COMMENTARY

Give Pathologists the Opportunity to 'Use All of Their Tools'

Mark G. Kris, MD

Disclosures

February 21, 2019

This transcript has been edited for clarity.

Hello. It's Mark Kris from Memorial Sloan Kettering. I would like to discuss my experience in recent medical meetings here in New York.

In the past week, I've had the opportunity to meet with many national experts. I've had meetings with real doctors—folks in practice throughout the United States—and also meetings with the physicians here in the New York Tri-State area. I've been able to get all kinds of information and opinions and an opportunity to see the range of thinking that my colleagues have. I want to share some of that with you and some of my conclusions from this time.

I think the one thing I've taken home in the way that lung cancer has come to be treated in 2018 is the need for multimodality care. I think every patient—every stage of their cancer journey, every stage of their illness—is a candidate for multimodality care. That is where the whole field is heading.

There isn't any case, now, that's just radiation, just surgery, or just medical oncology. All of the different modalities that we have—and there's more there, too—need to be brought into the discussion. Not every patient has to receive all modalities, but we need to consider all of the modalities in every patient. To take that one step further, it's not all of the modalities in every patient at diagnosis, but it's all of the modalities for every patient at every decision point. I'll give you some examples.

Too often, we're demanding and not discussing; we're exclaiming and not explaining.

First, I went to a lecture by Maureen Zakowski, a pathologist at Mount Sinai Hospital here in New York. She brought home some very, very important concepts to all of us who consult with our pathology colleagues. I first ask you to think about your relationship with your pathologist and to try to put yourself in their shoes.

You've all heard that saying, You really don't understand somebody until you've walked a mile in their shoes. I really think we need to do that. Pathology is a very different world and they have a different set of concerns, a different set of standards that they have to live up to, and [a different] approach.

[I'd like to highlight] a couple simple things that we understand. The first is the difference between surgical pathology and cytology. Many of us don't appreciate that both of them are specialties within pathology. They both can yield very important diagnostic information from the specimens they analyze and review; however, they are two very distinct specialties. People with expertise in one area may have a different set of expertise in another.

Consulting them both and making use of their different skillsets can be very important, particularly for different kinds of specimens. For example, a pleural effusion can be a tremendous asset for any kind of testing, even though it's not a tissue specimen and it's the cytologist who would give you morphology, immunohistochemistry (IHC) testing, or molecular results from that aspiration rather than a tissue specimen.

Second, pathologists can only render their best opinion when they get adequate material. That's not their issue—we supply them with the material. It's up to us and our colleagues that help us get diagnostic material to get the pathologist everything they need. That is, material for gross examination, microscopic exams, and all of the necessary IHC tests to help with the diagnosis and to look at parameters like HER2 or PD-L1. [We also need to provide] sufficient material for molecular [analysis]. The more we give our pathology colleagues, the more information they can give us back by using all the tools available to them.

It's also important that we think about our communication with our pathology colleagues. Too often, we're demanding and not discussing; we're exclaiming and not explaining. We really need to think about our relationship with our pathology colleagues and work with them.

Obviously, in the medical oncology field, it's all about the molecular pathway or the new drug. That's not necessarily the same literature that pathologists are reading or the same meetings that they're attending. When there is a new pathway or a new drug, we need to make clear to our pathology colleagues how important that is in our decision-making, and how we need their expertise to give us the information we need to make the best decisions.

That doesn't happen by magic. It happens by talking to the pathologist. They really need to know what we're looking for. Do we think it's lung cancer? Do we think it's colorectal cancer that spread to the liver? The more they know about that, the better the job they can do.

Another fact that we're being reminded of is that pathologists don't necessarily have access to the databases that we have access to. They may not have direct contact with the medical record that we create each time they're analyzing a specimen and trying to render a pathologic diagnosis. Please remember that and do your best to make sure that they have all of the information that you have. Don't automatically assume that they have access to [the same information], because sometimes the databases do not communicate or they are at different physical parts of the institution.

Finally, please remember, more than anything else, that our pathology colleagues are consultants; they are consultants on tissue. Giving them the opportunity to use all of the tools they have—microscope, measurement, IHC, FISH (fluorescence in situ hybridization), molecular testing—on that tissue specimen can help them give us the best diagnosis.

Use pathologists as consultants. Please treat them with the respect they deserve as consultants in that field. [If we do this], we will find much better information from each pathologic specimen, all of our lives are going to be happier, and our patients are going to receive better care.

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