A Department of Veterans Affairs patient with a suspicious breast abnormality waited approximately five months for a recommended biopsy after the agency’s community-care system classified the referral at its lowest level of care coordination, according to a new inspector general report.
By the time the biopsy was eventually performed in spring 2024, testing identified cancer. Subsequent imaging was consistent with stage 4 disease with bone metastases.
But the central finding in the VA Office of Inspector General’s October 6 report is not simply that something went wrong.
The VA personnel who initially classified the biopsy referral appear to have followed the rules.
The OIG found that the VA Eastern Colorado Health Care System appropriately assigned the patient’s breast biopsy referral a “basic” level of care coordination under existing Veterans Health Administration guidance. That designation allowed the patient to schedule the procedure herself and did not require the clinical review that accompanies higher levels of community-care coordination.
The case exposed what inspectors described as a vulnerability in the VA’s system: suspected cancer was not among the high-risk conditions that would necessarily trigger that additional clinical assessment.
“Had the administrative consult tool’s list of complex/chronic conditions included high-risk conditions, like suspected cancer,” inspectors wrote, community-care staff would have been required to conduct a clinical assessment intended to ensure the patient’s coordination needs were met and minimize the risk of harm.
The result was an unusual sequence in which several safeguards existed, but none ensured that a biopsy recommended after suspicious breast imaging was actually completed.
According to the VA OIG report, the patient, a woman in her forties, established primary care at the Alamosa VA clinic in fall 2023. Two days later, she reported a lump in her right breast and underarm that had been present for approximately two months.
A diagnostic mammogram and ultrasound performed later that year found right-breast calcifications and an enlarged right axillary lymph node. The radiologist classified the findings as BI-RADS 4, a suspicious abnormality suggestive of possible cancer.
Biopsies were recommended.
The patient’s primary-care provider ordered them that same day through VA community care.
Two days later, the patient chose to self-schedule the procedure with a local provider. In early 2024, however, she informed VA staff that the community provider had not received the necessary authorization. VA refaxed it.
Twelve days later, VA sent the patient a text message reminding her to schedule the appointment. A mailed reminder followed approximately one month later.
The biopsy still did not happen.
Meanwhile, the patient returned to the Alamosa VA clinic for a pre-operative appointment related to hip surgery. Her primary-care provider documented the abnormal mammogram among the patient’s medical problems, according to OIG, but did not mention it in the assessment and treatment plan.
Approximately three weeks later, VA canceled the biopsy consult after unsuccessful attempts to schedule the procedure.
Under VHA guidance, inspectors found, VA staff were permitted to do so.
That is where the bureaucratic mechanics of the case become more consequential.
VA’s community-care system assigns referrals one of several care-coordination levels: basic, moderate, complex/chronic or urgent. Referrals above the basic level require a clinical assessment in which a clinician reviews the medical record, applies clinical judgment and determines whether additional coordination is needed.
The patient’s mammogram and biopsy referrals were both classified as basic.
OIG confirmed that those classifications complied with existing guidance.
Had the biopsy received a higher designation, inspectors were told, responsibility would have shifted to clinical personnel charged with ensuring that the appointment was completed, actively engaging with the patient or provider, removing barriers to treatment and monitoring the patient’s progress.
Instead, the system permitted self-scheduling of a biopsy prompted by imaging suspicious for cancer.
Two months after the consult was canceled, the patient went to a community emergency department complaining of shortness of breath.
A CT scan found multiple enlarged lymph nodes and multiple bone lesions concerning for metastatic disease.
The patient contacted VA two days later and reported that she had been instructed to obtain immediate oncology follow-up. VA ordered another biopsy consultation.
Approximately two weeks later, the patient finally underwent diagnostic imaging and an ultrasound-guided biopsy. A community pathologist subsequently reported poorly differentiated cancer.
A PET/CT performed in early summer 2024 was consistent with stage 4 cancer with bone metastases, according to OIG. The patient began chemotherapy that fall and continued receiving oncology care in the community.
The inspector general did not conclude that the approximately five-month biopsy delay caused the cancer to progress to stage 4, and the report cautions that its findings do not establish legal liability or a standard of care.
The chronology nevertheless prompted inspectors to question whether VA’s community-care rules provide enough protection for patients with potentially serious diagnoses.
The referral classification was also only one of several breakdowns identified in the case.
OIG found that during the patient’s pre-operative appointment, her primary-care provider failed to coordinate follow-up for the outstanding biopsy and did not document a treatment plan or discussions concerning the abnormal mammogram, including the risks associated with delayed care.
The provider later told investigators that the patient wanted to prioritize her hip condition and recalled discussing the mammogram with her, but acknowledged that the conversation was not documented.
Inspectors warned that inadequate care coordination and documentation can disrupt continuity of care and potentially compromise patient outcomes.
There was still another safeguard that failed.
The Eastern Colorado system maintained a spreadsheet intended to track breast imaging and follow-up. OIG reviewed that spreadsheet and found that the patient’s late-2023 breast imaging results had not been properly recorded.
That meant a suspicious mammogram and its recommended follow-up had escaped not only active clinical management but also the facility’s tracking process designed to monitor breast cancer screening.
The facility hired a breast cancer screening coordinator in June 2025 and implemented a new tracking tool.
The problem, however, was not discovered in isolation.
A separate May 2026 VA OIG inspection of the same Eastern Colorado health system identified deficiencies involving the availability of community-care breast images, breast cancer screening and follow-up, and credentialing and privileging of a mammographer.
That investigation produced six recommendations intended to strengthen the facility’s breast-cancer screening processes.
As of September 28, five remained open.
The new investigation resulted in one additional recommendation with implications beyond Eastern Colorado.
OIG recommended that the VA under secretary for health consider adding high-risk conditions such as suspected cancer to the list of complex or chronic conditions used by the community-care consult tool.
VHA agreed.
In its response, the agency said it would review the existing list and assess whether it is feasible to expand it to include conditions such as suspected cancer.
The case presents an uncomfortable problem for a bureaucracy built around procedures, classifications and escalating levels of review.
VA staff had a patient with a palpable breast lump. Imaging identified a suspicious abnormality. A radiologist recommended biopsies. A VA provider ordered them.
The referral nevertheless remained “basic.”
The biopsy went uncompleted for months. The consult was eventually canceled. The abnormal imaging was absent from the facility’s tracking spreadsheet. And another opportunity to intervene passed during a primary-care visit without documented follow-up.
By the time the diagnostic process resumed, it was an emergency-department CT scan showing findings concerning for metastatic disease that brought the unresolved problem back into focus.
In this case, the most troubling finding may not be that someone ignored VA’s rules.
It is that the rules were followed, and a suspicious cancer finding could still fall through them.
