Conversations with oncology leaders

nenetus/stock.adobe.com

Exploring the future of veterinary oncology, Neal Mauldin, DVM, ACVIM, ACVR, Thrive Pet Healthcare’s national director of radiation oncology and chief medical officer for Petcure Oncology, and Julie Bulman-Fleming, DVM, DACVIM (Oncology), Thrive Pet Healthcare’s national specialty director of oncology and medical director and residency program director for Veterinary Cancer Group, share their insights on the evolving landscape of cancer care for pets. These distinguished experts bring a wealth of experience and a deep commitment to advancing treatment options and improving the quality of life for veterinary patients facing cancer.

Tell us a little bit about you both. What’s your background and experience, and what led you to oncology?

Mauldin: I grew up in a family that raised show dogs for a living so it seemed only natural that I would become a veterinarian. When I entered vet school, I had the intention of being a general practitioner and returning to practice in my local community. However, while in veterinary school, I met a medical oncologist, Claudia Barton DVM, ACVIM (Internal Medicine, Oncology), who became my inspiration to pursue specialty training and become an oncologist. I did my internship and residency training at the Animal Medical Center in New York City, followed by a clinical fellowship in radiation oncology at Memorial Sloan-Kettering Cancer Center, also in New York. I spent some time as a tenured professor and department head at Louisiana State University before returning to clinical practice in Western Canada.

Bulman-Fleming: I knew I wanted to be a veterinarian from about 3 or 4 years old. When I entered veterinary school, I learned about all the specialties available. During that process, my father was diagnosed with cancer, and I realized what a difference an oncologist can make during such a challenging and scary time. I completed my residency at Veterinary Cancer Group and now head the residency training program there.

Comprehensive cancer care for people has been around for a while. It’s moving into the veterinary medicine space. How is comprehensive cancer care for pets similar to or different from human care?

Mauldin: The single biggest differentiator between human and veterinary comprehensive cancer care is easy access to services. There are not as many veterinary specialists, and access to sophisticated medical technology is much more limited in the veterinary sphere. For example, those who do not live in a major population center may have difficulty accessing radiation therapy, necessitating the need to develop protocols that allow families to pursue radiation therapy for their pet even if they live 8-10 hours away from a radiation therapy facility. This has been a huge driver for the development of stereotactic radiation therapy protocols, which can be delivered in 2-4 days rather than the 3-4 weeks needed for conventionally fractionated protocols.

Bulman-Fleming: Veterinary Cancer Group has offered comprehensive cancer care to patients for over 30 years. This model allows clients to reach people dedicated to oncology every step of the way, from the moment they call to make their first appointment to their final radiation or chemotherapy appointment celebration. I’m very proud of our teams’ ability to help clients navigate this journey. As in human care, we collaborate extensively across specialties, as well as across the oncology realm. Veterinary medicine is working to catch up to human medicine regarding the size and breadth of their clinical trials and the established standards of care.

Since cancer treatment is customized to each pet, I’m sure there are multiple doctors collaborating on the treatment. In veterinary medicine, we don’t see all those doctors in one place. How do you achieve that collaboration?

Mauldin: As I mentioned, the single biggest challenge we have for the families of our veterinary cancer patients is access to specialists and technology. A major focus for our group has been expanding access to the expertise of our radiation and medical oncologists. There are only about 100 radiation oncologists in the world, so we have been very focused on expanding access to this valuable and limited resource. The pandemic significantly changed peoples’ attitudes towards telehealth consultations, and we have seen families accept this option to get the expertise and opinions they need to make an informed decision for their pet.

Additionally, advances in digital communication have allowed multidisciplinary plans to be created and executed even when the specialists are not in the same hospital or even in the same region of the United States. Obviously, the patient must eventually come to a physical facility for care, but a telehealth consultation can help ensure that the patient is directed to the correct specialist and that the family has at least a general understanding of the prognosis and treatment options available. Ideally, a patient would be seen at a multispecialty center that had everything necessary to provide comprehensive cancer care. When this is not possible, there are options to provide multidisciplinary care and to ensure that a veterinary cancer patient gets the best care possible.

Bulman-Fleming: Many of Thrive Pet Healthcare’s cancer centers are located within multispecialty centers or associated with specialists in a “campus,” where dentists, dermatologists, internists, neurologists, ophthalmologists, surgeons, and other specialists can collaborate on an individual case. Our patients are evaluated even before their first appointment to ensure they see the appropriate oncology service, and cases are often discussed with their referring veterinarian or specialist. In addition, as oncology is always evolving, medical and radiation oncologists worldwide can consult on unusual, unexpected, or challenging cases.

This sounds like team-based healthcare, which is something seen a lot in human medicine. With primary care doctors being part of that team, what should they know about?

Mauldin: I think the single biggest challenge confronting veterinarians today is the information explosion. It is impossible to keep up with advances in veterinary cancer therapy if you do not practice it every day and follow the literature closely. This is a problem for all of us as the digital age has presented us with far more information than we are able to process and remember. In human medicine, there has been a push to try and remove the stigma of a cancer diagnosis as our treatment options have increased and patient outcomes have improved. In many cases, cancer is now treated more as a chronic disease to be managed rather than a death sentence. The same technological advances are happening in veterinary medicine, and it’s important to realize that we have options today that were not available even 5 or 10 years ago. The first conversation with a family about the diagnosis of cancer in their pet can be a difficult and emotional process. It is important for them to understand that there are options for many patients and that, ideally, a conversation with the specialist who deals with those options daily is the best place to start.

Bulman-Fleming: Being on the front line, and usually the ones delivering the diagnosis of cancer, primary care veterinarians are an essential part of a pets’ oncology team. Being able to navigate the initial diagnosis and reach out for specialist insight where appropriate is key, and our primary care veterinarians are wonderful at doing this. As the first introduction to veterinary oncology, primary care veterinarians should assure their clients that the goal of veterinary oncology is a longer and better quality of life. I think understanding the primary concerns owners have, such as fear of adverse effects, and common questions about available treatment options, is most important. Chemotherapy and radiation therapy can be curative for some patients but also serve as a strong palliative, comfort focused role when appropriate.

What are some of the biggest misconceptions pet owners have about cancer care? What are the misconceptions in the veterinary industry?

Mauldin: I think the single biggest misconception for the families of veterinary cancer patients, and to a lesser extent the veterinary industry, is that there are limited or no options for a cancer diagnosis. Advances in technology have expanded our repertoire significantly, allowing us to treat conditions that we would've classified as untreatable just a few years ago. Improvements in radiation therapy technology have allowed us to minimize anesthetic events, treat patients in 1-3 fractions, minimize side effects and maintain quality-of-life, and produce outcomes that are similar to or better than those seen with conventionally fractionated protocols.

Additionally, many sites previously untreatable with radiation therapy, such as the lung, spinal cord, and liver are now common targets for stereotactic protocols. While I’m highlighting the advances in radiation therapy, it’s important to note that similar advances are occurring in the fields of chemotherapy, electro chemotherapy, immunotherapy, and personalized medicine.

Bulman-Fleming: Our pet family members are better educated than ever before. Despite this, there remains misconceptions about the prevalence of adverse effects after chemotherapy and radiation therapy, and how treatments are administered. Notable chemotherapy side effects occur in 10-15% of pets and include nausea, inappetence, lethargy, vomiting, diarrhea, and myelosuppression. These are transient and commonly treated at home. Owners are often also afraid that chemotherapy or radiation administration is painful which, thankfully, is not the case. Chemotherapy administration is akin to having a blood sample taken, and radiation therapy is akin to getting an X-ray.

Within the veterinary community, I feel our palliative options are often overlooked or misunderstood. One of the things I love about oncology is the ability to modify treatment plans when needed, either because of patient factors or client factors such as cost or scheduling.

Thinking about the future of cancer care for pets, what’s coming and how can primary care doctors prepare for it?

Mauldin: Veterinary oncology is a rapidly changing field that is undergoing immense technological advancements. If you are not making it your primary focus of practice, it will become increasingly difficult for you to keep up with these changes, especially in the age of artificial intelligence. The biggest message here is that the field of oncology is evolving at a fast pace, and what was true yesterday may not be true today. Therefore, it is imperative for pet owners to understand their options and make informed decisions as they advocate for their pets. Don't be left behind in this rapidly changing field. Stay informed and stay ahead of the curve! PetCure Oncology maintains a patient and veterinary portal at PetCureOncology.com that contains a wealth of information, as well as tools to help you request an appointment for your patients, get an imaging review, or speak with a radiation oncologist.

Bulman-Fleming: The field of oncology is ever-changing. New avenues include half-body radiation therapy for canine lymphoma, advancements in electrochemotherapy technology and immunotherapy. We have also offered targeted therapy (using tumor mutations to direct therapy) for several years now, and supporting research is starting to be published.

Primary care doctors can advocate for their patients through reading articles like this, attending local or regional continuing education lectures, and joining email list-serves. Veterinary Cancer Group sends monthly tips and continuing education notifications to veterinary industry subscribers at no charge. Please follow this link to be added to the distribution list.

Neal Mauldin, DVM, ACVIM, ACVR, is a pioneer in the field of veterinary radiation therapy, having practiced as a veterinary radiation oncologist for more than 35 years, and has supervised the treatment of more than 8,000 pets with stereotactic radiosurgery (SRS) since 2010. He provides clinical oversight, remote treatment planning and review, and oversees research for facilities across the PetCure Oncology network and serves as the National Director of Radiation Oncology for Thrive Pet Healthcare.

Mauldin is a triple-board certified veterinarian in the fields of internal medicine, medical oncology and radiation oncology, attaining board certification in veterinary radiation oncology the first year it was offered in 1994. He has authored over 25 peer-reviewed publications, written numerous textbook chapters, and presented invited scientific abstracts at over 40 national and international meetings pertaining to the specialty of veterinary oncology. He is past president of the Veterinary Cancer Society.

Mauldin has 4 rescued Shetland Sheepdogs, 2 Maremma Sheepdogs and 15 horses, with more on the way.

Julie Bulman-Fleming, DVM, DACVIM (Oncology) was born in Vancouver, British Columbia, Canada, and attended the University of British Columbia for her bachelor's degree in animal biology. Next it was on to Saskatoon, Saskatchewan where she attended the Western College of Veterinary Medicine and developed her interest in oncology. After graduating in 2007 with her Doctor of Veterinary Medicine degree with great distinction, she moved east across Canada and did a rotating internship in small animal medicine, surgery and critical/emergency care. Bulman-Fleming joined Veterinary Cancer Group as a medical oncology resident and completed her ACVIM residency in medical oncology in 2011. Her areas of interest include client education, palliative care and the role of the immune system in cancer development and treatment. Julie's personal interests include circus arts, rock climbing, camping, and cats.