By Han van Krieken
Acquired from The Pathologist
Laboratory medicine is in a state of flux right now. Not only are the tools needed to do the job evolving rapidly as technology advances, but the methods themselves and even the basic skills pathologists need are changing. Whereas once a pathologist might have spent an entire career behind the microscope looking at samples from patients in a single hospital, nowadays he or she must leave the laboratory and interact with the entire patient care team to ensure the best possible treatment for the patient – and, even when seated at the microscope, might be digitally viewing samples from across the world. But as pathology changes, are pathologists themselves keeping up?
There are a few challenges facing pathology at the moment. One of the most significant is convincing enough talented young people to enter the field – though, according to many senior pathologists, that seems to be improving. Han van Krieken, president of the European Society of Pathology (ESP), himself says, “I hear from colleagues in many countries that pathology is becoming the center of attention, attracting more people who are really interested in pursuing a lab-based career. It’s very important to encourage as much of that as possible, so that we are continually bringing in new perspectives into our profession.”
The other big challenge is finance. Pathology has always been viewed as extremely inexpensive – the tests have had excellent value for money, especially when compared with things like complex imaging techniques. But now that labs have begun to move more heavily into molecular testing, doctors and patients are starting to notice that the tests cost more than they used to. And it’s true that some are – a test that costs €1,000 is considered extremely expensive. But when that test is used to determine whether or not to administer drugs that cost €100,000 a year, the testing cost is quite negligible in comparison. Nonetheless, it can still be difficult to overcome the general feeling that pathology is becoming more expensive. van Krieken says that, though many pathologists do try to accomplish testing as cheaply as possible, sometimes it’s necessary to pay for quality.
“To some pathologists,” he says, “especially those educated in traditional methods, molecular biology can seem like a bit of a black hole. There are a lot of pathologists who are very interested and keen to interact with experts in molecular biology – but there’s also a group that is still a bit afraid of the dark, so to speak. They see so many new things happening at once that they feel overwhelmed. So I’d say there’s some work to be done in changing the mindset of those pathologists.”
But lab medicine professionals aren’t the only ones who still harbor reservations – the pharmaceutical industry, too, needs to be convinced. van Krieken uses lung cancer as an example of this, because there are tests that can revolutionize treatment of the disease – but only for a minority of patients. “What happens is that a patient’s tumor tissue will be tested, but most patients will not benefit from the results because they do not have the genetic alteration needed to respond well to the drug in question.” In many European countries, patients have to pay for that testing, which puts them in an unfortunate position when they’ve paid, but can’t benefit from the result. van Krieken’s solution is to move toward a system in which test and drug are integrated, so that payment for the drug includes all of the necessary testing. “I know that people in the pharmaceutical industry would be very interested in such an approach,” says van Krieken, “because they feel very strongly that an optimal test is crucial not just for patients, but for the industry as well, because their drugs will only work if administered to the right patients.”
For that reason, he considers it extremely important for in vitro diagnostics manufacturers, pathologists, and medical doctors to work closely with the pharmaceutical industry to try to effect change. That level of collaboration is an adjustment for many pathologists, so van Krieken and the ESP are working to alter the way laboratory professionals approach their work. So far, they’ve established an educational program, started a quality assessment program for molecular testing, and built alliances with medical oncologists, gastroenterologists, gynecologists and urologists. On the industry side, they are bridging the gap between the lab, the clinic, and the pharmaceutical industry, as well as helping patients and medical professionals to influence policymakers. But even then, says van Krieken, it’s not enough. “We need to engage more,” he says, explaining that the ESP hired a scientific director earlier this year to do exactly that. He highlights lung cancer diagnosis as one area this level of collaboration has recently revolutionized, and anticipates an upcoming change to brain tumor classification that will also include molecular testing going forward. With these changes and others, van Krieken is hopeful that pathologists will see the benefits of reaching out and join in to help make changes to the way molecular testing is done – and the way it’s paid for.
Not all of Europe is on the same page with regard to pathology. In some countries, laboratory medicine is very well-positioned – it’s taken seriously, has sufficient personnel, and is an appealing career for medical trainees. “In the Netherlands, we’re lucky enough to have that situation,” says van Krieken, “but there are other countries, such as Greece, that have difficulties – pathologists don’t get the recognition they deserve, young people don’t want to enter the field, and the science has not evolved into what we now call modern pathology.” ESP, he says, actively tries to support colleagues from those countries by providing them with good education through the European School of Pathology, which holds training courses all over Europe to bring the knowledge where it’s most needed. “We try to bring in those countries where pathology hasn’t yet reached the position we think it should have, and help them to raise its profile.”
For progress like that, ESP members are vital. “We can only help with progress once we have a foothold,” says van Krieken. “We need a person, or hopefully several people, who are willing to take up the challenge of advancing pathology in their country. Then we can support those people by bringing in teachers and running courses. That’s the way we try to work.”
“For a long time, I’ve felt that the era of the general pathologist who knows everything is over,” says van Krieken. “Even areas that used to be fairly simple have become more complicated in the sense that we can gather much more information about our patients and make precise, accurate diagnoses.” This, he says, is thanks to digital pathology. But even here, change is slow. “Pathology is quite conservative, he says, “and I do understand that, because what we do is built on the experience of our forefathers. Change is always difficult. And I think that when we looking through a microscope, we feel secure, because we’ve done it for so many years. Looking at the screen is a bit different – including for me. I’ve done a few hundred cases digitally myself, but I still feel more comfortable behind my microscope because I’ve been doing it for the past 30 years. Fortunately, I think it will be easier for younger pathologists.”
Speaking of the benefits of digital technology, van Krieken uses the example of an organ transplant patient who wanted to have a necessary biopsy done in his hospital. “I have no experience with transplant pathology at all,” he says, “so I needed the help of a colleague. When I received the slide, I just sent a link to two colleagues, one in the north of the Netherlands and one in the west – and I had an expert opinion for the patient within an hour.” Another thing he notes is that his patients are becoming more and more aware of how important a correct diagnosis is to their health. “More and more patients actually send me emails asking why I’ve made a particular diagnosis and whether I’m sure about it. I think that’s a very good development. It challenges me to an even higher level of accuracy, which I think digital pathology will enable.”
One thing that van Krieken is seeing in many European countries is that medical students, when choosing a specialty, are starting to look not only at which ones are the most lucrative, but also at what aspects of medicine they find most interesting. And for many of them, that’s the challenge of making a diagnosis using all the new testing and technology available to them. “So as we become more visible,” he says of pathology as a whole, “more people are thinking, ‘Well this might be interesting for me!’”
The key to this kind of progress is to make sure that pathology is very visible in medical curricula. “We used to be very visible in the old-fashioned curricula,” says van Krieken, “but we were visible as ‘those people who looked at slides and came up with weird diagnoses,’ and that’s it. In the more modern curricula, we play an integral part in the multidisciplinary team dealing with a patient’s issues. And I think that’s a much better way of showing what we actually do than demonstrating basic pathology as a separate discipline. Basic pathology is certainly important, but it’s not the way we work in our routine practice anymore.”
In his vision of the future, van Krieken sees the pathologist as part of a patient’s “support crew.” The pathologist’s job will be to gather a wide variety of information – morphology, immunology, molecular data, imaging – and provide it to clinicians so that they can make the appropriate treatment decisions. That’s why he thinks it will be important for pathologists to get involved with the patient care team, rather than remaining separate. “Communication is one of the most important skills a pathologist can have. That wasn’t always the case; I remember that when I decided to become a pathologist, one of my teachers told me, ‘You don’t have a communication problem – why would you become a pathologist?’ At that time, intelligent doctors who couldn’t communicate with patients would go into pathology. But nowadays, communication is key.”
True to this, van Krieken says the most rewarding aspect of pathology for him is the ability to interact with so many different colleagues on so many different topics. Life as a laboratory medicine specialist is filled with variety, and it’s the ability to explore that and connect his discipline to so many others that van Krieken finds appealing even after so many years. And there’s still plenty to look forward to as pathology evolves. “I think we have already made progress in many ways,” he says, “but it comes in small steps. And, looking back, what I think will be most rewarding in the end is the ongoing evolution of the discipline, and the way it brings people together.”