The Evolving Role of Pathologists in the Diagnosis and Treatment of Cancer

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In the past, the role of the pathologist was primarily to present anatomic pathology findings on various specimens, particularly at tumor boards. However, in the emerging age of personalized medicine and molecular diagnostics, the responsibilities of pathologist have greatly expanded into cancer-related work. To shed light on the evolving role that pathologists play in the diagnosis and treatment of cancer, The ASCO Post recently spoke with nationally regarded pathologist George Lundberg, MD, who serves as Executive Advisor for the online journal Cureus.

George Lundberg, MD

George Lundberg, MD

Open-Access Online Journal

What distinguishes Cureus from a very crowded field in medical publishing?

Accessibility for one. Cureus is an open-access primary source electronic medical journal. It is intended to make it easy to publish in contrast to the major medical journals. It is indexed in PubMed Central. We use peer review to eliminate egregious errors and also have a post-publication peer-review process—sort of the Yelp of the medical world. It has produced some incredibly good and thought-provoking content.

Cancer Commons

Please tell us a bit about the goals of Cancer Commons and your role as Editor-in Chief.

Cancer Commons is a not-for-profit organization headquartered in Los Altos that was founded by Marty Tenenbaum, PhD, and me in 2011. Our goal has always been to defeat cancer one patient at a time and to share knowledge across the globe, working collaboratively to achieve the best possible results for people with cancer. Our knowledge base comes from multiple sources, including patients, oncologists, pathologists, cancer centers, foundations, and industry. In short, we want to jump-start the processes that take research to the patient in a meaningful way.

Our services are free to patients with advanced cancer at all times. Patients can access us online and fill out a form for the Ask Cancer Commons program. Patients are then assigned through that system to one of our full-time PhD molecular oncologists, who will then help patients figure out what therapeutic approach would be best for them. Patients could be from Afghanistan or upper New York State. We do not provide medicine; we provide options beyond what a community oncologist might do.

We use the services of a substantial advisory board, which includes former ASCO Presidents Douglas W. Blayney, MD, and Peter Paul Yu, MD; a former U.S. Food and Drug Administration (FDA) commissioner; the president designate of the American Association for Cancer Research (to name but a few). We have the help of clinical oncologists in the field who provide valuable on-the-ground expertise.

We also have a Knowledge Blog, which offers a growing collection of in-depth articles for patients to learn about the latest treatment options and the promising direction of cancer research. In all, Cancer Commons is a valuable, easy-to-access, and free resource for people with advanced cancer, no matter where they live.

Leading Role for Pathologists

You’ve encouraged the pathology community to embrace new technologies and emerging therapies, especially in oncology. Please expand on the role of pathologists in the treatment of cancer.

I’m a pathologist and have a distinct memory of hearing the term molecular pathology in the 1950s, while I was a medical student at the University of Alabama at Birmingham. My professors thought in those terms. Now, over the past couple of decades, molecular oncology has come of age, so I’m very comfortable in this emerging space.

“I encourage my pathology associates, especially in academia, to lead the way in molecular diagnostics [for a multitude of cancers].”
— George Lundberg, MD

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Pathologists tend to lag behind much of the research. However, pathologists have always been core components in cancer research and clinical practice. However, the knowledge base of histopathologic diagnoses that lead to therapeutic options is not enough in the emerging world of molecular oncology. Molecular oncology diagnostics hold vital research and treatment implications for a multitude of cancers, so I encourage my pathology associates, especially in academia, to lead the way in molecular diagnostics.

The choice is stark. Pathologists in community hospitals or local laboratories can either be high-end shipping clerks in the lab test loop or they can become knowledge engineers by incorporating the new possibilities offered by artificial intelligence with automated and human expert systems, molecular oncology, to determine the best course of action for each patient with cancer.

Technologic Innovations

What are the most promising trends in clinical diagnostics, and how do they affect the pathology discipline?

The field of artificial intelligence and machine-learning algorithms offer a wide array of diagnostic and therapeutic possibilities. There’s some great work in this area coming out of Stanford, where computer scientists are creating artificial intelligence diagnostic algorithms for skin cancer. However, I see these magnificent innovations as another tool for pathologists, not replacing them. We have technology now in which you can scan an ordinary microscopic slide and apply artificial intelligence–driven programs to provide the correct anatomic answer leading to a diagnosis with a high degree of accuracy. It is mind-boggling how a computer can read a slide and come out with the right answer. However, it still takes a highly skilled pathologist to determine whether it is the right answer. So, we’re a long way away from being replaced.

Challenge of Balancing Innovation and Spending

Everyone on both sides of the aisle agrees that our spending is out of control and will eventually hamper the health-care delivery system. There’s no one answer to this incredibly complex question, but could you share your view on this challenge?

I’ve been a participant and an observer of our health-care system for many decades and do not have an answer to the single most important question: how do we deliver high-value care in a cost-effective manner?

All doctors want therapeutic interventions for their patients with serious illnesses to work. On the drug side, we have the FDA, which does a very good job at getting important agents through the pipeline and into the clinic. However, because of our peculiar system, the FDA is not allowed to factor costs into its evaluations. And in a laissez-faire capitalistic society, the pricing of drugs, procedures, and devices is essentially whatever the market will bear. So, in effect, there are no checks and balances on the system, which is one of many cost-drivers.

“Pricing is a double-edged sword because we need research and innovation, and that comes at a high price.”
— George Lundberg, MD

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Pricing is a double-edged sword because we need research and innovation, and that comes at a high price. We haven’t yet figured out how to balance innovation and spending in a way that doesn’t break the bank. For instance, some have floated the idea of having an FDA-like agency to approve procedures, such as surgery, but this idea might stifle innovation, and I can’t see it happening.

One way to reduce costs is by spending more time and resources on disease prevention efforts. We’ve made great progress in tobacco cessation programs, which have markedly reduced the rate of smoking. Now we need to translate that same kind of energy into the obesity crisis, which has become the number-one cause of preventable disease. Many of our medical societies have simply not gotten the message that this crisis is more than a calories in–calories out equation. It takes a multipronged concerted effort, and it is up to the medical community to take the lead.

DISCLOSURE: Dr. Lundberg is Editor-at-Large, Medscape, Executive Advisor, Cureua, Editor-in-Chief, Curious Dr. George Blog, and a member of the Board of Visitors at University of Alabama, Birmingham.