Pam Harrison

August 31, 2017

CHICAGO — Pathologists and laboratory medicine professionals will be taking a cold, hard look at all the tests physicians order, and why they order them, as part of their Choosing Wisely effort to cut down on unnecessary and even harmful orders that continue to burden patients and payers alike.

The fourth list of recommendations for the Choosing Wisely campaign — currently undergoing review — will be discussed at the upcoming American Society for Clinical Pathology (ASCP) 2017 Annual Meeting.

Dr William Schreiber

"We want to make sure that doctors do not order tests that are wasteful or inappropriate and generate more tests down the road," ASCP President William Schreiber, MD, told Medscape Medical News.

During a special Choosing Wisely workshop at the meeting, the goal will be to continue to identify which tests are useful, which tests might be considered an alternative to standard tests, and, most important, which tests should be avoided.

Pathologists and laboratory scientists see examples of inappropriate testing every day.

"Pathologists and laboratory scientists see examples of inappropriate testing every day," said James Wisecarver, MD, PhD, who is president-elect of the ASCP and chair of the workshop.

For example, even if a test for a disease that is not prevalent in the general population "has a relatively high specificity — meaning that a positive test is highly likely to mean the patient actually has the disease — there will still be more false-positive test results than true positives," Dr Wisecarver told Medscape Medical News.

These false positives are likely to trigger a series of other medical work-ups that will only serve to prove that the patient does not, in fact, have the disease in question. "All of the expense, physician time, patient time and inconvenience, as well as patient concern about health, are wasted," he explained. "All of the problems associated with overutilization and inappropriate utilization are exactly what I and my copresenters are going to discuss at our workshop."

More resourceful approaches to testing are sprinkled throughout the program. One salient example, which will be addressed by researchers from Stony Brook University Hospital in New York, is the cost of fundic gland polyp biopsy. The number of fundic gland polyps typically identified as an incidental finding during routine esophagogastroduodenoscopy has increased dramatically over the years, but so, too, has the cost of handling these benign entities.

With virtually no malignant potential, researchers argue that biopsy of these polyps can be effectively eliminated without compromising patient care. Similarly, rates of prostate-specific antigen (PSA) testing, although lower now than at their peak in the early 1990s, as reported by Medscape Medical News, are still unacceptably high.

During one presentation, researchers will be asking why consensus recommendations, at least those from the US Preventive Services Task Force (which discourages PSA screening in men of any age), are not being followed; rates of screening are still high in the United States, especially in men 50 to 59 years of age.

And the use of serum antigen testing for the initial detection of histoplasmosis, after urinary antigen testing, will be addressed by researchers from the Cleveland Clinic.

Changes in the Wind

Changes in the regulatory environment are bound to be implemented as payers vow to reduce out-of-control healthcare costs, and pathologists and laboratory medicine specialists will not escape their effects.

"What's happening now is that governmental organizations that pay for healthcare are expecting to see evidence that what's being done is being done in a cost-efficient manner, and there are going to be penalties for not providing evidence that we are doing things in a quality manner," Dr Schreiber reported.

To help practitioners arrive at the "right" diagnosis, delegates will be walked through the convoluted realm of advanced analytics involved in the transition from volume- to value-based healthcare by the team of Michael Caligiuri, MD, director of the Comprehensive Cancer Center at the Ohio State University in Columbus, and Colin Pritchard, MD, PhD, director of the genetics and solid tumors laboratory at the University of Washington Medical Center in Seattle.

"Tools are needed that can gather all aspects of a patient's current disease state — clinical, imaging, laboratory, histology, sequencing — to produce the best pathway for patient care," said Dan Milner, MD, chief medical officer for the ASCP.

"Pathologists must be at the forefront of this process and lead the teams to create the best possible outcomes for our patients," he told Medscape Medical News. The ASCP recently created, for specialists who want to learn how to better deal with big data, an online opportunity to go through a certificate program in informatics.

And changes are in the wind. During her Michele D. Raible Lecture for Residents, Elaine Jaffe, MD, head of the hematopathology section at the National Cancer Institute in Bethesda, Maryland, will explain that only people who are prepared for the changing healthcare climate will succeed.

New Technologies

The considerable buzz about new technologies — one of which is digital pathology — will surely be audible, at least in the corridors, at the meeting.

"Digital pathology makes it possible to take a glass slide with tissue on it and scan it to create a computer file that can then be sent over the internet or archived," Dr Schreiber explained.

This means that pathologists will eventually be able to review cases and make diagnoses from remote locations, he pointed out.

And the breakthrough technology of selective whole-genome sequencing will eventually allow pathologists and laboratory scientists to look at hundreds of genes at a time.

"This will allow us to read the genetic code and look for abnormalities that may be important in terms of the development of cancer, genetic disorders, or even multifactorial disorders, like heart disease, in which many genes may play a role," Dr Schreiber explained.

Global efforts in pathology will also garner attention. The headline speaker at the general scientific session — Ambassador Deborah Birx, MD, the US global AIDS coordinator for the President's Emergency Plan for AIDS Relief — will address the role that ASCP members, who work in the thousands of laboratories around the world, have played in improving the diagnosis and treatment of HIV.

Dr Zubair Baloch

Pathologists have also assumed a leadership role in shaping the diagnosis of certain malignancies. For example, removal of the "carcinoma" designation from a thyroid neoplasm because it is largely indolent and rarely metastasizes will be discussed by Zubair Baloch, MD, PhD, from the Hospital of the University of Pennsylvania in Philadelphia, who is chair of the meeting education committee and a member of the panel of pathologists and clinicians that made the recommendation.

"Before this change, most patients with this neoplasm were being overtreated," Dr Baloch told Medscape Medical News.

An emphasis on leadership is also evident in the numerous learning tracks structured into the meeting in which delegates interested in taking a proactive, professional stance can learn what it takes to be a good leader.

"Pathologists are always considered nerds; we're the guys who are sitting behind a microscope," Dr Baloch joked. "But this leadership track will teach many techniques that go well beyond traditional pathology education."

Arguably, the real value of attending any annual meeting lies in the personal aspects.

"What our meeting does best is bring together the latest developments in pathology and laboratory medicine to provide a variety of educational experiences and social opportunities for people to really talk to one another so that they get a sense of where pathology and laboratory medicine are really at today," Dr Schreiber pointed out.

Pathologists are always considered nerds; we're the guys who are sitting behind a microscope.

The intangibles of an annual meeting — opportunities to reconnect with colleagues from across the country and around the world, renew old friendships, and see what is going on elsewhere — make attendance worthwhile, Dr Baloch explained.

"By coming to the ASCP, people get a more holistic approach to pathology. It's not just academic pathology or just diagnostic pathology, the meeting goes way beyond that," he said.

"I want our meeting to provide that holistic approach by offering sessions that help you to become a better pathologist, a better leader, a better communicator, and to be a real part of this entire machinery," Dr Baloch said.

The meeting will come to a rocking close with a performance by a band of top-notch pathologists known as Lost in Processing.

Dr Schreiber, Dr Wisecarver, Dr Baloch, and Dr Milner have disclosed no relevant financial relationships.

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