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Journal of Clinical Oncology, Vol 25, No 23 (August 10), 2007: pp. 3557-3558 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.12.6615
In ReplyHarvard Medical School, Program in Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA Dr Berchuck and the Society of Gynecologic Oncologists (SGO) have offered thoughtful comments regarding my editorial,1 and I am in agreement with each of their points. They take issue with my statement that gynecologic oncologists "receive chemotherapy training as part of a surgically oriented fellowship." Dr Berchuck clarified this by explaining that gynecologic oncologists receive training in both disciplines, and that they are able to provide a comprehensive approach to the care of women with gynecologic cancers. I certainly agree with this, and it was not my intention to imply otherwise. Although Dr Berchuck described the training and skills of gynecologic oncologists very well in his letter, he did not analyze the Silber et al2 article in detail and did not explicitly challenge the conclusions of this study. This is a lost opportunity, but I will assume that it does not reflect an endorsement by the SGO of Silber et al's conclusions. Some of my best colleagues are gynecologic oncologists who have always viewed their relationship with medical oncology as synergistic and who have valued the contributions that medical oncologists have made to this important area. In addition, the American Society of Clinical Oncology has worked closely with the SGO to advance the cause of ovarian cancer patients throughout the world. If we are to win the fight against this disease, we must continue to work together and to recognize the strengths that each subspecialty has to offer. I am certain that Dr Berchuck and the SGO agree with this, and we are fortunate to have them as colleagues. It is my hope that the SGO will play a major leadership role in fostering the relationship between our two subspecialties and in discouraging any actions that might be viewed as divisive. The last sentence of my editorial says it all. In contrast to the measured response of Dr Berchuck and the SGO, Drs Blank and Curtin present a more impassioned rebuttal to my comments. Although there are some legitimate points in their letter, their ad hominem debating style is unnecessary and detracts from the power of their argument. They have chosen to twist my editorial into an attack against gynecologic oncologists, which it clearly is not. They have also taken several of my comments out of context, including those involving tumor biology. In my editorial, I offered a critical analysis of Silber et al's study, followed by a series of hypotheses (which Drs Blank and Curtin called "spinning a tale"). In particular, I raised the possibility that gynecologic oncologists and medical oncologists might sometimes see different types of patients, and that this may sometimes influence chemotherapy decision making. Based on my own practice, I believe that this impression is quite accurate. This suggestion should not be viewed as threatening, but rather as an opportunity to place Silber et al's data into a more productive context, and to determine how we can best complement each other's efforts. Since the facts speak for themselves, I invite the readership to review my editorial in the context of their letter and to judge the merits of our respective points of view. I appreciate the valuable insights offered by Drs Hoffman and Iqbal regarding the methodological problems inherent in Surveillance, Epidemiology, and End Results analyses. Many of their points were already discussed in my editorial and will not be repeated here. They raise an additional issue involving communication skills of medical oncologists and gynecologic oncologists, and they suggest that perhaps medical oncologists may be better positioned to handle psychosocial issues that arise during the course of this disease. Although this is provocative, I am sure that Drs Hoffman and Iqbal would agree that this is only a hypothesis that requires formal testing, and that gynecologic oncologists are also effective at providing their patients with compassionate care. Again, we should not focus on differences that could polarize subspecialists who are working toward the same goals. Instead, we should strive to enhance our solidarity for the good of the patient. I enjoyed reading the letters contributed by Drs McGuire and Markman, respectively, on this topic. Both are well-known medical oncologists who have played a central role in improving the survival of patients with advanced ovarian cancer, and they provide an important counterpoint to the conclusions of the Silber et al study. I agree with all of Dr McGuire's points, and I have hopefully clarified the issue of gynecology oncology training in my response to Dr Berchuck. Dr Markman points out that the Silber et al article has missed an opportunity to strengthen the relationship between gynecologic oncologists and medical oncologists, and I agree with this. We do not have the luxury of debating who is better, when neither gynecologic oncologists nor medical oncologists are good enough. Drs McGuire and Markman have articulated these points very well in their respective letters. As a final point, I have received several e-mails questioning the decision to publish the Silber et al study in the Journal of Clinical Oncology, given the methodologic problems inherent in their analysis. As the Associate Editor who handled this article, I made the decision to accept it because the Journal of Clinical Oncology has an obligation to present all sides of an issue, and there are times when an article such as this provides a unique opportunity to open a dialog that can be educational and productive. What better place to have such a dialog than JCO, a journal well known for attracting a critical readership that will ensure the self-correcting nature of science and clinical investigation? By publishing this work in JCO, I had hoped to give the readership a better understanding of the problems inherent in this type of analysis, and at the same time bring the specialties of gynecologic oncology and medical oncology into better focus. Based on the exuberant response to this article and my editorial, I believe that we have accomplished these goals. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES
1. Cannistra SA: Gynecologic oncology or medical oncology: What's in a name? J Clin Oncol 25:1157-1159, 2007 2. Silber JH, Rosenbaum PR, Polsky D, et al: Does ovarian cancer treatment and survival differ by the specialty providing chemotherapy? J Clin Oncol 25:1169-1175, 2007
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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