AMA Journal of Ethics^®

During my fourth year of medical school, after deciding that I would pursue obstetrics and gynecology as a career, I had the opportunity to spend four weeks on the service of a busy gynecologic oncology service at a tertiary women’s hospital. During those four weeks I developed an interest in this subspecialty of ob-gyn and came to appreciate the interactions between its practitioners and patients that so often played out against a backdrop of deeply personal and ethical dilemmas. The malignancies treated in the field of gynecologic oncology tend to affect those who are diagnosed in profound ways. These cancers are often aggressive, recurrent, and incurable. They often occur in young women, and treatments can carry with them radical surgeries and a burden of side effects that can alter the remainder of the women’s lives. Together, these forces create high-stakes, emotional, and stressful physician-patient interactions that, I believe, deserve a journal issue all their own.

I am extremely excited about the contributions to this issue. In the case scenarios, our expert commentators tackle dilemmas specific to the field: fertility preservation for adolescent girls receiving treatment for gynecologic cancer and patient confidentiality about an inherited increase in risk of breast cancer.

One contribution to this issue, from a pioneer in the field of gynecologic oncology, chronicles the events that led to the realization that a drug widely prescribed to prevent pregnancy loss caused cancer in the offspring born from those pregnancies and considers how we can learn from this unfortunate event. We then look to the future. This is an exciting time in gynecologic oncology; for example, we now have a vaccine for human papillomavirus that could potentially eradicate a cancer that was once the leading cause of cancer deaths among women worldwide. Why, then, as one article discusses, are there barriers to more widespread use of the vaccine? Additionally, as research efforts to fine-tune chemotherapeutic agents and regimens to fight gynecologic cancers continue, equipoise in study designs is a constant consideration. Another piece examines the importance of the equipoise principle to the field and questions whether it is ethical to assign some research participants less-effective treatments to clearly demonstrate a new treatment’s effectiveness, thereby making it more widely accessible to future patients.

As we continue to shed light on the etiologies of female cancers, we develop new treatments. With the newfound evidence that the fallopian tubes are an etiological epicenter for ovarian cancer, some have proposed prophylactic salpingectomies for women at a higher risk for developing this type of malignancy. Another contribution offers valuable background on this technique, examines the guidance of the American College of Obstetricians and Gynecologists, and communicates some experiences and thoughts on the future of surgical prophylaxis for ovarian cancer.

The thought of death is not easy to grapple with. As mentioned before, female cancers can be quite aggressive and often recur. Because of this reality, end-of-life discussions are particularly frequent in this field and sometimes involve people who are facing their mortality prematurely. In this month’s podcast, we interview a palliative care specialist at a large women’s hospital who participates in these discussions with patients on a daily basis and offers ideas to help physicians, nurses, and other care team members conduct these most difficult conversations. This issue also includes a literary analysis of the 1999 Pulitzer Prize-winning play Wit, arguing that the play depicts parallels between scholarly literary exegesis and the practice of medicine. These two pieces set the stage nicely for a contribution about the implementation and necessity of a formalized ethics curriculum during the ob-gyn residency.

I am delighted that all of these pieces will be together in one issue that focuses on the field of gynecologic oncology. However, I am even more excited that this issue sheds light on the patients who are at the center of these discussions. As a profession, we often focus on how we can improve our skill set, how we can become better. Sometimes, though, we must focus on understanding the human condition and the circumstances of the patients who stand before us. Through understanding the patient experience, we can be more effective practitioners. I hope that the pieces offered by this month’s contributors further the understanding of ethical issues in gynecologic oncology, facilitate meaningful conversation and debate among its practitioners and students, and, finally, help us all understand the experience of the patients affected by these malignancies.