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.