Pathologist Impact on Treatment Options

As a medical student considering pathology as my specialty of choice, I was frequently asked, “Why choose pathology? You are so great with patients—I don’t see you as a pathologist.” As I wrestled with my decision of what career path was right for my skill set, I contemplated what might be the motivation for these comments from the faculty in various clinical specialties whose opinions I held in high esteem. I went to the usual source to gather information – my student peers. I polled my closest friends, and one person said, “I just think you will miss out on the opportunity to help patients – just writing lab reports all day.”

Ultimately, pathology was my career choice. My decision was influenced by involvement with my pathology mentors—I recognized the tremendous impact that their decisions in the lab made upon the clinical care of the patients I was rounding on. Every day that I go to work, I take meaning from the unique ways that I can participate as a member of the healthcare team—providing clinicians the data they require to develop a personalized treatment plan for each of their patients. This collaboration with clinicians is fostered by a pathologist’s knowledge of the crucial clinical decision-making points that our clinicians face daily. Together within our departments, we come to a consensus on critical items which lead to better patient care.

Pathologists have an increasingly visible role in directing patient therapy due to many factors. These include standardization of treatment planning based primarily from pathology data-driven guidelines which include assessment of high-risk histologic factors for each tumor type, molecular testing for targeted markers, and extent of involvement by malignancies. Additionally, understanding the decision-making process and goals of therapy from the clinician is helpful to decide when testing for many of the new and evolving biomarkers will be necessary as well.

One such example of the pathologist's impact is exemplified by colon cancer. Therapy begins as soon as the specimen is transferred from the surgical suite. This infographic captures the journey that specimen and actions a pathologist takes to chart a treatment course for the patient. In patients with T2 invasive colonic adenocarcinomas, the presence or absence of lymphatic/vascular space invasion has become an important prognostic indicator which drives clinical decision making for patient therapy in the National Comprehensive Cancer Network (NCCN) guidelines. It means the difference between definitive surgery with clinical monitoring and chemotherapy treatment.

However, pathologists are aware of many instances where there are histologic mimics such as retraction artifact, as well as regional practice variations as to the strict definition as to what qualifies for vascular invasion. This is a representation of a “gray area” that often gets put into the “equivocal” category when controversy arises. Becoming aware of how these types of issues related to the guidelines allow pathologists the opportunity for consultation and consensus building in order to better assist clinicians in these critical decisions. But as we strive to reach those optimum levels of patient care, we need to not forget about self-care.

When discussing the topic of burn out with peers, one item that is frequently brought to the surface is that the tasks in our specialty can become mechanical. This statement to me indicates some members of our specialty feel detached from the rest of the team. Reaching out to our clinicians to discuss next steps for patients with equivocal/controversial results can help combat that feeling as we go about our daily work. Understanding the decision-making process and goals of therapy from the clinician is helpful to decide when testing for many of the new and evolving biomarkers will be necessary as well.

As a specialty, we have difficulty attracting interested medical students and retaining them as applicants for residency programs. Negative stereotypes of pathologists both in the media and perpetuated by our clinical colleagues may be an important cause of students not entering the field of pathology. One of the key insights I have gained from my interactions with medical students and members of the public is that many do not view pathologists as physicians, but more as technicians. Highlighting the ways pathologists are uniquely poised to participate as members of the healthcare team to provide clinicians data that is required to develop personalized treatment plans for each of their patients may be a way to pique the interest of new students to pursue this course of study.

Pathologists have an ever-growing impact on patient care—our diagnosis begins to chart the course for treatment of our patients. In the new era of standardized treatment protocols and the expanding field of immunoncology, which requires testing for different molecular markers, pathologists are uniquely qualified to serve as consultants to ensure the appropriate testing algorithms and protocols are followed. As we stand at the crossroads of implementing value-based care and personalized medicine, we must leverage the strengths of our specialty training as experts in laboratory medicine, data collection, and interpretation of testing results. Collaborating with our clinical colleagues will be essential to achieve these goals.

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