Cancer is as unique as we are – treatment must be too
With molecular pathology we can now understand the genetic basis of cancers and improve patient outcomes through personalised medicine. Hospital administrators can advocate for changes to pathology services to make the most of these recent advances.
The pathologists’ job is to know about the nature of disease. Back in the first century BC, Hippocratic physicians documented different types of tumour and used the word ‘karkinoma’, from the Greek for ‘crab’, to describe non-healing cancers.1 That was more than two thousand years ago, but we are still learning about this complex and still mysterious disease. It is only in the past four decades that we have truly started to explore the implications of each individual’s genetic or molecular profile for their risk of developing cancer and how they might respond to treatment.*2 I would argue that our growing understanding of the inherited or acquired genetic mutations underlying the disease is one of the greatest insights we currently have about identification and management of different tumour types and sub-types. Now that we know genetics are so involved in the causes of cancer, it makes complete sense that the disease differs from patient to patient according to individual genetic profile, including the DNA inherited from previous generations. And to make medicine personalised it makes complete sense that we need treatments that take these differences between individuals into account.
Our challenge as pathologists is to provide the information that enables the best possible management of the individual patient. Traditional diagnoses of cancer consisted only of a morphologic description of the patient’s tumor. However, molecular pathology enables us to look inside the cells at the genetic material, giving a more detailed diagnosis and potentially allowing the choice of a treatment that targets a specific abnormality. Clearly, this has implications for the patient and the patient’s care team who need to make a treatment choice and monitor the patient’s response. But it also has implications for hospital administrators too. I will discuss all these in my chapter in the forthcoming Future of Pathology report. But for now, suffice to say that we need molecular pathology. Results show that patients who receive targeted therapies can live longer than those who receive conventional treatments.3 ‘One-size-fits-all’ treatment does not suit every patient, and as Prof. Ray McMahon, who I interviewed for the report, pointed out, “pathologists are required to review tissue otherwise we are potentially wasting drugs and money on unnecessary treatment.”
To provide an effective and efficient diagnostic and monitoring service for cancer patients which incorporates the benefits of molecular pathology, pathologists need your support. This needs to come from all stakeholders, but in the Future of Pathology report I explore why hospital administrators in particular can play a central role. Pathologists need their help to overcome challenges in terms of growing workload and shortage of pathologists. We need their help with patient education and expectation: I have seen that many patients with cancer who come in to hospital are aware of and expect personalised treatment. Hospital administrators are the ideal advocates for the benefits that molecular pathology can bring to a hospital, and they can forge links with academia and industry that are invaluable to developing molecular pathology as a specialty. Pathologists can support hospital administration too, providing guidance on which diagnostic tests to use, by engaging in research that supports patients and raises the profile of the hospital, and by working with information technologists to provide systems that will best serve the changing requirements of the diagnostic process.
No two patients are the same and no two tumours are the same. All stakeholders need to work together to develop pathology services that have the capability to take account of these differences and tailor treatment accordingly. Only then can we claim that what we are offering our patients is personalised medicine and the benefits that come with it for them and our hospitals.
* The rise of ‘precision medicine’ began in the 1980s with the development of immunohistochemistry. This method permitted pathologists to investigate relatively easily the expression of various proteins on histological slides obtained from surgical specimens. These expression levels would soon turn out to be relevant for sub-classifications of tumours that were not accessible by light microscopy alone
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1. Papavramidou N, Papavramidis T, Demetriou T. Ancient Greek and Greco–Roman methods in modern surgical treatment of cancer. Ann Surg Oncol 2010;17:665–667.
2. Birner R, Prager G, Streubel B. Molecular pathology of cancer: how to communicate with disease. ESMO Open 2016;1:e000085.
3. Schwaederle M, Zhao M, Lee JJ et al. Impact of precision medicine in diverse cancers: a meta-analysis of phase ii clinical trials. J Clin Oncol 2015 Nov 10;33(32):3817–3825.