Guidance

Issuing provisional or verbal pathology reports

Published 17 July 2020

Introduction

This guidance aims to reduce the risk of patient mismanagement as a result of presenting provisional or verbal reports to clinical teams. This can happen on rare occasions when there is a change in diagnosis in the final report, or following additional tests where an addendum report is issued.

Provisional reports

Pressure is often placed on pathologists to issue provisional reports to meet multidisciplinary team meeting (MDTM) deadlines to help meet clinical targets. This happens particularly for preoperative samples, such as core biopsies. We discourage this and it is not considered good practice.

Examples of potential patient mismanagement include cases involving:

• immunohistochemical stains for myoepithelial markers, where the differential diagnosis is between a complex sclerosing lesion or an invasive carcinoma
• further haematoxylin and eosin stain (H and E) levels when microcalcification is not present in initial sections

Note that this guidance does not refer to the situation where a sample has not yet had additional predictive marker assays (such as hormone receptors or HER2) when there will be no change to the diagnosis.

Verbal reports

Some reports are issued verbally at an MDTM before the histology report is authorised. This might happen when:

• a case is waiting for further tests, which might change the diagnosis (for example, if the current diagnosis is provisional)
• the pathologist has not had time to authorise the histology report before the MDTM

Both these scenarios confer risks to patient management and are discouraged.

Recommended actions

Case discussion

Defer case discussion if there is diagnostic uncertainty and ancillary tests are required (such as levels for detection of microcalcification or immunohistochemistry). The multidisciplinary team (MDT) should recognise that further additional tests will be required in a small number of cases.

Defer the case discussion until the following MDTM when the final diagnosis has been made and the definitive histology report has been issued. This means the patient can be appropriately counselled and managed.

Delaying appointments can cause anxiety for patients, but may be less distressing than being given an uncertain or even incorrect diagnosis. The MDT should have processes in place to contact the individual and defer their appointment if necessary.

MDTM recall dates

MDTM recall dates should realistically reflect laboratory turnaround times and allow pathologists enough time to assess specimens. This will vary between laboratories. There should be at least one working day for processing core biopsies from the point the biopsy is received in the laboratory.

For example, a biopsy taken and sent to the laboratory on a Monday could be reported and ready for MDTM discussion on Wednesday. Timeframes will be longer for surgical resection specimens. Vacuum-assisted biopsies for evaluation of microcalcifications most frequently require additional H and E levels, and it may be appropriate for MDTM scheduling to take this into account.

Provisional reports

Only issue a provisional report in exceptional circumstances. If this happens, the report must clearly:

• state that it is provisional
• give the diagnostic uncertainty and differential diagnoses
• note what further tests are pending

It may be appropriate not to give a histological diagnosis code (B1 to B5) in a provisional report, to highlight that the report is not complete. This may also apply to cases that are sent away for expert second opinion.

Add an addendum to a provisional report when any ancillary test results have been assessed. This addendum must clearly indicate that it is the final diagnosis, for example, by using capital letters. Format the report to make it obvious there is an addendum included.

Transcribe as part of the addendum or add as an attachment any external report from an expert second opinion. Once a final diagnostic report is issued, discuss the case again at an MDTM and document any decisions made. This ensures there is appropriate multidisciplinary discussion of the final management plan.

All departments should have a standard operating procedure (SOP) for issuing provisional and addendum reports.