Pathologists face a stark career choice

Disclosure. I am a pathologist, and I work at the interface of molecular oncology and information technology.

Approximately 600,000 American cancer patients emerge uncured from standard of care treatment by medicine, surgery, and radiation each year. That is 1,600 every day. What then?

Enlightened palliation on the way to hospice care does make sense for many. But now there are additional options based upon emerging science.

Molecular testing of the actual cancer tissue may place the cancer into a narrow subtype that may match the patient with a promising molecular therapy or at least guide the patient into that clinical trial that gives them their best chance, in addition to advancing science.

The alphabet soup that describes cancer genes, mutations, and pathways includes EGFR, KRAS, EML4-ALK, AKT, BCL, MITF, CDK, C-KIT, GNAQ, BRAF, and GNA11. What chance has the average physician, much less the average cancer patient, of staying up to date in this rapidly changing field? Virtually none.

Pathologists have always been the leaders in cancer research and practice. But our knowledge of gross pathology and microscopic patterns that have led to histopathologic diagnoses that lead to best therapeutic options is no longer enough. Molecular oncologic diagnostics hold important research and therapeutic implications for many, and soon, most cancers.

Academic pathology has no choice but to lead with oncologic molecular diagnostics for research and for patient care at academic medical centers.

But pathologists in community hospitals and local laboratories do have a choice.

They may choose to be shipping clerks on the front end of the brain to brain loop, doing the clinician’s bidding, and clerical transcribers and recorders on the interpretation and action end of that patient care lab test loop.

Or, pathologists may become clinical molecular specialists on the front end, determining what molecular tests, if any, should be done on each cancer, where they should be done, and at what cost.

And, on the back end, pathologists can become knowledge engineers, blending the wonders of artificial and real intelligence with automated and human expert systems, the Internet, and molecular oncology to determine the best action for each cancer patient.

This approach actually works for melanoma, some lung cancers, many breast cancers, some colorectal cancers, and soon, probably prostate cancer, among others.

So, pathologists, take your choice: flunky, or informed scientist-clinician?

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

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  • S Raza

    “What chance has the average physician, much less the average cancer patient, of staying up to date in this rapidly changing field?” I would say that this depends, in any case, on the way information is organized. Couldn’t you envision, for instance, a really user-friendly database that is widely available and easy to use, and which eliminates the need to painstakingly go through research papers as they come out? Although you would be right to say that we do need specialist molecular pathologists who can do more than pattern recognition and are ‘informed clinicial-scientists’, even those interested primarily in histology nonetheless drive the molecular car without knowing the first thing about how it’s made.

  • Winston Liauw

    I don’t think it is a stark choice – this is a chance that will have to happen in the same way that there are resource implications around installing the molecular pathology labs and having standards for them. The molecular pathologist will be providing a consultative service and ideally would attend multidisciplinary team meetings in order to facilitate the discussions around interpreting the molecular test results. As the volume of information increases there will need to be specialists that understand the dysregulated pathways and their interactions in order to guide therapy. If it was just about single genes then the oncologists could handle the job.

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