Dr. Carter and colleagues have provided us with a thoughtful review of the significant reproductive issues affecting gynecologic cancer patients. Survivorship and posttreatment-related concerns continue to gain public attention. This review of the physiologic and psychosocial reproductive issues faced by gynecologic cancer patents is welcome and timely.
The history of the survivorship movement dates back to the 1960s, when children with leukemia began to achieve improved survival due to successful clinical trials. Twenty-five years later, Dr. Fitzhugh Mullan wrote a groundbreaking article in the New England Journal of Medicine entitled "Seasons of Survival." This manuscript stimulated physicians and patients to think about a new way of portraying the cancer experience by describing different phases of living with, through, and beyond cancer. In 1985, this physician stated that "The challenge in overcoming cancer is not only to find therapies that will prevent or arrest the disease quickly, but also to map the middle ground of survivorship and minimize its medical and social hazards." The number of cancer survivors has tripled since 1971, and more than 4% of the over 10 million cancer survivors are women treated for gynecologic malignancies.
The authors provide a thorough review of surgical options for fertility preservation with respect to early-stage cervical and endometrial cancer, as well as ovarian tumors. A variety of reproductive options for cancer survivors, including family-building options, are also discussed. The issues surrounding cancer diagnosed during pregnancy as well as cancer arising from pregnancy are addressed.
Most notably, the authors highlight the myriad psychosocial issues that may affect these patients. Women with a new cancer diagnosis face the associated stress. Additionally, the possibility of infertility may prove to be a compounding event, often described as a "double trauma" or "adding insult to injury."[2,3] The authors note that gynecologic cancer survivors who became infertile due to treatment often report feelings of sadness and grief that persist more than a year posttreatment. Such issues are frequently linked to sexual dysfunction and menopause resulting from cancer treatment.
What can be done to help women with gynecologic cancers who face infertility issues? As with many other survivorship issues, the solution seems to be a combination of communication, recognition, and validation of concerns, as well as appropriate interventions.
Studies by Cassileth and others reinforce the concept that cancer patients want information about their care and expect physicians to initiate the dialogue. Furthermore, women desire more confirmation on the after-effects of cancer treatments including physical, sexual, and emotional aspects. Many women would like their partners included in such discussions.
As oncologists, we are obligated to initiate this discussion. We occupy a unique position in terms of coordination of effortwe are the hub of the decision-making wheel. Treatment options, fertility concerns, and sexual functioning issues are among the spokes that drive that wheel. While we may not be able to guarantee a specific outcome, we must ensure that our patients are aware and consider all possible options relating to their unique situation. Gynecologic cancer treatment cannot take place in a vacuum. We must broaden the lens to address survivorship issues such as reproductive and sexual health concerns.
The P-LI-SS-IT Model
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2. Baider L, Peretz T, Hadani PE, et al: Transmission of response to trauma? Second-generation Holocaust survivors' reaction to cancer. Am J Psychiatry 157:904-910, 2000.
3. Schover L: Sexuality and fertility after cancer. New York, John Wiley & Sons,
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9. Lee SJ, Schover LR, Partridge AH, et al: American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol 24:2917-2931, 2006.