Talking Hope: What every woman should know about gynecologic cancers

Talking Hope is brought to you by City of Hope, an NCI-designated comprehensive cancer center and Orange County’s most advanced cancer care. We bring together renowned cancer experts, grateful patients and leaders in the cancer community to share vital conversations, personal journeys and unique insights into the disease that is diagnosed in one in three people during their lifetime and impacts us all.

Advocate for yourself. It’s one of the most empowering things an individual facing gynecologic cancer can do, says gynecologic oncologist Joshua G. Cohen, M.D., F.A.C.O.G., F.A.C.S., Medical Director, Gynecologic Cancer Program, City of Hope Orange County. We spoke with Dr. Cohen about what drew him to this unique specialty and breakthroughs that are bringing patients the greatest hope for recovery.

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Darrin Godin: I'm Darrin Godin, chief of staff for City of Hope Orange County, and this is Talking Hope. Our guest today is purveyor of hope Dr. Joshua G. Cohen. Dr. Josh Cohen is a board-certified gynecologic oncologist and is the medical director of the Gynecologic Cancer Program at City of Hope Orange County Lennar Foundation Cancer Center. Thank you for joining us today, Dr. Josh.

Dr. Joshua G. Cohen: Oh, it's my pleasure. Thanks for having me, Darrin. How are you?

Darrin Godin: I'm doing well, thank you. So, you're an Orange County boy, born and raised. Tell me about your family and what led you to pursue a career in medicine.

Dr. Joshua G. Cohen: Yeah, thanks again, wonderful to be here and amazing to be back in Orange County. So I was actually born in Redlands in the Inland Empire and in San Bernardino County. Moved to Orange County when I was five years old. I have an identical twin. His name is Dr. Seth Cohen. He's also a doctor here at City of Hope. He's an urologist. And we have a younger sister, her name is Heather. She's three years younger than us and she's a dentist here in Orange County. And growing up, really had a very, very lovely childhood in rural California, in Northern Orange County.

I think really one of the things that brought me to medicine was watching my grandfather, who was not from this country, he was actually from Poland, had over relived the whole Holocaust, lost his whole family in the Holocaust, really made every stride he could to build a life for himself here with his family in the United States. And he developed a lot of health problems as people get older. So he had congestive heart failure, needed surgery, triple bypass ultimately. And I watched the healthcare system fail him on some level and there really was a lack of communication. So, this was someone, his first language was not English. He understood things well, but not well enough when you were talking to a medical provider to really make quick decisions. And even at a young age, 10, 11, 12, I was saddened by that. I thought we could do better.

And so that combined with my interest in science and helping people really brought me to medicine. My brother Seth, also independently as an identical twin, perhaps made the same decision. And in high school, we both applied for a program where you could apply to medical school as a high school student. And so we both applied to an eight-year combined program in Northwestern University in Chicago. And we were lucky both to get into medical school out of high school.

So, they said, "Yes, we want you to come to Northwestern and go to medical school." Part of that was you would do the undergrad program there as well. So it was actually a seven-year program. And that brought me to Chicago, which I never expected to be in with the cold weather, but it was great to be there. And 25, what, 20 years later here I am at City of Hope. But to get back to your original question, really seeing someone go through the healthcare system and feeling like we could do better was the initial reason. And then my interest in science and caring for patients really brought me to this point.

Darrin Godin: Well, thank you for sharing that. And that's a pretty cool story about you and your brother going to school together and continuing to work together even today. I'm sure there's more we could talk about with that as well. So what drew you to specialize in oncology?

Dr. Joshua G. Cohen: Yeah, and actually when I was in medical school, I did research in head and neck cancer and I loved the intersection of science and medicine. I loved that you could really ask a very pertinent question in the lab and start to answer that question, both by seeing patients in clinic and doing more tests in the lab. And so when I was in medical school, I spent a year doing research at the NIH, the National Institute of Health, and I really thought I was going to go into head and neck surgery. But during my third year of medical school, I fell in love with OB-GYN, and I loved the different aspects of it. I loved that there was primary care. I loved that there was surgery, and I loved the relationships that you can develop long-term with your patients. There's very few fields of surgery now where you get to really see patients over different aspects of their lifetime.

And so when I went into OB-GYN, my interest in surgery, in addition to my interest in research, brought me to oncology. And I love that gynecologic oncology is really one of the few fields in oncology where you get to do both the surgery and at least do some of the systemic treatments, the chemotherapy, the immunotherapy, and the targeted agents. And I love that journey where you could really be the navigator on many levels for someone's cancer diagnosis from their initial treatment with surgery through the systemic treatment.

So now we have wonderful collaborators. I have wonderful medical oncologists I work with, I love them all. They're all great. But I love that that's a nuance of gynecologic oncology, where you get exposure to both the medical oncology and the surgical oncology all in one as a gynecologic oncologist. And so that was unique, combined with my interest in research in ovarian cancer and endometrial cancer, really that brought me to this field.

Darrin Godin: That's awesome. So, what is your message to people? Your shout it from the rooftop message about gynecologic cancers?

Dr. Joshua G. Cohen: I think my most important message is advocate for yourself. I think we know that unfortunately, at least for ovarian cancer, we don't have good screening mechanisms. And the most important things that we see are early signs, which could be abdominal bloating, pelvic pain, changes to bladder and bowel habits. If you're peeing more frequently or you're having more frequent bowel movements, while you may think this is normal or maybe you're tired or gaining weight, that could be a sign of something that you need to address with your physician or your medical team. So, what I would empower people listening or patients, advocate for yourself. We as physicians, we as healthcare providers want to hear from you. If you're worried, if you're having abnormal bleeding, abnormal vaginal discharge, pelvic pain, those are things you should let someone know about because it could make a difference in making an early diagnosis for you for a gynecologic cancer that we may not otherwise find.

My second message is routine screening. We have cervical cancer screening with pap smears. Just like colonoscopies for colon cancer, pap smears are very effective and as long as you go to your OB-GYN or your primary care doctor and you get your pap smear screening intervals, we can usually keep you safe and prevent people from developing cervical cancer.

And then within that is being an advocate for your kids and your relatives. The HPV vaccine is here, it's a well-studied vaccine. We know that it can prevent over 90% of cervical cancers if patients receive the HPV vaccine in their early teens, which is the recommended age for patients through the CDC and the FDA. So I would say if you're an adult, if you have kids, if you're a grandma or a grandfather and you have grandkids, maybe you're a younger adult up until the age of 45, ask your doctor about an HPV vaccine because it could be the difference between preventing cervical cancer and not.

Darrin Godin: Thank you, Dr. Josh. What are some of the trends we're seeing right now in women's cancers or specifically gynecologic cancers?

Dr. Joshua G. Cohen: We're seeing personalized medicine. I think really, we've talked about this for decades and I think we're pretty much here now with the advent of immunotherapy, which is really the new horizon for cancer treatment, and molecular signatures in tumors, looking at the molecular breakdown of the DNA. So the DNA of a tumor can be different from person to person. And we now have many different targeted drugs that can really be applied to specific mutations and specific tumors. So the ability to take someone's tumor's DNA and do an analysis and then say, "We think you're going to respond to this medication versus another medication," is a huge win because we can avoid toxicity, we can tailor the treatment.

And I view cancer in many ways as other chronic conditions. And what I'll say is we live in California, other people have heard me mention this before, but Magic Johnson was diagnosed with HIV in the early nineties. We didn't have much to offer patients for HIV, but he's living a long, happy, healthy life because we made HIV chronic. He's on antiretrovirals that keep the viral load low and he lives a long, happy, healthy life.

We really truly hope for a cure. And my goal in life is to cure gynecologic cancer. For those patients where we cannot cure gynecologic cancer, what I hope is that we can make it chronic, like HIV. You stay on a medication, it keeps the tumor cells at a low volume, and you live your life. And we have more of those drugs with personalized medicine. So, I think the age of personalized medicine is here. We now have to get smarter about which drugs to use and we need to develop newer drugs, which is one of the reasons City of Hope exists to develop those newer drugs. But it's a very exciting time to be in gynecologic cancer.

Darrin Godin:  Awesome. You're touching on something that's very specific to the City of Hope Orange County as well, it's the reason we came here is for this highly specialized research and treatment and care. So what else excites you about the Irvine campus and the opportunity you have in leading the gynecologic cancer program?

Dr. Joshua G. Cohen: Well, one, it's such an honor to be back in Orange County. I mentioned that I grew up in Yorba Linda, and what a gift to be able to come back to the place that you grew up in and help care for the community. And being gone for many years, it's so wonderful to be back here with my wife Jackie, who's from Ohio, and my kids that are eight years old, Dave and Harper, and help be here in the community and care for patients. What I love about City of Hope is I really think we're going to provide access to clinical trials. We're going to provide access to new discoveries. We're going to provide a level of care that I would want for anyone, whether it's my grandfather, who I mentioned, from Poland, or someone I'm meeting on the street.

We want that level of care for patients. I don't want someone to have to drive to Los Angeles. I don't want someone else say, "I have to drive to Duarte." I used to work at an institution in Los Angeles, and I always wondered, why do people drive two hours on the 405 freeway to us? And I think it was to get that level of care that they want, that they would want for their family. And I'm so excited that we're going to deliver that here at City of Hope Orange County, that we are delivering that for patients with gynecologic cancer and with the ability that we have to provide both support with our social workers, our nurse navigators, physical medicine, rehabilitation, survivorship.

I mentioned my brother, who's a urologist, Dr. Seth Cohen, who specializes in all the complications that happen from treatments of cancer, like radiation challenges to the pelvic floor, bladder prolapse, urinary incontinence. We have a team of subspecialists that we've brought to Orange County to really focus and help patients who are complex and who have dealt with the side effects of cancer or not, but they're just complex and need that level of care that would've required them to leave Orange County for it.

Darrin Godin: And we're so glad to have you, Dr. Josh, as well. So, I hear a lot about this integrated approach to gynecologic cancer care or urogynecologic care. What exactly does that mean and how does that benefit our patient?
Dr. Joshua G. Cohen:    Yeah, so let me give you an example. So if you're a patient who is suffering from interstitial cystitis, which is inflammation of the bladder, can be very painful, can be agonizing, and you also have ovarian cancer, your care can be very divided. You may see a gynecologic oncologist on one day, who's focusing on examining you for a cancer occurrence or talking about chemotherapy, but you may never address the issue that's probably impacting your life almost immediately, which is painful urination, frequent urination, pain from the pelvis that's probably not related to a cancer diagnosis.

And so Seth and I, Dr. Seth Cohen, we see patients on the same day. So, if you have a condition that requires a urologic evaluation of the pelvic floor and a gynecologic cancer condition or concern for cancer, we can work together and do interventions on the same day. Or if you need a surgical procedure, do those on the same day.

Another example is endometriosis. Endometriosis is not a cancer condition, but it's something that can really impact someone's quality of life, both with bladder pain and dysfunction and pelvic floor dysfunction. We have the ability to do an evaluation on the same day by looking in the bladder with your urologist, Dr. Seth Cohen, and me doing an exam to see if we are concerned about any involvement of the ovaries of the uterus or the pelvic floor with endometriosis and give you a better treatment recommendation in one day, versus having to meet with different providers across different health systems that may take two to three months to do.

Darrin Godin: Well, that's incredible. So same day under the same roof, convenient for the patient, better, faster answers. Patients know what's going on a lot sooner. So that's great. I referred to you at the top of the podcast as a purveyor of hope because that's what you do. You're offering hope to your patients every day and you're having an impact on their lives and their families. So I'm wondering, Dr. Josh, what does hope mean to you?

Dr. Joshua G. Cohen:  For me, hope means living a meaningful life on your terms. I think that one of the things that we find with cancer patients is that you feel like you've lost control. You've lost control of your ability to interact with your family. You've lost control of your own health. You feel like you're really at the whim of what happens both from a tumor standpoint and from the providers you meet. What I want us to do here, and what I truly believe hope is, is living life on your terms in a way that's meaningful. And that answer is different for everybody. And I continue to be amazed by the answers I get from patients. And no matter where you are in dealing with the diagnosis, whether it's cancer or another complex condition, we all want to live a meaningful life and do the things that we want to do.

And one of the challenges that we face is that medical care is to the point where we could keep doing treatments that may or may not be helping, but if your quality of life is suffering to the point where you're not living a meaningful life, then we need to adjust. We need to use a different treatment. We need to switch to something different. And my hope and belief here at City of Hope is that we do that really, really well.

And so I think we're going to offer that level of hope to patients to provide them with a meaningful life on their terms. And no one has a crystal ball. No one knows what the future holds for any of us, but I know that we all want to be able to say what we want to say to our loved ones and live life the way that we would choose to, whether we have cancer or not.

Darrin Godin: I love that. Living a meaningful life on your terms, I think that's a great definition for hope. Your patients rave about the way you deliver care. I'm sure you know that they really appreciate who you are and how you care for them. So, I'm wondering, is there a patient that has really had an impact on you and on the way that you practice? And if so, can you tell us that story?

Dr. Joshua G. Cohen: Well, I'll tell you about a family, and the patient is an important part of my life as well. But I was taking care of a 72-year-old grandma with three daughters and eight grandkids. And she had a long course of treatment with ovarian cancer. We had years, we got years for her. But unfortunately, the cancer found its way around our best treatments. And it was that time where the treatments were too risky and the treatments were actually making her life worse, not better. And I remember very clearly sitting down with her and the family. This was actually in the hospital. She had had something called a bowel obstruction where she really wasn't able to eat or drink anymore because of the cancer. And her daughters were there and her grandkids were there. And we had a very good talk and she was really at peace with things.

And there were some very sad, but very meaningful and happy moments in that setting. And as I was leaving, her seven-year-old grandson came up to me, really no reason whatsoever for this kid to really approach me, but he just came up and he just said to me, "Thank you so very much for the time that I had with my grandma." And man, that got to me. Yeah, it got to me. Because really, he's seven years old, there's really no reason for him to do that. But it just reminded me that even if the cancer is not cured, that there's a meaningful existence both for the provider and for the patient. And we have to do everything we can to find that meaning and optimize quality of life.

So, for me, that left an indelible mark on me, that little grandkid. And may, maybe it's me thinking back to my grandpa, going to the cardiologist and hearing he may not have much time left because his heart was failing and trying to do better for him. But certainly that hit home for me.

Darrin Godin: Absolutely. And I know you mentioned you have your own eight-year-olds, right? Twins as well. Is that correct?

Dr. Joshua G. Cohen: Yep.

Darrin Godin: I just really resonate with that story. Kids make a big difference. Well, thank you for so much for sharing that story. Dr. Joshua G. Cohen, Medical Director of Gynecologic Cancer at City of Hope Orange County. Thank you for your time and for all that you do for our patients and our families. And thank you all for listening today. Until next time, I'm Darrin Godin and this is Talking Hope.