How do we initiate such a discussion? The P-LI-SS-IT model developed by Jack Annon describes four progressive levels that can be used to guide assessment and develop interventions.[7] These steps include permission, limited information, specific suggestions, and intensive therapy. By raising the subjects of sex and infertility, we give patients permission to talk about their concerns. This also helps acknowledge and legitimize their feelings and ideas and gives them the opportunity to ask questions.

The next level in this model involves providing information relevant to the patient's concerns. Written information is often appreciated in addition to face-to-face interaction. Specific suggestions should then be provided and strategies developed for dealing with infertility and other issues. Ultimately, more intensive therapy may be required for those with significant sexual or mental health problems. The success of this model rests on the ability of the physician to provide the patient not only with accurate information but also with an opportunity to openly discuss her feelings.[8]

Future Directions

As the authors state, it is incumbent upon us, as oncologists, to identify "mechanisms to facilitate adjustment and adaptation in cancer survivorship."

In addition to opening a dialogue, as illustrated by the P-LI-SS-IT method, we must also recognize that a comprehensive approach to the care of gynecologic patients must be established. The successful recognition and treatment of fertility issues, sexual concerns, and other problems faced by gynecologic cancer survivors requires a multidisciplinary approach. The care of these women is often complex and should include gynecologic oncologists, reproductive endocrinologists, perinatologists, and others who can be members of an effective team. As advocated by the American Society of Clinical Oncology, "fertility preservation approaches should be considered as early as possible during treatment planning."[9]

Finally, more research detailing the psychosocial concerns and unique needs experienced by cancer survivors of reproductive age is needed. With the population of cancer survivors continuing to grow, it is incumbent upon us as health-care providers to identify and address the concerns of these women whether they be reproductive, sexual, physical, or psychosocial in nature.

Conclusions

The reproductive concerns of gynecologic cancer patients are an important part of cancer survivorship issues. We applaud the authors for describing these issues and also for providing resources and suggestions for areas for increased communication between patients and their health-care providers. Our challenge is to continue to identify reproductive health concerns and develop successful interventions for survivors of gynecologic malignancies. Only then can we truly meet the challenges of survivorship and "minimize its medical and social hazards" described by Mullan more than 2 decades ago.[1]

—Diane C. Bodurka, MD
—Charlotte C. Sun, DRPH
—David M. Gershenson, MD