Thanks to a little dog named Poppy, we now have a blood test that can detect dog cancer before the dog experiences any symptoms.
Listen in to learn how the OncoK9 blood test by PetDx uses next-generation sequencing to determine if your apparently healthy dog has cancer DNA floating around in her body. While this test won’t give you a diagnosis, it can be used as a screening test to find cancer before it causes symptoms of illness, letting you get a head start on treatment for your dog.
This simple blood draw is one of the newest tools for dog lovers to use to battle canine cancer.
Links Mentioned in Today’s Show:
About Today’s Guest, Dr. Andi Flory:
Dr. Flory is a specialist in medical oncology with nearly two decades of experience practicing and publishing in the areas of early cancer diagnosis, treatments, trials, and novel diagnostic test evaluation. A diplomate of the American College of Veterinary Internal Medicine in oncology, Dr. Flory graduated from the Ohio State University College of Veterinary Medicine and completed additional training at Florida Veterinary Specialists and Cancer Treatment Center in Tampa, Florida, and Cornell University.
In 2019, she treated a small dog named Poppy for pancreatic cancer. Poppy lost her battle with the disease, but left an indelible mark on Dr. Flory, leading her to a newfound passion for cancer genomics. Soon after, Dr. Grosu tapped Dr. Flory to launch PetDx and serve as its first chief medical officer.
Prior to PetDx, most recently she co-directed the oncology internship and served as a medical oncologist at Veterinary Specialty Hospital in San Diego. Dr. Flory founded the medical oncology service at a sister hospital, Veterinary Specialty Hospital – North County. Prior to that she was a staff oncologist, resident advisor and co-chief of the oncology department at The Animal Medical Center in New York City. She has served as a principal investigator for national and international multi-site clinical investigational studies.
Dr. Flory is constantly expanding her knowledge in cutting-edge areas of veterinary medicine. She holds a certificate in genomics from The Johns Hopkins University along with certificates in cancer genomics and precision oncology, and genetic testing and sequencing technologies from Harvard Medical School. In addition, Dr. Flory is a skilled lecturer. An avid snowboarder and passionate foodie, when not keeping up with two preschoolers, Dr. Flory loves to travel, spend time with her husband, sons, their cat Mochi, and dog Cheyenne.
To join the private Facebook group for readers of Dr. Dressler’s book “The Dog Cancer Survival Guide,” go to https://www.facebook.com/groups/dogcancersupport/
This episode is sponsored by the best-selling animal health book The Dog Cancer Survival Guide: Full Spectrum Treatments to Optimize Your Dog’s Life Quality and Longevity by Dr. Demian Dressler and Dr. Susan Ettinger. Available everywhere fine books are sold.
Have a guest you think would be great for our show? Contact our producers at DogCancerAnswers.com
Have an inspiring True Tail about your own dog’s cancer journey you think would help other dog lovers? Share your true tail with our producers.
If you would like to ask a dog cancer related question for one of our expert veterinarians to answer on a future Q&A episode, call our Listener Line at 808-868-3200 www.dogcanceransers.com.
Dog Cancer News is a free weekly newsletter that contains useful information designed to help your dog with cancer. To sign up, please visit: www.dogcancernews.com
[00:00:00] >> Dr. Andi Flory: Lymphoma, hemangiosarcoma, and osteosarcoma are like what I call the big three. Right? Those are the most aggressive, and our detection rate in dogs with one of those three cancers was 85%.
[00:00:14] >> Announcer: Welcome to Dog Cancer Answers, where we help you help your dog with cancer.
[00:00:20] >> Molly Jacobson: Hello friend. Today on Dog Cancer Answers, we’re investigating OncoK9. It’s a liquid biopsy that detects cancer early in a simple blood draw, basically the stuff of science fiction. The test is made by PetDx and their chief medical oncologist, Dr. Andi Flory, is joining us today to talk about this really interesting testing technology and what it promises for our dogs.
Dr. Andi Flory, thank you so much for joining us today.
[00:00:54] >> Dr. Andi Flory: Lovely to be here. Thanks so much for having me.
[00:00:56] >> Molly Jacobson: So when I first heard about this new test, I thought it was science fiction. I’ll be just completely honest with you. It sounds like the future is bright. It sounds like those movies they made for like the World’s Fair in the sixties. Like, in the future, we’re gonna have flying cars and a blood test that detects cancer early.
Are we there? Are we in the future? Is this science fiction?
[00:01:25] >> Dr. Andi Flory: That’s a great question. I mean, it, it really is science fiction, isn’t it? It’s like, how can this possibly be that you can detect cancer with just a blood test? And it’s funny because as veterinarians, it is a very common question that we get.
Can’t you just tell if my dog has cancer from a blood test or from the blood work that you did? So we’re kind of very used to this, to talking about this, and we’ve talked about it for so long and had to say that doesn’t exist, like there’s no such thing as a blood test for cancer. So that’s kind of the preface is like most veterinarians have had that conversation with families.
And you know, when you first hear this word liquid biopsy, I think it, it conjures up all these like possibilities. You’re like, wow, if you could really diagnose and detect and understand a patient’s disease better with just a blood draw, that would be practice changing. And so, you know, going through the clinical study that we performed, which was in 1,100 dogs with and without cancer, so just a, a really, really large study, and seeing all these cases of the ability to detect multiple types of cancer – so 30 types of cancer with just a blood draw – I mean, it really, it sounds like science fiction, but it’s actually true. So I would say, yeah, the future is here.
[00:02:48] >> Molly Jacobson: In our Facebook group for people whose dogs have cancer, probably every other day there is a sort of general despairing post from somebody who says, I just don’t understand why there isn’t just a test that could have told me. Because if I’d known earlier, I would’ve taken action. And that’s the promise of OncoK9. And, um, I would like you to just tell me a little bit about exactly what is going on in the body.
How is the test administered, what is it looking for, how long does it take to get results back? And then what are the things that people need to do afterwards? Also, I really wanna know what cancers you can reliably detect. So let’s just talk a little bit about the test itself.
[00:03:31] >> Dr. Andi Flory: Yeah. So what this test is looking for are little bits of DNA. And this is, these little fragments of DNA circulate in the blood. And they circulate outside of any cell. And so it’s called cell-free DNA.
[00:03:45] >> Molly Jacobson: Okay.
[00:03:46] >> Dr. Andi Flory: So cell-free DNA, there’s a constant source of it in the body because it comes from cells as they die and they release their DNA into the blood. And so it’s, there’s just a constant source of this because there’s constant cell death happening in the body from normal cells.
[00:04:02] >> Molly Jacobson: That’s apoptosis.
[00:04:03] >> Dr. Andi Flory: And that’s apoptosis. Exactly. But also from cancer cells. And so the subset of cell-free DNA that comes from tumor cells, we call circulating tumor DNA or ctDNA.
[00:04:14] >> Molly Jacobson: Okay.
[00:04:15] >> Dr. Andi Flory: And that’s what this test is looking for. So the technology that makes this possible is a technology called next generation sequencing, which, the way I like to explain this is if you think about a dog’s DNA, the entire set of instructions in all of their DNA, that’s called the genome. And the genome is present in every single cell in the body apart from some red blood cells.
That DNA, if you kind of lay that end to end, that’s the genome. And if we think about the way that next generation sequencing works, you’re basically taking these little fragments of DNA and you’re figuring out almost like the little pieces of paper that come out of a paper shredder, where did this fragment come from?
How does it fit into this puzzle? And then you look at the whole puzzle and you say, do I see in here a cancer signal? And a cancer signal is essentially spelling errors in the DNA that shouldn’t be there. And these spelling errors can be really, really small. It can just be a single letter that’s misspelled.
But if it happens in an exact right place that we know is associated with cancer, then that can lead to cancer. Or it can be very, very big changes that affect very large stretches of the genome. And so we look by multiple different methods at the patient’s genome and we determine then whether a cancer signal is present in that patient’s sample.
Now these little fragments of DNA, they have to – they are very short lived in the body. They only last for minutes to hours. So we have to stabilize them with a special blood collection tube that stabilizes the sample. And so you asked about how the test is performed. The test is performed like any other blood draw, like a patient would have for any routine lab work that they have performed, that is pulled into two of these special blood collection tubes.
And the volume’s a little bit bigger than your typical kind of lab top machine type of test that would be run at your veterinarian because it’s like, it’s like doing a biopsy, right? Just like a biopsy is a relatively larger piece of tissue than you would do if you were doing an aspirate for example, where we’re just taking a few cells out. A biopsy of the blood is no different. We need a little bit more because we’re looking for this DNA that’s present at very, very, very tiny quantities.
[00:06:38] >> Molly Jacobson: So how much blood is being taken?
[00:06:40] >> Dr. Andi Flory: It’s about one tablespoon.
[00:06:41] >> Molly Jacobson: A tablespoon. Okay.
[00:06:43] >> Dr. Andi Flory: Yeah, when we put it into like baking concepts, it really doesn’t sound like a lot. And that is actually a safe amount to draw in the vast majority of patients that we see down to about a five pound dog.
[00:06:54] >> Molly Jacobson: Okay. ‘Cause my dog’s eight pounds, so a tablespoon of blood to me sounds like, like more than it would to someone who has a Great Dane.
[00:07:02] >> Dr. Andi Flory: Exactly, exactly, right?
[00:07:04] >> Molly Jacobson: Okay. So I wanna make sure I understand this. You’re taking these large for veterinary medicine generally, but small for, you know, our imagination, we don’t have to worry about it, blood draws.
[00:07:16] >> Dr. Andi Flory: Yeah.
[00:07:16] >> Molly Jacobson: You’re taking a lot of blood out for your purposes, ’cause you wanna see how many, as many little bits of DNA that are circulating as possible. They’re stabilized so they don’t change, they don’t disintegrate on the way to the lab. And then when they’re at the lab, you look at – are you getting the cells, the genome of the dog? Are you getting that from those, the circulating DNA, from the free DNA that you’re getting in the sample?
[00:07:42] >> Dr. Andi Flory: Yeah. We’re sequencing the DNA that’s in the sample.
[00:07:45] >> Molly Jacobson: That’s in the sample. Okay.
[00:07:47] >> Dr. Andi Flory: Yeah.
[00:07:47] >> Molly Jacobson: And then some of the DNA sequences that you see will not sort of, you won’t be able to match them along the sequence. You’ll say, uh, this is the same as right here, but it’s just a little bit off or, wow, this looks like this section, but a lot of changes have been made, and that’s basically a cancer signal.
[00:08:05] >> Dr. Andi Flory: That’s right. So we match it to a canine genome. So just like in humans, the canine genome has been sequenced, we know what the normal sequence is, and then we can compare and say, what is abnormal. That’s right.
[00:08:19] >> Molly Jacobson: Okay. I see.
So this is getting, obviously, the DNA fragments of normal cells that have undergone apoptosis and are just leaving the body because it’s their time to go, there’s DNA samples from that, those will look, and they’ll fit easily into that canine genome that has already been sequenced that you guys have as sort of your, this is what the perfect puzzle picture looks like. And here’s where this piece of it is.
And then the cancer DNA will not quite fit along that puzzle. It’s like the puzzle piece – it should be there, but like a corner’s missing or there’s an extra little corner on it or something. Okay.
[00:08:55] >> Dr. Andi Flory: Or there’s more, there’s like, you know, 20 puzzle pieces where there should just be one. That’s not normal, right? You shouldn’t have that.
[00:09:02] >> Molly Jacobson: Right. That is not normal.
[00:09:03] >> Dr. Andi Flory: Yeah.
[00:09:03] >> Molly Jacobson: That’s when you call the puzzle company and say, I, clearly, something’s wrong here.
[00:09:09] >> Dr. Andi Flory: That’s exactly right.
[00:09:11] >> Molly Jacobson: Okay. Well, that is fascinating. And so you said that there’s a stabilizing agent, does that mean, does this have to be refrigerated on its way to the lab or do we have to worry about that when the sample goes off?
[00:09:23] >> Dr. Andi Flory: No, actually. What’s so fascinating about these tubes is that they stabilize the sample for seven days at room temperature. So no refrigeration, no freezing. You don’t have to spin the sample. In busy veterinary clinics, you don’t have to kind of hunt down like a styrofoam box and an ice pack and-
[00:09:39] >> Molly Jacobson: Yeah.
[00:09:40] >> Dr. Andi Flory: -all of the things. You just pop it back in the box and then send it.
[00:09:44] >> Molly Jacobson: So does the veterinarian order this test?
[00:09:47] >> Dr. Andi Flory: Yeah. So it’s by prescription only through a licensed veterinarian. So it does need to be ordered by and drawn by and submitted by a veterinarian.
[00:09:56] >> Molly Jacobson: Okay.
Are there veterinarians who, if I bring my dog to their clinic, will say, Oh, you’re here for your wellness check, but your dog’s eight. And now I think maybe we should add this in. Do you wanna do it? I’ve got the box right here.
[00:10:09] >> Dr. Andi Flory: Yes.
[00:10:10] >> Molly Jacobson: Is that happening right now? Or do they have to make a call?
[00:10:14] >> Dr. Andi Flory: Yeah, so that’s happening now and it’s my dream that that would happen everywhere, right? So that we could give so many more dogs the opportunity to have this test and find cancer earlier. So the way to sort of find out if there is a clinic in your area that is offering the test, there’s really a few ways, one is that you can go to our website at petdx.com and go to the Pet Parents page and you’ll find a clinic locator.
[00:10:39] >> Molly Jacobson: Okay.
[00:10:39] >> Dr. Andi Flory: And you can find out who is offering the test. But the test is actually also available through our major veterinary diagnostic distributors, like IDEXX and Antech, and these are very common diagnostic companies that most veterinarians use. So even if they’re not aware of it yet, they can order the kits to do this test most likely because most of them are using one of those diagnostic companies.
[00:11:03] >> Molly Jacobson: Wonderful.
And generally, when a test is available through a diagnostic company that reassures a lot of the skepticism that a veterinarian feels because they know that that distributor has vetted, and the company has vetted that test on their level and feel like it’s worth offering and keeping in stock and that they assume it’ll be needed at some point, otherwise they wouldn’t keep it.
[00:11:23] >> Dr. Andi Flory: Absolutely.
[00:11:24] >> Molly Jacobson: Well, that’s wonderful. So even if your veterinarian doesn’t have it in stock, usually those distributors get things to them like within a week, but it’s often the next day.
[00:11:34] >> Dr. Andi Flory: Yeah.
[00:11:34] >> Molly Jacobson: All right. So it’s really possible to get this pretty quickly and reliably. And then the testing, how long does that take?
[00:11:40] >> Dr. Andi Flory: Yeah, the turnaround time is usually between about 10 and 12 days from the time the sample’s received at the lab, but sometimes it’s faster than that. So it could be about a week. But the turnaround most of the time is between 10 and 12 days. And that’s calendar days.
[00:11:55] >> Molly Jacobson: Calendar days, not business days. Okay.
[00:11:57] >> Dr. Andi Flory: Not business days. Yes.
[00:11:58] >> Molly Jacobson: Well, that’s nice. So what are the kinds of cancer that you feel confident are reliably being picked up on?
[00:12:06] >> Dr. Andi Flory: So in our study, we were able to detect 30 types of cancer. So this is really a multi cancer test.
[00:12:12] >> Molly Jacobson: Wow.
[00:12:13] >> Dr. Andi Flory: And we, we broke it down to look at cohorts of like, what are the most common cancers that veterinarians see, diagnose, and manage. Lymphoma, hemangiosarcoma, and osteosarcoma are like what I call the big three.
[00:12:27] >> Molly Jacobson: Yeah.
[00:12:28] >> Dr. Andi Flory: Those are the most aggressive. And our detection rate in dogs with one of those three cancers was 85%.
[00:12:34] >> Molly Jacobson: Okay.
[00:12:35] >> Dr. Andi Flory: So really, really phenomenal that the test could pick up 85% of those very, very aggressive cancers. Now, if we add to that another five cancers – which rounds out the top eight most common cancers that dogs get – so adding to that soft tissue sarcoma, mast cell tumor, mammary gland carcinoma, malignant melanoma, and anal sac carcinoma, those are the top eight most common cancers.
So, so those five, in addition to the lymphoma, hemangiosarcoma, and osteosarcoma – and the detection rate in that group is 62%.
[00:13:07] >> Molly Jacobson: Wow.
[00:13:08] >> Dr. Andi Flory: So really when you consider all of the most common cancers that dogs get, the test is able to pick out the majority of them.
[00:13:17] >> Molly Jacobson: And this is earlier than probably you would – you’re picking these things up before the dog gets sick, basically.
[00:13:23] >> Dr. Andi Flory: We can.
[00:13:24] >> Molly Jacobson: From my perspective as a dog owner, it’s when my dog starts to feel sick that I start to worry about things like cancer. Before my dog gets sick, I’m not worried about things like dog cancer. Well, I am now because I’ve had dogs with cancer, but most people who haven’t yet had to deal with this don’t, and cancer just side swipes them.
And to know that you’re picking it up but your dog’s not sick yet, I think would take a tremendous amount of, of anxiety and trauma to deal with on an emotion level, but it would in fact, lower your trauma a little bit to know that you caught it early.
[00:14:00] >> Dr. Andi Flory: Absolutely, because I think there’s more benefits to finding it early than just – what some of the things that we’ve talked about so far like that the patient, the dog, is feeling better. So they have a better, like they’re starting from a better place.
[00:14:15] >> Molly Jacobson: They’re stronger. They can tolerate.
[00:14:16] >> Dr. Andi Flory: But there’s other benefits. Yeah. Like from, from a family’s point of view, you have more options to consider if your dog is diagnosed when they’re feeling healthy versus, you know, when they’re feeling sick. So the most common example that I like to give here is anyone that’s been through hemangiosarcoma diagnosis with their dog unfortunately knows that most of those dogs are diagnosed because their tumor is bleeding.
[00:14:40] >> Molly Jacobson: Right.
[00:14:40] >> Dr. Andi Flory: And they end up in the emergency room or they end up at their vet very, very sick because they’ve lost a lot of blood. And by that point, the cancer’s pretty advanced.
[00:14:50] >> Molly Jacobson: Right.
[00:14:51] >> Dr. Andi Flory: And so, you know, being able to detect it before it even causes any bleeding means that the family has more options to choose from. Like they’re not sort of forced into this sometimes middle of the night urgent decision that’s happening at the ER clinic of, you know, here’s what has to happen. Like you have to do this right now, basically to – and there’s really no other, there’s no other options right now in the middle of the night. You know, we have to consider a blood transfusion or immediate surgery or both.
And so it, it kind of puts you in that position of being able to have more choices really, and have the time really to choose what is best for your dog and for your family.
[00:15:32] >> Molly Jacobson: Right. So if I get – let’s say that in this hypothetical, where I have a dog, I’ve gone in for a wellness check, the vet says, you know – I have a Maltese. They’ll say, you know, your little girl’s, she’s 10. This is when we start to think that maybe it’s, you know, she’s getting older and her risk of cancer has gone up. One out of two dogs over the age of 10, typically, that’s about roughly half over the age of 10, will get cancer. And so there’s this test, we could do it, we might find something we might not.
If we find something we can do follow up tests, right? This is not an actual diagnosis. This is a test that could lead to a diagnosis. Am I correct about this?
[00:16:12] >> Dr. Andi Flory: You are. And that’s a really good point to bring up. So this is a screening test. It’s not a diagnostic. And what that really means is that we as veterinarians won’t make important decisions like treatment or euthanasia just on the basis of a test like this alone. It’s really – it’s a piece of the puzzle, but it’s not the whole picture, right? You really have to then pursue further testing to understand exactly what is going on and to get a definitive answer and diagnosis on what’s happening.
[00:16:41] >> Molly Jacobson: Right. Okay.
Do you have general guidelines on when you would recommend this be used for dogs who are otherwise healthy?
[00:16:49] >> Dr. Andi Flory: Yeah. So we recommend it as an annual screening test for all dogs over the age of seven.
[00:16:55] >> Molly Jacobson: Okay.
[00:16:55] >> Dr. Andi Flory: And because there are some breeds that tend to, if they get cancer, or even if they’re at high risk of cancer, they can get it earlier in life, some dogs should start as young as the age of four.
[00:17:10] >> Molly Jacobson: Are Rottweilers in that category?
[00:17:13] >> Dr. Andi Flory: Rottweilers are a breed that is at high risk of developing cancer sort of in their lifetime. If you have a question about any particular breed, we put together a study where we looked at about 3,400 dogs with cancer and determined by breed what’s the average age that they developed cancer. And we used that to make a recommendation for when should a particular individual start cancer screening. And so we have a tool on our website called the Cancer SAFE tool, which stands for Screening Age For Early detection. And that’s cancersafe.PetDx.com.
[00:17:50] >> Molly Jacobson: Okay.
[00:17:51] >> Dr. Andi Flory: And you can go on there and you can put in your pet – or for veterinarians listening, your patient’s – information, their breed, their age, and their weight, and determine in this particular dog, when should I consider starting cancer screening.
[00:18:06] >> Molly Jacobson: Wonderful. That’s a good place for us to stop and take a quick break. And then we’ll come back with Dr. Flory and we’ll talk a little bit about the competition out there.
And we’re back with Dr. Flory. And we’re talking about OncoK9, a liquid biopsy test. Is there anybody else who’s doing something like this, or how does it compare to other people who are doing these early cancer detection tests?
[00:18:32] >> Dr. Andi Flory: So there really aren’t any competitors in the veterinary space. This is really the only Multi-Cancer Early Detection or MCED test, it’s the only next generation sequencing based liquid biopsy that’s available for dogs that can detect a wide variety of cancers. There are other blood based cancer tests, but they’re very different in terms of technology and what they look for and the clinical use of those. So that’s pretty different from what this test is looking for.
[00:19:01] >> Molly Jacobson: Okay. So you’re really looking at the genome.
[00:19:03] >> Dr. Andi Flory: That’s right.
[00:19:04] >> Molly Jacobson: And you’re really looking at the DNA.
[00:19:05] >> Dr. Andi Flory: That’s right.
[00:19:06] >> Molly Jacobson: Okay. And that’s why we’re saying liquid biopsy.
[00:19:09] >> Dr. Andi Flory: Yeah.
[00:19:10] >> Molly Jacobson: That’s a great marketing term.
[00:19:11] >> Dr. Andi Flory: Yeah. I wish we made it up, but we did not. That came from the human side. It’s a great, it’s a great, isn’t it? It just, what it conjures up. Yeah.
[00:19:19] >> Molly Jacobson: Absolutely. Absolutely.
Is this test covered by pet insurance companies?
[00:19:25] >> Dr. Andi Flory: The insurance companies that we’ve talked to so far, most of them do not seem to be covering it for the screening use, so in a dog where cancer is not suspected.
[00:19:35] >> Molly Jacobson: Okay.
[00:19:35] >> Dr. Andi Flory: But another use for this test that veterinarians are using it for is as an aid in diagnosis. And what that really means is, okay, you have a patient that has clinical signs or something in their, in their clinical presentation that makes you suspect cancer in this individual, but it’s kind of challenging to diagnose. Either you kind of can’t get to that part of the body easily, or, you know, it’s gonna require some sort of advanced testing that you don’t have in your clinic, something like that.
So this is a test that can determine is cancer signal present in this patient. And so for that use where the veterinarian suspects cancer, it seems that some insurance companies are actually covering that part of it.
[00:20:17] >> Molly Jacobson: I see. That’s helpful. I was, just last December, our little dog has been fighting cancer for four years.
[00:20:25] >> Dr. Andi Flory: Oh my gosh.
[00:20:26] >> Molly Jacobson: She’s amazing. She’s 14 and a half. And we brought her in, I thought for back pain, but we also saw that there was uh widespread masses in her abdomen that in order for us to understand, biopsy, you know, to biopsy, we’d have to open her up. And at this age that’s not happening, you know, that’s just not what we’re doing.
So this would’ve been a really nice thing for us to be able to ask for at the vet clinic to say, Hey, can we just do this one test? And then maybe we’ll know what we’re dealing with. In our case that would’ve just given us a piece of information that we wouldn’t have necessarily acted upon.
[00:21:02] >> Dr. Andi Flory: Yeah. Sometimes it just helps you understand, and sometimes, as a family, make decisions, because you know, a lot of times if you have these clinically challenging cases where it’s like, it could be this, it could be this, it could be this, and, and I don’t really have a good way to, to answer the question, sometimes it really would help to kind of narrow it down in terms of what you choose for treatment or, you know, which pathway you go down. Like, do you go to a specialist or do you not, or that sort of thing, so-
[00:21:29] >> Molly Jacobson: Right.
[00:21:29] >> Dr. Andi Flory: I think you’re right. There’s sometimes just these really challenging situations where it can be very helpful to know, to kind of guide the path.
[00:21:37] >> Molly Jacobson: She had a diffuse pattern in her liver scan, ultrasound. And basically they were like, well, it’s either a liver infection or it’s metastasis and we don’t know which. And the only way we found out, we ruled it out by a couple weeks giving her some liver support and then retesting and her liver values had gone down even more. So probably metastasis. But this would’ve actually probably got us closer to knowing that and maybe sooner.
[00:22:05] >> Dr. Andi Flory: Yeah. Sometimes it’s just that piece of the puzzle, like I said, that kind of makes it kind of come into clearer focus what’s what’s happening.
[00:22:12] >> Molly Jacobson: Right. And that may or may not be – for me, at this point with this dog, it’s not really something that I probably would’ve chosen to do, just because it would only have been for my own curiosity. It wouldn’t have changed the way I treated. But I know a lot of people who would’ve said I absolutely wanna know what that is, and I wanna know what’s going on so that I can organize my thinking around it. Or maybe they’re not so – a lot of people don’t think about cancer as much as I do.
[00:22:40] >> Dr. Andi Flory: Yeah. Unfortunately you’re intimately connected.
[00:22:42] >> Molly Jacobson: In every way possible. Okay. So how much does this cost?
[00:22:46] >> Dr. Andi Flory: So the test is sort of available through those three different channels that I mentioned, and it’s going to vary a little bit in terms of where the test is coming from, but in general, it’s usually $500 or more.
[00:23:01] >> Molly Jacobson: Okay.
[00:23:01] >> Dr. Andi Flory: So it just kind of depends on the clinic and, you know, how it’s received by the clinic.
[00:23:07] >> Molly Jacobson: Right. So obviously the veterinarians are going to be charging around $500 to us.
[00:23:12] >> Dr. Andi Flory: Right.
[00:23:13] >> Molly Jacobson: All right. And then possibly more, depending on what else is going on, they’re, where they’re located and all of their other business decisions that they make as business owners.
[00:23:21] >> Dr. Andi Flory: That’s right.
[00:23:22] >> Molly Jacobson: And is there any wiggle room there? Is there anything that people can do to bring that cost down if, especially if insurance isn’t covering it?
[00:23:30] >> Dr. Andi Flory: Yeah. That’s a good question. I will say that we, you know, we currently have a program that helps to fund the workup in the case of a positive test. So if, uh, you know, if you receive a cancer signal detected, we actually have a program to help fund at least part of the workup to try to find cancer. So-
[00:23:50] >> Molly Jacobson: Oh.
[00:23:51] >> Dr. Andi Flory: That’s not an indefinite program, but it is available now. And so that certainly can help financially.
[00:23:58] >> Molly Jacobson: So I would, as a client of a veterinarian, I would say, yeah, I wanna spend the money on this test because I know that if it’s positive, then PetDx is going to help with the follow up tests to determine whether there’s illness or not.
[00:24:12] >> Dr. Andi Flory: That’s right.
[00:24:12] >> Molly Jacobson: And you’re doing that I assume as a business decision, because that’s interesting, useful information for you about how your test is used in a clinic and what kind of results you’re getting and it helps you to add to your case studies of took the test, got a positive signal, and yes, in fact there was cancer and this was the outcome.
[00:24:31] >> Dr. Andi Flory: It definitely does that, it gives us lots of case studies to be able to share with veterinarians, to help them understand how does this fit into your clinical workflow. But it also helps both pet parents and veterinarians understand the process of what do I do after a positive result-
[00:24:49] >> Molly Jacobson: Right.
[00:24:50] >> Dr. Andi Flory: -and how important that process is. Like you mentioned before, it’s, it’s really important to follow up on a positive test result, right? See where this cancer signal is coming from. And so if veterinarians and pet owners go through this process and kind of can go through it without the burden of the financial discussion as well, it gives everyone just more comfort with the process, and so that then veterinarians can really understand how important, and the kind of outcomes that come from doing the workup.
[00:25:21] >> Molly Jacobson: I see. So how much are you covering those follow ups? Sounds like it’s a substantial help.
[00:25:27] >> Dr. Andi Flory: Yes, up to a thousand dollars.
[00:25:29] >> Molly Jacobson: Okay. Well that covers plenty of diagnostics in most veterinary clinics.
[00:25:34] >> Dr. Andi Flory: Yeah.
[00:25:34] >> Molly Jacobson: So you said, uh, that, you know, find out where the signal’s coming from. So you’re identifying a specific cancer signal, right? Like, oh, we’re picking up osteosarcoma, is what you tell the vet. And then they will do scans to see where the bone tumor is, or they-
[00:25:50] >> Dr. Andi Flory: So not yet completely. So really it’s a qualitative answer. It’s a yes/no. A cancer signal has been detected, or there’s no cancer signal detected in this sample.
[00:26:02] >> Molly Jacobson: I see.
[00:26:03] >> Dr. Andi Flory: However, we are able to predict the cancer signal origin, meaning the cancer type, for some cancers. And so for right now, that’s hematological malignancies, lymphoma and leukemia specifically.
[00:26:17] >> Molly Jacobson: ‘Cause those are in the blood.
[00:26:19] >> Dr. Andi Flory: Well, it’s not actually because of that. It’s because they have a pretty, um, specific signal that’s very recognizable.
[00:26:26] >> Molly Jacobson: Okay.
[00:26:27] >> Dr. Andi Flory: And so the goal is – and we are very optimistic – that will be able to add more cancer types as time goes on.
[00:26:35] >> Molly Jacobson: Okay.
[00:26:35] >> Dr. Andi Flory: Yeah. But so, so for right now it’s really a yes/no cancer signal or not. But then for that subset of that particular type of cancer, we can also predict what type of cancer it is.
[00:26:48] >> Molly Jacobson: Well, that’s fantastic. Okay. So that’s really good to know. So it’s a yes/no. And then the veterinarian would say, all right, we know something’s going on. Let’s do a thorough workup. Let’s do an ultrasound. Let’s do an x-ray. Let’s start there and see what we can find. And let’s take a closer look at the blood work and see what might be in here.
[00:27:07] >> Dr. Andi Flory: That’s exactly it. Yep. So we’re just kind of, go on a hunt and find out, try to find out where could this be coming from. So, you know, find if there are lumps and bumps and enlarged lymph nodes and anything you can see on x-rays or ultrasound, or you know, that you can feel in the abdomen or things like that. And then take samples of those things to look and see if you can find cancer somewhere.
[00:27:27] >> Molly Jacobson: Okay. And so for a limited time, you guys are helping to subsidize those costs for people. So I’ll make sure that that’s in the show notes as well. And everything that we’ve talked about will be linked to in the show notes. Okay. Tell me about something that really surprised you. Like what’s a case that you looked at and you said, okay, this is surprising. I am shocked.
[00:27:48] >> Dr. Andi Flory: Yeah. I mean, I think it’s, and we’re, we see these cases every week where it’s screening patients. So patients that are not, their veterinarian and their family does not suspect cancer for any reason, but they’re just a higher risk individual. So they’re, they’re at higher risk of cancer because of their age or because of their breed.
[00:28:10] >> Molly Jacobson: Uh-huh.
[00:28:10] >> Dr. Andi Flory: And so they’re running OncoK9 as a screening test to try to identify cancer early, and then the ultimate diagnosis of cancer in patients that don’t have any clinical signs, so no signs and symptoms yet, is really amazing. We had this case a couple of weeks ago of a patient that had the test as a screening test and ultimately, kind of fast forward through all the clinical details, was diagnosed with a type of lymphoma of the liver-
[00:28:40] >> Molly Jacobson: Whoa.
[00:28:40] >> Dr. Andi Flory: -which universally, when I see those, are really only diagnosed because of clinical signs. So signs and symptoms that they stop eating, they’re very sick, their liver values on their blood work are are really high. Often their liver function is abnormal, so they’re in liver failure. Those, that’s how we usually diagnose these cases.
So to have a patient like that be diagnosed before any clinical signs or before any changes in the liver values on the blood work, that’s just phenomenal because it means that that patient has a chance at a better outcome because they’re able to start therapy from a, a place where they’re feeling healthy and their chance at response to treatment is just so much better and their prognosis is better.
[00:29:26] >> Molly Jacobson: Well, sure. If we catch things early, then the treatments always have a better chance of success just from that one factor. That is a critical – especially with something like lymphoma, that’s incredibly aggressive disease. And so catching it early and starting treatment early would be really, really important.
So how did they decide to run, this particular family, did they just ask for it? Did the veterinarian suggest it because of the risk factors of the dog? Or do you know anything about what prompted them to actually run the test?
[00:29:59] >> Dr. Andi Flory: I do, actually. In that particular case, that family had just been through a cancer diagnosis and treatment with their other pet.
[00:30:07] >> Molly Jacobson: Yep.
[00:30:08] >> Dr. Andi Flory: And that is such a common question that I get as an oncologist is what can I do to catch this earlier in my remaining dog, remaining pet, remaining cat, remaining everything, like my other family members I’m worried about. So what can I do for them to try to be proactive about if, if they’re gonna develop it, to try to be proactive in finding it.
And so it’s, you know, families that are already aware of canine cancer, they’re absolutely the ones that are asking for this test and, and are really wanting to do this for their dogs.
[00:30:40] >> Molly Jacobson: So I’ve seen this a lot since 2007 when first started working with people with dogs with cancer, that oftentimes it’s the person who loves their dog and wants to help their dog that sort of leads, leads the veterinarian to the new tool or the new test or the new theory. And then the veterinarian investigates it and says, okay, well, if you’re open to trying it, let’s try it.
So this is one of the patient-led sort of driving forces in even being able to treat cancer to the extent that we are are today, because people have been asking for things that veterinarians might have some hesitancy over because they’re new.
[00:31:17] >> Dr. Andi Flory: I love that idea.
[00:31:18] >> Molly Jacobson: Yeah. Are you finding that with OncoK9? Are you, do you have skepticism in vets or are they embracing it?
[00:31:25] >> Dr. Andi Flory: That’s such a good question, but I, I love that idea of pet parents being the one that finds new technologies, new treatments, new everything, and kind of presents it to their vet because we are definitely finding that, with ambassadors like that, that discover our test and read about the science and read about um, the technology and present it to their vet and then kind of get their vet interested, and then their vet contacts us or, or reaches out to us and, and we provide more information.
So absolutely we find that as a way to spread the word. And that’s really the, the job – you said at best I mean, vets are skeptical. We’re a skeptical bunch. We’re very data driven people. And so, you know, vets typically like to be able to look at all the data and make a decision for themselves about a new technology. And so I think everyone’s well aware of that, um, pet owners, especially. And so, yeah, we’re, we’re definitely seeing that.
And that was a big part of the reason that the study that we did, which was performed at 41 sites on four continents and involved 1,100 dogs, is really so compelling. Because in veterinary medicine, we just don’t see studies like that. I mean, the studies that we’re used to, especially for diagnostics, are like, 17 dogs were used to validate this test and, you know, 19 for this one and 52 for this one.
So, you know, good for some things, but really a rather small sample size for a lot of the tests that we’re used to using. So we really wanted to have a very large set so that it was really kind of very clear when we were seeing, you know, cancer signal versus no cancer signal in this group of dogs with and without cancer. And with a wide variety of cancers, that was really important for the development of that study, that for these skeptical vets, that we would be able to convince them with the data. So, um, so far vets are really, really excited to read the study.
[00:33:21] >> Molly Jacobson: Well, that’s good. And you had it independently verified, right? You have a peer reviewed paper at this point that is looking at it.
[00:33:29] >> Dr. Andi Flory: Yep. It’s a peer reviewed paper published by the Public Library of Science and a journal called PLOS One. And it’s the largest clinical validation study ever performed in veterinary cancer diagnostics.
[00:33:40] >> Molly Jacobson: Okay.
[00:33:40] >> Dr. Andi Flory: And that’s called the CANcer Detection in Dogs or CANDiD Study.
[00:33:44] >> Molly Jacobson: CANDiD Study. Okay. So we’re gonna make sure that there are links to that study in the show notes, obviously for our listeners, but we also have a lot of veterinarians who listen to this program. So I know that they’ll wanna look at that, and as part of their data collection efforts. I understand there’s a human version of this liquid biopsy test.
[00:34:05] >> Dr. Andi Flory: Yeah, there’s a company called GRAIL. I’ll say that there are a lot of companies out there that are doing blood based liquid biopsy to do a variety of, of things for cancer management in people, whether it’s detection or some sort of management of their treatment process.
But there is a company that is doing multi cancer early detection, or MCED, as well. And that’s a company called GRAIL and they have a test called GALLERI, G A L L E R I. And so this is now available for people, it’s recommended for people age 50 and older, particularly with a family history of cancer.
[00:34:41] >> Molly Jacobson: Okay.
[00:34:41] >> Dr. Andi Flory: And it can detect 50 types of cancer with a blood draw, which is just phenomenal because the majority of the cancers that it can detect are not cancers where there is a screening paradigm. Meaning that in most people, the way that they’re diagnosed with those cancers is because they develop signs and symptoms, by which point we know that a lot of those cancers are gonna be in advanced stages and then providing that cure or very long term control is usually minimal for those advanced stage cancers.
[00:35:10] >> Molly Jacobson: Okay. So that kind of gets me into something that I wanted to talk a little bit about, which is sort of the science fiction aspect of this.
Knowledge is power. However, is there such a thing as knowing too much? Do we really always wanna know all of the things that are going on? I mean, my understanding is that at any given moment in the human body or the dog’s body, there could be tumors developing that the immune system is detecting and taking care of, and that they never develop into something that we would identify as cancer, but there are actually tumor cells that could be populating.
Are these tests finding things that are so small and so insignificant that will never develop into something more later? Are we catching them too soon? Do we really wanna know what we have, or do we wanna wait until it’s actually quote a problem?
[00:36:01] >> Dr. Andi Flory: That’s a great question. And I think – I have to be honest, when we were first putting together the study, I had the same thought. And I thought, what if all of these dogs are just walking around with tumor DNA in their blood and they have a cancer signal. Like what if, you know, half of all dogs at a certain age are like, just, you know, have really, really minuscule amounts of DNA. And we didn’t really know what we were gonna find.
What we end up finding is that the false positive rate, meaning the dogs from the normal dogs cohort that we detected cancer signal in, was only 1.5%.
[00:36:40] >> Molly Jacobson: Oh.
[00:36:41] >> Dr. Andi Flory: So extremely low.
[00:36:42] >> Molly Jacobson: Okay.
[00:36:43] >> Dr. Andi Flory: And we followed those dogs over time and we retested them when we could, and we followed them. Some of those unfortunately had passed away by the time we were able to kind of do the analysis, and so some of those could have had cancer and might have been like true positives rather than false positives. But the remaining ones, we ended up finding cancer in two of them. And then we kind of followed, it was only about four additional patients that we have been following over time.
So a very, very low percentage of false positives. And, you know, that was a relief to me because when you think about a screening test, the number one thing that you don’t wanna do is just scare a bunch of families, right, by having a high false positive rate.
[00:37:27] >> Molly Jacobson: Right.
[00:37:28] >> Dr. Andi Flory: And so being able to have such a low 1.5% false positive rate is just great because it means that we really can trust these positive results.
[00:37:38] >> Molly Jacobson: And just to be absolutely crystal clear, a false positive is when a test comes back positive for an illness and is incorrect, that it turns out it should have been negative. And so if you’ve got a 1.5% false positive rate, that means that 98.5% of the time, if this test says there’s cancer, then when you go and look and you do further testing or imaging, you’re gonna find it.
[00:38:04] >> Dr. Andi Flory: Kind of but, but not really ’cause then when we get into statistics and statistical definitions, the number that you’re talking about there is called the Positive Predictive Value or PPV.
[00:38:14] >> Molly Jacobson: Right.
[00:38:15] >> Dr. Andi Flory: So that is the really important metric when you’re thinking about a specific patient. And so if I’ve gotten a positive result in this patient, how likely is it that I’m gonna find cancer. And so the PPV rate is very, very high with this test, and our estimated PPV is between about in the high seventies to the high nineties.
[00:38:35] >> Molly Jacobson: Okay.
[00:38:36] >> Dr. Andi Flory: So most of the time, if you get a positive result, it is because that patient unfortunately does have cancer and it, you know, if we do a workup, we will ultimately find it.
[00:38:47] >> Molly Jacobson: Okay. So the PPV is the 70 to 90% rate, which is still, if I got, if I knew that the PPV on a test was 70 to 90%, I’d be like, yeah, let’s do a scan.
[00:39:00] >> Dr. Andi Flory: Yeah.
[00:39:00] >> Molly Jacobson: I mean, for myself as a human, with my own physician, I would wanna follow up and say-
[00:39:05] >> Dr. Andi Flory: Yeah.
[00:39:06] >> Molly Jacobson: -oh, that’s a pretty high rate. Let’s look for more information.
[00:39:10] >> Dr. Andi Flory: And that’s exactly it, is just the importance of following up. So if a positive result is received, then that’s where it’s really important to find out where is this signal coming from in the body and look for it. Yep.
[00:39:24] >> Molly Jacobson: Okay. That’s a good place to take a break. And when we come back, I want to hear a story that you were telling me during our last break about how you started PetDx. We’ll be right back with Dr. Andi Flory.
And we’re back with Dr. Andi Flory. So Dr. Flory, you were going to tell me about how you started PetDx. Why don’t you go ahead.
[00:39:49] >> Dr. Andi Flory: Yeah, so I’m a veterinarinary medical oncologist, and I had a little patient, her name was Poppy. She was a little eight pound mixed breed dog. She was so adorable. She had these big fluffy ears, almost like a Papillon kind of ears. Just adorable. And her family was obviously smitten with her as everyone was when they saw her.
So Poppy, unfortunately, like a lot of patients that I see, her cancer was found because of clinical signs. And by the time they kind of figured out what was going on with her, her cancer was just everywhere. It was, it was just widespread. And so, you know, to have to share that discussion with the family that is so smitten with their tiny little dog who they’ve just fallen in love with – it’s their first dog too –
[00:40:34] >> Molly Jacobson: Oh, no.
[00:40:35] >> Dr. Andi Flory: – that, you know, there are always things that we can do to keep her comfortable for as long as we can, but this isn’t something we’re unfortunately gonna be able to cure or control in the long. It’s a hard discussion to have. It’s kind of a devastating feeling. As I kind of went through the process of getting to know Poppy’s family, I found out that Poppy’s dad is an MD by training and that his expertise is in genomics and liquid biopsy and he developed this technology on the human side.
And for him, it just really immediately clicked. He was like, you know, I didn’t have the opportunity, but we could have detected cancer earlier in my dog. And I wanna do this for other people. Like I have this expertise and I know teams that can do this, ’cause I’ve done this on the human side, you know, can we do this for dogs?
And he asked me, do you think that this is, is needed, is desired, in veterinary medicine? And I was like, are you kidding? I’ve been asked for years whether there’s a blood test for cancer. Like, yes, we need this right now!
[00:41:36] >> Molly Jacobson: Yeah.
[00:41:37] >> Dr. Andi Flory: So we co-founded PetDx in 2019, and that was really it, with the goal of earlier cancer detection in dogs.
[00:41:46] >> Molly Jacobson: That’s amazing.
So that’s the human test that is, and the inspiration for OncoK9.
[00:41:53] >> Dr. Andi Flory: Right. And that whole, the technology on the human side with the next generation sequencing and cell-free DNA based testing, on the human side, it was initially developed for pregnancy for non-invasive prenatal testing. Which, again, we were talking earlier about sounding like science fiction, when I was pregnant with my first child and I was offered that test, I was like, this sounds like science fiction.
You can take my blood, and determine if there are chromosomal abnormalities in my baby. I mean, that, that sounds like science fiction. But that’s where this technology originated was for use in pregnant women, which is, has been used in millions and millions of women at this point.
[00:42:32] >> Molly Jacobson: Amazing.
I think that genetic testing, it is science fiction. And it is, I really believe, the future of medicine, that we are going to have a very personalized approach to diagnostics and also treatment.
[00:42:46] >> Dr. Andi Flory: Yeah.
[00:42:46] >> Molly Jacobson: And we’re lucky-
[00:42:47] >> Dr. Andi Flory: Yeah.
[00:42:47] >> Molly Jacobson: -that there are people who are focusing on this and really taking it and creating these tools.
[00:42:53] >> Dr. Andi Flory: Yeah. It’s really exciting.
[00:42:54] >> Molly Jacobson: Is there anything else that you feel like our listeners really need to know about OncoK9 or PetDx in general?
[00:43:03] >> Dr. Andi Flory: I mean, I would say that we know that cancer is the leading cause of death in dogs, and we know that most cases are detected because of clinical signs, by which point cancer is typically pretty advanced.
And if we can shift that paradigm and shift when that cancer diagnosis happens to earlier, there are just so many benefits for veterinarians, pet parents, for the dogs. And so the thinking, it’s, it’s a mind shift thinking, right, of thinking about cancer while your dog is still healthy. It’s a shift in mindset for, for pet parents as well as veterinarians, right? And so – that’s what I would say is so exciting to think about what this could mean for cancer outcomes for our, . if we can just shift when that diagnosis happens to earlier.
[00:43:53] >> Molly Jacobson: Right. To earlier when they’re, they’re feeling better, they’re feeling healthier, they tolerate treatments better. You can improve their diet and their lifestyle and all the other things that we know that support a healthy body that is better able to fight cancer and obviously all of the other diseases that dogs can get, but cancer is the number one killer of dogs. And I think that a lot of dog lovers only find that out when their dog gets cancer.
[00:44:18] >> Dr. Andi Flory: I know. And it’s so sad, right? Because you’re, you know, for, for so many people, it’s just not on their radar yet. So programs like yours are just so important to get the word out and get the message out so that, you know, every patient that we detect earlier is just, it just makes my heart sing because it’s like, think about just the, the impact on that whole family. It’s just, it’s really amazing. I get emotional.
[00:44:42] >> Molly Jacobson: Yeah. No, my heart dog is in her elder years and we’re doing, you know, we’re basically in hospice stage. And every single day is just a blessing for me.
[00:44:53] >> Dr. Andi Flory: It is.
[00:44:53] >> Molly Jacobson: Because she’s still with me.
[00:44:55] >> Dr. Andi Flory: Yep. And that’s why I became an oncologist, because the impact of just every single day that you get to look at your dog and spend with your dog and they wag their tail at you is just, it’s such a gift.
[00:45:06] >> Molly Jacobson: It is. So given that, and that may be the answer to my last question, but what is the one thing you really wish people would know about their dogs or about their dog’s cancer diagnosis from your hard won experience?
[00:45:22] >> Dr. Andi Flory: I would say that, you know, I think that everyone that goes through a cancer diagnosis always has questions about what could I have done differently. And I think that that’s a very, very common question that I get. And so if you’re listening to this podcast, you’re probably gonna have dogs in the future, right? So even if you’re already going through cancer diagnosis right now with a pet, you have, probably, other dogs or you will in the future.
And so this just means that you have an opportunity of something that we now can do, which is just, it’s so exciting to think about how this could change things.
[00:46:01] >> Molly Jacobson: Yeah, I appreciate it.
Well, Dr. Andi Flory, thank you so much for joining us here on Dog Cancer Answers. We covered a lot of ground, and I’m really excited about having you on as a guest. I hope you’ll come back in the future.
[00:46:14] >> Dr. Andi Flory: Thank you. I would love to. This is fantastic. Thank you for having me.
[00:46:20] >> Molly Jacobson: And thank you listener for joining us today on this kind of futuristic sci-fi edition of Dog Cancer Answers. I don’t know about you, but a simple blood draw to detect cancer early when my dog is still feeling healthy, and acting healthy, and by all clinical signs is healthy, is exciting. I like the idea of early detection so that we have more options and more time to deal with the number one killer of dogs.
And remember it is not a diagnosis, it is simply a screening test. It says yes or no. So if it’s a yes, is it worth following up and seeing if there really is cancer? Uh-huh. Absolutely. That it can reliably predict the presence of cancer in the eight most common cancers is pretty powerful. So it’s definitely worth asking your veterinarian about and seeing if it might be appropriate for your dog, your healthy dog.
I’m looking forward to following up with Dr. Flory and PetDx as they get more information in the coming months and years. Remember to follow us on the socials and please, if you’re on Facebook, join our Dog Cancer Support group. It is the best place on the internet for people whose dogs have cancer. You’re gonna find people who are non-dogmatic, non-judgmental, and endlessly supportive.
I’m Molly Jacobson. And from all of us here at Dog Podcast Network, I am wishing you and your dog a very warm Aloha.
[00:48:02] >> 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 date.
Dog Cancer Answers is a presentation of Maui Media in association with Dog Podcast Network.