Clinicians, researchers, and survivorship communities are beginning to recognize the late effects of cancer treatment, such as infertility, and the negative impact this can have on cancer survivorship. Reproductive concerns that emerge within cancer experiences have been shown to be negatively associated with quality of life. Gynecologic cancer can present before childbearing has been started or completed, during pregnancy, or can even arise out of pregnancy, as is the case with gestational trophoblastic disease. Parenthood has been cited as an important aspect of cancer survivorship. As a result, interest concerning fertility preservation, reproductive concerns, and family-building options in cancer survivorship has increased, in addition to awareness of the emotional ramifications of cancer-related infertility. Education and support are clearly an essential component of cancer survivorship. Furthermore, more attention and investigation is still needed about the reproductive issues of gynecologic cancer survivors in the future.
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
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. 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.
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."
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.
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.
Diane C. Bodurka, MD
Charlotte C. Sun, DRPH
David M. Gershenson, MD
The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
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