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Failure to Directly Communicate Unexpected Cancer Finding Leads to Delayed Treatment

March 26, 2021

It is a good idea to copy primary care physicians or physicians coordinating the patient’s care on pathology reports in addition to the physician who has obtained the specimen. A clinician who performs a biopsy and sends the sample to a pathologist may not otherwise be involved in the patient's care. If the pathology report is only sent to the clinician who performed the biopsy, an actionable diagnosis may never get to a physician who is in the best position to initiate or coordinate treatment.

In the following case, the numerous physicians involved in the patient’s treatment failed to communicate among themselves and failed to follow up. Consequently, an unexpected cancer diagnosis languished in the pathologist’s electronic health record (EHR), to which the physician coordinating care did not have access.


The pathologist should have directly communicated the unexpected cancer finding to the radiologist and urologist.

Case File

A urologist ordered a cyst aspiration for pain relief. He did not suspect malignancy and did not order cytology. The radiologist who performed the aspiration independently ordered cytology. The pathologist found malignant cells in the cyst aspirate. The pathologist entered the diagnosis in the EHR, assuming the radiologist and urologist would access it there. The pathologist incorrectly believed the urologist had access to the EHR system used by the pathologist. However, the only way for the urologist to obtain notification of the results was by direct communication, mail, or fax. The radiologist did not review the results, assuming the pathologist would communicate any positive results to the urologist.

Two years after the discovery of malignant cells, while the patient was in the hospital for an unrelated issue, she was inadvertently advised of the cancer diagnosis. The patient filed a lawsuit against the urologist, pathologist, and hospital for causing treatment delay.


The finding of malignant cells in the cyst aspirate would be considered a significant, unexpected diagnosis, as the aspiration was done for pain relief. Pathology experts testified that the pathologist had a duty to directly communicate the diagnosis to both the radiologist who performed the aspiration and the patient’s urologist.

Medical Liability Risk Management Recommendations

It is worth erring on the side of caution and making a telephone call when the urgency, significance, or unexpectedness of a diagnosis is questionable. Consider the following recommendations.1,2,3

  • When there is a cancer finding, determine whether it may be unexpected. If there is a chance it is unexpected, directly contact the ordering physician and ensure receipt of the pathology report by the ordering and primary care physician (or physician coordinating care). The College of American Pathologists (CAP) also has online Cancer Reporting Tools that can help guide reporting.
    • If a diagnosis is delivered by telephone, document in the pathology report or medical record the date, time, persons involved, and transmission mode.
    • Request an acknowledgment of receipt of pathology results by the provider.
  • Clearly identify on the pathology report that it contains an urgent or significant, unexpected pathology diagnosis.
  • Provide whatever information is necessary and available to ensure that the urgency or unexpectedness of the diagnosis is understood.
  • Ensure that communication and tracking systems are delivering pathology results to referring physicians and other relevant clinicians in a timely and reliable manner.
  • Do not assume that entering a diagnosis in an EHR will sufficiently communicate the diagnosis.
  • Specifically bring significant information reported in an addendum to the treatment team’s attention.
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.

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


1. Susan C. Lester. Manual of Surgical Pathology. 3d. 2010. Elsevier. Philadelphia, PA. “Chapter 4: The Surgical Pathology Report.” (not available online at the time of publication)

2. Michael H. Roh, Andrew G. Shuman. “I Might Have Some Bad News: Disclosing Preliminary Pathology Results.” AMA Journal of Ethics. 2016 Aug;18(8):779-785. DOI: 10.1001/journalofethics.2016.18.8.ecas3-1608

3. Raouf E. Nakhleh (ed.) Error Reduction and Prevention in Surgical Pathology. Springer Science+Business Media. New York. 2015. “Chapter 12. Communicating Effectively in Surgical Pathology.” (not available online at the time of publication)

Filed under: Patient Care



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