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Failure to Communicate a Positive Biopsy Leads to Delayed Cancer Diagnosis

March 26, 2021

A diagnosis of cancer does not always need to be directly communicated. However, special care must be used to ensure receipt of the diagnosis by the clinician in the best position to coordinate or provide treatment to the patient. The following case highlights the importance of creating a “paper trail” that proves pathology diagnoses were sent to the intended clinicians.

More Information About Communicating Critical Findings along the Continuum of Care

Overview: Healthcare Communication: Case Studies and Best Practices for Communicating Critical Findings

Part 1: From Radiology to ED

Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician

Part 3: From Primary Care Physician to Patient


The defendant physicians failed to notify the patient of a positive biopsy resulting in delayed breast cancer diagnosis.

Case File

A radiologist reported a mammogram impression of Category 4C (suspicious of malignancy) to the patient’s OB/GYN. The OB/GYN ordered a biopsy. The biopsy was completed by a radiologist, who sent the sample to a pathologist. The pathologist diagnosed infiltrating moderately to poorly differentiated ductal carcinoma. It was the pathology lab’s practice to send pathology reports to the ordering physician and the patient’s primary care physician (which in this case was the OB/GYN). However, in this case, the report was not communicated to the OB/GYN, and the CC on the report only listed the radiologist. The radiologist received the report but assumed someone else would advise the patient of the results. The patient was never informed of the results and assumed they were negative. One year later, the patient learned of the cancer diagnosis. She sued the OB/GYN, radiologist, and pathologist.


Experts were in disagreement over whether the standard of care required the pathologist to send the report to both the ordering physician (radiologist) and the primary care physician (OB/GYN). In this case, the primary care physician was known; therefore, there was even less reason for the pathologist’s failure to notify her. The pathologist could provide no evidence of having communicated the cancer diagnosis to the OB/GYN other than testifying that doing so would be his standard practice. The OB/GYN vehemently denied receiving the pathology report. Each defendant blamed the other: the OB/GYN for not following up, the radiologist for not passing the information to the OB/GYN, and the pathologist for not communicating the diagnosis to the OB/GYN. If the pathologist had evidence of having communicated the diagnosis to the OB/GYN, he most likely would not have been involved in the lawsuit.

Medical Liability Risk Management Recommendations


Evidence of the communication of a diagnosis can become a critical aspect of a pathologist’s defense in a malpractice lawsuit. Consider the following recommendations:

  • Ensure communication of an actionable diagnosis (e.g., cancer) to the ordering clinician and the primary care physician.
  • Ensure that the system used for communicating pathology diagnoses leaves a paper trail or otherwise verifiable record.
  • Periodically review the communication system and electronic reports to ensure the integrity and consistency of transmissions.

Ordering Physicians

Redundancy in a communication system makes it safer. Do not assume that a different member of the patient’s healthcare team will communicate an actionable diagnosis to the appropriate clinician. Err on the side of caution.

  • Ask the pathologist how long it will take to provide a diagnosis and provide the information to patients.
  • Follow up on pathology reports that are not received in the expected time frame.
  • Encourage patients to contact your office if they have not been advised of results within the expected time frame.
  • When creating a pathology requisition, list all the patient’s relevant clinicians so they receive copies of the pathology report.
  • Provide pathologists with sufficient information to determine whether a diagnosis is unexpected.
  • If you are not the patient’s primary care physician and you are requesting a pathology consultation, advise the primary care physician so they can follow up if the results are not received in a timely manner.

A clinician who requests a pathology consultation is generally held responsible for following up on the results and communicating them to the patient’s clinicians in the best position to use the information for treatment purposes. Prompt diagnosis and treatment often requires the coordinated effort of the patient’s entire healthcare team. Avoid being the weak link in the communication chain.

This content originally appeared as part of the March 2017 release of the NORCAL Group Risk Management publication, Claims Rx, “Communicating Critical Findings — A Three-Part Series, Part 2: Anatomic Pathologist to Ordering and Primary Care Physician.” This release and many others are available in the Claims Rx Directory for download. Policyholders will also find instructions for obtaining CME credit for select releases.


Filed under: Case Study, Patient Care



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