Imagine yourself in a veterinary surgeon’s examination room, bracing for the details of wound care, pain management and an exhaustive (and alarming) list of potential post-operative complications, when the doctor surprises you with an announcement: “With luck, we can avoid surgery altogether.”
Can this be true? Did you and your dog show up at the wrong appointment? Most of us who wield a scalpel for a living hope that the answer is no. In my opinion, surgery should be reserved for cases in which it is, handsdown, the best option — or, barring that, something to fall back on when attempts at more conservative treatment have been exhausted. For me, it comes down to a simple philosophy: if the patient were my dog and there were some decent alternatives to going under the knife, I’d be all for them.
However, things get complicated when we are a little too eager to embrace these alternatives. We become a marketer’s dream, easily swayed by anecdotal “evidence” and vulnerable to the allure of excessive optimism. In these heady veterinary times, as we are inundated by breakthroughs barreling down the medical pipeline, it pays to slow down and cast a critical eye on new options.
Take, for example, stem cell therapy for the treatment of canine osteoarthritis (OA). Debilitating joint pain, particularly when it is secondary to chronic hip dysplasia, accounts for a significant proportion of my caseload (more than 20 percent of dogs suffer from OA), and often spurs discussions about total hip replacement (THR). For the most part, THR is elective, the last trick in the bag when weightloss programs, physical therapy, acupuncture, joint supplements and a long list of nonsteroidal anti-inflammatories are no longer working. Now, a company named Vet-Stem is promoting another unique angle of attack: regenerative medicine.
Basically, the idea is this. Under anesthesia, your dog has some fatty tissue extracted. This sample is shipped to the company’s lab, where it is processed to extract stem cells, which are then returned to your veterinarian. With your dog once again under sedation, these stem cells are injected back into his or her arthritic joints. Over 500 dogs have received stem cell therapy in the past six years with (according to the company’s website) more than 80 percent of owners reporting improvement.
Blame my scientific training for a sense of wariness (and truly, this is not the same as skepticism). It’s just that anecdotes, owner testimonials and feel-good videos of stiff, sore, geriatric dogs transformed into leaping “puppies” make me start hunting for the evidence- based data. When I combed the scientific literature for information on stem cell therapy in dogs, I discovered just two studies, both sponsored by Vet- Stem. Though this gives me pause, the overall results were impressive: statistically significant improvements in lameness, less joint pain and improved range of motion. There are, however, a few points worth noting.
Only 35 dogs were involved in the two studies; all the dogs were also on anti-inf lammatory medications, and the duration of effect was only taken out to 180 days. From my perspective, on paper, stem cells hold lots of promise for the treatment of OA, but I’d like to see more independent studies, more patients and an absence of concurrent medications. I’d also like to know how long a course of treatment is likely to last.
Naturally, the media are quick to tout the possibilities of a sexy new treatment, but when they do so at the expense of tried-and-tested surgical techniques, I find myself beginning to bristle. For example, Time magazine ran a story touting the merits of canine stem cell therapy while attacking the proven option of THR. It suggested that recovery from the surgery would take “up to six months” and would be “four times as expensive” as stem cell treatment.
I practice in a hospital where, all told, stem cell therapy costs about $2,500 and THR about twice as much. Clearly, they are both expensive, and both require general anesthesia. However, THR has been available for dogs since the 1970s and there are hundreds of independent, peer-reviewed scientific articles to back its use as well as define both its benefits and its limitations. If I too succumbed to the easy and powerful allure of the anecdote, I could tell you that the vast majority of dogs on whom I perform THR are taking 30-minute walks twice daily by three months after surgery (and I have observed Labs with normal, full, weight-bearing function the day after surgery!).
Today’s dog owners demand something more than the archetypal, scalpel- happy bravado of a typical surgeon, and rightly so. But please, when seeking alternatives to traditional options, ask questions and demand answers before you write off the proven in favor of something new and speculative. I will continue to entertain alternatives to surgery because I strive to be a surgeon who — as Dr. Abraham Verghese says in the extraordinary novel, Cutting for Stone — appreciates that “the operation with the best outcome is the one you decide not to do.”