Medical malpractice is a difficult subject in our profession. It evokes emotion, judgment, and often criticism—especially toward those who serve as expert witnesses. As an oncologist who has reviewed hundreds of cases over the last decade, I understand the hesitations. Most of my work in this space focuses not on standard of care, but on causation: not whether a mistake was made, but whether an earlier diagnosis or intervention might have changed the outcome. In most cases, I never offer a standard-of-care opinion.
But every once in a while, a case surfaces that leaves a visceral impression.
A few years ago, I reviewed such a case, and it has stayed with me ever since. I was deposed on it recently, and the memories came flooding back. For clarity and professionalism, every detail of the case has been significantly altered, but the essence—the core failure—is instructive.
The Missed Window
Imagine a middle-aged woman presenting with persistent discomfort, anemia, and blood in the stool. A scan shows gastric wall thickening and a sizeable lymph node nearby. While her initial endoscopic biopsy is non-diagnostic, the radiology and clinical picture are clear: this is likely cancer.
She is discharged and referred to oncology.
Three weeks pass before she sees the oncologist. Another month goes by before she can get a second biopsy, which again is non-definitive. And then, for the next two months, multiple additional procedures are attempted to confirm what everyone already suspects. Meanwhile, no treatment is initiated. No oncology board review. No radiation consult. No port placement. Just growing tumors, declining clinical status, and the quiet passage of time.
Perhaps the repeated “negative” results gave the impression to the patient and family that all was well—that there was no urgency. But as oncologists, we must recognize the weight of how we communicate. The way we frame the clinical and radiographic story—our impressions, our gut feeling—can significantly shape a patient’s perception of urgency. We are not just clinicians; we are narrators of medical truth. And how we narrate that truth can determine whether patients follow up sooner, whether plans move forward as expected, and whether care is truly proactive rather than reactive.
Eventually, a biopsy confirms the obvious: invasive gastric cancer. A PET scan—finally performed nearly six months after her initial presentation—reveals widespread progression and a new suspicious lesion. Yet, rather than initiating urgently needed systemic therapy or addressing the dominant disease, the oncologist orders another unnecessary procedure—further postponing action.
The patient, once full of questions and a quiet determination, never received a single dose of treatment. She died within months of that last clinic visit. Her decline didn’t follow the natural course of an aggressive disease—it was hastened by inertia, by excessive caution, by missed opportunity. It was the stillness of inaction that allowed time to run out. For those of us who carry these moments, it is the kind of case that stays with you—not because of what happened, but because of everything that didn’t.
A Systemic Failure in Judgment and Timing
This wasn’t a failure of technology or access. It was a failure to act.
In oncology, we often talk about urgency without panic. But there’s a difference between thoughtful pacing and clinical inertia. In cases where radiology, symptoms, and labs point overwhelmingly toward malignancy, waiting months for confirmatory biopsies—especially when multiple procedures have already failed to provide tissue—is not just poor judgment. It borders on abandonment.
At the time of reviewing this particular case, I couldn’t help but sense the presence of implicit bias—subtle, perhaps unintentional, but deeply consequential. It raises broader questions about how decisional hesitancy may manifest differently depending on a patient’s background, presentation, or perceived complexity.
Yes, we want tissue confirmation. Yes, we want precision medicine. But we also must understand when the burden of proof has already been met.
Treatment Shouldn’t Be Held Hostage by Pathology Alone
The standard in oncology is not perfection, but reasonableness. If clinical consensus strongly suggests active disease, steps must be taken in parallel:
- Present the case at tumor board. If procedures or diagnostic steps are delayed, call your colleagues or admissions to expedite the process. Refer to a tertiary center if your facility is unable to perform the necessary workup in a timely manner. Perhaps have consensus to start systemic therapy while pending additional confirmatory biopsies.
- Engage surgical and radiation colleagues early—ideally with a direct phone call or face-to-face conversation. Don’t just refer—connect. Make it happen. If your institution lacks the capability to perform timely or specialized procedures, actively seek alternative biopsy strategies such as EUS-guided lymph node biopsy, CT-guided biopsy, or open surgical biopsy. When necessary, refer the patient to a tertiary care center to expedite diagnostics and ensure comprehensive care.
- If potential delay for definitive local therapies such as ablation, radiation, or surgery is anticipated, consider earlier initiation of systemic therapy. This approach may help buy time, alleviate symptoms, and potentially recalibrate disease trajectory. Consider empiric treatment if the disease is symptomatic and progressive.
- Schedule port placement, labs, and genetics while awaiting final confirmation. In this case, the PET wasn’t performed until 3–4 months later, during which time additional findings emerged. Yes, new information can come up—but I’d rather learn that sooner. Perhaps had the additional procedures been done alongside the multiple EGD attempts earlier, we might have been positioned to act more decisively.
If the picture walks, talks, and behaves like cancer—we need to act.
A Cautionary Tale for All of Us
This patient’s case (again, heavily altered for privacy) reminds us that delay is not always benign. When a patient presents with what is likely locally advanced cancer, the window to intervene is short. Systemic therapy, even one cycle, could have changed her course. Perhaps not cured her, but potentially prolonged her life, improved her symptoms, and given her a chance.
Instead, she passed away without ever receiving treatment. That fact alone should trigger reflection.
As oncologists, we must balance caution with compassion, and protocol with pragmatism. Our patients depend on us to not just know the science, but to act on it. When the signs are clear, even in the absence of a perfect pathology report, we must find ways to move forward.
Delay, in the context of cancer, is not neutral.
Time matters. Days and weeks are an eternity to a patient.
Let this story serve as a reminder: the greatest harm is not always what we do. Sometimes, it’s what we fail to do.
Disclaimer: This blog post is for educational and general informational purposes only. All case details have been significantly changed to protect patient identity and ensure HIPAA compliance. Any resemblance to actual events or persons is purely coincidental. This is not legal or medical advice and reflects general medical considerations based on cumulative professional experience.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. He brings a wealth of expertise to the complex and challenging world of oncology.
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