Because of her strong family history of breast and ovarian cancer, a 45-year-old patient was referred to a clinic that provides cancer risk assessment. She met with both an oncologist and genetic counselor, and reported that her mother was diagnosed with breast cancer at age 56 and that a cousin was diagnosed at age 30. Genetic testing was discussed as an option, but the patient was concerned it would affect her health insurance because—at that time—legal protections for such information were not available. The patient was advised to follow up in a year in order to update her family history and review any new clinical information.

A year later, the patient was seen for the first time by a new gynecologist for annual breast and pelvic exams, which were considered normal. The patient told the gynecologist she wanted her ovaries removed, due to her family history. The gynecologist advised against an oophorectomy, explaining to the patient that her ovaries appeared healthy and she needed the estrogen because her risk for developing osteoporosis was high.

Within a year, the patient was diagnosed with ductal carcinoma in situ. Her oncologist updated her family history to include her breast cancer diagnosis, her sister’s breast cancer diagnosis at age 46, and her maternal grandmother’s ovarian cancer diagnosis at age 52—information she had provided inconsistently during prior history takings. The patient was placed on Tamoxifen.

Six months later, during her annual physical, the patient’s gynecologist palpated a mass between the rectum and vaginal septum. The gynecologist told the patient that he would evaluate the ovaries during a laparoscopic surgery to remove the mass. He told her he would only biopsy and possibly remove the ovaries if they looked abnormal. During surgery, the mass was found to be benign; the ovaries appeared healthy and were not removed.

At the following year’s annual gynecologic exam and pelvic ultrasound, the patient again discussed removing her ovaries with the gynecologist. He advised against it as long as she was still menstruating, and because she was already showing early signs of osteoporosis. The gynecologist was unaware that the patient was taking Tamoxifen for her breast cancer, which countered the estrogen benefit of maintaining the ovaries.

Within six months of this exchange, the patient complained of lower pelvic pressure and pain and was diagnosed with ovarian cancer. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and sigmoid colectomy. She was found to have extensive additional adenocarcinoma involvement through out her pelvis, and her five-year prognosis is poor.

1. The patient refused genetic testing, and did not return to the cancer risk assessment clinic until after she was diagnosed with ovarian cancer.
   A physician who encounters a patient who refuses recommended testing or treatment is advised to maintain an ongoing dialogue and document recommendations that were declined. This will serve both parties well when and if the patient’s personal and family history changes.
   
   
2. The gynecologist did not remove the patient’s ovaries when he evaluated them during laparoscopic surgery.
   The defense’s medical experts maintained that the condition of her ovaries did not meet the criteria for removal, according to the standard of care at that time. The medical expert retained by the plaintiff suggested that a conclusive diagnosis of the ovaries was not possible through visual observation. Further, at the time of the surgery, the patient had breast cancer, was taking Tamoxifen, had a strong family history of breast and ovarian cancer, was already perimenopausal, and had requested an oophorectomy.
   
   
3. The gynecologist did not know that the patient was being treated with Tamoxifen, lowering her estrogen at the same time that the gynecologist was saving her ovaries to maintain her estrogen levels.
   Updating a patient’s medical and family history, and medication history, on an annual basis, is key to recognizing new or elevated risks in time to respond pre-emptively.
   
   
4. The gynecologist opposed the patient’s request to have her ovaries removed. The patient’s priority was to prevent the onset of ovarian cancer (and she was not planning on having any more children). The gynecologist wanted to preserve her healthy ovaries to help prevent osteoporosis.
   How do you manage a patient request that is not completely clinically justified? Nonalignment of expectations between provider and patient can complicate the care process and trigger complaints following a poor outcome. Communication with patients in situations like this must include acknowledgment of patient concerns and careful explanation and documentation of your clinical rationale. In this case, further communication may have surfaced the Tamoxifen treatment.
   
   
5. The gynecologist and the oncologist did not share critical information about this patient’s treatment. The patient did not discuss her desire to have her ovaries removed with her oncologist, and did not mention her Tamoxifen treatment with her gynecologist.
   A system that counts on the patient (alone) to convey relevant information is as prone to error as one that excludes the patient from the dialogue. Patients may assume that all the providers they see communicate directly, and clinicians may assume that the patient will provide comprehensive information. Asking your patients for details of other health care encounters—and, when necessary, following up with co-treating colleagues—is a key component of history taking and treatment.
   
   
6. Limited documentation of the patient’s concern about ovarian cancer placed the gynecologist at risk.
   Proper documentation supports clinical rationale. The written record functions as a tangible reminder of the clinician's thought process. From these notations, other clinicians, and anyone else reviewing the case, can discover why the clinician treated the patient as he or she did. Notes about patient requests that are denied can help dispel any later impressions that the doctor ignored the patient’s concerns.
   
   
7. A mock trial and focus group were to tests how a real jury might respond to the evidence.
   The lay participants considered the patient’s inaccurate family history, her reluctance to pursue a second opinion or switch gynecologists, and her aversion to genetic testing, and they found the patient close to 100 percent responsible for her situation. When decision to move forward with a jury trial was hampered by the unavailability of a speedy trial date, both sides agreed to binding arbitration. The arbitrator’s conclusions against the defendant physician led to a settlement.