Twiggy's Legacy: The Battle Against Transitional Cell Carcinoma (TCC)

My friend, Amy, was kind enough to share the story of Twiggy and her battle against bladder cancer. Twiggy's case was so typical it's spooky. She was a real sweetie. She fought bravely and made her contribution to beating the disease.

Shortly after losing Kami, my beloved Cocker Spaniel, I agreed to foster Twiggy, a 13-year-old Shih Tzu, described as "healthy."

I hoped she would cheer me up but right away I noticed that something was very very wrong.  

She had been boarded at her vet after her owner moved to a nursing home.  On the front lawn, she made a series of tiny little tinkles  rather than doing her business as if she'd been "holding it."  I went back in and the woman at the counter told me she was just nervous.

I insisted something was wrong.  

As if on cue, Twiggy made a tiny puddle in the waiting room. There was no blood visible, so they guessed she had a UTI Urinary Tract Infection and gave me some antibiotics for her.  She'd been their customer for all of her 13 years, so I trusted their judgment.

She was a cute little doll and fit right in with my other two, and she really did warm my heart. 

But the antibiotics made almost no difference. I brought her back to the vet and got another one.  Again, almost no improvement. I couldn't believe a mere UTI could make life that hard for her.  I knew something else was going on, so before her next visit to the vet, I timed her peepees on a few walks and found that she couldn't walk longer than about 15 seconds before having to squat again.

I took her back to the vet and told them about my observation.  

The vet talked about trying another antibiotic, but this time I was even more insistent that something was very wrong.  She had improved a bit, but not nearly enough.  In response, the vet palpated her bladder more carefully and determined it was full. He left to consult with the more experienced vet in the practice.  While she was out, Twiggy squatted to pee and was still in her squat when her vet returned to the exam room.  "See?"  I said. "She's been at it for five minutes and this is all the  puddle she could produce."

The vet watched while Twiggy continued to strain, then left again.  

She came back and said they'd do an x-ray to see if there was a stone.

Sure enough, the x-ray showed a blockage but they couldn't tell what it was.  

We scheduled her for surgery, and I had a few days to look up the possible causes of urinary blockage on the web.

One of them was terrifying:  transitional cell carcinoma (TCC), an aggressive and deadly cancer with a very poor prognosis for dogs and humans alike.  

Coincidentally, Purdue University, a mere 2-hour drive away, was the main research center for this type of cancer in dogs, and also in humans. I had just received a long-awaited check so I decided that if it turned out to be TCC, I'd spend some of it helping Twiggy, which would also help others.

In surgery, they found that she did indeed have a tumor, and sent it to a lab for a pathology report.

Twiggy continued on antibiotics while we waited for the devastating news.  It was TCC.  The older, more experienced vet in the practice, had personally lost a dog to this disease, so he understood the gravity of the news.  He also appreciated my decision to take her to Purdue and made a referral for us.  He was a big help in ways I didn't anticipate.

By the time I met with the Purdue oncologists, I had become quite fond of Twiggy, yet I was still grieving for my sweet cocker spaniel.

I just couldn't imagine putting Twiggy down so soon after losing Kami.  

If anyone could help Twiggy, these people could.  They are the people to see for TCC, and I hoped for good news.

The bad news was that Twiggy's cancer was inoperable (TCC often is), and rather advanced.  

Without treatment, she had weeks to months left to live.  Dr. Debra Knapp explained to me the way that outcomes are classed, and I glommed onto stable disease, i.e. no growth or spread of tumors, as my hope for Twiggy.  The best, of course, would be a cure, and I didn't dare hope for that.  The worst was continued growth, metastasis, and death. Other than the TCC, Twiggy really was quite a healthy little thing.

If only cancer could be kept at bay...

The good news was that Twiggy qualified for the chemotherapy studies they were conducting.  Dr. Knapp outlined the types of treatments and the amount of time and expense required on my part.  Grants would pay for part of the expense, but not all.

One study seemed particularly promising, but it required treatments three times a week every other week.  

I couldn't take that much time away from work, so we scratched that option.

A related study involved one trip per month to Purdue for chemo and one trip to Twiggy's own vet halfway through the month for chemo there, where they would keep a supply of the chemo.  

I opted for this, as I had just enough vacation time to do it.  The study would pay for the drug and I would pay for most of the other expenses, which amounted to less than $500/month.  In addition to chemo, Twiggy's monthly visit to Purdue would include documenting changes in her tumor via ultrasound, a check for tumors in other parts of her body, and bloodwork to check for adverse reactions to the chemo.  Her vet had lost his own dog to the disease, so he seemed eager to help.

Twiggy did really well for a long while, but she did turn out to have a serious problem with UTIs.

Having a tumor in the bladder creates an environment for UTIs to take hold.  Purdue cultured her urine at every visit.  One of her bacteria was so resistant that I had to use an extremely toxic (to humans) antibiotic.  To prevent the destruction of my bone marrow I had to wear gloves to handle the pills!

Twiggy's quality of life improved quite a bit.  

She could walk much further between squats and enjoyed life with me and her new housemates. Trips to Purdue didn't bother her at all, and she'd been going to the same vet her whole life, so she was comfortable there too. Sometimes there was blood in her urine, which seemed to be related to tumor cells dying off in the first few days after chemo. Otherwise, for a long time, she did very well.

Twiggy didn't get sick as much from the chemo as from all the antibiotics she constantly had to take.  

I kept changing her from one food to another as each one became associated with tummy aches for her. Or she was just a picky eater that demanded variety -- I didn't know much about her past habits.

Unfortunately, the chemo didn't halt or reverse the disease.  

At most, it may have slowed it down a bit.

After my vacation time had its annual renewal, I decided to switch her to the more time-consuming protocol.  

I would drop her off on Monday mornings and pick her up on Friday afternoons every other week.  Twiggy got to the know the staff quite well and they adored her.  She never showed an iota of fear when we entered the waiting room.  It was as if she had two families now.

The new trial didn't help either, and Twiggy was running out of options.  

Dr. Knapp suggested taking her off the study and trying a chemo that had shown success in the past.  Alas, this didn't help her either.

Then one day, while Twiggy was straining to pee, she started shaking, and she continued to shake afterward.  

Knowing that shaking can sometimes be a sign of pain, I took her to the emergency room, and they confirmed that there was something going on with her kidneys.

Dr. Knapp had prepared me for this: eventually, the bladder can no longer empty quickly enough to prevent urine from backing up into the kidneys. 

I took Twiggy to Purdue the next day and they found that Twiggy had tiny kidney stones stuck in her ureters (the tubes between the kidneys and bladder), and they would not be able to pass due to the tumor.  Typical treatments for stones would not be options for her because of cancer.

They gave her something for the pain and I made arrangements to drive to Purdue to be with her for her final shots.

When I arrived, all the staff was there to greet me, many with tears in their eyes.  They were fond of Twiggy and they had spent almost as much time with her as I had.  Dr. Knapp briefed me on Twiggy's condition and I was glad to hear that they had already learned something from Twiggy.

Even though I wanted them to learn from her, I suddenly felt a pang of guilt for letting them use Twiggy this way, and I regretted that her final days would have been spent in a hospital. I told them that I wished Twiggy could have spent her final days at home with me, and they arranged for me to take her home for a little while. They gave her a pain patch and gave me some instructions on how to keep her comfortable. Twiggy perked up when she got home and rallied a bit, but soon she needed intravenous fluids.  Her vet back home trained me on how to administer it and I gave her those fluids twice. The first time she perked up a lot.  The second time it didn't make a difference. I had to admit that there really was nothing that could be done to keep her comfortable.

I wanted Purdue to be able to do a necropsy (the animal equivalent of an autopsy) and to keep her tumors.  

If her tumors were resistant to this one promising chemo, culturing them to study them with future drugs would be very very important.  Also,  I planned to keep Twiggy's ashes, and I really didn't want her tumors. I was angry at them and I wanted to keep only the Twiggy that I loved. I feel silly admitting that, but it's how I felt. Those tumors didn't deserve the honor of sitting on my memory shelf with Kami's ashes. They deserved to be cultured and abused into submission. And yet oddly, they were part of Twiggy too, and it would mean part of her could live on.

I drove back to Purdue and met with a resident.  It was a beautiful Fall day (September 12, 2010), and the hospital was quiet.

The resident agreed to let us give Twiggy her final moments outside. 

We spread her favorite blanky under the shade of a tree.  Twiggy seemed oblivious to her disease, her nose twitching in the breeze.  Her final breaths were curious doggy sniffs.  It was the most lovely experience I could imagine for Twiggy.

I only had Twiggy for about six months, but she will live in my heart forever.  

If willpower could keep cancer at bay, Twiggy certainly could have defeated it. She was a little diva and she knew how adorable and lovable she was. She was the boss of me within days of coming into my life. Looking back, I'm still angry at a disease that affected a part of the body that seems so worthless. It's really just a sack of muscles -- nothing metabolic about it at all.

I can understand lung or liver cancer being fatal, but bladder cancer just shouldn't be a killer. 

The bladder doesn't have a big enough "job."  When I first learned about this disease I thought it was a strange disease for Dr. Knapp to choose to specialize in, but after watching its relentless progression in an otherwise healthy dog, I can't imagine any cancer being more worthy of her efforts.

Dr. Knapp and the staff frequently thanked me for letting them study Twiggy.  I thought it was a little strange because I considered them to be doing all the favors.

Not only were they helping Twiggy, they'd devoted their lives to defeating a terrible disease.  

I realize now that it must be hard for them to get patients. The disease is so aggressive that many people would rather not fight a losing battle

And it usually isn't discovered until there's been a blockage. By then, as in Twiggy's case, the disease is quite advanced.  

And even though they work hard to give the patient the best chance, it's a big commitment on the owner's part as well.

I am very grateful to Purdue and to Twiggy's vet for helping me give Twiggy a chance and for fighting such an unfair disease.  

When I think about Twiggy's experience at Purdue, I am reminded of a slogan I learned from a favorite professor in grad school:

"Sometimes losing battles are the only battles worth fighting."


IMPORTANT NOTE: The University of Michigan is collecting samples of certain cancers in certain breeds to determine the role of genetics.  I have sent mammary cancer samples and blood samples for two Cockers that passed away (from other causes!)

Further reading:
Transitional Cell Carcinoma


  1. I too took my dog( toy poodle ) to Dr Knapp. Unfortunately the outcome was the same. But, I can’t say enough about how good Purdue is, and especially Dr Knapp. For anyone doing research on where to take your dog with TCC this is it. She is the foremost authority. She has written over 100 papers on it. They were kind, responsive, understanding and most importantly realistic. I felt local vets gave false hope for money. I drove her 5 1/2 hours for appointments 11 hrs round trip. I donated her body for necropsy too. Amy, I have walked a mile in your shoes. I had her (Sophia) 11 years. She was my baby. It hurts.

    1. So sorry about your baby. Some things even the best veterinarian cannot fix. <3


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