In our area, you need a referral from your regular veterinarian to schedule a consultation with an oncologist. Our veterinarian spoke with a surgical oncologist, provided Ellie's medical records, and advocated for Ellie to get in as soon as possible.

Is there evidence the cancer (or potential cancer) metastasized elsewhere?

In Ellie's case, when I agreed to surgery, we did not know for sure if her tumor was malignant or not; the odds were about 50/50. However, she had a full-body CT that didn't show any overt signs of metastasis. She was marked "clear" of metastasis. Metastasis (spread of cancer outside the original tumor) indicates cancer and is associated with worse outcomes. For example, if her tumor were malignant and had metastasized to her lungs, removing the original mass would not be adequate.

Is there evidence the cancer (or potential cancer) has invaded the vasculature (blood vessels)?

Likewise, invasion of a cat's blood vessels indicates cancer. Benign tumors usually do not invade tissue outside of the original tumor. The invasion of blood vessels limits the effectiveness of surgery, as cancer cells may remain in the vessels (and there is a higher chance of metastasis). 

In Ellie's case, her tumor was adhered to her vena cava (the main blood vessel in the abdomen) but had not invaded the vena cava itself (this was decided by looking at her CT). Surgically removing the tumor meant scraping the mass off the vena cava. Scraping the vena cava made the surgery more risky; if the surgeon scraped off a little too much, she'd catastrophically hemorrhage.

The lack of metastasis and no invasion of the vasculature made surgery a more effective treatment if the mass was cancer and also made it more likely the mass wasn't cancer.

If cancer is confirmed, what is the grade of the cancer? 

From what I understand, the grade of the cancer is only definitely determined by biopsy. Surgeons removed Ellie's mass and biopsied it; it came back as a low-grade cholangiocarcinoma. Low-grade cancers tend to grow more slowly and have a lower chance of metastasis. Higher-grade cancers tend to be more aggressive in terms of both growth rate and metastasis.  

A fine needle aspiration of the new tumor on Ellie's liver found at her first chemo appointment showed well-differentiated atypical growth. I believe this probably was the exact finding of her original mass (which is why her original mass's cytology came back inconclusive). They only assume the new tumor is cancer because the biopsy of her original mass came back as cholangiocarcinoma (this cancer tends to come back). Well-differentiated growths look more like normal cells. In cases where these tumors are cancerous, the cancer tends to grow slower and have less chance of metastasis.

What is your cat's current quality of life?

For Ellie Mae, she has/had a good quality of life both before surgery and now during chemo.

She eats enough and even begs for food; she drinks enough, enjoys snuggling and playing, and doesn't seem to be in pain. If you struggle to assess your cat's quality of life, try one of these formats to help you. 

Working with your veterinarian, you may improve many items on these lists. For instance, Ellie ate very little before we started an appetite stimulant. Her tumor pushed into her stomach. First, I tried feeding her small meals every hour. When she didn't maintain her weight doing that, we started Mirataz. She's still on it now - she regained all her lost weight and even added some.

If your cat is not drinking enough, try giving them squeeze treats. Most brands are 90% water. Ellie's struggled with and taken medicine for arthritis for years. Without that medicine, her mobility would be affected. Again, my point is that sometimes, alterations to your cat's routine might improve your cat's quality of life.

Another factor here is whether your cat wants to fight or give up. Generally, if your cat is acting more or less like themselves, your cat probably isn't done. Hiding, aggression, and depression (lack of interest in normal activities) may indicate your cat no longer wants to fight. I am fortunate that Ellie has shown an enthusiasm for life.

Please note that quality of life can change from day to day. I admit that I freak out when Ellie has a day where she doesn't eat as much as usual or is not quite as loving. Rationally, I know every cat has these days, whether they are dealing with cancer or not. But I find myself getting very upset very quickly. And usually, things are better the next day. Look at trends: are there more good days than bad? 

Will treatment provide additional time for your cat with a good quality of life?

Evaluating whether treatment will provide additional good quality time for your cat is tricky. In Ellie's case, when I agreed to surgery, we did not know for sure if her tumor was malignant or not; the odds were about 50/50. For me, I did not want her to die because a benign tumor grew so large that it affected her ability to eat and breathe. I knew if it was malignant, the odds weren't good (depending on the type of cancer) - even if they removed it. But I did not want to spend the rest of my life wondering if I could've "fixed" this (given that surgery was an option). Even though Ellie's mass was malignant and was cholangiocarcinoma (the differential with the worst outcome), I believe surgery gave her extra time. So far, she's had a good 6 months where she's been acting like herself - even while receiving chemo.

Again, with chemotherapy, I was told chemo had a 20% chance of helping (defined as slowing or limiting growth). We agreed that as long as Ellie had a good quality of life, there was nothing to lose. Five months later, her quality of life is good. Either her cancer is slow-growing, or the chemo is working. Do I feel bad about surgery and chemo? Not right now. I believe both of these treatments have provided us additional time together - with Ellie having the quality of life she had before she got sick. Even though we won't beat her cancer, the months of extra time we got when she felt good made the treatment worth it.

What other health issues does your cat have?

I decided to proceed with Ellie's surgery and chemo because I knew she was otherwise healthy. Like most 13-year-old cats, her kidneys show degenerative changes, and her joints show evidence of arthritis. Her CT revealed asthma. The CT suggested she also had hypertrophic cardiomyopathy - but an echocardiogram showed her heart was normal. We actively manage these conditions so they do not impact her quality of life.

Is surgery an option?

The location of Ellie's tumor was the sticking point for whether surgery was possible. The radiologist who did her ultrasound thought surgery would not be possible. As I mentioned before, the mass was adhered to the vena cava. Her portal vein also went through the mass. Nicking one of these vessels could be fatal. A CT was required to get a better look at the location of the mass and if surgery was an option.

In Ellie Mae's case, her tumor became large enough that it pushed into her stomach, and she didn't want to eat. If surgery was no longer an option, even a benign tumor would've killed her as it would have eventually become big enough that she couldn't eat and she'd struggle to breathe. Even though surgery would essentially cure a benign tumor, if surgery weren't possible, there was nothing we could do. 

Because surgery was an option for her, I couldn't imagine not taking the chance to remove it since it would essentially "cure" her.

Another consideration is whether resection will be complete (if the tumor is cancer). Complete resection means surgeons get all the cancer. As expected, because Ellie's tumor was so large and adhered to the vena cava, the biopsy showed that cancer cells went right up to the edge of the removed tissue. Resection was incomplete. For many benign tumors and some cancers, incomplete resection is enough. We hoped that her mass was benign or one of the cancers that wouldn't likely grow back. Unfortunately, her cancer often grows back even in cases where resection is complete!

For certain types of cancer, like most types of lymphoma, surgery is usually not an option as oncologists prefer to treat it with chemotherapy.

An oncology consultation means learning about (via additional diagnostics) and discussing your cat's health and quality of life, the tumor, and the potential outcomes. 

You need not commit to treatment just because you sought more information. You can consult with an oncologist and then decide not to do surgery. If you do surgery, you do not have to do chemo. For Ellie, each chemo treatment is predicated on her quality of life NOW. From where we are standing now, after surgery and ten chemo treatments, it might look like a package deal. But it was not. I got a consult with a surgical oncologist to get more information. When metastasis looked unlikely, the blood vessels weren't affected, and her health was otherwise good, I considered surgery. I couldn't bear the thought of Ellie dying from a removable benign mass. Each visit, each treatment, is a step. Just because you took the last step doesn't mean you have to take the next step. Living one day at a time has never been my forte. But that is the best way to approach a cat with cancer. You can't plan out the course of the disease or how your cat will react.

The decision on whether to treat your cat's cancer or not is a very personal one. Each case is different because there are so many variables involved. Because I approached Ellie's case aggressively (based on the specific details of her case), it might seem that I am advocating for everyone to follow the same path. Please understand that I am not. Any decision approached from a place of love for your cat isn't wrong. I know how scary and confusing this is. Hopefully, this post helps you come to a conclusion that brings you peace with your decision.