1. You are a real advocate for cancer patients when it comes to discussing topics that may not be part of an oncologist-patient conversation after a cancer diagnosis; for example, sexual health during cancer treatment. How and when do you think this type of discussion should happen? Is it relevant for all cancer patients?
Dr. Dizon: I think the topic should be discussed at the beginning, when cancer is first diagnosed. What I’m hoping is that it becomes a part of the comprehensive initial history and physical we all take when we first meet our new patients. It’s as important as any other aspect of the review of systems. In fact, we typically address issues of employment, marital status, children, to name a few. We go beyond the scope of physiology quite readily, so why not also cover sexual health history? This conversation doesn’t have to be scary and it doesn’t have to be lengthy, but the important part is that it sends the message to our patients that even if it isn’t something important right now, or something you don’t want to discuss, that “door” is open, and I am willing to engage you in that discussion. So when the patient feels like he/she needs to bring something up, they know that you’re okay about having that discussion.
I think it’s very important to bring up sexual health when we think intimacy is going to be impacted by our treatment, but it’s my sense that we often do this more readily with men than we do with women. For example, with men who have prostate cancer, doctors are really great about going into issues regarding impotence and erectile dysfunction with regard to the surgical or androgen deprivation therapies. But we don’t readily do that when we’re discussing the role of aromatase inhibitors (AIs) for women with breast cancer. That is, clinicians don’t usually discuss that these drugs can cause sexual side effects such as pain with penetration and vaginal dryness, which are experienced by a lot of women on AIs, and even if we do, I think most of the time it’s just cursory. In summary, I think the conversations about sexual health are important for all cancer patients. It’s not all about intercourse. It’s also about intimacy, and it’s also about experiences of pleasure, which are universally acknowledged concerns and part of the human experience that needs to be acknowledged as such.
2. Maintaining fertility in younger patients with cancer is an issue that seems to have come more into focus over the last few years. Do you think oncologists are doing enough when it comes to preserving fertility in those patients who may wish to have children after cancer treatment?
Dr. Dizon: I think doctors are more cognizant that fertility is an issue, but there’s still a lot of subconscious bias around whether we actually do discuss fertility with our patients. For example, we think the issue might not be relevant because a patient is single, or because she’s 38, or even because the prognosis of her cancer is so terrible. As a result of these biases, I don’t think everyone who should have a discussion about fertility is necessarily having one.
One of my colleagues here at Mass General, Mary Sabatini, oftentimes makes a point of saying to her patients, “If you’re having trouble having a child, I will help you with that. But make sure you enjoy the pleasure of each other’s company. Make sure the sexuality is not impacted even as fertility becomes challenging.” Because sometimes, in women who are dealing with infertility, where their sole purpose is to have a child, the pleasure that comes with a sexual encounter can go away because the goal has shifted, and it becomes work. Clinicians don’t necessarily need to be skilled in terms of discussing the gamut of all the sexual complications of cancer treatments, but to assume the issue of fertility was discussed just because the topic of sexual health was raised would be incorrect.
3. There has been a lot of excitement and press around the developments in precision medicine and targeted therapy for cancer in recent years. However, you recently wrote a blog post with Lecia Sequist in which you talked about the disappointments of precision medicine. Can you talk a little about those disappointments, and how clinicians should address them with their patients?
Dr. Dizon: When I contacted Lecia Sequist to write the blog with me, I thought we would probably have a very similar experience of talking about precision therapy with our patients; that is, we receive the results [of molecular testing] and see that no mutation is targetable with a drug. It was very eye-opening to hear Lecia’s perspective on the issue of the hype around targeted therapies, because she practices thoracic oncology, where there’s often an expectation that patients with a targetable mutation will respond well to the treatment directed at that mutation—but that isn’t always the case. It’s like there is an expectation for some patients that because they have a targetable mutation that they’ve won the cancer “lottery,” so to speak. But just because they have a mutation doesn’t automatically guarantee a durable response. Lecia’s viewpoint was just so revelatory for me, because she essentially says that even if patients have a targetable mutation, they can still die of their cancer. In contrast, I am not finding mutations with the available testing in my own clinic—a disappointment of a different kind.
My hope as a clinician is that I will see more and more people shift from being poor prognostic to good prognostic in my lifetime. We saw it with HER2-directed therapies in breast cancers, and I hope to see it with other tumors in the future. But for now we are not in the situation where a specific mutation can predict with 100% certainty that a treatment will be successful. We certainly don’t yet have it for ovarian cancer; we don’t have it in triple-negative breast cancer, either. We have it to some degree for a few types of lung cancer, but not all. We have to remember that right now, a lot of our patients are not going to experience the fruits of precision medicine.
One of the ways we’re working toward that goal is to try to heighten our understanding of tumor biology. Right now, we have access to tumor genomics, but my sense is that the key may lie beyond that; it might be in functional proteomics, evaluation of epigenetic mechanisms, or copy number alterations. Right now, unfortunately, I’m not finding useful genomic information for the vast majority of my own patients [women with gynecologic and breast cancers].
Financial Disclosure: Dr. Dizon has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.