Full Transcript

Dr. Venable: Welcome to the Veterinary Cancer Pioneers podcast, the show where we delve into the groundbreaking work of veterinary professionals who are dedicated to advancing the field of veterinary oncology. I'm your host, Dr. Rachel Venable, and I'm thrilled to embark on this journey with you. All right. Hello, everyone, and thank you for joining us today. I'm honored to be here as we shine the light on remarkable individuals who are pushing the boundaries of veterinary medicine to combat one of the most formidable foes pets face: cancer.

In this podcast, we'll probe the minds of veterinary cancer pioneers, those who have dedicated their careers to unraveling the mysteries of this complex disease. We'll explore breakthrough research and discuss the latest advancements and diagnostic techniques that are paving the way for personalized treatment plans tailored to each individual animal.

Today, I am honored to introduce our special guest, Dr. Betsy Hershey. Dr. Hershey is one of the few boarded veterinary oncologists who also provides an integrative approach to pet cancer. Dr. Hershey received her doctorate from the University of Minnesota. She then completed an internship in small animal medicine and surgery at the University of Pennsylvania and a three-year residency in medical oncology at the University of Wisconsin-Madison. She became a diplomat of the American College of Veterinary Internal Medicine of Oncology. She's also received certification in veterinary acupuncture from the Chai Institute and the China National Society of Traditional Chinese Veterinary Medicine. She's also trained in Chinese herbal medicine, food therapy, ozone and ultralight therapy, and hyperbaric oxygen therapy. Dr. Hershey has won numerous awards for her research on inhalation chemotherapy and vaccine sarcomas and cats and has been included in the Manchester Who's Who among executives and professionals for her professional accolades and achievements. She has authored and co-authored multiple publications, including several book chapters. She opened Integrative Veterinary Oncology in Phoenix, Arizona, and it's a practice that's focused on providing holistic and comprehensive care for animals facing cancer.

Get ready to be inspired as we delve into the remarkable journey and insights of Dr. Hershey, a true trailblazer in the world of veterinary cancer care. Thank you so much for being here today, Dr. Hershey.

Dr. Hershey: Thank you for having me. It's truly an honor. 

Dr. Venable: No, it's certainly honor is all mine. Reading your background, I have one question. You grew up in very cold places, but now you're in the desert. What was that transition? 

Dr. Hershey: You get used to it after a while. I remember when I first moved here, and I was working for Mary Kay Klein, she was always cold if the weather was under 70, and I used to laugh at her because we would wear shorts if the weather was 40, where I grew up and where I trained, and now I'm just like her. If it's under 70, I'm cold, and I'm wearing a sweater.

Dr. Venable: Nice. Now, I can understand that. I always think it's interesting how people move around or if they stay in the same spot. What got you into veterinary medicine?

Dr. Hershey: I consider myself a late bloomer. It's not something that I wanted to do from the time that I was little. In fact, when I was in college, I struggled with what I was going to be when I grew up. I always loved the sciences, so I was in science and math. I thought about getting a PhD in math and teaching. Then I had a conversation with my counselor, who was a chemistry professor, and he said we were talking about my love of animals, and he said, have you ever considered veterinary medicine? He set up an internship with his veterinarian who took care of his cats, and so I spent some time in the veterinary clinic, and I thought, yeah, this is something that I could do. I was so excited about I'm going to be a vet that I told my mom, and she said to me, you know what, of all the things that you said that you wanted to be when you grow up, this is the one thing I can actually see you doing. I guess it was meant to be, but it didn't come at five years of age. It was a process through college, and I ended up having to take an organic chemistry class during the summer to catch myself up with the prerequisites, but it's been the best decision ever. It's truly a love.

Dr. Venable: That's awesome. It is interesting. You hear people that, yes, since they were five new and then others when they were older; I was a senior in high school, so I get it. I was that later bloomer, too, so that's really interesting. That was so nice that your advisor was so proactive for you. That's really great. 

Dr. Hershey: Yeah. He was definitely one of a kind for sure. Yeah. He was a brilliant man, but just a very nice man as well. Right. He certainly sounds like it, and then what got you into oncology? Well, I was a late bloomer, and that's a concern as well. During veterinary school, I wanted to do Zoo and Wildlife Medicine. In fact, I did a lot of externships during my senior year. I spent eight weeks at the National Zoo in D.C. I spent four weeks at SeaWorld in Orlando. I really thought that was the path I was going to take, but everybody I talked to in the field said you really need to do a small animal rotating internship first and get experience before you start looking at residencies and positions in Zoo and Wildlife Medicine. I did my internship at Penn. My very first rotation was oncology, and I fell in love with it, and that's where I wound up. But we do a lot of exotics oncology, so I love to do the exotics, so I still get some of that exotics in what I can. 

Dr. Venable: That's great because there's not a lot of people that do exotics. 

Dr. Hershey: We do work a lot with the exotic veterinarians just because we're not so accomplished at getting blood from some of these little critters, and some of the birds, too, are hard to handle. But I love to do it, and we've worked and collaborated with some of the exotic veterinarians, so that's a lot of fun for me. 

Dr. Venable: Oh, that's really cool, and it does seem like you like to try a lot of different things, including the holistic. I feel like a pet owner, I know I get a lot of questions about supplements and trying holistic. What's your philosophy on that? And then also, I kind of want to know how you got into it. 

Dr. Hershey: So when I first started in oncology practice, I finished my residency, and I was working for Dr. Klein, and I got to a point where I felt there was so much more that we could do to support our patients, even if they were undergoing conventional treatments, but there were some owners that didn't want conventional treatments. There were some patients who may not have benefited from conventional treatments, and yet the pet was still relatively happy and having a good quality of life. I just didn't believe that there was anything more that we could do for these patients. So that's how I started out, started training at the Chi Institute, learning acupuncture, and it just sort of built from there. Sometimes, when I look into a new treatment or a new supplement, it's because one of my clients has come to me and said, what do you think about this treatment, or what do you think about this? And I think, yeah, let's try that. So I'll do some research. Sometimes, things don't pan out the way that you want to. There's a lot of things that we try that we don't really do on a regular basis because they didn't work very well or they had some toxicity, but I think that's true of conventional medicine as well. But there's so much that we can do with supplements. There's so much we can do with ozone and hyperbaric therapy, even if it's just improving the quality of life of that patient and buying some additional time. And a lot of these things I do in conjunction with conventional medicine. So we're not poo-pooing conventional medicine. I still believe very much in surgery and chemotherapy, radiation, and immunotherapy, but we're using a lot of these treatments as an adjunct to conventional therapy. And I do very much believe that it can help improve responses to therapy. It can improve quality of life, and it can even improve survival time in some cases. 

Dr. Venable: Oh, it is interesting. And I think a lot of people, that's what they're looking for, right? I think they hear about supplements or they see some stuff online. So, what do you recommend for oncologists? Because I know for myself, I get a lot of questions, but I don't always know. Are there any good resources like when clients start asking you, or what do you recommend on that front? 

Dr. Hershey: Yeah, I mean, sometimes there's not; there are so many different supplements out there. Even as a trained person, it's very difficult for me sometimes to wade through what's a good supplement and what's not a good supplement. I try and stick to things that I know and people that I know, veterinarian-run products and companies to try and, because you can't know everything about everything. So, I stick with Jing Tong Herbal because I train with Dr. Xie at the Chi Institute, and he's an exceptional veterinarian, an exceptional leader and teacher, and a man of very high integrity. So I believe in the work that he's doing; I believe in the quality of care that he puts into his supplements. I've seen the facility, and some of the CBD supplements we use are predominantly Rx vitamins because I have a relationship with Dr. Rob Silver. So sometimes you're using products of people that you know and you trust. It can be very difficult to wade through a lot of the supplements that people are bringing you. And I do believe it's possible to over-supplement a patient. Some owners will come, and they're trying to get 30 different products into their pet, and the pet's not eating, and the pet's vomiting and you very much can do that with supplements. It's not just conventional therapy that can cause those side effects. So we try and pair it down to just some basic supplements, but a lot of it is training, too. I mean, I trained at the Chi Institute. I still teach at the Chi Institute. We teach, and I teach labs in acupuncture at the U of A. I've done some classes here in Phoenix. I travel to the Chi Institute and teach. So, I'm always learning, and I learn new things, and I learn new things from other practitioners. I do ozone as well, but I still go to the ozone meetings and some of these virtual meetings. Even in the meetings that I teach at, when you watch the other practitioners, you learn something new. And so I think a lot of it is just being open-minded and calling on your colleagues that do some of this stuff to help you out. I never hesitate. I have a direct line to a lot of the specialists in Phoenix that I talked to about certain cases. I will consult with the Chi Institute if I need some help selecting verbal therapies. I talked to some of my other holistic colleagues. It's teamwork. We're all learning, and as long as we're open-minded and we continue to learn and grow, I think we'll never be tired of this profession or any profession, but just don't stagnate, I guess. I'm always willing to try something at least once. Sometimes, it doesn't work out, and I don't ever try it again, but sometimes, things have been really beneficial to bring into the practice, and we continue to offer it. I hope that answers the question. 

Dr. Venable: Oh yeah, no, and I felt like that was great because it is important to be open-minded, right? And if anything, not just because you don't want to miss out on something that could help these patients, but also, like you said, you don't want to get stagnant. It's like you need to keep learning and growing because otherwise, I think that could even be some other problem with burnout, right? It's like you just keep doing the same thing, and you're not really growing or learning. So I think that makes a lot of sense. So, for people who are interested in learning more about the supplements, like maybe trying to do a little bit more integrative, would you recommend the Chi Institute, or is there any good website where they could find some of the CE and things? 

Dr. Hershey: I mean, there's a couple of things. The Chi Institute is predominantly Chinese medicine. So you're gonna get Chinese herbal therapy. There is a, I can't remember the exact name of the website, but Rick Palmquist and, gosh, I'm forgetting names now. There's an integrative website that you can learn, like Western Herbology and other types of supplements, through those classes. I don't know if there are great sources. I mean, you can certainly buy books on the subject. Chi Institute has an herbal handbook that’s sort of my go-to guide. I have enough knowledge of those herbal supplements, but sometimes I need to look at the book to decide which of two or three I'm thinking of are going to be best for that patient based on some of the signs and what we call Chinese medicine patterns that I'm seeing in that patient. But even in the Chi classes that I teach and I've trained, I've probably been doing acupuncture and herbal therapy for 15 years. I don't feel like I know much of anything. I certainly know more than the people who are coming along and just learning it in the last six months, but I always tell them don't hesitate to open the book. I have my acupuncture books, I have my herb books, by my desk, just like I use my palm handbook for drug therapy. I'm constantly looking up things, I Google a lot. I'm just as bad at Dr. Google as anybody else. But obviously, I'm looking for publications and things to support that. But that's usually how I do it, or I'll go online and find which one of my colleagues might be better knowledgeable in something than I am and pick their brains.

Dr. Venable: I think that's true. We're all a team, right? Like you said, looking people up and just reaching out, especially those more specialized, like the integrative or just trying new things and kind of along with the trying new things, what have you seen lately? I feel like there's been a lot of different diagnostics and even some treatments that have come out in veterinary oncology in the last few years. Anything that you're excited about or that you're using more than once?

Dr. Hershey: Right, now, we're using the liquid biopsies that are offered through, what is it, pet oncology and NuQ. I don't think I've used the NuQ. And, of course, ImpriMed is probably the thing that I use the most. And a lot of that is, I've been practicing for 25 years already, and I say over and over again, I feel like maybe until recently, we really haven't made much advances in the treatment of lymphoma since I was a resident. We're pushing the same chemotherapy protocols. We've tried the University of Wisconsin CHOP protocol. They tried escalating the doses of doxorubicin and cyclophosphamide. And you can go up a little bit on the cyclophosphamide dose, but we couldn't go up on the doxorubicin dose without significant toxicity. They tried taking that 25 weeks and making it 19 weeks, where you're doing all of the chemotherapy treatments weekly. Guess what? That wasn't any better than doing it over 25 weeks. And so I went back to the 25-week protocol because the owners are always looking forward to, “Oh my goodness, we can go to every two weeks.” And if there was no advantage to doing 19 weeks, we went back to 25 weeks. 

There've been some new drugs on the market. I think, you know, Tanovea being one of them, I've been using that more and more. I think it's actually turning out to be a fairly good first-line drug for some patients; although a little bit more pricey, it's looking to be very good as a second-line drug for a lot of patients. Laverdia, to be fair, I haven't been overly impressed with the responses that I've gotten from Laverdia, but I do think there's, you know, a role for it for owners who just want oral therapy and don't wanna do IV drugs. And also the fact that it does not induce multi-drug resistance. So, it's something that the general practitioner could potentially start the pet on the dog until they can get in to see an oncologist. There's not enough of us, you know, even in Phoenix, there's not enough of us in trying to get these lymphomas in a timely fashion is still always a challenge. So some of the, you know, we have some new drug therapies, but I still feel like, you know, we're still doing CHOP, we're still getting the same results we did 25 years ago, but now we have the ability to test the patient's response to chemotherapy through ImpriMed's chemotherapy sensitivity assay. And I'll be honest, I'm still learning, and I do feel a little bit, and I've had a whole conversation with ImpriMed, so nothing I'm gonna say is nothing that I haven't said to them already, but you know, they are, and they're terrific to work with. But if you have a question about how to interpret the test, they're not veterinarians; they can't help you interpret the test, they won't help you interpret the test. So sometimes I feel a little bit like I'm out here on my own, like interpreting it, and you're wondering, like, am I making the best decisions for this pet based on how I'm interpreting it? I hope other people are interpreting it the same way, but I guess there's a big presentation coming up at VCS. So I think as we, more of us, do this test and we give the feedback to the company, I think we're gonna learn, you know, whether we're interpreting this test or not. And I do think it's helpful, it's helpful in the sense that I can, I have a fairly good sense if a patient's gonna have an initial good response to therapy, and if they're likely to maintain that response at least through the first four months of the protocol. I can't predict what happens after that. I can't tell the owner, “Oh, your dog's gonna be a, you know, a six-year remission survivor as opposed to a 12-month remission survivor.” But I at least can tell them that they have, they'll have an initial response to therapy. I also can tell the dogs that are gonna do very, very poorly. So when the ImpriMed comes back, and it shows a very low percentage of patients that or a low percent chance of response for that particular patient, that they're likely to progress within the two to four months. And then when you look at their single drug prediction model and those CHOP drugs are pretty low on the list, or they're below the 50 percentile for their prediction score, you know, like this isn't gonna go well, and that has clinically panned out for those patients. Now, most of my owners still wanna try, but at least I can alter their expectations of how much time we're gonna buy their pet. 

What's more interesting is in the patients that don't look like CHOP responders, now what? Now, what do you do with their chemotherapy? Because the whole goal, in my opinion, is we're trying to personalize or individualize the chemotherapy treatment, and at least based on the historical studies, the majority of dogs are going be initial CHOP responders. We're still treating the majority of our patients with CHOP, but there are those that aren't CHOP responders. How do you make up a protocol for them? One of the patterns I've sort of been seeing as I go along, and I think we sort of knew this even before ImpriMed came along, is that T-cell lymphomas are harder to treat. Shorter remission times struggle to get them into remission, and most of the time, their CHOP graphs have a low percentage. They're likely to progress within two to four months, but if you look at their single drug prediction model, then Christine and Cyclophosphamide are usually pretty high on the list, but Doxrubicin is low, and Lomustine is higher on the list. So one of the things that I've started doing, and a lot of us were doing this anyway, is taking out the Doxrubicin in their CHOP protocol and putting in Lomustine. So you're having a little bit of a modification there. That's sort of an easy modification to make, in my opinion, but the dogs, where I have so many other drugs that are at the top of the list, and all the CHOP drugs are lower on the list. I've made up doesn't sound very scientific, but I've sort of made up a protocol for some of these patients using the drugs at the top of the list. So, for example, I had one dog that was getting a Tanovea-Vincristine-Asparaginase protocol. That dog actually did quite well. He did not respond to CHOP. So a lot of the dogs where the owners want to do the ImpriMed, the ImpriMed can take up to two weeks to get results. And you can't wait two weeks to start treatment on these patients. So the recommendation for me to the owner is let's start CHOP. We'll usually get through one to two treatments before I get the results back. Once we get the results, we'll see what the results tell us, but I'll also get to see in those first two weeks of treatment how your dog is responding to CHOP. And that helps me make the decision as well. So this particular dog that was on Vincristine-Asparaginase-Tanovea treatment was not a CHOP responder. He had very little reduction in his lymph nodes with the first two treatments of CHOP. Vincristine worked a little bit better. Cyclophosphamide didn't touch him at all. We switched him to that protocol. He went into remission, and his remission lasted a year. And this was a dog that was not a CHOP responder. I thought that was quite impressive. When he did relapse, he didn't respond well the second time. And we lost him pretty quickly. But to have a year, I think, in a dog that had a very poor or no response to CHOP was still pretty impressive. And I do think that the knowledge of the ImpriMed results contributed to that. Otherwise, what I tell my clients, too, is it takes a little bit of the guesswork out. What did we do before ImpriMed? Well, we started everybody on CHOP unless they wanted to do some sort of modification. And if they responded, we continued. And if they didn't, we just started throwing other drugs at them. We just try one drug. If it doesn't work, you try another drug. And so you're guessing a little bit with this drug work, with that drug work. This takes a little bit of the guesswork out. So, I feel like I have a much better chance of improving response and remission time. We'll see if that holds true once we collect enough cases. But at least from individual cases, I do think it's been very helpful in many of them. 

Dr. Venable: Yeah, that is really interesting. Because who would have thought Tanovea-Elspar-Vincristine? That wouldn't have been a combination that would have come to mind otherwise. So it's really cool that the dog had a year's response because I wouldn't have expected that. 

Dr. Hershey: No, me neither. But definitely. 

Dr. Venable: Oh, that is exciting. Because I do agree with you. Because so often, it's like outside of CHOP, it's kind of spin the chemo wheel. I feel like that's always the joke, right, that oncologists make. It's kind of like, well, we try, you know, I always try to use stats and studies. But at the end of the day, it is.

Dr. Hershey: We're spinning the wheel. Yeah. So when I was a resident, I actually made a wheel of rescue that had a syringe as our spinner. And we would spin the wheel sometimes just for fun. I mean, we made educated decisions for our patients. But that's, yeah, that's kind of how you feel sometimes, you're just spinning the wheel, and whatever the syringe lands on, that's the drug you're going to try next. 

Dr. Venable: Right? And you were saying that owners seem to like the test or kind of like to know. I mean, is that your experience? So that's your experience. Like most people want to kind of get a sense. I mean, as you said, we don't have a crystal ball. You can't say, oh, you're going to be in remission for multiple years versus multiple months, you know. But do you find a lot of pet owners find this helpful? How does that conversation go?

Dr. Hershey: I have not really had much trouble selling the test to my clients. I would say I offer it to every lymphoma that comes in the door. Assuming their lymph nodes are still big, some of them come in on prednisone. They're in remission. We can't collect the test if they're in remission, but we offer it at relapse now as well. But I offer it to every lymphoma that comes in the door. And I would say probably 90% of my clients will opt for the test. And I explain it just how I just explained it in terms of giving us an idea of whether their dog's going to be a responder, whether they're going to be responsive to CHOP, whether there are other drugs that might be better with the whole goal of trying to improve that particular dog's response and remission time. And that's what the owners want. They want more time. So if we can give them the hope that this might help us to buy additional time, then by just guessing on their chemo, most owners are for it. And we're starting to offer it at relapse now as well. See, learn something new every day. However, I recently learned that the drug efficacy can rearrange itself at relapse. So those drugs aren't necessarily going to be in the same order of which they were in their single drug prediction model at initial diagnosis. So we are offering the ImpriMed now at relapse for owners. I would say there's probably a percentage of patients that have the test redone. I would say maybe 50% of my clients are opting to retest with ImpriMed. The company gives a discount for a retest. So we also offer a discount for a retest. So it's about half the price of the original ImpriMed test. Some owners do it. Some don't. If the owners don't, we just refer back to the initial ImpriMed test and hope those drugs still might work.

Dr. Venable: Yeah, that's something I've seen as well, where the relapse, the drug shift. So it is interesting because I don't think we had that knowledge. I can't think of a study that had really noticed that dogs, when they relapse, it's like, they really, it's totally, it's almost like a different lymphoma, in a sense than what you initially started treating. 

Dr. Hershey: Yeah, and I agree with that, too. I had a conversation with the company, and I was like, oh, that's interesting. Never thought about that before. 

Dr. Venable: Yeah, it is really interesting. And I think, too, like you mentioned, they are getting more data. And yeah, I think at VCS, I know they're planning on presenting more. As they get more data, it is interesting to learn all the different things that we're learning that we really didn't know before. And how are you seeing the responses with those relapse patients? Does it seem like it, and I know this isn't necessarily data that they totally have? They're still gathering it. But are you seeing, like, if you pick one of the higher responding drugs, that they're responding to that? Or what are you seeing with the relapse patients? 

Dr. Hershey: It's hard to say because I haven't done enough of them, to be honest. And what we used to do, and I still do a lot of, is that they were initially responsive to CHOP. And they've been off protocol for several months as I recycle them back through CHOP until CHOP stops working. And then I start looking at some of the other rescue drugs. I did have one dog recently that, on his initial ImpriMed, Mitoxantrone was the number one drug on his list. And it was above Ducks Rubicon. So, we ended up substituting Mitoxantrone for his Doxorubicin and his initial CHOP protocol. And he went about a year. And before his relapse, we retested him with ImpriMed. And now I think Doxorubicin is higher than the Mitoxantrone on his ImpriMed list. So we restarted CHOP but put Doxo back in. And he's in remission and doing well. He's about almost, I think, to week 25. So that dog will kind of be interesting to see. It's hard to say. I just haven't done enough cases really to know. 

Dr. Venable: Yeah, that is really interesting, though, especially as you're falling along these kind of unique cases. It is interesting to see how all that's going to play out. Earlier, you also mentioned liquid biopsy. I know that's another kind of hot topic that's going on. And the OncoK9. How are you using that one in practice? 

Dr. Hershey: I haven't used it a lot, to be honest. In a couple of cases that I used it on, we were not sure if some abnormalities on ultrasound were cancer or not. So, we were using the biopsy to try and increase or decrease our index of suspicion. The first case was a middle-aged Rottweiler who came to see me. She was recently diagnosed with Addison's disease, but she also had a thickening of her GI tract. And the specialists that had been working her up for the Addisons were convinced that she had GI lymphoma. I wasn't quite so convinced. We opted to send out a liquid biopsy. It came back negative. And so we ended up referring her to Internal Medicine Specialists to manage Addison's disease. And she ended up living another year. So, for sure, it wasn't GI lymphoma because they don't live a year with chemo most of the time. And I can't remember what she passed away of, but it wasn't cancer. So that was a case that we used it in. 

Another more recent case was a dog that came to see me. The dog had been to see a surgeon for a workup of a lip melanoma. They were considering recutting the dog's lip. The dog had a CT scan. On a CT scan, they found a splenic mass. And then the owner came to see me for a second opinion because he wasn't necessarily keen on cutting the dog's lip and then cutting the dog's abdomen if it wasn't cancer. So we ended up sending off a liquid biopsy. It did come back negative. And so, my understanding is that liquid biopsy has been validated most for lymphoma and hemangiosarcoma. And those were the two cases we were testing for. Other cancers are a little bit harder to know at this point. But that dog came back benign. And so, we ended up just bringing the dog back a month later to repeat an ultrasound to see if there was any change in the mass. And the mass had grown. And even though the liquid biopsy was benign, I told the owners, it's grown. I would feel better if we got it out and had a biopsy on it. So he did go to a surgeon, had a splenectomy, and recut the lip as well. And it came back as a splenic hematoma. So, it was correct, but even hematomas can rupture. So, it was probably still a good idea that we got the splenic mass out. Because if it's growing, I feel better getting it out. Those are probably the cases I used it most in. I think it would be helpful, but I don't know how far they are in validating it for using it for knowing if your patient's out of remission. So if you have a lymphoma, or if you have a sick patient that you can't document with their cancer is relapsing on x-rays and ultrasound, it might be helpful with that. But I don't know that they have enough data on that yet. They might know, but at the time I asked them, they did not. 

So I think right now, that's just for dogs. I do, for cats, do a lot of the VDI testing for my GI lymphoma cats, especially my small cell lymphoma cats. Because a lot of them don't have much to monitor on ultrasound, some of those cats that are diagnosed with small cell lymphoma have no ultrasound abnormalities. They have an endoscopy or surgical biopsy that confirms the small cell lymphoma. And so I'll usually get the VDI test. So, you can measure the thymidine kinase level, and you can measure the haptoglobin baseline before you start treatment. And then I use that as part. It's not the only thing I use, but I use it as part of my monitoring going forward to see if the patient is responding to therapy, especially if I don't have anything on ultrasound. Like there's not a mass to say it's decreasing in size. Although we still ultrasound those cats as well to make sure that there are no progressive signs that are occurring as well. I do find that very helpful. It's hard to say to use it as a diagnostic tool, though I have used it to increase my index of suspicion. For small cell lymphoma, owners cannot afford to do an endoscopy or to do a surgical biopsy, but we want something that gives us a better feeling for this lymphoma. However, there is a huge overlap in the results of those testing between small cell lymphoma versus large cell lymphoma versus IBD. So, you have to use your clinical judgment as well. 

Dr. Venable: Yeah, that can be a tough one, right? It can be hard to diagnose those cases. Because yeah, doing endoscopy or surgery, all those owners, that's already kind of a frail cat, so they don't really want to do it. And yeah, you can really run into money issues at that point.

Dr. Hershey: I've certainly treated a fair number of cats based on VDI testing that was highly suggestive of lymphoma. If it was IBD, a lot of the treatment is the same. You put them on steroids, and if they're not responsive to steroids, a lot of times, they go on chemo as well. So I explain all of that to the clients. And it's with their consent that we're doing these treatments without having a tissue diagnosis. But in an ideal world, yes, we always want to have a definitive diagnosis. We always want to have a tissue diagnosis. But guess what? We're living in the real world, and that's not always possible. So, you have to use your best clinical judgment. And I find a lot of these blood tests through VDI, liquid biopsy, and the docs to be very helpful as part of that diagnostic tool. 

Dr. Venable: Yeah, I know that sounds really good. And it's nice to know what other people are doing, right? Because it is sometimes challenging when you're trying to figure out, like, wow, we need to, like you said, we live in the real world. I need to figure out how I can help this patient. But where's that middle road? So it's good to hear what other people are trying and what their success has been. What do you think is one of the biggest challenges in veterinary oncology? 

Dr. Hershey: Oh, gosh. That's a hard one. I mean, I think some of it is, for me, I've always wanted to have an option available to a client, even if they couldn't do the Cadillac treatment. I never want an owner to feel like they can't do something for their pet. Not every owner is going to come to see an oncologist for whatever reason. But we have owners that span the spectrum in terms of financial ability. I have owners who love their pets deeply, want to do cancer treatment, and want to help their pets but can't afford a $10,000 treatment. I want to have something available for them to treat their pet. And that's to a certain degree where a lot of the holistic comes in as well. Because sometimes conventional medicine doesn't have all the answers either. And for lymphoma, I always tell people you have to at least have them on steroids. We're not going to get remission with herbs. Can it improve remission in combination with steroids and chemotherapy? Absolutely. There are plenty of patients where chemotherapy may or may not work, but I might be able to help the owner with herbs. Maybe we can slow the growth of the cancer down.

Maybe we can help the patient feel better. And certainly, some of the supplements aren't cheap. And if you're doing 20 of them, people can spend a lot of money on supplements, too. However, if you're smart and you use a few key supplements, a lot of people can afford to do that. And so I always want to have something available. And that's also the nice thing about metronomic chemotherapy is those protocols are very affordable for most people to do, even with the blood work monitoring. So I never felt, that other colleagues, not necessarily downplay what other colleagues can do, but I see a lot of patients who come to see me because they didn't feel they were getting help elsewhere. They were told, well, you have to do this treatment, or there's nothing I can do. That's absolutely not true. There's a lot of things that we can do. And if we're not expanding our minds, and we're not learning new techniques, and we're not offering affordable treatments, how are we helping our patients, and how are we helping our clients? Some of these corporate veterinary practices are charging $10,000 for a CT scan and another $12,000 for surgery; who can afford $22,000? I'm in the field, and I can't afford $22,000 for surgery on my pet. How are we helping them? I get it. It's a business. We need to pay our bills. We need to make money. But I'm doing just fine, and I'm helping people, and I have treatments that will fit just about anybody's budget. And that, at the end of the day, for me, that helps me sleep at night. I'm helping people. 

Dr. Venable: I love that. And I think it is so true. You don't want to leave someone feeling helpless. I mean, they already feel helpless when their pet has cancer. And then if you basically tell them, look, we can either do this expensive thing or this. And don't give them another option because you're right. Supplements, hospice palliative type stuff, it's always options, and it's usually less expensive. And I think, like you said, too, as long as they know what the expectations are, why not offer it? Why not help them? Because I've seen, because I talk with people all over the country and recently talking with a gal down in Texas. And it was crazy what she was looking at for what you were just talking about the CT and surgery, and then staying at night. It was much bigger numbers than I was expecting. Yes, it is wild. So I think it is really important. And I think it fits with a lot of your approach of just that holistic all-in-one. It was like, well, how can we, at the end of the day, how can I help this person help their pet? So I think that's beautiful. I love that you're doing that, and I really enjoyed talking with you. And I think it's exciting. And definitely, people can know that you're doing all kinds of things in Phoenix. So, definitely anyone. I think it's mostly oncologists listening, but my neighbor was telling me how much she enjoyed listening to the other one. And she's got two dogs. So everyone knows that you have all kinds of good options and different things to do down in Phoenix. And also, I guess to mention before we get up that you're part of the Yale vaccine. So you're one of the few sites where people can come for that. I guess before we go, if you want to mention a little bit about that vaccine. 

Dr. Hershey: Yeah, so this is another case of my clients bringing something to my attention, but it's probably been a year or more. I had a client who found the information on the Yale vaccine and brought it to my attention. I said, I've never heard of it, but let me reach out to the researchers. I have no shame. I'll talk to anybody. So I reached out to the group at Yale, Dr. Mark Mamula, and told him I had a client that was interested. And then, all of a sudden, we became a center for some of their safety studies. And so we're familiar with the Yale vaccine. So when they started a much bigger scale study for certain tumor types like hemangiosarcoma, osteosarcoma, and transitional cell carcinoma, they asked us to be a center for that. It's a very exciting immunotherapy. There's a lot of really exciting preliminary work that's done. This is an efficacy study, so we're still learning. Will it work? Will it improve? Remission times will improve survival times. Can we shrink tumors with it? For most of the patients, it's not being used as a single therapy, although there are a few that are getting just the Yale vaccine for their tumor. But many times, it's combined with surgery, chemotherapy, and radiation therapy. Because it is a clinical trial, the patient cannot be in another clinical trial, and they cannot have another immunotherapy. So, if they've been treated with the Torigen vaccine or the Ardent immunotherapy vaccine, they are not eligible for the Yale vaccine. But this particular vaccine targets EGFR, so epidermal growth factor receptor, which is over-expressed or is normally expressed on many cancer cells, those three in particular. And so it's given as a subcutaneous injection on the neck, and we do it twice, 21 days apart. And there's some blood sampling that we are obtaining for the researcher. So, we will obtain a blood sample just prior to the first vaccine. We'll obtain a blood sample just prior to the second vaccine, and then there's a third blood sample that's obtained approximately three weeks after that second vaccine. And what the researcher is looking at is the patient's body mounting an antibody response or making antibodies to EGFR. And hopefully, at some point, will that correlate with response to therapy or remission time improved survival? The whole goal is to hopefully get this to be approved by the FDA or the USDA and make it a commercially available vaccine that anyone can have access to. The time will tell. Very exciting. 

Dr. Venable: Right. Yeah, I know. That's exciting. And I love how you are very open-minded and willing to try anything, but then you also analyze it and see how you like it and how things are going. Like you said, you try it once. 

Dr. Hershey: We'll see. I'll try anything once. I remember my lead technician, Terri, who has been with me for 13 years. And she's always telling me that every time we interview a new staff member, they'll ask her why she's been here so long. And she said because I'm waiting for the next thing. I want to see what happens next. So we're always trying something new. 

Dr. Venable: Oh, I love it. I think that's great. Thank you so much for talking with us today. It's certainly been my pleasure. 

Dr. Hershey: Thank you. 

Dr. Venable: Well, that's it for this episode of the Veterinary Cancer Pioneers Podcast. If you enjoyed this episode and gained valuable insight, we would be so grateful if you could mention our podcast to your friends and colleagues. The Veterinary Cancer Pioneers Podcast is presented to you by ImpriMed.