Updated: Jan 7, 2021
This is Lloyd's story. He is receiving a Classical Chinese Medicine herbal protocol after a diagnosis of oral squamous cell carcinoma and has reached a complete clinical remission. Lloyd is fortunate because he came to see me when the tumor was relatively small, so we had more options. Lloyd's story mirrors the story of two other dogs who came to see me for palliative treatment after biopsy diagnosis of oral squamous cell carcinoma when their people didn't want to pursue surgery to remove part of the jaw.
Surgery and radiation are the standard of care for this tumor type, but it's important to share that there may be other options if the disease is caught early and is located in the front of the mouth. (Disease in the back of the mouth may be more aggressive.)
Hopefully stories like Lloyd's will spark interested in research into herbal supplements for the palliation of oral squamous cell carcinoma in dogs, potential mechanisms of action of herbs which might explain these kinds of results, and help us help our patients live the best lives possible. The illustration of the timing of tumor response, first stable disease and months later eventual regression, is also typical of my experience with other pets. This illustrates how herbs may work differently in the body than most conventional medicine treatments and that response to herbal therapies can often take a long time, requiring careful monitoring, patience and persistence.
Background information on Canine Oral Squamous Cell Carcinoma
(Before I continue, I want to mention that cats are different. But we all know that! )
Squamous cell carcinoma is the second most common type of oral cancer in dogs. The front part of the jaw (rostral location) is the most commonly affected location. In up to 75% of cases tumors will invade the underlying bone. When tumors are located in the back of the jaw (caudal location) they are typically associated with a more aggressive behavior and carry a less favorable prognosis. Metastasis (tumor spread to distant locations) is uncommon with rostral tumors, occurring in less than 20% of cases. Risk of metastasis increases with tumors in a more caudal location (up to 40%).
Treatment options are dependent on how large the tumor is and whether it has spread. Surgery is the treatment of choice and the standard of care for tumors in the front part of the mouth. CT scan is performed to determine how invasive the tumor is and how much underlying bone is involved. Since most tumors have underlying bone involvement, surgical removal with 2cm margins around the tumor is usually recommended to ensure all the tumor is removed. Depending on the location of the tumor, this can mean removal of the front quarter of the jaw or the whole front part of the jaw. Tumors located on the lower jaw have lower recurrence rates (10%) and higher median survival times (ranging from 19-26 months) with 91% 1-year survival rate. For tumors on the lower jaw recurrence rate is higher (29%) with published median survivals between 10-19 months and a 57% 1-year survival rate.
Factors which help predict a better outcome and potential for longer survival are known to be
1) rostral location
2) small tumor size
3) complete surgical removal with clean margins
4) no evidence of metastasis
For tumors that cannot be successfully removed, radiation is usually recommended. Median survival time with radiation is reported to be about 15-16 months. Dogs with smaller tumors live longer. For tumors less than 2cm, progression-free survival is over 5.5 years. For larger tumors regrowth happens more quickly, with progression free survival of 2.3 years and 8 months for tumors measuring 2-4 cm and greater than 4cm respectively.
Chemotherapy has been used as a palliative treatment but survival time is more difficult to predict. Response rates to chemotherapy are between 25-60%. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used in a palliative care setting (comfort care) and may result in remission in a small percentage of dogs (17%).
Lloyd came to see me in late January of 2020 at the age of 12 years young. A gingival mass had been debulked from the front part of his jaw in early January. Biopsy was consistent with a papillary squamous cell carcinoma. Lloyd was feeling well at home with a normal appetite. He was receiving Gabapentin, Dasuquin and Cosequin for arthritis. He was receiving no other supplements. He was eating an over the counter kibble diet.
Only 21 days after his debulking surgery, in which all of the visibly affected gum tissue but no bone was removed, the tumor had already grown back to a size of 1.8x1cm. Chest radiographs and evaluation of the lymph nodes showed no evidence that the tumor had spread. His bloodwork showed a mild anemia (HCT 35.5%) but was otherwise unremarkable. CT scan was not pursued because surgery and radiation were not being considered at that time and results would not change our palliative care approach. Additionally, because he had lost teeth due to tumor invasion, it was expected we would find bone involvement on the CT scan.
Lloyd's parents were very reluctant to pursue surgery given his age. They had some financial sensitivity but were primarily interested in making sure Lloyd lived as comfortable a life as possible for the time he had left. Based on the favorable results I was able to share regarding good long term disease control with two previous patients (see their stories below), Lloyd's parents decided to try herbal therapies first to see if we could slow the growth of the tumor before finalizing their decision about surgery.
Lily was diagnosed on biopsy with a squamous cell carcinoma on her right upper jaw, rostral location, and experienced a complete remission with palliative Chinese Herbs. CT scan performed prior to starting her herbal protocol confirmed the presence of bone involvement and that the tumor extended across the midline of her hard palate. She lived almost 5 sassy years after diagnosis, ultimately leaving the world due to a collapsed lung lobe at the age of 13.5 years with no evidence of her oral tumor.
Ace was diagnosed on biopsy with a squamous cell carcinoma on his right upper jaw, rostral location. His tumor was just under 2cm when we started his herbal protocol. He experienced a complete remission with palliative Chinese Herbs. He was lost to follow-up 2.5 year after his diagnosis when his family moved out of state. On his last recheck there was no visible tumor in his mouth.
We started Lloyd on a comprehensive herbal and supplement regimen which included two Classical Chinese Herbal formulas: modified Xue Fu Zhu Yu Tang and Huo Luo Xiao Ling Dan. We did not start Lloyd on any non-steroidal anti-inflammatory drugs (NSAIDs) in favor of first assessing response to Huo Luo Xiao Ling Dan, which contains Ru Xiang (Boswellia/Frankincense), Mo Yao (Myrrh), Dan Shen (Salvia) and Dang Gui (Angelical Root) and had been used in my practice as an effective "herbal NSAID" instead of NSAIDs in the past. We also tested his Vitamin D level and omega-3 fatty acid levels with commercially available tests.
Lloyd came back 2 weeks later and the tumor had not increased in size. Given the initial rapid growth, we elected to continue his current treatments. His omega 3 fatty acid level was low so we also started an omega-3 fatty acid supplement at that visit. At his recheck 3 weeks later, now March 2020, the tumor was still stable, measuring 1.8x1.2cm. His vitamin D level was low so we also started a vitamin D3 supplement. At this point, given Lloyd's excellent quality of life and encouraging results in slowing tumor growth, his parents elected to continue his current treatments.
This is a photo of Lloyd's tumor at his visit in March 2020.
Lloyd came in to see me every 2-4 weeks for the first few months, after which time we were pleased to see the tumor shrinking and increased his recheck interval. He continued with his herbal protocol and on his recheck today looks to be in a complete remission with no visible evidence of tumor on his jaw. Notice how long it has taken for the tumor to shrink. Lloyd's parents have been diligent in continuing all his treatments and are thrilled with his quality of life. He has had no adverse effects from his herbs and takes them twice daily in some cream cheese. He is also eating a balanced fresh food diet now and loving it.
April 2020 visit: tumor measurement 1.5cm x0.8cm
June 2020 visit: tumor measurement difficult to acquire as it is mostly gone
October 2020 visit: no evidence of disease
Lloyd is a super sweet guy and always cooperative for our photos. We just love seeing him at his visits! It has been a rewarding experience to help him and his family arrive at a treatment decision which fit their goals for his care. His parents have been diligent about giving him his treatments regularly and attending all his scheduled follow-up visits. We have been monitoring his tumor response, bloodwork and vitamin D levels regularly. Lloyd did require a dose decrease of his vitamin D3 supplement, as his 2 month recheck was a bit above our target. However his calcium level has remained normal. Because Vitamin D levels are highly influenced by diet, it is not unusual for an adjustment to be needed when the diet is changed. This is one reason monitoring is important. He has had no signs of toxicity from his treatments, which will be continued long term as long as they remain effective.
Lloyd is a great example of what is possible when we are willing to think outside the box and work together to carefully choose treatments based on the unique needs of each patient and family. I am grateful to Lloyd and his family for entrusting his care to me and for allowing me to share his story.