This is the story of my cat Woodrow’s battle with feline lymphoma (lymphosarcoma, or LSA). Approximately two years prior to his lymphoma, he experienced renal failure, which continued in a "mild" form for him (for the most part), and was well-controlled by diet and medication. Although his renal disease was not severe, I joined the online list for feline chronic renal failure caregivers (see the CRF web site link, below – the group can be accessed through the Feline CRF Web site’s home page). It was lucky for me that I did, too, because they were very supportive when I first discovered Woodrow’s lump, and someone on the list put me in touch with the ONELIST feline lymphoma group (this also can be accessed through the links listed below).

I will discuss Woodrow's diagnosis for lymphoma; the background work I performed while waiting for his diagnosis; the treatment protocol used in Woodrow's care; and Woodrow's particular response to his treatment. I also include (in the "Links" section) some of the most useful Internet sites available at the time I was researching Woodrow's illness. If you are aware of other sites that are now available and may be useful as a resource for other people who have cats with cancer or with chronic renal failure, please e-mail me at the address below with the name of the site.

The day after his 14^th birthday, I combed Woodrow the way I always did each week: I would lie him on the bed or floor on his back, and the scratch his neck to get him to relax. Only this time, something was different. On the very first scratch, I felt a huge lump, the size of a walnut. It hadn’t been palpable 8 days before when I combed him, but it was now. I felt the bottom fall out of my stomach: this was the cause of the sense of dread that I had felt all the previous day.

Then it occurred to me that maybe it was just an abscess from a gum or dental infection – he had been having those kinds of problems the past couple of years. But when I checked the position of the lump, it was too far down to be dental in origin. I looked at the clock: it was less than 30 minutes before my vet closed, so I wouldn’t be able to get him there today. I called and made an appointment for the first thing on Tuesday morning (the next day). He wouldn’t eat that night, or the next morning.

My vet examined him and told me there were several possibilities: a salivary gland tumor, a thyroid tumor or lymphoma. He told me that the prognosis was better for the first two than for the last, at least at Woodrow’s age. He wanted to do an x-ray, draw some blood, and do a biopsy. Because of Woodrow’s history of kidney problems, he recommended a fine needle biopsy rather than an excisional biopsy, even though he told me that, not infrequently, the pathologist would not be able to determine what it was from a fine needle biopsy, and in those cases the excisional had to be done. He did the testing, and sent the sample off; he called me that Friday to let me know that the results of the fine needle biopsy were inconclusive. I took Woodrow in the following Monday to have the excisional biopsy performed. In the meantime I had noticed that one of his pupils was markedly larger than the other, and remarked on this to the vet. He asked more questions and examined him, but was unable to definitively determine the cause.

The blood tests were completed first, and indicated that, while his thyroid T4 level was a bit low, the profile did not display the pattern that would be expected for a thyroid tumor. The x-rays indicated that the mass in his neck was pressing against his trachea, and was spread over a large region internally.

At this point, Woodrow was eating, but not as much as usual, although he clearly was still hungry for his food. He would eat a small fraction of what he normally ate in a much longer time; if I didn’t keep the other cats away, when he wandered off and then came back, there would be no food left, so I fed him by himself for a longer period of time. The vet had told me that he would expect the results to be back by Friday, and that he would call me when they came in. Late Friday afternoon I still had not heard from him, so I called, but the office was closed early for the weekend. I spent all weekend terrified that the sample had been lost, or screwed up, or any one of multiple imaginative calamities. I called first thing Monday morning and found out that the results had come in on Friday, and that it was lymphoma. He recommended surgery to remove as much of the mass as possible (although, since it was growing in and around certain delicate and important structures, there was no way it could all be removed), followed by chemotherapy. I scheduled the surgery for later that week.

Later that day I began to wonder if it made sense to ask for a second opinion with a specialist. I thought it would ordinarily be a good idea, but I hesitated because Woodrow’s tumor was so large, and was growing SO fast. I was concerned that it might take as long to get in to see a veterinary specialist as it does to see a human specialist, and I didn’t think Woodrow could afford that kind of time. I posted this to the crf list, and someone reasonably suggested that if the wait turned out to be that long, they might squeeze me in earlier if I told them how fast his tumor was growing.

So I called my vet back that same afternoon, and told him that although I would still like for him to treat Woodrow, I would like to get a second opinion. He said he would set it up if I could tell him when I could take Woodrow in, and I told him anytime; he called back a few minutes later with the name of a specialty clinic and an appointment for the next morning.

I arrived at the clinic the next morning and was shown into an exam room where a technician came in and took Woodrow’s history and general information and entered it into a computer. Not long after she left, Dr. S, the oncologist who would be working with Woodrow, came in and introduced himself and examined Woodrow, and asked some more questions about his illness. The he outlined the treatment options on the blackboard, discussing the benefits and drawbacks of each. We arrived at a decision on the protocol and set up Woodrow’s first treatment for Thursday and Friday of that week.

The protocol chosen for Woodrow’s treatment was the Wisconsin-Madison Feline Lymphoma Protocol (see below). Dr. S said that he might adjust it somewhat, based on Woodrow’s individual response, but that this would be the general regime he would follow.

Woodrow came home late Friday afternoon (after his first chemo session, with vincristine and asparaginase, with prednisone to be administered at home), and seemed to be in good shape. He was sent home with some medications and some of Hill’s a/d food, to encourage him to eat more, which he did. He seemed to be feeling better and eating better and I was pleased with how he was doing. In fact, his tumor shrunk significantly from where it had been, and I was impressed by such a large response in so little time.

He went in for his second treatment (Cytoxan and Elspar) the following week (one day only), and continued to do well. He continued to take his medication and eat the a/d, and no longer was losing weight. However, late the next afternoon, he began to vomit – first after eating, and then just stomach acid. I called and was told to bring him in to the clinic for emergency admission. Blood tests indicated that he was hypercalcemic, and that this was causing the nausea and vomiting. He was admitted and ended up staying 6 days. With treatment, eventually the nausea and vomiting disappeared after a few days, but he still refused to eat. I came to visit him every day, and checked in more frequently by phone to find out how he was doing. When he still had not eaten on the 6^th day, Dr. S recommended inserted a feeding tube. However, that could have meant a significantly longer stay at the clinic, and I felt at this point that Woodrow might well not be eating because he was depressed, since he was a big Momma’s boy and had never been away from home for more than 2 days.

I asked if I could take him home and see if he would eat there. His oncologist agreed, but only if I agreed to monitor his eating closely, and to bring him back right away if he vomited again even once. He sent me home with medications to control his high calcium, anemia, low potassium and poor appetite and the schedule for giving them. Two of them had to be given by subcutaneous injection, which I had not done before. He said that he could teach me how to do it, or I could bring him in 3 times a week to have it done. I decided to learn how to do it myself, and so he showed me and then had me practice a couple of times, and said to call if I needed help with it. In fact, the injections turned out to be the easiest to give him, although he was good about taking all the meds. At first, he didn’t like it, but eventually I learned that if I gave him the meds so that I minimized the number of times per day I was coming at him to medicate him, he handled it without any stress. I also got in the habit of talking him through it, telling him, "OK this time it’s two shots, and three pills, and one liquid, and that’s all," or whatever the case was.

Fortunately, he did eat at home, without any vomiting, although he soon stopped eating out of the bowl -- at which point I had to feed him the a/d through a syringe. Although this process sometimes is called force feeding, I would not have done it if force were involved. Woodrow did seem hungry, but when he would go to his food bowl, he seemed to find the smell unappealing (or non-existent, I’m not sure which). In any case, he didn’t seem to mind my feeding him with the syringe at all – if he had, he wouldn’t have hesitated to let me know – and so 4 times a day I loaded up a 60 cc syringe and fed him. It was like giving a bottle to an infant. The only part he didn’t like was that some of the food would always end up getting on the fur around his mouth, and then he would paw at it (effectively spreading it around, thereby making himself even more irritated). I had to feed him as fast as possible because the longer it was on his fur, the crankier he got about wanting to stop the feeding and wash it off himself. So I fed him as quickly as possible and then washed him up with paper towels in warm water.

Although Woodrow did well once he got home, Dr. S decided to postpone the next chemo for a week, given the rough time his body had been through – the idea being that it would be better to let his body rest up and gain strength before giving another round of chemo, just in case he might have another serious side effect. His third chemo treatment was therefore 10 days after the second, and consisted of vincristine and prednisone (again, the prednisone administered at home, daily). His tumor was still clinically in remission at this point, and had been for several weeks. He continued to do well, although with the weight loss he had endured, he looked thinner than he had in years, and moved around a bit more slowly – the way an older, arthritic cat might. But other than that, you would not have known he was sick. He still enjoyed doing his regular activities and being king of our feline household. He loved sitting in the sunroom during the day, on his favorite perch on the cat tree, and sleeping either on my bed or in his little cat bed at night. He played still, although not as vigorously; but he clearly was still enjoying himself, which was my main objective for him.

He returned for his fourth chemo session the following week (Cytoxan and asparaginase); however, a couple of days before I took him in, I noticed that the lump in his neck was beginning to grow again. I showed it to his oncologist, and he told me that Woodrow’s tumor probably was no longer in remission, and that although we could try other protocols or other drugs, the likelihood of achieving another remission was remote. I was dumbfounded, since I had thought that once the original remission was achieved, it meant that we had a good six months or more. In other words, at the outset my impression was that there were two possible outcomes: either no remission, which meant that he would die fairly soon; or a remission, which meant that he would have at least six months, and possibly much longer than that, to live (and live well). He had the chemo and came home, but now I knew we had much less time than I had thought – probably not more than 3 weeks, according to his oncologist. As discussed below, I asked the oncologist for signs to watch for to tell me when it would be time to euthanize him, given my criteria (which was that I wanted to euthanize him when it got to the point that his suffering could no longer be ameliorated or controlled).

Once I knew that the tumor was returning, I hardly slept at all. I would fall asleep, with Woodrow on the bed as usual. However, now any time he moved, even if only to resettle himself, I would startle awake and be unable to sleep again that night. I hated to leave him alone for any length of time because I was afraid he would decline quickly while I was away and be suffering until I came home. I posted his condition to both e-mail lists, and people there were very supportive; I printed out some of their e-mails out and placed them on the walls near where he liked to hang out – especially the ones that had pictures of flowers, since he loved flowers. I also kept his music tape running whenever he was in the bedroom. In general, he wasn’t too fond of music (especially when I would sing). In fact, the only singer he liked was Madonna, so I had bought him a tape that had his favorite Madonna songs on it. I had been playing it in the car for him when we were travelling back and forth from the oncologist; now I brought it in and played it for him at home as well.

A week after this fourth chemo he returned for the fifth – mitoxantrone and asparaginase. Other drugs were considered, but I rejected them because I felt that the risk of serious side effects (like diarrhea and vomiting) were too high relative to the likelihood of better outcome. While he was at the clinic for this treatment, the oncologist noticed that he was eating litter, which he said could be due to either nausea or anemia. Since I used clumping litter, and since he suspected that Woodrow’s tumor had now spread to his intestines (it had demonstrably spread to other tumors in his neck) he recommended that I no longer use the clumping litter. He said that Woodrow could end up with a bowel obstruction, so instead I should use newspaper or something along those lines. Since there was more than one cat at home, I had to empty all the pans of clumping litter. I replaced the litter in some cases with folded newspaper, in some with shredded newspaper, and in some with the pads they use for incontinent dogs (they’re like huge diapers, and very absorbent). There are 5 pans in the laundry room, and I replaced the litter in all of them. Woodrow came in to use them. He stepped in the first pan, dug underneath to find the litter, and finding none, stepped out with disgust to try the other pans. He did this with each pan in turn, and realized that NONE of the pans had litter in them –and then very pointedly peed on the floor next to them. He never did like the pans that way, but after that he started using them.

However, I did notice that, unless he were doing it in a hidden spot in the apartment, he wasn’t defecating at all. At the same time, he could no longer ingest 60 cc’s of food at once: if I fed him substantially more than 30 cc’s at once, he would vomit up the difference right after I finished. So he had to be fed more often, but still he wasn’t pooping. The oncologist had me give him a laxative, but still nothing happened. Finally, when he went in for his 6^th chemo, I told the oncologist that he hadn’t pooped in over a week, as far as I could tell – although since I was working very long hours, there were plenty of opportunities for him to poop outside the pan without my noticing.

The oncologist explained that he could give Woodrow an enema, but that it might release bacteria that could kill him. However, without an enema he would become more and more obstructed, and he was is no shape for surgery to remove an obstruction. So I left him there for the enema and picked him up later that afternoon. The oncologist said Woodrow had come through it well and seemed to be feeling much more comfortable. He told me to call him any time between then and the next visit if there were any problems, or if I had any questions, and to have them page him if he weren’t on duty. Perhaps he sensed that, although Woodrow still was no worse than he had been a couple of weeks previously, that he might start downhill soon.

I took him home and fed him right away, as he hadn’t eaten since early that morning. He ate well, and I played with him for about 30 minutes afterwards, and then went into my office to work. About 30 minutes later, at 12:30 am, I came out to check on him. At first he looked fine – he was sitting in his favorite perch. But as I approached I could see that he was lying with his neck and head flat on the perch, rather than held up as usual, and that he was working hard to breathe. His breathing was labored – a little like a dog panting, only not so rapidly. Since he sometimes did this when he was frightened, and since he had had a rather stressful day, I picked him up and petted him for a while, talking to him softly and telling him everything was ok. After another 30 minutes, he was no worse, but also no better. I realized that it might not be fear causing his breathing problem, but I hated to call the oncologist at that point because it was 1:00 am. I decided to wait longer and see if things improved. I even considered waiting until the clinic opened, but I sensed that his problem was too serious for that long of a wait. So an hour later I called the clinic’s emergency number and told them Dr/ S had asked to be paged if Woodrow were having a problem. The rest of the story appears below, in e-mail I sent to the lists that had supported us through Woodrow’s illness, as well as to some friends and family members who had been supportive.

{Below are two e-mails I sent out both to friends and family members who had been following Woodrow’s illness, and to the crf and feline lymphoma lists. The first was sent the afternoon of his death, and the second was sent a week or so later, after I received several responses to the first. I realize that other people have different views about euthanasia, and I was not trying to persuade anyone to adopt mine, but rather, to let those who were interested know how my experience with it had gone.)

Dear friends,

Yesterday Woodrow went back to the vet for a general checkup and ended up staying for additional chemo and an enema. He came home in the early evening, and I fed him at 11:30pm and then held and played with him for a half-hour. He then went to sit on his favorite perch of the cat tree in the sunroom, so I went into my office to do some work. When I came out to check on him a 1/2-hour later, he was lying with his head flat on the perch, as though he didn't feel well. I went over to check on him, and his breathing was labored. I held him and tried to see if I could get him to feel better for about 90 minutes, but his breathing only became more labored.

When I had picked him up, Dr. S had told me that he was going off duty for 3 days, but would be in town, and that he wanted me to page him not only if Woodrow needed to be euthanized, but also if I had any questions or if I thought Woodrow might be having a problem. So finally I

did, and he asked me to go to the clinic where he works, and said one of the residents would see us, and said that person would call him in if he felt it would help. So I took Woodrow in around 2:00 am, met with the vet he recommended, and they wanted to keep him overnight and run some tests and just keep an eye on him, and said that Dr. S would come in first thing this morning to check on him.

Dr. S called me this morning and told me that Woodrow had an infection, and that he had given him some antibiotics, but that if he didn't improve by late this afternoon, it would be time to put him down. I asked if he thought it would help for me to come visit him (Woodrow is a BIG momma's boy), and he said not right then, because they were still working on him, but he thought when they were finished it would be a great idea, and that he would call me back when it was a good time, probably in an hour or two.

Less than an hour later he called, although I was on the computer and didn't get the message from my phone until 15 or 20 minutes later. I called him back, and said Woodrow was doing much worse, and he thought it was time to euthanize him, so I told him I would be there in 45 minutes or so (depending on the traffic).

When I got there, they brought Woodrow to me wrapped in a towel (because of the enema, he still was having little bits of uncontrolled diarrhea). I held him and talked to him for a 1/2 hour or so, and then Dr. S came in and asked me if I wanted more time, and whether I agreed that we should do it, and what I thought of Woodrow's behavior. Just then Woodrow started to make little cries like he was in pain. I said I want to do it NOW, because I don't want him having pain.

The way he does it is to put a catheter in the cat's leg and then flush the catheter, inject the drug, and then flush the catheter again. He does it this way so that the owner can hold the cat however and where they want.

Because of the towel, I held Woodrow the way you would cradle an infant in both arms, and I remained standing and he asked me if I was ready and I said yes. He flushed the catheter, and then asked me again if I was ready for the solution to be injected, and I said yes. So he did. Then he flushed it again. After a minute or so he took his stethoscope and told me Woodrow was gone. It was very peaceful. I loved that I could hold him the whole time, and I just kept whispering throughout the procedure that I loved him and thanked him for being my cat.

They let me stay alone in the room with him as long as I wanted. Dr. S came in when I was ready to give him up and talked to me for a while. Several of the people there who had worked with Woodrow told me to call any of them if there was anything they could do.

I had him cremated, and they handle all the details and will call me when the ashes are back. I am probably going to send them to a woman whose work I saw in a recent Cat Fancy, who makes urns just for pets.

I miss him so much! I will miss his snoring on my bed at night, and his VERY prompt nose-taps when his majesty's breakfast time arrives every morning. And his "helping" me with the laundry. And his "help" when I am typing on the computer keyboard. And his swift and sure "Left Paw of Doom", which he was famous for at the clinic (if you were doing something he hated, he would never bite or scratch: he would SLAP you with his left paw, really hard, with the claws not extruded. Then he would LOOK at you. If this failed to drive the point home, he would SLAP you again). I will miss his trying to figure out "doorknob principle", and the nights he accidentally (?) locked me out of the bedroom because while he was tapping the knob trying to get it open, he accidentally (?) hit the push-in lock. I will miss his acting as referee when Lily and Clawed (a very little and a very big cat, respectively) would tussle with one another. And I will miss the fact that although he was indifferent to most music, he ADORED Madonna (before I even knew who she was), and would literally run over and sit on top of the radio every time a song of hers came on (I finally broke down and bought him a Madonna tape).

Thanks for listening,

Nancy, for Woodrow

------------------------------------------------------------------------

Subject: EUTHANASIA WARNING -- IMPORTANT

Several people have responded to my post on Woodrow's passing, regarding how beautifully they thought Woodrow’s oncologist had handled his euthanasia. I benefited from a warning that some on the crf list some time ago posted; I don't remember who it was, but they had their regular vet treating their cat, only to discover when they took him to be euthanized that the vet did not allow owners to be present at the euthanasia. Soon after I first took Woodrow to the oncologist, I broached the topic of my criteria for when I wanted Woodrow euthanized. I wanted to make sure that we weren't going to have catastrophic disagreements over when the right time would be. I also asked for his input: since he's an oncologist, I figured he's dealt with this a lot, and has seen a wide range of views and has formed some of his own. One thing I liked about him was that he was very open to all aspects of this discussion, including telling me how he had handled the same situation when two of his dogs had cancer. The other thing I discussed with him, at a later date, was EXACTLY how the euthanasia would proceed (this is the first animal I have had to euthanize). He told me it was up to me if I would be present. He also

told me about how he prefers to use the catheter, so that people can hold their pets if they want, or pet them, which apparently is difficult (if not impossible) to do if the injection is being given directly into the cat through the skin (rather than through a catheter).

I know this is a dismal topic to discuss, and I felt a bit like a pessimistic ghoul discussing it with him while Woodrow was still doing well, but I didn't want to risk any problems with when or how Woodrow would be euthanized. And I'm glad I did, because I was able to give Woodrow exactly the kind of ending I wanted for him, at the time I felt was best for him -- and without any risk of snags, because the oncologist and I had discussed everything thoroughly.

There are several things I learned during Woodrow’s illness – some by default – which I will pass along for those who are interested.

For any illness with your cat: If you’re not sure about the treatment recommended for your cat, get a second opinion. Or a third. Or whatever it takes until you are sure. Learn as much as you can about the illness and the options for treating it. Decide what you want for your pet, and also what you don’t want. Be clear about this with the vet and techs – without being rude, of course. The same is true if you’re not happy about the way you or your pet is being treated by your vet and/or staff. Try talking it out first, but if they can’t or won’t do what you want, find someone who will.

For cancer: I think the best thing I did was to get a second opinion with a board certified veterinary oncologist. If there isn’t any near you, try a board certified veterinary internist. Even if you are happy with your primary vet, as I was, veterinary oncology is changing so quickly that it’s extremely difficult for a general practice vet to keep up.

Ask for copies of all notes and tests on your pet as they are done. And keep your own notes (on what you notice about your pet after each treatment, response to medications, about what the vets tell you, etc.). These can help your vet in making treatment decisions, and help you avoid confusion later on. With Woodrow’s care, the medications were so numerous, and the amounts and timing changed so often that – even though I have a fairly good memory – I couldn’t have kept it all straight.

For feline cancer, maintaining good nutritional status is very important. Make certain your cat is weighed on the same scale each time it goes in to the clinic. If it starts to lose weight, ask if either Hills a/d or Clinicare are advisable. These are nutritionally complete cat foods that also are nutritionally dense: that is, they contain everything your cat needs for long-run good nutritional status, but in smaller portions. This way, cats that can’t or won’t eat enough to maintain their weight can be fed smaller portions and still not lose weight.

It took me several months after Woodrow’s death to stop blaming myself for all the things I did wrong during his illness. In the end, I accepted that he just didn’t get as much extra "good time" as I wanted him to have.

I did have Woodrow’s ashes sent to the woman whose work was written up in the Cat Fancy article; she was very respectful and did a great deal of work for it. She asked me to send information and pictures about him. You can see the urn she designed especially for him at her web site; the link appears below. I recommend her without hesitation; tell her Woodrow’s mom sent you.

It also took me 15 months after his death to finish writing this up – it was just so painful.

One of the things that I saw over and over again on the crf list was that when someone’s cat died, in the long run they ended up acquiring another cat – whether they intended to do so or not. I looked around for a couple of months and acquired two kittens, both black and white Persians. They are Sean and Zorro, and it is the first time I have had two kittens at the same time. Watching them play together, and with the other cats, is so much fun. And watching them grow and develop and learn is even more enjoyable. Of course, they don’t replace Woodrow, and I still miss him tremendously. Some times it seems as though he has been gone for years; and some times it feels as though he were here just yesterday.