Pathologists play significant role in cancer detection

Date: 10/23/2013

SPRINGFIELD – Rarely, if ever, do viewers see pathologists depicted on television medical dramas such as “Grey’s Anatomy.”

October is Breast Cancer Awareness Month and a time to recognize the changing role of pathology in breast cancer diagnosis and treatment.

Pathologists are doctors who work in a hospital or clinical laboratory, where they serve as essential members of the medical team. Often considered “consultants” to referring physicians who perform biopsies on suspicious lesions, pathologists study the biopsy tissue under a microscope to identify the disease or abnormality. In the case of breast cancer, the resulting lab reports are then used by a care team – including the patient’s oncologists, surgeon, radiologist, pathologist and others – who come together in a breast conference to determine the most appropriate treatment for the exact type of breast cancer identified.

“When patients get a diagnosis, they may be tremendously relieved or their life could be forever changed. As pathologists, we don’t come face-to-face with our patients, but the human connection is still there for us,” Dr. Christopher Otis, pathologist, Baystate Medical Center, said.

Otis noted the tremendous evolution in breast care over the past 30 years since he began his career as a pathologist in the early 1980s.

“Back then, as now, it was not unusual for a woman with a lump in her breast to undergo surgery to have it removed. As she remained under anesthesia, a tissue sample was delivered to another room for diagnosis by a pathologist. But the next step was often radically different than it is today: If it was determined to be cancer, the patient could immediately have a radical mastectomy with the removal of all the lymph nodes under her arm. Today, this is an extremely rare procedure,” Otis said.

Dr. Giovanna Crisi, one of Baystate’s lead breast pathologists, said some 75 percent of breast lesions detected by screening are benign, but for the malignant lesions, there is much work to be done by the pathologist in providing an accurate report to the patient’s doctor. This report serves as the basis for diagnosis, prognosis, and effective treatment.

“Advancements in molecular and genetic technologies have allowed us to recognize cancers under the microscope with different biological behaviors, as compared to the ‘one size fits all’ diagnosis of past days. Breast cancer is not one single diagnosis. There are a variety of cancers, a lot of different subtypes,” Crisi said.

“We look at a breast tissue specimen to determine whether a lesion is benign, a precursor to cancer, or cancer – all of which require different treatments, ranging from no surgery to surgery to excise the tumor. In some cases, risk or atypical lesions may be watched closely because they may or may not lead to the development of breast cancer. We then identify the cancer by type and grade, which tells us whether the cells involved are slow or fast growing, and also test for the expression of estrogen and progesterone receptors, and HER-2/neu protein, which will aid in deciding what type of therapy may be beneficial or not,” she added.

Otis used a baseball analogy to describe the level of expertise required of a pathologist in making a diagnosis.

“If you bat .400 in baseball like Red Sox left fielder Ted Williams did in 1941 (.406, to be exact), you are considered an exceptional hitter. But, at best, that means you are being successful just 40 percent of the time. As pathologists, we have to ‘bat’ 1.000 and make the right diagnosis 100 percent of the time,” Otis said.

“A patient’s life is changed in our hands and eyes. We can’t miss or overdiagnose a cancer. We have to be fastidious and make a correct diagnosis every time. That is what our lives are like as pathologists, and it can be stressful. Most people don’t understand the amount of effort that goes into a diagnosis,” he added.

Otis said similar to selecting a breast surgeon based on the doctor’s experience and skills, patients should carefully consider the pathologist and laboratory involved in their treatment.

“We pride ourselves on our accuracy. The decisions we make must be accurate, not only for the benefit of the patient, whose lifesaving treatment depends on our specific diagnosis, but also for avoiding unnecessary treatments that can cost many thousands or even tens of thousands of dollars,” said Dr. Richard Friedberg, chair, Department of Pathology at Baystate Medical Center, who added that patients sometimes seek out his team for second opinions, bringing in their samples themselves for review.

For more information on the Baystate Regional Cancer Program, visit baystatehealth.org/bch, or for more information on Baystate Reference Laboratories, visit baystatehealth.org/brl.