Nutritionist Lindsey Bullen on Diet and Dog Cancer | Dr. Lindsey Bullen

[00:00:00] >> Dr. Lindsey Bullen: For the thousands of patients and clients that I’ve worked with, only a handful are on their first iteration of their plan. You know, nutrition, medicine in general, is an iterative process. Things change. Pets are not just static, their disease is not static – it’s dynamic and ever-changing, and we as clinicians need to be flexible.

[00:00:20] >> Announcer: Welcome to Dog Cancer Answers, where we help you help your dog with cancer. Here’s your host, James Jacobson.

[00:00:28] >> James Jacobson: Hello friend, and welcome to Dog Cancer Answers. You’ve probably heard it on this show and probably lots of other places on the internet, “Check with a boarded veterinary nutritionist.”

The problem is there aren’t that many of them, as you will hear on today’s show, but we tracked down one of them. Her name is Dr. Lindsey Bullen. She lives in North Carolina and she has lots of information on how to prepare the foods that will best benefit your dog, whether they’re dealing with cancer or not.

Dr. Lindsey Bullen thank you so much for being with us today.

[00:01:05] >> Dr. Lindsey Bullen: Thank you so much for having me. It’s a pleasure and an honor to be here.

[00:01:09] >> James Jacobson: Well, we have finally found a specialty within veterinary medicine that has fewer colleagues than oncology, and that is nutritionists, like you.

[00:01:21] >> Dr. Lindsey Bullen: That is absolutely right. We were established in the early 1980s, and since that time, a little over a hundred have been credentialed. Most of them are in academia, um, or they are in industry, with only a handful in private practice like myself.

[00:01:38] >> James Jacobson: That’s cool. So most of them are working like for the pet food companies and the pharma companies?

[00:01:42] >> Dr. Lindsey Bullen: Correct.

[00:01:42] >> James Jacobson: What was the thing that made you decide to go into this specialty?

[00:01:47] >> Dr. Lindsey Bullen: Yeah. So I actually wanted to be a surgeon. My dad is a human surgeon, so slicing and dicing is something that I was familiar with, and, uh, inappropriate dinner topics were very appropriate in our household. But I had really good surgery mentors, but they were all dudes. And I didn’t know how to be a surgeon.

I didn’t know how to be a wife. I didn’t know how to be a mom, because I didn’t have all of that in a nice mentor package. So I said, you know, I’m gonna be a general practitioner because they specialize in everything. I can do surgery, I can have a family, I can be a spouse, I can do everything I want. And then I did uh, an internship that had a nutrition focus, and I said, you know what, I changed my mind yet again. I love math. I love education. I love communication. And I love that every single patient presents a puzzle, even if they have the same disease state. And so that is when I fell in love with clinical nutrition.

[00:02:43] >> James Jacobson: Interesting. Okay. So the slicing and dicing is still there-

[00:02:46] >> Dr. Lindsey Bullen: Oh I still love it.

[00:02:47] >> James Jacobson: -but you’re doing home cooked foods.

If you’re cooking at home, there’s slicing and dicing, which I guess raises the first question I want to talk about, which is a lot of people are cooking for their dogs. What’s your perspective on that?

[00:02:59] >> Dr. Lindsey Bullen: Yeah. So my job as a nutritionist is to figure out what the pet parents want to do and to help guide them so that they can do that safely, or if it can’t be done safely, to educate them on the, you know, pros and cons or risks associated. So if a pet parent decides that a home cooked meal is what they want to do and what their pet deserves, then I can help them do that safely. I personally don’t have the time or energy to even cook for my two sons, five and two, I do it because I have to, but.

[00:03:32] >> James Jacobson: There’s no kibble for kids.

[00:03:33] >> Dr. Lindsey Bullen: Right. There, I mean, it’s, if they could eat cereal all the time, they would, but I’m like, no. But you know, if my poor animals ever needed a home cooked diet, they would be kind of out of luck right now ’cause I just, I don’t have it in me. But it can be done safely, you know, with some guidance, with some education. And the good news is there’s companies now that can actually take home prepared recipes from board certified nutritionists, such as myself, prepare it, and then deliver it. So if pet parents are kind of in the same boat that I am the, you know, it’d be nice, but I barely do it for myself, there are things that they can do to maybe, you know, still provide that for their pets.

[00:04:08] >> James Jacobson: So you say that veterinary nutrition is a new specialty it started during the eighties?

[00:04:12] >> Dr. Lindsey Bullen: Uh-huh. Yup. In the eighties.

[00:04:14] >> James Jacobson: Okay. So what was the genesis of it as a specialty?

[00:04:19] >> Dr. Lindsey Bullen: That is an amazing question. I wasn’t alive yet when it started.

[00:04:25] >> James Jacobson: Of course not. Me neither.

[00:04:26] >> Dr. Lindsey Bullen: No, to be fair. I was born right around that time. So, I mean, that, that’s a great question. And the funny thing is that because there’s so few of us, I actually know a couple of, you know, the key players from the genesis and I need to sit down with them over a glass of bourbon and say why? Like, why, why this, why that? You know, when we think about the difference between an internist and a nutritionist, we still have to know the same disease states.

We still have to know the pathophysiology. And what that means is, you know, how the disease manifests, what are the signs and the symptoms, how to diagnose it. Whereas an internist, you know, might preferentially choose medications and therapies, and of course, nutrition as well, the nutritionist will really buckle down and think of it biochemically, and in terms of a pet’s metabolism and try to accomplish, you know, a similar type goal with diet first. And then of course we’ll reach for the drugs. And I think the important thing to keep in mind is that nutrition should not necessarily be used in lieu of appropriate medications, but as an adjunct to appropriate therapies.

And there’s times when diet is absolutely the first step and, and, and it’s great because we might be able to reduce drugs or eliminate drugs, but there are definitely cases where you need both.

[00:05:39] >> James Jacobson: So do you adhere to the old, you know, Hippocrates, you know, vet, let food be your medicine? Do you adhere to that?

[00:05:46] >> Dr. Lindsey Bullen: Oh, absolutely. I’ve even got like the Hippocratic oath framed on the wall.

[00:05:51] >> James Jacobson: Okay. So, I mean, it seems like it’s taken a while, until the eighties, when veterinary medicine started to say, Hey, let’s really look deeper into the nutritional pieces of it. So prior to that, again, I know you’re not a historian in this, but what would you, I mean, there didn’t seem to be a lot of focus on the nutrition from a medical perspective.

Is that fair?

[00:06:14] >> Dr. Lindsey Bullen: I think that’s fair. You know, at least many of the historic texts and tomes, if you will, that I’ve read, most of the research was done in actual like performance animals. So there was, you know, a lot of research done in cattle and sheep and pigs because, really, when we think about it, that since they’re in production, we wanted to get them as big and bulky and muscular as quickly as possible so that we, potentially, could consume them depending on, you know, what your preference is.

And then it, you know, we said, okay, now we’ve got animals in research settings. And really, it kind of started, um, most of the cat research started with like mink and ferrets because of the fur trades. So they were like, okay, how can we make these furs beautiful – which I personally, I don’t wear furs but that’s where a lot of the research started. And then it was like, okay, we have all of these animals in research. We’ve got our production animals. Now animals are starting to become part of the family. They’re not just the farm dog or the farm cat, which has a place for certain people, of course, but for example, like my pets are part of the family and that’s what a lot of people are starting to feel.

So the research has developed – instead of, let’s optimize performance, let’s optimize fur for a coat – let’s make these pets live as long as possible and have that life be a good quality life. And to do that, they need appropriate nutrition. So an analogy I really like to share with my pet parents is if you put diesel in a car, and it’s not gonna go well. It might not even go at all. You might actually break your gas tank, like my sister did. Um, she’s gonna be mad at me for sharing that. But if you put the right type of gas in the vehicle, it will go very well. It will go very smoothly. And that is food. That is nutrition.

If you put any food in a body, it’ll go, it might not go well. But if you put the right type of food, the right nutrients, the right proportions, it will thrive. That will be optimized. The pet will be optimized.

[00:08:08] >> James Jacobson: So, how do you find the right fuel for your dog?

[00:08:13] >> Dr. Lindsey Bullen: So your listeners are gonna get really tired of me saying this, but it depends on the individual pet.

Every single pet is unique. You know, you get three Boxers in a room, they’re all gonna have different needs based on their activity level, based on their physiologic state, so are they growing, are they adult maintenance, are they reproducing. Based on, you know, do they have any disease processes? So if they’re otherwise healthy, there are set guidelines in terms of minimums and maximums that a pet should have and that has been established through years and years and years of research.

But as soon as you make things complicated with the uniqueness of the pet because of a disease process, those nutrients change, the ingredients that they need change. So back to your question, how do you figure that out? Well, talking to your veterinarian and having a positive relationship and a mutually trusting and respectful relationship is gonna be key because they’re gonna see your pet from the time they’re an adorable puppy or kitten, all the way up through end of life. And so they’ll be able to help as your pet’s nutritional needs change. Because they will change.

[00:09:17] >> James Jacobson: Okay. But you and I both know that most veterinarians don’t have a lot of education when it comes to nutrition.

[00:09:27] >> Dr. Lindsey Bullen: Way to call it like you see it. You’re right. So one of my missions through life is actually to get more nutrition training in vet schools. And it is a slow mission, it’s taking a long time. But this is one of the reasons why I accept almost every single speaking opportunity that is offered to me, because I want to get accurate information out there, whether it’s to pet parents, to veterinary students, to veterinary technician students, or my colleagues.

You’re right. There’s only a handful of veterinary schools that actually have a nutritionist, a board certified nutritionist, or a nutrition department. So one of the things that we all can do is to write to those vet schools and say, hire more nutritionists! We want experts teaching the classes. But the other thing is, when I talk and mentor veterinary students, is I make sure they hold themselves accountable, you know, you don’t know what you don’t know. So take advantage of those nutrition continuing education courses. It’s also okay – and pet parents, I hope you’re listening – it’s okay for your veterinarian not to have every answer.

Nobody knows everything about everything. If they tell you that, they’re lying or they’re arrogant. I know a lot about nutrition, but I don’t know a lot about a lot of things. And so if your veterinarian says, that’s a great question, you know, what do I have to feed Fluffy, that’s a great question. I don’t have the answer to that, but I’ll help you find that out – that is a veterinarian that you can trust because they just admitted that they don’t have the answers. They’re not gonna make something up, which is great, but they’re gonna help you find a resource, such as myself or others like me, that can get you the accurate information to help your pet.

[00:11:01] >> James Jacobson: Okay. So if you have a vet who punts and says, I don’t know, but let’s get a veterinary nutritionist on board and they find you, or one of your 99 other colleagues, what is the-

[00:11:13] >> Dr. Lindsey Bullen: Probably five other, but.

[00:11:15] >> James Jacobson: What is the intake process?

[00:11:18] >> Dr. Lindsey Bullen: That is going to be dependent on the individual. Um, the truth is, just like every other veterinarian during the pandemic, we are seeing more cases than we’ve ever seen in our entire life. And burnout is real. And so it is really challenging and stressful from a pet parent perspective because when it is urgent and emergent for your pet, you want help at that time. And I don’t blame the pet parents. I feel the same way about my pets. I feel the same way about my kids. But we need patience because, I shared with you earlier that I’m starting a new professional endeavor soon, and before I gave notice I was booked out three and a half months.

Most nutrition services are booked out for, you know, 2, 3, 4, even five months, which again, if it’s an urgent problem, it is so stressful and so hard, uh, for the pet parents, because they might not be able to get in in a timely manner. I just want to share with you from a veterinary perspective, it’s really hard on us too. I wish I could help everybody that has contacted me. So I’ve been out of work for two and a half weeks now, and I have about a hundred requests that I have, unfortunately, had to decline because I’m not currently associated with a hospital and it breaks my heart every single time. It absolutely does.

So in terms of your question, what’s the intake process – I would recommend if you have any inclination that your pet is in need of specialized therapy, contact a nutritionist sooner rather than later, because it is gonna take several weeks, potentially months, to get in with them. Some nutritionists do have emergency appointments.

When I, you know, worked at my previous hospital, I’m about to set up a service at a new hospital, I anticipate having emergency blocks that are set aside for true emergencies so that we can help in more, you know, in more urgent timeline. But most of us are booked out, so be patient, be kind. We work by referral only. We can see patients in person if we’re affiliated with a hospital. Some of us do independent consulting from the comfort of our own home.

[00:13:12] >> James Jacobson: I was gonna say this feels like a very telemedicine-y kind of thing.

[00:13:17] >> Dr. Lindsey Bullen: It absolutely can be. As long as we have all of the information that’s accurate that we need, we 100% can do a very good tailor job for the individual pets. The important thing for pet parents to keep in mind is what we spit out is only as good as the information that we get. So if a pet hasn’t had, you know, blood work or diagnostics or a physical exam for three years, well, the diet I create is gonna be based on three years ago, plus what I think is maybe happening. Whereas, you know, if they had blood work two months ago and I see that their kidney values are starting to change a little bit, I can go ahead and say, okay, I interpreted your pet’s a little under conditioned.

We need to up the calories. Kidney values are increasing here, decreasing here. I need to help protect your kidneys a little bit more. So the more information I have, the better job I can do for my clients and for my patients.

[00:14:05] >> James Jacobson: So let’s talk a little bit about the intake process. What are the tests that they should have before someone consults a nutritionist?

[00:14:13] >> Dr. Lindsey Bullen: So you might hear the word minimum database, most veterinarians hate that term, but what I would be looking for is complete blood count, or a CBC. So that’s gonna give me your red blood cells, I want to make sure you’re not anemic. Or when I say you, obviously the pet. I want to take a look at the white blood cells. Is there any evidence of inflammation or infection, or are the blood cells really low, and I’m worried that maybe the pet is critically ill. What are their platelets doing? Do they have enough platelets, high, low? All of those things can kind of help me get a general idea of the overall health of the pet and if they have higher protein requirements. Then I want a full chemistry panel.

And that one’s tough because depending on the age, depending on which lab runs it, it might omit pancreatic values. It might omit certain electrolytes. And so by electrolytes, I mean things like phosphorus, and potassium, magnesium, sodium, calcium – those are things that nutritionally, because I’m an expert in metabolism and biochemistry, I want to know what are the pet’s electrolytes doing? I want to know, does this pet have evidence of pancreatic inflammation and overstimulation? I want to know exactly where their kidneys are. And the big kicker is I want a paired urinalysis.

So what that means is when the blood was drawn, I want a urine sample at that time. That will tell me the pet’s hydration status, or if it’s a first morning urine and it’s inappropriately concentrated, I’ll say we might have evidence of chronic kidney disease starting to develop. So all of this is really, really good information. I would ideally also like to have what’s called a T4 or a thyroid level, especially for my weight loss cases. There’s a pet that’s obese, I want to make sure that they don’t have hypothyroidism.

[00:15:54] >> James Jacobson: Do you get that T4 from blood?

[00:15:56] >> Dr. Lindsey Bullen: That is correct. All of these are blood samples except for the urine and the urine can be a free catch. So as long as your knees aren’t shot, you know, you can squat down behind your dog with a ladle and try to catch their pee first thing in the morning.

[00:16:07] >> James Jacobson: So how many vials of blood? And you say, is this something that probably should go to a specialty lab?

[00:16:13] >> Dr. Lindsey Bullen: Yeah. So most veterinary clinics can either run it in house or they can send it off, again, depending on it, what they have in house, ’cause there’s a couple different machines. I prefer to send it off because I know that’s all they’re doing. And I know I’m getting everything I’m asking for. In terms of vials of blood, it’s not a lot. So even if you have a tiny little Yorkie or a tiny Chihuahua, we even have what are called, like baby tubes. So we’ll just say here’s a little half milliliter of blood. For my dog, I’ve got like a 70 pound Boxer, I’ll probably take two milliliters of blood. It’s not even a teaspoon, not even a teaspoon of blood.

[00:16:48] >> James Jacobson: So not a lot of blood draw to get a lot of information, but you say that-

[00:16:51] >> Dr. Lindsey Bullen: I am not exsanguinating the patients. That is correct.

[00:16:54] >> James Jacobson: So, and the pee is easy, but don’t do it in the morning because it could give you a false value.

[00:16:57] >> Dr. Lindsey Bullen: So I actually would like it to be in the morning as long as they haven’t drank any water, but I need to know the time that they took it. So if they, you know, take the sample, but they get their blood three hours later, I need to know what time that pee was taken.

[00:17:11] >> James Jacobson: Okay. So most vets have the laboratory facilities to do all the phosphorous and all that stuff or, and the T4, and all, do you think?

[00:17:21] >> Dr. Lindsey Bullen: Most of them do. That’s correct. So the majority of them can run it in house, but some mobile veterinarians don’t, you know, have access because that equipment is really expensive. So for me, you know, I will typically order things and have it sent out to a laboratory. And even when I worked at a very busy specialty hospital, we would run in-house labs for emergencies, but then anything else where the patient was stable, we would actually send it out to a lab and then we would get it back very quickly.

[00:17:49] >> James Jacobson: Okay. And so once you get the data back, as a nutritionist, you open up your laptop, you get the data, and what do you do with it?

[00:17:56] >> Dr. Lindsey Bullen: Ahh, I pour myself a cup of coffee or a scotch on the rocks-

[00:18:00] >> James Jacobson: Or bourbon. We got bourbon, scotch, coffee.

[00:18:01] >> Dr. Lindsey Bullen: And I was like, I do love bourbon, but not while I’m on the job. My preference is to actually go through all of the patient records before I talk to the client. I want to make sure that I have a very clear picture of what, you know, medically and physiologically is going on with these patients before I get on the phone with the client.

[00:18:21] >> James Jacobson: How many years back?

[00:18:22] >> Dr. Lindsey Bullen: Oh, that’s a good question. I am probably a little bit more, I guess aggressive than some of my clients, because depending on the patient, even one year could be like hundreds of pages. I typically ask for two to three years of labs or diagnostics, because it’s not a lot of words, it’s just results, and I can track the trends. I really like trends. But I will ask for like a full year or two years of complete medical records. Ideally they’re digital. Handwritten, I have a hard time deciphering sometimes.

[00:18:53] >> James Jacobson: Imagine.

[00:18:53] >> Dr. Lindsey Bullen: I know. I was like, if everyone’s handwriting is as bad as mine, it’s a wonder we can communicate at all.

[00:18:59] >> James Jacobson: Okay. So you pore over the medical records, hopefully typed-

[00:19:02] >> Dr. Lindsey Bullen: Hopefully.

[00:19:03] >> James Jacobson: -and you review the data from the lab that was done specifically for this, plus prior labs. Are you like entering all of this into your own, like, little system, or is this all going into your cranium?

[00:19:14] >> Dr. Lindsey Bullen: Um, a little bit of both. So I am a very visual person and I also have the memory of a goldfish because I have children that don’t sleep very well.

[00:19:25] >> James Jacobson: It’s a common theme here.

[00:19:26] >> Dr. Lindsey Bullen: So. I know, right? So when I’m going through the records – and I do require a referral form from the primary clinician, and it is that primary clinician’s job to write down what they are concerned about. And then, of course, the pet parent is part of the team so I include them in. I actually have kind of an appointment template that I’ve created where it’s got the patient name so I can remember who I’m talking about, it’s got, you know, the top problems the veterinarian is concerned about, with room to add problems that the pet parent is concerned about.

Then I have kind of diagnostic concerns that I have, and that can be challenging because sometimes, you know, the primary veterinarian may or may not have discussed them or the pet parent may or may, you know, not forget that something was discussed. So I make sure that anything that will affect what I do nutritionally that might be abnormal, that is documented so I can talk with them about it with the year next to it. And then I kind of type down just a couple little ideas I might have, keeping in mind again, that how I help the pet parent is absolutely up to them. I could recommend the best plan in the world and if they’re not interested in doing it, I’ve just wasted everybody’s time and money.

So I’ll just kind of jot down my ideas ahead of time, but I always make sure that it is a team approach and a discussion with the pet parent. And then we have the one hour appointment where I get to know the client, where I get to know the pet. And I usually do a 10, 15 minute let me tell you what I think I know, but please interject and tell me if you agree, if you disagree, if you want to add anything, and then we go into their treatment plan creation.

[00:20:58] >> James Jacobson: So is it part of the intake information that you are taking in about what they’re currently eating, what they’re currently feeding?

[00:21:05] >> Dr. Lindsey Bullen: Absolutely. My poor clients have a five page dietary history form that is required to be submitted before I talk to them.

[00:21:12] >> James Jacobson: Why five pages? What kind of questions do you ask?

[00:21:14] >> Dr. Lindsey Bullen: Because of all the information.

So it depends on what’s going on, right? Like if I have a happy, healthy dog with no problems, it probably doesn’t matter, to the extent as if they were sick, what exactly they’re feeding, because basically I can have that conversation and say, what are you trying to accomplish, I’ll recommend the best that, you know, agree that you’re willing to do, okay, we can go from there.

But let’s say for example, um, I’ve got a dog that has food allergies. I actually want to know everything she’s eaten historically, because I might not know what her trigger is. So I do know her trigger. I know her trigger is poultry, so chicken, turkey, it’s also beef. But when I don’t know what a patient’s trigger is, I can go back and look at the dietary history – and I do investigate, I don’t just say, oh, that says Purina Pro Plan Chicken and Rice. I will pull up the ingredient list to make sure that it doesn’t also include, you know, other things like fishmeal or blah, blah, blah. And then I make a list of all the protein exposures ’cause those are things that I need to talk to the client about.

I make sure – there’s an allergy section. So, you know, do you think your pet has allergies? And the reason it says, "do you think" your pet has it, most of the time they don’t, but a lot of pet parents feel that their pet might. And again, my job is to try to help them create a plan that is as safe for their pet as possible.

So if they think their pet has it, who am I to say that they don’t? I can do my job safely, assuming that everybody’s allergic to everything. So there’s an allergy section. There’s also a section to ask about their feeding philosophies. Nutrition, even though it’s a science, is a very, very emotional topic, and so I want to make sure that if, you know, a pet parent is strongly opposed to feeding canola oil, that they tell me that so I don’t include it in their recipe. There’s plenty of other oils I can choose from. Or if they want organic, you know, I can talk with them about what organic is, can you actually find truly 100% organic dog foods, you really can’t. You can find organic ingredients in dog foods, but to be a hundred percent organic, that’s really challenging. The next page is going to be treats. Treats are huge with, you know, clients and uh, relationship with their pets. So I will go through and calculate how many calories the pet is getting. Uh, quiz, how many calories do you think a pet should get from treats per day in terms of percent? What do you think James?

[00:23:28] >> James Jacobson: Hmm. Well, I would say it depends. I would say, I’m gonna pull one of yours – it depends. It depends on the, uh, the animal and what what’s going on with them and the size of the animal.

[00:23:39] >> Dr. Lindsey Bullen: So it certainly does, but definitely no more than 10% of their total calorie intake.

So whether they’re fat or not, I will go through and calculate it and then educate the client and say, Hey, Fluffy looks good, but 50% of calories are coming from Chicken Jimbo’s or your, you know, whatever it is. And those are not giving them the nutrients they need. So we need to start talking about a shift in terms of calories and nutrients.

If there’s a homemade diet, then that’s even more pages because I want them to go through and check which ingredients they don’t mind using, which ingredients they, like, want me to steer away from, and then we have that conversation as well. And then the last page is all the fun legal disclaimers, you know, check, check, check, I agree that Dr. Bullen’s doing her best.

[00:24:22] >> James Jacobson: So let’s talk about allergies for a moment, ’cause you said that a lot of people think their animal is allergic to something. How do you know? I mean, how do you know if an animal is allergic to pork, or chicken, or beef?

[00:24:36] >> Dr. Lindsey Bullen: Yeah. Awesome question. I’m so glad you asked that. The gold standard of determining if a pet has a true food or dietary allergy is through a feeding trial.

There are so many blood, saliva, hair allergy tests out there. Those are not accurate for food allergens. Those are accurate for pollens, um, they’re accurate for dust mites, I know dermatologists that will use them for environmental allergens, especially to, you know, create immunotherapy, er, shots for pets. But if one is concerned that their pet has an intolerance to an ingredient, what you would do is eliminate everything they’ve ever been exposed to, see if they get better, and then the real thing you do is you feed it back to them and watch their response.

Now, most pet parents are like, Oop, Nope, we cured it, I do not want to go that route. I, I’m good, I don’t care what they’re allergic to. But some of them will actually do the re-introduction. So for example, my dog has both food and environmental allergies, which is really annoying because when I did the diet trial with her, she was like 85% better. So I was like, okay, you did respond favorably to a diet change, but you still have allergies. That is unfortunately because of the environment. I am in a swamp in North Carolina, it’s humid all the time.

You know, we have standing water even when it’s a drought. And the poor thing is allergic to grasses and trees and molds and mites and all the things. And so diet gets her about 85 to 90% of the way, and then the environment unfortunately kind of keeps her itchy most of the time.

[00:26:05] >> James Jacobson: Okay. Obviously, we are on Dog Cancer Answers and we are gonna talk about a dog cancer diet when we come back. We are speaking with veterinary nutritionist, Lindsey Bullen. We’ll be right back.

We are back. Okay. Let’s talk about dog cancer diets. What do you recommend?

[00:26:28] >> Dr. Lindsey Bullen: What do I recommend? Ooh, well that depends on the type of cancer and what the goal of the pet parent is for their pet. And I am speaking from experience.

[00:26:37] >> James Jacobson: Let’s break those two down, okay. What kind of cancer, and what is the goal. So how does osteosarcoma different than hemangiosarcoma versus lymphoma?

[00:26:48] >> Dr. Lindsey Bullen: So the first thing is gonna be – in my opinion – what is gonna be the longevity, what is the prognosis for the pet. So, for example, when I was pregnant with my first son, my gigantic, hundred pound German Shepherd, who at the time was the love of my life, don’t tell my husband that, he ended up having hemangiosarcoma and had to have emergency surgery a week before I delivered my son.

And for, you know, those of you out there that have a pet or have had a pet with that, I’m so sorry. I, again, can empathize. I’ve been through it and it’s terrible. The crazy thing is lifespan really depends on how extensive it is when you find it, when, you know, when they have their crisis. We were lucky, all things considered. It had not spread visibly. So by the time you find it, it has unfortunately spread, but not visibly. And so typical prognosis for that, and he didn’t have any crazy, you know, post-surgical issues, was gonna be a couple of months, with or without chemotherapy.

Now that particular dog loved to run. He loved to eat. And I personally chose not to do chemotherapy. That doesn’t mean chemotherapy is wrong, I absolutely advocate for it. I was poor. I actually couldn’t afford it at the time. But I also, for me, knew that his quality of life was dependent on him feeling good for whatever amount of time I had left with him. And I expected him to not live past two months.

So back to the diet, I gave that boy whatever he wanted. I called it his butter and whiskey phase. And you know what happened? He got overweight and he lived five months because we were really lucky. And so at about three months, I was like, you’re overweight now, I should probably dial this back. I wasn’t a nutritionist yet. But, you know, the point there, of the story is, based on the prognosis, it was most important to me from both a veterinary perspective and also pet parent perspective for him to eat. Now, I didn’t care if it was cat food. I didn’t care if it was dog food. I did want it to be complete and balanced. I didn’t want to quicken things. I just wanted him to enjoy eating and to be happy.

Whereas if we think about lymphoma, and a low grade lymphoma that is curable, really, we need to be thinking about, you know, supporting the patient, or the pet, through their chemotherapy processes, because that is hard, hard on the body, but we also need to keep in mind that we don’t want to negatively interfere with any of the therapies that are going on.

So for those of you that are unfamiliar with chemotherapy and radiation therapy, how they work is they are basically poisoning the rapidly dividing cells. And in the body that, those are the cancerous cells, but unfortunately it’s, you know, also some of the other cells as well. And then the body will scavenge up all of these dead cells and hopefully, you know, you get all of the cancer. Obviously there’s more to it than that, but that is the nutritionist perspective of chemo.

So what happens if we give these pets a lot of antioxidants? Well, unfortunately that is actually protective, to the cancer cells as well as the healthy tissues. Antioxidants aren’t bad, you have to have them, but my philosophy is no extra antioxidants during chemotherapy, no extra antioxidants during radiation therapy. But once the treatment plan is completed, then you can consider additional supplementation if you’ve talked with your veterinarian and your oncologist about it.

And so when we talk about diet again, how does that come in there? Basically these bodies, they develop cachexia. So cachexia is an active breakdown of muscle mass. It’s an increased energy requirement. And that is on top of the normal metabolic needs of an otherwise happy healthy dog. So what we have to do is give them high protein to help support them through their inflammatory phases.

We don’t cause inflammation, but we’re supporting them through inflammation ’cause their body’s gonna do it anyway. We want to give them proteins to replenish and recover their normal cells that are dying. We want to give them higher fat if they can tolerate it, because fat has over twice the calorie density, or energy density, compared to protein and carbohydrates.

And depending if they’re anorexic, which a lot of them, you know, go through during chemotherapy – or even if they just have a flare and they don’t feel well – typically we will lower the carbohydrates as well because the carbohydrates provide a very instantaneous release of glucose, and the longer you’ve been anorexic or without food, the more your body switches away from using glucose as an energy substrate and starts using protein and fat. And if you give too many carbs, too much energy to a dog or a cat that’s been anorexic, we can actually cause something called refeeding syndrome if they’ve been anorexic for a long time, and that in and of itself is a crisis too.

So for me, I tend to choose diets that are higher protein, higher fat, lower in carbohydrates, high energy density, ’cause I want them to have as many bang for their buck for each bite. But again, it depends on where the cancer is. So if you have renal lymphoma or kidney lymphoma, I might have to drop the protein and the phosphorus because suddenly their kidneys are involved. So again, your readers are gonna be mad at me because a lot depends. A lot depends.

[00:31:49] >> James Jacobson: Okay, well, let’s break down some of this. So the cachexia has an impact also on the dog’s appetite or lack of appetite, right?

[00:31:56] >> Dr. Lindsey Bullen: Absolutely. I’m glad you brought up appetite. Appetite is negatively affected by almost everything. And it is only positively affected by a hormone called ghrelin. And so we have so many different factors that can negatively impact or stop a pet’s appetite that we are trying to combat that is associated with cancer.

So pain makes you not want to eat. Nausea associated with your medications, or if you have GI lymphoma, makes you not want to eat. Stress because you are going back to the vet three times a week for chemotherapy, or you’re getting into the car, makes you not want to eat. And then this pro-inflammatory hormonal storm that happens with cancer, that makes you not want to eat. There are so many reasons why these guys don’t want to eat that compounds the cachexia that they’re already exhibiting from their disease that it can be a losing battle, especially if it’s not targeted swiftly and, um, severely.

[00:32:53] >> James Jacobson: And it is targeted through, this is where a drug would come in.

[00:32:56] >> Dr. Lindsey Bullen: Um, drugs or me. So my goal always is to try to get the pet to eat voluntarily if they can. So, you know, these guys are at a higher risk of anesthesia and I, I will, you know, avoid feeding tubes if I can, but those are great options for certain pets.

So-

[00:33:15] >> James Jacobson: But I meant some of those drops, those, what do you call them?

[00:33:17] >> Dr. Lindsey Bullen: Like palatants or appetite stimulants, right? Yeah, absolutely. So basically what my kind of rule of thumb is, is I take a look at their current diet and say, what can we do to modify it, to make it more appeasing to you? If it’s canned, can I heat it up? Can I warm it to, you know, reduce or to, I should say, enhance the aroma and the flavor? Okay, that didn’t work. Um, can I find a topper or a palatant to make it better? So cats typically like acidic and protein flavors. Dogs do have sweet taste buds. So they might like a little sweeter, you know, so things like yogurt and honey, and – again, keeping in mind, it’s a small amount, so you’re not negatively impacting the nutrients – baby food. These are all things we can add to their food or mix in to make them more palatable. Okay, that didn’t work. Is there a similar food, but from another manufacturer? Okay, that didn’t work. Can we do a homemade diet that somebody like Dr. Bullen, you know, created? Okay, darn it. That didn’t work. Let’s try some appetite stimulants.

There’s multiple out there. There is capromorelin or Entyce for dogs. It’s Elura for cats. That is a ghrelin mimetic, it mimics natural physiology. It’s a wonderful product. Full disclosure, I am on their speaker bureau because I believe in the product. I like it because it mimics natural physiology.

Another really good option is Mirataz. That is a transdermal or skin contact appetite stimulant that’s FDA approved in cats. There’s the oral or caplet Mirtazapine, that’s what Mirataz is. For dogs, you know, there’s Cyproheptadine. There’s a lot of different things that we can reach for as veterinarians that might be able to kind of get them through an anorexia event.

The other thing that’s really important to keep in mind, again, that we had touched on, anything can make you not want to eat. So if they’re in pain, you give them pain meds. If they’re nauseous, you give them anti-nausea medications. If they’re dehydrated, or if they have a fever, you give them fluids. You give them antibiotics if/where appropriate.

So you want to make sure that those symptoms are also being treated and then, and only then, they still are not doing well, I will talk to the pet parent about – temporary, ideally – assisted feeding, and that would be a feeding tube.

[00:35:25] >> James Jacobson: Okay, let’s talk a little bit about the, you, you really waxed on almost as a foodie when you were talking about all these various flavors. The role of, of deliciousness of, I mean, and I’m sure there’s a much more scientific medical term for it, but how delicious it is-

[00:35:42] >> Dr. Lindsey Bullen: Oh I like deliciousness. That’s good. Yeah. You should coin that.

[00:35:45] >> James Jacobson: So the role of deliciousness, it seems to me like an important ingredient in this whole process.

[00:35:50] >> Dr. Lindsey Bullen: Yeah, absolutely. And we have to keep in mind that, you know, at any age you can unfortunately get cancer. And a lot of our pets are developing picky appetites even before they get sick. So they might have a picky appetite and they’re normal, and then they get cancer and their appetite is even pickier because of all the reasons we talked about. It is so important that the diets have the deliciousness factor to try to get them to eat, because if they don’t have the energy and the nutrients coming in from food, then it is a losing battle because they’re basically going to cannibalize their own tissues and that is not conducive to life. So it is so, so important that we get these guys to eat – ideally to eat what’s appropriate – but to get them to eat and to keep their energy, to get those nutrients, so that they can give it a good, good fight.

[00:36:39] >> James Jacobson: So, what is your position on the concept of like, well, we’ll try this and we’ll try this and what, you just try different things versus some, I think older thinking that had been around for a while, which is, this is the thing you have to do and you have to do this even if the dog doesn’t want to eat it. It sounds like you’re saying, no, it should be appealing.

[00:36:57] >> Dr. Lindsey Bullen: Yeah, so different nutritionists, different veterinarians, are gonna have different opinions. I am of the opinion that if they die because they’re not eating what I ask them to eat, then we’ve all lost. Right? So, you know, if they’ll eat what I told them to eat, it’s a good day, I pat myself on the back, everybody gets hugs. But the truth is, for the thousands of patients and clients that I’ve worked with, only a handful are on their first iteration of their plan. You know, nutrition, medicine in general is an iterative process. Things change. Pets are not just static. Their disease is not static. It’s dynamic and ever-changing, and we as clinicians need to be flexible.

So, you know, again, for example, I have a cat with kidney disease and she was on a diet. She developed a different disease, so I had to switch her. She refused it and I was like, seriously, like the one diet that is good for you. Now, luckily through a three month transition, I got her onto it, but that pet might not have three months.

Right? And so instead of battling with the pet parents, instead of battling with the pet, then we say, okay, well if they didn’t like option number one, which is the best, what is the next best? Okay, what is the next best? Okay, what is the next best? And the truth is, you know, there have been patients that I’ve worked with where they are on an incomplete and an unbalanced, homemade diet, and I had that conversation with a client and I said, what is your goal? And they said, I just want a few more days with them. And I said, okay, then feed them what they want. Like, like if you want a couple of days-

[00:38:23] >> James Jacobson: McDonald’s fries would work, yeah?

[00:38:25] >> Dr. Lindsey Bullen: Yeah, absolutely. Yeah. Before I, I euthanized my, my sweet Gus, he got Oreos. You know. Not saying feed your dog Oreo, by the way, but.

[00:38:34] >> James Jacobson: That is not medical advice. But yeah, I know, I get it.

[00:38:35] >> Dr. Lindsey Bullen: That is not medical advice.

[00:38:37] >> James Jacobson: Yeah.

[00:38:37] >> Dr. Lindsey Bullen: But it was his last day, you know? And so I, I think it’s important again, to have that positive, trusting, and respectful relationship with your vet so that you can have a realistic discussion and say is your goal to get them to live as long as possible? Okay, then they need to be eating this diet. Or is your goal to make the time they have left with you quality time? Well, then let’s talk about option B, C, D.

[00:38:58] >> James Jacobson: Okay. So many of the people who listen to this podcast, this show, are really interested in extending the quality of life for their dogs. So if quality of life is what your central focus is, what foods should you consider and what foods should you avoid?

[00:39:18] >> Dr. Lindsey Bullen: That’s a loaded question because it, it, honestly, it depends.

I think having the pet enjoy what they’re eating is really important. And from a pet parent perspective, we find that important too. You know, I shared with you, I decided not to do chemotherapy, again, A, because of cost for me at the time, but because I wanted my dog to enjoy eating. And that was my choice. That’s what I chose for him, because that was his marker of a quality of life.

I knew he was sick when he stopped eating. I knew how much he loved to eat. So when we talk about things to potentially feed your pet, think about your pet as the individual they are, you know, what treats do they like? Treats are actually, again, you know, you want to try to make sure they’re less than 10% of the total caloric intake so they don’t unbalance the diet, but if they’ve got a couple of days left, give them some treats. You know, you can actually crush the treats up and sprinkle them on the food or in the food, or make a treat gravy and get them things that they like to eat.

People food is not bad when used in moderation. I will actually use – so I think I shared my dog is allergic to poultry and to beef, I’ll actually give her chopped up ham baby food when she isn’t feeling well to get her to eat because it enhances the flavor. So I would say again, that’s a very vague and wishy-washy answer and I apologize because it truly depends. But I would say talk to your veterinarian, you know, about what is safe to give your pet and have that conversation to see what you can add to their food to make it more enticing for them.

[00:40:44] >> James Jacobson: If your vet really wants to talk about it.

[00:40:47] >> Dr. Lindsey Bullen: And if they don’t, you look me up on the directory, it’s acvn.org/directory. There’s a bunch of us out there and we would be happy to help because this is a hard thing.

[00:40:56] >> James Jacobson: Okay. So that’s a resource to find all 99 of your colleagues.

[00:41:00] >> Dr. Lindsey Bullen: Yup.

[00:41:00] >> James Jacobson: The ones that are in private practice, just a few, actually. A few dozen. A C V I M.

[00:41:04] >> Dr. Lindsey Bullen: Um, acvn.org/directory. Now the truth is, so our college, the American College of Veterinary Nutrition, just got integrated into the American College of Veterinary Internal Medicine. However, acvn.org/directory is still active currently.

[00:41:20] >> James Jacobson: We will put a link in the show notes. So if you decide to cook for your dog, because you have the time and the inclination, are there some things to watch out for, to avoid?

[00:41:33] >> Dr. Lindsey Bullen: Absolutely. So again, it depends on your pet’s prognosis. If, you know, a pet has two to three weeks left to live, then feeding them an incomplete or unbalanced diet is unlikely to manifest in that amount of time. So it is unlikely, you know, that you would necessarily need to shell out to talk to me on an urgent matter.

That being said, you know, it really depends on what other organs are involved. Now, if your pet has gone into remission or they have a slightly longer prognosis, it is gonna be really important to reach out to an expert, such as myself, that is licensed to formulate, that understands not just the, you know, mechanics of how the ingredients work together, but also your pet’s unique state and disease processes to create the – so for example, when I am evaluating a homemade diet, it should have five major components. It should have a protein source. In my opinion, preferentially, it should be an animal protein. It should have a fat source. Now that can be animal skin, it can be an oil.

A lot of my clients love coconut oil and olive oil. Those aren’t bad oils, they actually don’t have all of the essential fatty acids that pets need. They need things like safflower, sunflower, and walnut, and canola oil. It should also have, depending, you know, again on the patient and what they’re needing, some form of carbohydrates plus or minus fruits and vegetables. And so that could be anything from oats or quinoa, you know, rices, pasta. I can get super super creative – I’ll tell you my most creative recipe in a second – but that is gonna help provide an additional source of nutrients and glucose and energy. It also helps us balance out the other macronutrients like fat and protein, so I can tailor it to the pet.

The fruits and veggies are gonna provide all of the things we just talked about, but also fiber. Fiber is great for the colon. It should have a multivitamin, and not just any multivitamin. They are all created differently and human multivitamins can be toxic to pets because the, you know, typically we don’t eat a complete and balanced diet.

We’re also significantly bigger than our pet counterparts. And so if I gave a little tiny Yorkie my prenatal vitamins, I’d probably kill it very quickly. You know, so again, talking to somebody that understands all of how these ingredients work together. And then really it should have an extra calcium source.

So we’re talking about either, you know, eggshells, or we’re talking about calcium carbonate, which is a nice, fancy word for Tums. And even if it has all five of those components, it is unlikely to be balanced. So in the 3,000 cases I’ve had, I have had one client who had all the time in the world that was close and she hand calculated every single nutrient.

So shout out to her. And I was, I was shocked. I was like, wow. Like you’re you’re, you’re not quite there, but you are super, super close. Every other diet I’ve ever analyzed has nutrient deficiencies, nutrient excesses, and/or it is inappropriate for that pet’s disease states.

[00:44:31] >> James Jacobson: Okay. So that then begs the question, do you often encourage people to do, not home cooked diets?

[00:44:40] >> Dr. Lindsey Bullen: That is, that is correct. So for me, you know, I have to take into consideration, A, what’s best for the patient when they come to me, but I also have to talk to the client about what they’re trying to accomplish and then analyze their lifestyle. Right?

And most of us are incredibly busy and don’t have the time or the money to be home cooking. And there are thousands of commercial products, you know, kibble, fresh, you know, frozen, canned, that are available on the market that absolutely can be appropriate to patients and specifically cancer patients. When I have the client that’s like, nope, I want to do it, my job isn’t to discourage them. My job is to say, okay, you’ve elected to do this, let’s talk about how we can do this safely together. And then I talk about, you know, the time invested, the money invested. I do try to make it as easy as possible. Like I’m not gonna be like, you shouldn’t do this, so here’s a really hard recipe.

Like, that’d be terrible. I try to make it simple for them using ingredients they feel comfortable using. If they want to batch cook, I will give, you know, them the recipe in terms of batches. I talk with them about cooking methods and freezing methods. So I, I do really try hard to, um, to help if that’s the direction they want to go.

But in terms of, you know, testing safety and quality, commercial products, in my opinion, are actually superior if they are from a reputable manufacturer, because when we think about a homemade diet that I create, it’s actually a feeding trial of one. It’s a feeding trial of your pet. Because it’s gonna depend on where you get your ingredients.

It depends on if you decided to add a little flair, even though there’s a little disclaimer that says don’t do flair. You know, whereas many of the commercial diets that are available, again, from reputable manufacturers, test the ingredients, before they come onto their property, they test their products for pathogens and bacteria, for contaminants, they test the diets in terms of digestability, they do feeding trials. So there’s a lot of quality control that goes into commercial production. But again, my job is not to argue with my clients. If they choose to home cook, I will support them and I will help them do it safely for their pet.

[00:46:41] >> James Jacobson: Awesome.

We’re gonna take a break again, but when we come back, the question of carbohydrates. We’ll be right back.

We are back. So carbohydrates, and dogs with cancer, or dogs in general. What’s your view?

[00:47:01] >> Dr. Lindsey Bullen: All right. So this is probably going to be a controversial topic and some of the listeners might turn me off right now. But my job as an expert in the field is to share with you accurate information and, obviously in this case, my professional opinion.

So in terms of carbohydrates and pets in general, it is inaccurate to say that they cannot tolerate or cannot utilize carbohydrates. They absolutely can. So when we think about what a carbohydrate is, we’re talking about – so there’s actually kind of two things. There’s carbohydrate ingredient. So that’s like rice and, you know, quinoa, and potatoes and whatnot.

And then we have carbohydrates on a nutrient level, and really we’re talking about like glucose there. Uh, so carbohydrates, there are enzymes in the saliva that help you break down carbohydrates. There are enzymes in the, throughout the GI tract and from the pancreas that specifically help you break down carbohydrates.

There are enzymes in the body based on the concentration of glucose that you just ate to help you push that glucose into the cells. Carbohydrate ingredients don’t just provide glucose, they are a source of amino acids, they’re a source of fatty acids, they’re a source of vitamins, minerals, and they are really great source of fiber. And fiber feeds beneficial bacteria that lives in the GI tract and can help with colonic health.

So there’s all of these parts of carbohydrate ingredients that can be helpful. So in my professional opinion, and, um, other nutritionists, carbohydrates are not bad, and animals absolutely can utilize them. I know this is for dogs, but when you think about cats, cats absolutely are obligate carnivores, that being said, they have all the same types of things that dogs do so they can utilize carbohydrates, just typically on a lower concentration.

Now, if we pull that back in, in terms of restricting carbohydrates for dogs with cancer, again, my favorite answer on this show, honestly, it’s gonna depend. So if you have that pet that, you know, needs high energy, is muscle wasting, then you absolutely can restrict carbohydrates because the nutrients that they’re gonna benefit from the most are gonna be the protein and the fat in the diet.

There has been a little bit of research out there, um, associated with lymphoma, that showed that cancer cells preferentially utilize glucose, and that it can increase lactate production in the body. That is true. But the thing to keep in mind is that those cancer cells are like honey badgers. They don’t give a you-know-what. They are gonna do whatever they want to do because it’s cancer and cancer sucks.

Like that’s just the truth of it. So if I restrict glucose-creating nutrients in the body or, you know, in the diet, rather, the body is still gonna make glucose because there are cells in the body that have to have it. So if you take away all of the carbohydrates in the diet, which you can do, then the body will actually spend more energy breaking down gluconeogenics, that means new glucose making, gluconeogenic amino acids to make glucose for those cells. So it’s actually harder on the body, it’s more energy for the body, if there’s not just a little bit of carbohydrates in there. But again, I can make a diet without carbohydrates, I can do that, but it depends on if their kidneys can handle that level of protein.

It depends on if their liver can handle that level of protein. And when most pet parents look at "cancer diets," and I say that with air quotes ’cause we’re on the radio, many of them are very, very low carbohydrate and that’s okay. That’s absolutely okay, because it’s high protein, high fat, it’s doing all the things I want it to do. But the question is can they use it? Absolutely, they can. If I give them carbohydrates, will it make the cancer worse? It actually, it will not.

[00:50:41] >> James Jacobson: Okay. So many things to talk about. Will you come back in the future and talk more to us about diet?

[00:50:49] >> Dr. Lindsey Bullen: If you would like me to come back, I would be honored and delighted to come back. Absolutely.

[00:50:53] >> James Jacobson: I would love to. I think one of the questions that we have a lot, and we just don’t have time for on today’s episode, is what can I feed my dog to prevent this stuff from ever happening in the first place? I bet you have some thoughts on that.

[00:51:04] >> Dr. Lindsey Bullen: I would say, cancer, again, it’s a honey badger.

There’s no rhyme or reason. You can get it when you’re old, you get it when you’re young, and it is heartbreaking, no matter what age you get it. Keeping your pet nice and trim, an ideal body condition score, feeding them a complete and balanced diet, obviously, you know, not including ingredients that are known to be carcinogenic or cancer causing, is gonna help prime your pet for health.

But we do have to keep in mind that sometimes we get really, really bad luck. And like, with my sweet Gus-Gus, you know, he was in the prime of health, and at eight years old, I lost one of my best friends. And I’m a vet, like I did everything, you know. So feeding them a diet that’s complete and balanced that fits their lifestyle, having those annual exams with your veterinarian – I know that’s not food – but make sure you’re getting your pet checked up every year, or twice a year if they’re older, because if we can catch it early, sometimes that makes all the difference.

[00:51:58] >> James Jacobson: Dr. Lindsey Bullen thank you so much for being with us today.

[00:52:01] >> Dr. Lindsey Bullen: Thank you so much for having me. It has been an absolute pleasure and I am super excited that you would like me to come back.

[00:52:09] >> James Jacobson: And thank you for joining us today on Dog Cancer Answers. We really appreciate your joining us and hitting that play button because food matters. And so I think Dr. Bullen will come back on some future shows to talk more about diet and its role in dog cancer.

If you have some questions that you would like addressed on a future episode of Dog Cancer Answers, please get in touch with us via our website at DogCancerAnswers.com. All the notes from today’s show, the links to the websites that she mentioned, are in the show notes and also on our website at DogCancerAnswers.com. Stay through to the end of this episode, because you will hear some previews of other shows that are available on DPN, Dog Podcast Network.

That’s it. I’m James Jacobson. From all of us here at Dog Podcast Network, I want to wish you and your dog a very warm, Aloha.

[00:53:08] >> Announcer: Thank you for listening to Dog Cancer Answers. If you’d like to connect, please visit our website at DogCancerAnswers.com or call our Listener Line at (808) 868-3200. And here’s a friendly reminder that you probably already know: this podcast is provided for informational and educational purposes only.

It’s not meant to take the place of the advice you receive from your dog’s veterinarian. Only veterinarians who examine your dog can give you veterinary advice or diagnose your dog’s medical condition. Your reliance on the information you hear on this podcast is solely at your own risk. If your dog has a specific health problem, contact your veterinarian.

Also, please keep in mind that veterinary information can change rapidly, therefore, some information may be out of date. Dog Cancer Answers is a presentation of Maui Media in association with Dog Podcast Network.