molly’s treatment. She has a pretty sensitive stomach. As such, shortly after her TCC operation and before her 1st chemotherapy treatment, Dr. Cerf switched her from Piroxicam (pill), which she didn’t tolerate very well, to Metacam (liquid form). In addition we give her a slurry of Sucralfate 3x per day. We have had no problems since then.

    While this is still a work in process I am much more optimistic than when we started and would not hesitate to urge anyone that has an extraordinary attachment for their dog and the means to go the same route.

    A huge thank you to Dr. Dean Cerf for your passion and dedication to this important specialty which drives you to champion and evolve procedures to fight and ultimately win the battle against TCC. Last but not least thank you to Kathy Wyder to whom we entrust our Molly for chemotherapy and more.

    Denis Conway
    Melville N.Y.

  3. Since I live on the other side of the country (California), I dont have the opportunity to visit Dr Cerf’s surgery and have the -for me- most logical and seemingly successful treatment for my dog who has just been diagnozed with TCC.
    She is a 10-year old lovely mutt who is in excellent health-well, at least that’s what we thought until last Saturday.
    It’s not possible to cut her tumor out (for being at the trigoanl area) but it seems like the cancer hasnt spread anywhere else.
    My questions is this: since I dont have access to the treatment that Dr Cerf offers, should I STILL go for a peroxicam AND chemotherapy option…or JUST with the peroxicam.
    My aim is to prolong Marvi’s life but to keep her quality of life and not make her suffer unnecessarily.
    Thanks for your advice and thanks for your work that may help many doggies. I just hope that more vets are going to listen to your results more so we are not denied the option to have our pets treated in a way that we see as more successful-just because we happen to live on the west west coast!
    Gabriella Megyesi
    Walnut Creek, CA

    • My dog was just diagnosed with TCC
      and I have no idea what to do next
      I live in martinez CA, I don’t have much money
      Do you have any suggestions for me??

  4. We have a mantra at Ridgewood Veterianry Hospital that has serrved us well and is responsible for the developement on Ultrasound Guided Endoscopic Ablation (UGELAB) of transitional cell carcinoma of the canine urinary bladder. “NEVER GIVE UP”. I wish you lived closer so we could provide the laser treatment but that does not mean there is nothing you can do. Definately talk to your oncologist about treating with Mitoxantrone and Piroxicam as this combination provides the best median survival time after the UGELAB procedure. If this fails, we have recently seen so promising results using Vinblastine and your oncologist might consider a new drug, Palladia, which was developed to treat mast cell tumor but might offer some hope with bladder cancer as well . You have some VERY capable oncologist on the west coast and hopefully, you will have a laser surgeon there in the near future.

    • Our 11 year old dog, Polar Bear, was diagnosed today with TCC. It is a 3 cm tumor in the trigone area, which our vet said is inoperable. Is this actually operable when using your clinic laser procedure ?
      thanks, Trina Seligman

  5. When my 13 year old German Shepard/Collie mix Dylan started having accidents in September I thought she was just getting old then after it started snowing (Alaska) I noticed some faint pinkness in her urine. I took her to the vet right away but the Dr. was unable to collect any urine @ that visit but he did notice a mass in her bladder when he used the ultrasound. He suspected TCC but it took several weeks to dx, due my work schedule and clinic hours not aligning. He called with the news and said it was inoperable due to location. He mentioned that dogs have an average of about 6 months lifespan with this DX. He suggested the piroxicam, which I did get and an anti nausea medication which was out of my price range @ 100$ a month. I don’t recall discussing lasers or chemo but since money is an issue I suppose it would have been pointless… yeah, we could save your dog but it’s too expensive for you. Dylan immediately developed an ulcer (black poo and some occasional vomiting) so we started the less expensive Famotidine and Sucralfate TX. She recently started vomiting up “coffee ground” looking stuff an it has me worried. I wish I was able to save her because she really saved me… I picked her up down in Seattle when I was a street punk, I literally hitchhiked the westcoast with her. She gave me something to care about because at that time I didn’t care about anything. She gave me a reason to come home. Does anyone know if this hurts them? When should I let her go?

  6. We have an 11 y old wheaten terrier that has ttc in trigon too. Her back legs are weak (not sure why). She can’t navigate stairs very well. Is on peroxicam only. She is tolerating it. Not sure to whether to put her on chemo as well in hopes to improve her mobility/quality of life.

    • The literature shows that the Median Survival time for the combination of mitoxantrone and peroxicam exceeds that of peroxicam alone by a significant margin. You should ask your veterinarian about evaluating the spine TCC spread to the sublumbar lymph nodes and the spinal cord. An MRI of the spine might be helpful. As you can see in the BLOGS above mitoxantrone and peroxicam is not a very difficult treatment for these kids.

      Best luck, hope all goes well for you guys.

  7. Does anyone know of someone in the Contra Costa County area that can help me with my 10+ year old
    Shih Tzu with TCC

    • I am not sure where oyu live in California but there are many fine oncologists in your state. Go to http://www.vetcancersociety.org/ and use search for a member to locate someone in your area. Several of them are aware of the UGELAB procedure as it has been presented at the annual conference on two occassions.

      Good luck. Hope your pup gets some extra time.

    • I’m late to this conversation having only just found this blog…

      For those of you in Contra Costa County, CA I highly recommend Dr. Martin Crawford-Jakubiak (board certified oncologist & internist) at Sage Veterinary Centers. My Border collie Daisy is being treated by him for TCC (with chemotherapy). She was diagnosed in February 2010, and I am happy to report her disease is static; she is happy and feisty and still going at 110%.

      Hope this helps some of you in the area!

      • Barbara, that’s wonderful. Given that the median survival time for bladder TCC is about 180 days, that’s fantastic to see that Daisy has survived for almost three and a half times that.

        Can I ask what chemotherapy treatments Daisy is getting? I’d like to discuss any possible options with my oncologist for my little girl, and it would also be helpful just to know as we will be discussing our next steps with her in the next month or so.

        Also, did you have surgery performed at any time?

        Thank you,
        Chris.

  8. Dear Dr. Cerf,
    My dog was recently diagnosed with TCC and after the scope procedure the doctors told me the urethra was nearly blocked and that laser surgery would not be an option. She is on piroxicam and had her first round of chemo last week with no side effects, her blood counts were normal at the 1 week check up. Unfortunately, she has a foley catheter in her bladder now because her urethra tore during the scoping procedure, and the radiation oncologist was not comfortable beginning treatment. She IS able to urinate normally and I don’t need to manually empty her bladder through the catheter now, but she is trying to go very often, especially during the night and it appears to be extremely uncomfortable for her.

    Is she a candidate for your laser surgery? I would gladly drive up to NJ from MD if it would help her.

    Thank you!

  9. Sorry to hear that your pup has TCC. To date essentially everyone thought that TCC of the urethra could not be treated. Ultrasound Guided Endoscopic Laser Ablation (UGELAB) has reversed this situation. If you go to our home page and click on “View Actual Laser Procedures Performed By Dr. Cerf” you will be presented with several options. Choose “Urethral” and you will be able to view the actual surgery of a dog with the urethra filled with tumor. At the end of the surgery you will see that the urethra is entirely patent (open). Please share this with your oncologist. At this point chemotherapy will be needed to try to slow the tumor down and prevent metastasis. My job is to open the “pipes” and buy time so your oncologist will have time do the his/her job.
    Unfortunately, it is difficult to get this information “out there” so your oncologists are giving you the best information that they have at hand. Our work with UGELAB has just been accepted for publication in the Journal of the American Veterinary Medical Association and we hope it will be published in September 2011. At that point most people will know that there is hope for palliative treatment of TCC of the urethra.
    To date the best published median survival time for TCC is approximately 350 using a combination of mitoxantrone and peroxicam. However, most oncologists point out this cannot be reached in the urethra where obstruction causes death before metastasis kills the pet. In our study we showed that UGELAB provided a median survival time of 380 in the urethra. Not only can we use laser to treat the urethra but the median survival time exceeds any other treatment currently available for any location in the body.
    I would be happy to consult with your oncologist and provide abstracts on the procedure as presented to the Veterinary Cancer Society, the American College of Veterinary Internal medicine, and the Veterinary Endoscopy Society. While I cannot promise ant particular results, the procedure is most definitely applicable to TCC of the canine urethra.
    Good luck and let us know how we can help.

  10. Thank you, Dr. Cerf! I watched the videos, and have a renewed hope for my baby! I am in contact with your office and hope that you will be able to help us!

  11. Humans and dogs are both mammals and share a similar immune system.

    A review of ChemoQNA.com should help you decide whether or not to administer chemo to your dog.

    The bottom line is that you really want to strengthen and intensify the immune system . . . not depress it.

    I hope this helps because I love my innocent and beautiful dog and will do anything to keep him happy and healthy.

    Richard

    • Maintaining a healthy immune system is essential in the battle against cancer. In some cases, for example melanoma, vaccines can be used to stimulate the immune system specifically in an attempt to attack the cancer cells. Often the best approach is a multifaceted one where the body as a whole, including the immune system, is stimulated and the tumor is specifically targeted i.e. with chemotherapy and/or laser treatment.
      To date I am not aware of any successful treatments that utilize the immune system alone to fight this dreadful cancer. I truly believe that we must currently use all of the tools at our disposal to give these kids happier, more comfortable, and longer lives.

  12. My 12 year old beagle was just diagnosed 3/24/2011 with TCC (Bladder).

    Her Doctor prescribed Piroxicam 3mg. daily & Cytotec 50mg. 3X daily (every 8 hours).

    Is this what she needs?

    Going for a 2nd opinion tomorrow morning.

    • Sorry for the delayed response as I was out of the country until today.

      Your veterinarian did the right thing getting the Peroxicam started along with misoprostol to protect the stomach. Your second opinion may have provided additional information about treating TCC. Peroxicam is the “gold standard” for NSAIDs and helps provide a longer median survival time (MST) when combined with Mitoxantrone. This chemo combination provides a MST of about 350 days as opposed to approximately 280 with a single agent treatment protocol.

      If the tumor is in the urethra or trigone these MST projections will most likely not be reached as dogs with tumor in these locations generally die of obstruction before the tumor spreads. In these cases the use of diode laser applied through a cystoscope and guided by ultrasound has proven to provide a MST equal to or exceeding that of the peroxicam/mitoxantrone treatment.

      You may want to consult with a board certified oncologist by contacting the Veterinary Cancer Society at http://www.vetcancersociety.org/ to see if they feel your little girl is a candidate for the laser (UGELAB) treatment.

  13. Hello. My dog was diagnosed a couple of weeks ago with TCC in the trigon area, and I have two questions I’d like to ask regarding this article:

    1. Am I correct that you are the only surgeon who performs UGELAB?
    2. My dog is also showing some weakness in the legs (as lison wrote about above for his/her wheaten). If the TCC has spread to her spine and/or her sublumber lymph nodes and spinal column, can the surgery address that as well?

  14. And a third question I should have though to ask – she is currently undergoing chemotherapy. Can the surgery be performed while an animal is undergoing chemotherapy, or would the treatments need to be discontinued, and some period of time need to pass before she could have the surgery?

    Thanks.

  15. I think the answer re: Chemotherapy and surgery is it depends. In Molly’s case – see Jan 16 2011 on this blog – she received Chemotherapy on the same day as her 2nd (follow-up UGELAB ) procedure and she was fine. However, Molly consistently has a low white blood cell count when we do a CBC 10 days after chemotherapy. In our case – and I suspect in all cases – I know there would be no UGELAB until Molly’s blood counts and urine where in good order. We are planning a follow-up UGELAB – in early July to “take a closer look” and hopefully confirm the good news we have been getting on the Ultrasounds. However, if there is any visible reoccurence Dr. Cerf will hopefully hit it with the laser and we will follow that with her scheduled chemotherapy barring any other issues. Molly – a Bichon Frise – seems to have a high tolerance for both the chemotherapy and the surgery.
    Hope this helps
    Denis

  16. Hello Chris,
    I am sorry to hear that your pup has to deal with this difficult cancer. I hope we can make your journey easier. To answer your questions, I am not aware of any other doctors doing UGELAB on a regular basis. We developed the procedure at Ridgewood Veterinary Hospital and hope that in time others will learn the procedure as the need is extreme and not everyone can travel to New Jersey for the treatment. Having said that, we have gotten to know some wonderful “parents” from as far away as Florida, Texas, North Carolina and even North Pole Alaska. I am sure that in time other doctors will learn this extremely valuable procedure. The key to success, as has been demonstrated in human medicine, is to find a facility that has done many of the procedures. This past week we performed UGELAB on our 92nd patient and have completed nearly two hundred procedures.

    If the tumor has, regrettably, spread to your dogs spine the UGELAB procedure would not help with this aspect of the disease. In our experience metastasis to the spine is fairly uncommon and I would be looking for another explanation for the hind limb lameness…

    Surgery can be done while undergoing chemotherapy. We just need to time the UGELAB procedure so it does not coincide with the drop in white blood cells following the chemo which usually occurs at about 10-14 days. Since the laser procedure kills much more tumor than the chemo and much faster, I have no problem postponing the chemo a few weeks if needed. A study presented at the Veterinary Cancer Society in 2002 shows that debulking the tumor statistically improves the response to chemotherapy

    Hope this helps!! Good luck and best wishes for a better outcome!

    • Dr. Cerf, thank you very much. I’m actually already in touch with someone on your staff, and in fact I need to follow up and see if they have all of the information that they need. The good news is that I was told that from a preliminary analysis, my little girl (okay, 70 pounds is not so little, but she is still my little girl) looks like she’s a good candidate for the surgery.

      With respect to the cancer spreading to the spine, our oncologist did examine her lungs and found no problems there at all, and, understanding that metastasis can occur anywhere in the body, based on that and your information that it’s uncommon I will take this as positive news.

      Thanks again, this does help, and I’m hopeful that I’ll be scheduling the surgery with you very soon.

  17. Hello Dr. Cerf,

    My nearly 12 year old terrier mix was diagnosed with TCC back on 12-16-10. We have undergone six treatments of Mitoxantrone (1 shot every three weeks) and she is on Piroxicam as well. She had surgery to remove a tumor in the apex of her bladder and has a tumor in her lower urethra entering her vaginal vault. After six treatments, the tumor (originally 2cm) was no longer palpable and there was no evidence of regrowth.

    After the sixth shot, we switched her to an oral chemo pill (Chlorambucil) which she received once every other day.heArted about six weeks the rumors showed evidence of regrowth. The one in her apex has returned (.5cm x .5cm), the ‘thickening’ in her trigone area is now a small mass about the same size, and the tumor in her urethra is palpable again.

    We have restarted the Mitoxantrone shots and she will receive her second one tomorrow. I just came across your laser procedure and want to know if there is a size limit to the dogs it can work on. She is only 12.5 pounds and we have not been able to get a scope and camera/other tool in her urethra at the same time because of her size.

    We are working with a great oncologist in Las Vegas and I know we are doing everything possible for her. But this laser procedure seems like it may be really beneficial for her. Are you in the process of training any other doctors to do this procedure, particularly on the west coast?

    Thank you for your time,
    Dana

    • Hello Dana,

      It sounds like your baby might be a candidate for laser treatment. We have treated dogs that weighed as little as 8 Lbs. The tumor in the apex is of little concern as dogs with TCC die of obstruction long before they die of metasatic disease. The mass in the trigone is of much greater concern. Ultimately your oncologist is the best source of medical treatment. What we do is to keep these kids alive long enough for the chemo to work. Currently I am not aware of any doctors doing this procedure on the west coast. While I have lectured extensively on this procedure the lectures were provided primarily to oncologist who need an adjunctive treatment rather than to surgeons who could provide the treatment. Hopefully, others will start doing the procedure as our requests for the laser procedure exceed our ability to respond.
      Best luck with your baby and let us know how we can help!

      Best regards,
      Dean J. Cerf, D.V.M.

  18. *I’m sorry- she was on the Chlorambucil for nearly three months, not six weeks.

  19. Hello, we have an 11 yr old Portuguese Water Dog, Lily, who started to continue to strain or try to urinate, after initially voiding. This started in the middle of May. We visited our vet, and tried 2 different antibiotics “hoping” it was just an infection, and at the time, thinking our worst case scenario would be bladder stones. – Well, after an x-ray, ultrasound and urine culture – no infection, but a mass in the trigone area of her bladder.
    This is devastating news, and we are unsure as to the course of treatment to make our little girl ( she does not think she is a dog – or act like anything less than the Princess she is) as comfortable as possible. She is acting completely normal, other than the “re-squatting” as we have named it. We do not want to put her through any trauma or stress, but we don’t want to let go, and can’t even think of that, while she is really not showing any other signs or symptoms. Our vet at HoHoKus Animal Hospital, recommended both your laser surgery, Dr. Cerf, and / or that we visit Dr. Clifford, an oncologist at Red Bank Animal Hospital, who also recommend your laser surgery as an option, when we saw him yesterday. At that visit, they took a chest x-ray that came back okay -and they drew blood. We should have blood test results on Tuesday. I also called your office on our way home from Red Bank, and left my number for a call back to make an appointment on Monday.
    We have decided that we do not want to go the traditional surgery route, and have her cut open.
    We are interested to find out if there are any statistics available that compare BOTH the survival rate, and quality of life, in dogs that have gone through – 1. NSAID (we have started her on Deramaxx 25mg) with chemotherapy -VS. 2. UGELAB, along with NSAID & chemo.
    I am sure this is something we can discuss during a consultation – but I thought the question, and answers might help others that are faced with TCC and trying to figure out what is best for their pets/family members, who might not be as fortunate as we are, to live in NJ, and only 10 minutes from your office.
    Thank you.

    • Hello Sherri,

      Let me start by saying that you are already working with two awesome veterinarians! Dr. Schruer has always held my respect as one of the finest veterinarians in New Jersey and I am very proud of Dr. Clifford who began his journey to become a veterinarian at Ridgewood Veterinary Hospital and is now one of the leading oncologist in the United States. You are already in very good hands!

      I agree that your questions would be best answered in a consultation that addresses your girls issues in particular, but also agree that answers to youe questions may help others as well.

      The answer to your question is simple. Dogs treated with a nsaid and chemotherapy have a median survival time of 350 days based on a study done by Dr. Caroline Henry with regard to mitoxantrone and piroxicam. The exception is that dogs with tumor in the trigone or urethra live a much shorter time as these patients die of obstruction, rather than metastasis, long before the chemo has a chance to work. In our study, accepted for publication in the Journal of the American Veterinary Medical Association, we demonstrated a median survival time of 380 days. The outstanding feature of the UGELAB procedure that dogs with tumor in the urethra, previously considered those with the worse prognosis, actually maintained a median survival time of 380 days. This statistical data was based on the first 38 dogs that we treated, none of whom had chemotherapy though all were treated with a nsaid. Starting one year ago last March, all dogs have been treated with laser and a chemotherapy protocol. It will be another year before we know if chemo on top of UGELAB provides a statistically improved median survival time. This week we will be treating our 95th patient and I believe the results of our next study will be very telling.

      Clearly, Ultrasoound Guided Endoscopic Laser Ablation (UGELAB) of transitional cell carcinoma of the urethra provides a superior treatment modality. Addtionally, tumors of the trigone are best treated with laser. Ultimately, we will need to rely on our oncologists to provide a long term treatment and potentially a cure. In the mean time our job is to keep the “pipes” open and keep our kids alive, comfortable, and happy!!

      Dean J. Cerf, D.V.M.

  20. Dr. Cerf–

    Our almost eleven year old Sheltie was diagnosed with TCC bladder cancer on August 19. She began showing symptoms about June 1 but our vet did blood work and urinalysis at that time and everything was normal.

    She has two good sized tumors in her bladder and another tumor in the Trigone area. A chest X-ray has been done and there has been no obvious metastasis to other areas.

    She was immediately started on a daily dose of 2.5mg piroxicam (along with 5mg pepsid twice a day) which seemed to make her feel better and has made it easier for her to urinate. She can urinate a good amount on her first attempt when we take her outside, but she will then make several more attempts to urinate. She acts like her bladder doesn’t completely empty on her first and subsequent attempts.

    She sleeps the entire night without having to be taken outside to urinate. During the day, if we take her outside every couple of hours, she doesn’t have accidents in the house.

    She is very alert, has a good appetite, and still loves to play ball. She does not appear to have lost any weight and no one would know that she was ill, except for her long and frequent urination attempts.

    After 19 days on the peroxicam, she became mildly constipated and threw up twice. On advice of the oncologist who has seen her, we have stopped the peroxicam for two days. She is now holding her food down and her bowel movements have returned to normal. We plan to resume the peroxicam tomorrow, on an every other day regimen.

    The oncologist sent specimens to Washington State University and the results show that her genetic make-up makes her a poor candidate for Mitoxantrone, although it might be a consideration if given in very low dosage.

    We are in Houston, TX, and apparently there are two facilities close to us that could do the laser surgery (Gulf Coast Vets and Texas A&M).

    We are trying to decide what to do next. Based on my description of the situation, what would you recommend for our Sheltie?

    Thanks–

    • Thad, can you identify where you found out that Texas A&M can perform UGELAB surgery on dogs? If this is correct, it may possibly make this a more feasible option for me logistically.

      Thanks.

      • Chris–

        I was told by Dr. Claudia Barton at A&M that they have a surgeon (Dr. Cook) who could perform a laser ablation.

        Dr. Barton advised that we could contact Dr. Cook via “Canine Internal Medicine” at 979-845-2351.

        Good luck, we have not yet decided whether to go that route. Our Sheltie was able to take 2.5mg of peroxicam for 19 days but then developed gastric issues. We are in the process of switching to another similar medicine that she may be able to better tolerate.

        ***************************************************************************************

    • Hello Thad,

      Sorry to hear that your girl has this dreadful disease. I sound like she is definately a candidate for UGELAB laser treatment. We have worked with Texas A&M twice with regard to TCC treatment. One to conult on a case that they treates at the university and, recently, to treat a case that they referred up to us from Austin. Reach out to Dr. Love at Texas A&M to see if he can give you some direction. If not, get back to us though I am not aware of anyone in Texas doing this procedure on a regular basis.

      Let us know how we can help.

      Best regards,
      Dean J. Cerf, D.V.M.

  21. Hi Dr. Cerf,
    First off, thank you for making this blog available to us dog owners whose dogs have been dx’d w/ TCC.

    My name is Debbi Robinson and my husband live in Spruce Pine, NC and are needing information and help for our dear dog “daughter”, Ginger whose dx for TCC was just confirmed (cystoscopic bx) Wednesday, 9/14/11. We are frantic to seek out the best care and treatment options for her that we can. My husband, David, is an M.D., (a General Surgeon with a sub-specialty in Burns, Trauma & Surgical Critical Care), so we “get” the seriousness of tackling this head-on. He also said that your UGELAB procedure is what they do in people and we are hopeful that it could help GInger.

    I’d like to give you a little hx to preface my couple of questions. Ginger is an 11 y/o SF lab mix. Around May 1 of this year, she exhibited symptoms of a UTI. I got her into our vet and he US’d her, did a urine C/S and diagnosed a UTI with a “boatload” of bladder stones. She was started on Amoxicillin, Deramaxx and Tramadol prn and continued on that for 8 weeks. We switched her diet to a watered down canned food (Iams) twice a day and discontinued all dry food.

    At her 8 week re-check, (early July), all the bladder stones had dissolved, but on US there appeared to be a mass at the apex of her bladder. Vet switched her to Simplicef x 1 week and continued the Deramaxx. (I also started her on DHA……based on Dr. Greg Ogilvie’s research……, Glutamine, Arginine and Transfer Factor Plus). At re-check a week later, the mass appeared to have shrunk, was less solid looking and had started to pull away from the bladder wall. He had us continue the Simplicef for another 2 weeks, as well as the Deramaxx and Tramadol.

    Approximately 1 1/2 weeks after finishing her AB, (we are now around mid-August), she seemed to be a bit off and was peeing very bloody urine again. Vet US’d her and said that the mass was now larger and that he was suspicious for TCC bladder cancer. He did not see on US nor feel on physical exam any lymphadenopathy. He drew blood for the antigen test which came back positive, as well as Urine C/S. Switched her to Cipro 500 mg bid, Cerenia 60 mg. 4 days on 2 days off, Tramadol prn, Pepcid AC, and Piroxicam was started She did not do well on the Cipro (no appetite, muscle aches and pains, etc.). After cultures came back, she was switched to Keflex.

    Fast forward to Thursday, 9/8: Our vet, nor any vet in Western NC, has the ability to do cystoscopy, so my hubby borrowed the equipment and he and our vet performed a cystoscopic exam on Ginger to obtain bx’s to get a definitive dx and start chemo (Mitoxantrone and Piroxicam). Almost immediately, they encountered another mass at the urethral opening (ughhhh!), no obstruction however. As stated above, path came back TCC. Sorry this was long………….

    Ginger is scheduled for her first Mitroxantrone tx this coming Tuesday, 9/20. Her current meds are: Piroxicam, Tramadol and Pepcid AC, as well as the aforementioned supplements. I am also weaning her on to the “Dog Cancer Diet” of high protein, high fat, low to no simple carbs, low complex carbs.

    My questions are:
    1. How soon should we/could we get Ginger in to see you for UGELAB work up?
    2. Will it be beneficial or not or make no difference….to get a couple of the Mito tx’s done before seeing you?
    3. Given that Ginger first started having trouble in early May and given that she only started the Piroxicam in August, with MST what they are and we are now 3 weeks into September (so 4+ months since onset), are we “behind” in the game and need to play catch up”?
    4. What is the approximate range of costs for UGELAB?

    Thank you so much for taking the time to read my post. My hope and prayer is that you will be able to help our dear Ginger. With Kind Regards, Debbi and David Robinson

    • Hello Debbi,

      So sorry to hear that your girl has this dreadful disease. To answer your questions:
      1. We should evaluate her as soon as we can so we can develop a game plan without getting “behind the eight ball”.
      2. It does not matter if she gets mito first as nothing kills TCC better than laser and studies show that tumors that are first debulked respond better to chemotherapy.
      3. No need to play catch up as UGEALB improves the MST regardless of tumor location.
      4. Costs vary depending on location, size of patient, and length of stay but a typical treatment with a hospital stay of several days would be $6-8000.00 all included.

      I hope this helps you make some decisions. Ironically, tomorrow we will be treating another girl from North Carolina! It is her forth treatment and she is doing great!!

      Best luck,

      Dean J. Cerf, D.V.M.

  22. In December 2008 our dog (12 yr old female pit/chow mix) was diagnosed with TCC. She would get check up’s every 6 months and we took her in as usual just before Thanksgiving. The check up went well and as we were walking out of the vet’s office she urinated on the floor when I was checking out. It contained blood and they said she must have a bladder infection. She had never ever had an accident like this before. We cancelled our Thanksgiving trip because the kennel in AZ would not be there around the clock to medicate her. The culture did not show infection but there were epithelial cells which is not normal. Our vet had it sent to a pathologist who initially said it was not cancer. At the same time, we tested her for cushings. She was positive for cushings after spending an entire day at the vet being tested. The following day, the vet called to tell us she also had bladder cancer and they referred us to a local oncologist. We went in the following morning for our consult. Our veterinary oncologist was Dr Greg Ogilvie of California Veterinary Specialists in Carlsbad, CA. Luckily this was less than 8 miles from our home. At the time of diagnosis she was given less than 30 days to live. The tumor was in the trigone area amongst other areas along the bladder wall. She probably had TCC for many months or even years because she had been on Dermaxx since 2005 and we believe it kept the tumors under control.
    When you hear the news, it’s up to you if you want to take an aggressive approach to treatment or not because it will run thousands (and thousands) of dollars and no treatment is guaranteed.
    We put all of our trust in Dr Ogilvie and chose an aggressive approach. The day of her diagnosis we started her chemo with mitoxantrone. We also switched the Dermaxx to Peroxicam and added el-gen drops (rejeneril). The peroxicam was too hard on her liver and kidneys so we switched back to Dermaxx after a while. Both Dermaxx and Peroxicam are NSAIDS but Dermaxx does not have the cox 2 inhibitors like Peroxicam. You really need to constantly check Creatinine, BUN and ALK PHOS while on these medications.
    Her main treatments were:
    Mitoxantrone 12/2008 – 07/2009 every 3 weeks: very consistent shrinkage. Every month she had an ultrasound and every month were positive changes. The best change was that the tumor detached from the trigone area and moved further down the bladder wall. The shrinkage was amazing with this stuff. No side effects at all with this chemo.
    Ccnu 03/2010 – 04/2010 – In March 2010 we noticed she was limping so we brought her in to find out the TCC metastasized to her lungs. It was not bad but it had spread. Because of the spread, we switched her chemo to CCNU. After a month we did an ultrasound and it did help some but not as much as Dr Ogilvie expected so we immediately switched to AB1010. No side effects with CCNU.
    AB1010 05/2010 – 09/2010 – This stuff is really good. It was killing her tumors inside out. They were also shrinking. Possible side effect: rear leg edema. Not confirmed, but a possible cause.
    2 rounds of Radiation 07/2009 (5 days), 11/2009 (6 days). Absolutely made a positive difference in tumor shrinkage. Side effects are colitis that is permanent but gets better as time goes on. It was nothing that really bothered her that much. It’s just messy. Tylosin and pre/probiotics help with the side effects.
    Other medications concurrently: Sucralfate, TMPS, Tylosin, Denamarin, Pet Tabs Plus, Glucosamine & Chondrointin, Pepcid, Iron, Tramadol, Ursodiol, Levothyroxine/Soloxine, Dermaxx, DHA, Rejeneril, Pre/Probiotics, Interceptor, PPA, Benedryl, Metaclopramide, Gabapentin, Cerenia.
    I recommend immediately changing the diet (we switched her over to Solid Gold Barking at the Moon), cancer lives off carbs so they need a low carb diet. I also recommend adding DHA and the Rejeneril drops (Alimentary Science has a website). The Rejeneril is amazing. It gave her the energy of a puppy. With age she had a slight blue tinge (not bad) to her pupils. The Rejeneril got rid of the blue tinge. It is amazing stuff and well worth the money. I can’t say enough about it. She was begging to go for a 30+ minute walk twice a day. It gave her that much energy. She lived for her daily walks.
    Having a dog with TCC takes a lot of work. Do not underestimate the level of care required. She had to be medicated 14 times a day. It is life changing. No more traveling, up all day and night because they require constant care and supervision. You have to track everything, like the straining, blood, bowel movements, anything out of the ordinary.
    In September 2010, just a couple days after a fantastic check up with Dr Ogilvie, she suddenly got really sick with a bad infection which we tried to get under control for 3 days. We thought she would pull through because she was a fighter and always so happy. In fact, Dr Ogilvie said he had never seen her happier with such a sparkle to her just a few days before. All of the sudden the infection just took over and spread to her brain. We were right there with her when it started spreading to her brain and we knew we could not let it go on. She never suffered the entire time she had cancer. She was not killed from the bladder or lung tumors, but obviously the cancer contributed to her infection and death.
    We were able to keep the cancer completely under control for 22 months. Those were the best 2 years she ever had. She really was a happy dog and even happier every day. The chemo does not affect animals like it does with people. It really does not. It typically makes them tired. Sometimes the first afternoon they will become nauseated but typically they are just fine. If you give them Tylosin, Metaclopramide and Cerenia right after their chemo, they really won’t have any side effects. I would never hesitate doing this again in the future if it happened to us again.
    I hope this information helps people and gives them some additional medication information that they may want to try on their pets with TCC. We were extremely fortunate to have a world renowned veterinary oncologist for our dog and we are so thankful that he helped her live a genuinely happy life the entire time she had cancer. She lived 14 wonderful years and will always be with us.

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  25. Dr. Cerf, thank you so much for this blog and for the exchange of information it provides. My just-11-year old bichon frise was diagnosed with TCC in early November. My vet arrived at the diagnosis in a roundabout way: my dog was having what I would describe a petit mal seizures. The vet started with a blood panel and saw elevated liver values– then an ultrasound– liver was fine, but there was the TCC.

    We are seeing a wonderful oncologist at CARES in Bucks County, PA, who is treating her with piroxicam and mitoxantrone. Mackenzie tolerates it very well and is lively and playful. She still has the little seizures, but I am told by all vet folks that the two problems are unconnected.

    I found an article you had written through googling TCC,and when I took it to my oncologist, she indicated that she knows you and thinks the UGELAB procedure is highly promising.

    The surgery is very expensive, I know, so I have a few questions:

    1. At what point should an owner consider the surgery? The tumor is not directly in the trigone area but toward the side of the bladder, so there is no obstruction to date. My oncologist labeled it stage 1– lungs are clear, lymph nodes are soft. Is it better to wait until the tumor has grown somewhat in order to buy maximum time for the dog– or is it better to do it sooner to avoid the potential of metastasis?

    2. In the video interview that you have posted, the beagle that had been treated had had nine procedures, if I heard that correctly. How common is it to have multiple surgeries? Does the intial surgery cost cover subsequent procedures or not?

    3. I am a little confused about the potential for life extension. I believe the average with piroxicam and mitoxantrone is around 300 days (?) and the median for the pups who have had the surgery is 380. Is that about right? What is the longest any dog has lived beyond the surgery? the shortest?

    Thanks so much for any response. This decision is so important to me– I love this dog but do not believe in life extension without life quality.

    • Hello Peg,
      Sorry to hear your little girl has this nasty tumor, however I am happy that she is currently handling her medicine well and acting so playful. Her apparent normal behavior is a blessing and a curse. A blessing because she does not know she has a problem and a curse as most dogs feel and act normal until late in the disease process when the tumor is much more advanced. These pets might be better served if the tumor caused some discomfort early on so we would start looking with ultrasound earlier as early detection is often the best weapon we have in fighting cancer.

      You are correct that the surgery is expensive and it may not be for everyone. Just as early detection is so important to better outcomes so is early intervention. With regard to TCC in particular, I currently approach the treatment of males differently than females. Males require a small incision in order to place the cystoscope into the bladder. This creates an opportunity for the cancer to spread to the incision site. For this reason I often postpone surgeries in males until there are signs that obstruction are developing or surgery is necessary because of bleeding, straining, discomfort, etc. In general, in females we want to intervene as soon as possible to prevent the tumor from growing into the trigone and obstructing the ureters and/or urethra. There was also an abstract presented at the annual meeting of the Veterinary Cancer Society (Josel 2002) that demonstrated debulking (decreasing the size) of the tumor burden significantly improved the effect of the chemotherapy. For these reasons, I believe, females should be treated as early as possible.

      The UGELAB procedure will not prevent metastasis. The primary goal of UGELAB is to prevent the development of obstruction as most dogs die of obstruction from TCC before they develop metastasis. Again, debulking may enhance the effect of the chemotherapy which, currently, is the only way to try to avoid metastasis.

      The need for multiple procedures is largely dependant on the location of the tumor. One little poodle, Chloe, who we treated several years ago lived three years with only two treatments. She died at seventeen years of age due to congestive heart failure, not her transitional cell carcinoma. On the other hand, dogs who already have obstructive lesions, for example, in the urethra, may require multiple treatments. We treated one little girl, Jackie, who had been given two weeks to live, at a prominent NYC hospital, because her urethra was obstructed. She was referred to Ridgewood Veterinary Hospital for the UGELAB procedure. Jackie was treated approximately every 8 -12 weeks and lived for 3.75 years with an excellent quality of life. Location is everything with transitional cell carcinoma. There are additional costs for additional treatments though the costs may be less if we do not wait for the tumor to grow all the way back and the tumor will grow back.

      The statistics on survival can be a little confusing. The median survival time (MST) for mitoxantrone and peroxicam is between 280 and 350 days depending on how the data in censored. Median survival time means half of the dogs lived longer and have lived shorter. I believe most veterinarians would agree that those dogs with obstructive lesions in the urethra will be on the short side of the bell curve. In our study, recently published in the Journal of the American Veterinary Medical Association 1/1/12, we demonstrated a MST of 380 days for the UGELAB treatment of transitional cell carcinoma. Interestingly, the MST was 380 days in the urethra as well, demonstrating UGELAB is an effective palliative treatment of obstructive TCC where chemotherapy alone might not have time to work. The reference sited above(JAVMA 1/1/12) was based on our initial treatment of the first 38 dogs and none of these dogs had chemotherapy. We recently treated our 98th patient and the majority of the sixty subsequent patients have had some degree of chemotherapy. Our next study is aimed at determining if debulking of transitional cell carcinoma followed by chemotherapy significantly increases the median survival time.

      The longest time a patient has lived following UGELAB was Molly and she lived over six years with one treatment! The shortest time was eleven days in a dog who had complications from surgery. There were a few dogs who did not survive the surgery and there are a number of possible complications that need to be discussed but these are beyond the scope of this blog.

      I hope this helps you. This is a very difficult cancer to fight and you have some difficult decisions to make. This is ALL about quality of life and, while we have not always been able to provide this we have been successful enough to know we need to keep fighting the battle. In most cases it is the best chance they have. No one should go forward with this procedure unless they thoroughly understand the risks and are prepared to lose. On the other hand, doing nothing most certainly means losing

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