Prostate Cancer Diagnosis and Prognosis: Histopathology

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:05Hospital and AstraZeneca.
00:07 --> 00:09Welcome to Yale Cancer Answers with
00:09 --> 00:12your host doctor Anees Chagpar.
00:12 --> 00:14Yale Cancer Answers features the
00:14 --> 00:16latest information on cancer care by
00:16 --> 00:17welcoming oncologists and specialists
00:17 --> 00:20who are on the forefront of the
00:20 --> 00:21battle to fight cancer. This week,
00:21 --> 00:23it's a conversation about prostate
00:23 --> 00:25cancer with Doctor Peter Humphrey.
00:25 --> 00:27Doctor Humphrey is a professor of
00:27 --> 00:29pathology at Yale School of Medicine,
00:29 --> 00:32where Doctor Chagpar is a professor
00:32 --> 00:34of surgical oncology.
00:34 --> 00:36Peter, maybe we can start off by you
00:36 --> 00:38telling us a little bit about
00:38 --> 00:40yourself and what you do.
00:40 --> 00:42I'm a practicing surgical pathologist
00:42 --> 00:44which basically means that I
00:44 --> 00:47look at a glass slide under a
00:47 --> 00:50microscope and render a diagnosis,
00:50 --> 00:54often cancer diagnosis on tissues that
00:54 --> 00:56we received from other physicians,
00:56 --> 01:01including biopsies and and resections,
01:01 --> 01:04and so microscopes have always interested me.
01:04 --> 01:07Ever since I was very young and
01:07 --> 01:10looked through a microscope at pond
01:10 --> 01:13water when I was in elementary school,
01:13 --> 01:15but it was actually taking
01:15 --> 01:18care of a patient in medical school
01:18 --> 01:20that really helped direct me into
01:20 --> 01:25pathology and if I can give that story.
01:25 --> 01:28I was a third year
01:28 --> 01:29medical student and
01:29 --> 01:33hadn't really decided on a specialty.
01:33 --> 01:34And was considering a number
01:34 --> 01:35of different specialties,
01:35 --> 01:38including medicine and internal medicine.
01:38 --> 01:41Pathology wasn't so
01:41 --> 01:45high on the list until
01:45 --> 01:48there was an occurrence with one
01:48 --> 01:51patient and she was on the internal
01:51 --> 01:54medicine ward and she had rib pain
01:54 --> 01:57and the radiologists were able to
01:57 --> 02:01identify a lesion in the rib and
02:01 --> 02:03the differential diagnosis that
02:03 --> 02:05we considered clinically and the
02:05 --> 02:08radiologist considered was quite lengthy
02:08 --> 02:13so it really took a biopsy which
02:13 --> 02:15then went to surgical pathology and
02:15 --> 02:17in order to establish the diagnosis,
02:17 --> 02:20and so I I went down to surgical pathology.
02:20 --> 02:23the laboratory where the attending
02:23 --> 02:25surgical pathologist was looking,
02:25 --> 02:28at slides with their resident
02:28 --> 02:31on the service and I asked if they
02:31 --> 02:33had seen the biopsy from this
02:33 --> 02:36particular patient and he said he had,
02:36 --> 02:38and then he pulled out the slide
02:38 --> 02:41and went through it and in pretty
02:41 --> 02:42short order said oh,
02:42 --> 02:44this is metastatic cancer from
02:44 --> 02:45the salivary gland,
02:45 --> 02:48which was a diagnosis that was not
02:48 --> 02:51really considered in this patient.
02:51 --> 02:54It turns out she did have a history of
02:54 --> 02:56salivary gland cancer 10 years prior
02:58 --> 03:00so it occurred to me that this was
03:00 --> 03:03the way to really help patients
03:03 --> 03:05by helping render diagnosis.
03:08 --> 03:10I find that fascinating, because certainly
03:10 --> 03:12if you had a patient with rib pain,
03:12 --> 03:15metastatic cancer from a salivary
03:15 --> 03:17gland would not be top of the list.
03:17 --> 03:21Did the pathologist know about the distant
03:21 --> 03:24diagnosis of salivary gland cancer?
03:24 --> 03:26I think this particular
03:26 --> 03:28cancer was so distinctive that
03:28 --> 03:31he was able to suspect salivary
03:31 --> 03:33gland cancer right away.
03:33 --> 03:34I'm not sure if he knew the history,
03:34 --> 03:36but he was an excellent
03:36 --> 03:38surgical pathologist and being
03:38 --> 03:39an excellent surgical pathologist
03:39 --> 03:41I'm sure he had asked the
03:41 --> 03:43resident for the history first,
03:43 --> 03:45as they examined the slide.
03:46 --> 03:49Yeah, it's just absolutely fascinating,
03:49 --> 03:52but now you've kind of transitioned
03:52 --> 03:53still looking at cancers,
03:53 --> 03:56but now you're into the world
03:56 --> 03:58of genitourinary pathology,
03:58 --> 04:01tell us a little bit more about how
04:01 --> 04:03your interests transitioned to that.
04:06 --> 04:09In residency a big
04:09 --> 04:11part of pathology residency,
04:11 --> 04:13which is pretty broad based,
04:13 --> 04:17we rotate through a number of different
04:17 --> 04:19services, subspecialty services and
04:19 --> 04:22those services work with specific
04:22 --> 04:25clinicians and it's disease
04:25 --> 04:28focused and usually organ site
04:28 --> 04:32focused. For example,
04:32 --> 04:34as a genitourinary pathologist,
04:34 --> 04:37I interact very closely with the
04:37 --> 04:39urologist and medical oncologist
04:40 --> 04:43to treat urological cancers as well
04:43 --> 04:45as radiologist and interventional
04:45 --> 04:47radiologists to deal with these
04:47 --> 04:48type of cancers and specifically
04:48 --> 04:50for the genitourinary system,
04:50 --> 04:53this is just an introduction.
04:53 --> 04:57We basically address cancers that arise in
04:57 --> 05:01the prostate and testis and bladder and
05:01 --> 05:06kidney, so it turns out when you are
05:06 --> 05:07in formative years,
05:07 --> 05:10one should never underestimate
05:10 --> 05:13how a single patient or a physician
05:13 --> 05:17can impact the development of
05:17 --> 05:20the individuals who are young and
05:20 --> 05:22deciding in medical school or pathology.
05:24 --> 05:27So I was a first year resident and
05:27 --> 05:31I rotated through the VA hospital
05:31 --> 05:33which was right across from Duke
05:33 --> 05:34University Hospital,
05:34 --> 05:37which is where I did my residency.
05:37 --> 05:39And there was a fascinating rotation,
05:39 --> 05:41and another excellent surgical
05:41 --> 05:43pathologist was the attending there,
05:43 --> 05:47and we saw quite a lot of prostate cancer.
05:47 --> 05:51And at the VA hospital,
05:51 --> 05:54this was several decades ago,
05:54 --> 05:57dating myself a number of decades ago,
05:57 --> 05:59there was not much known about
05:59 --> 06:00prostate cancer,
06:00 --> 06:03and treatments were relatively limited,
06:03 --> 06:05so it seemed to me that this was
06:05 --> 06:06an area where
06:06 --> 06:10there is much to be learned about diagnosis
06:10 --> 06:13and prognosis as well as treatment of
06:13 --> 06:14that particular cancer.
06:14 --> 06:17So that's really how I became
06:17 --> 06:19interested as a first year
06:19 --> 06:21pathology resident in
06:21 --> 06:21genitourinary cancers,
06:21 --> 06:23and specifically prostate cancer
06:24 --> 06:26Let's dive a little
06:26 --> 06:28bit more into prostate cancer.
06:28 --> 06:31I think that so much of again,
06:31 --> 06:33what we do is really dictated by
06:33 --> 06:35the biopsies that we take.
06:35 --> 06:38So if somebody has
06:38 --> 06:41a mass in the prostate or an enlarged
06:41 --> 06:43prostate, even more globally,
06:43 --> 06:46sometimes a biopsy will be done,
06:46 --> 06:48and that'll be sent to the
06:48 --> 06:50pathologist and it's really up to
06:50 --> 06:52you to try to figure out is this
06:52 --> 06:55cancer or is this something benign?
06:55 --> 06:57And if it's cancer,
06:57 --> 07:00how bad of a cancer is it which
07:00 --> 07:02really dictates
07:02 --> 07:04is this something that we treat at all,
07:04 --> 07:08or something that we simply watch?
07:08 --> 07:11How do you make those decisions?
07:11 --> 07:14How do you make that differentiation from
07:14 --> 07:17benign to malignant and within malignant,
07:17 --> 07:20the different grades of prostate cancer?
07:21 --> 07:23So it's really quite a long
07:23 --> 07:26educational process to be able to
07:26 --> 07:28diagnose benign versus malignant,
07:28 --> 07:31and it turns out that what's so fascinating
07:31 --> 07:33is that every single biopsy is different,
07:33 --> 07:36even if we render an
07:36 --> 07:38umbrella diagnosis of benign tissue.
07:38 --> 07:41For example, the lining tissue of the prostate.
07:41 --> 07:43There could be a number of
07:43 --> 07:44benign mimicker's in there,
07:44 --> 07:46meaning benign tissue looking
07:46 --> 07:48like cancer under the microscope,
07:48 --> 07:52but it's not, and we have
07:54 --> 07:55a differential diagnosis.
07:55 --> 07:57We consider a number of different
07:57 --> 07:58benign entities before deciding
07:58 --> 08:00on a malignant diagnosis,
08:00 --> 08:02because that's such a huge step
08:02 --> 08:04to take for us and for the patient
08:04 --> 08:08and the patient's treating physician.
08:08 --> 08:11So that's what I particularly enjoy,
08:14 --> 08:16that diagnostic work and it
08:16 --> 08:17can be arduous sometimes.
08:17 --> 08:19Sometimes it's very straightforward
08:19 --> 08:23that a particular biopsy is benign
08:23 --> 08:25and sometimes straightforward that
08:25 --> 08:27it's malignant, but other times
08:27 --> 08:29there are benign conditions under
08:29 --> 08:31the microscope that look like cancer
08:31 --> 08:34and cancer that can look benign.
08:34 --> 08:36So we've been fortunate in this area
08:36 --> 08:39to have some tools to help us and
08:39 --> 08:41those include antibodies that can
08:42 --> 08:44help us recognize specific cells under
08:44 --> 08:47the microscope and in certain cases
08:47 --> 08:50that can be relayed to us,
08:50 --> 08:52but it still requires judgment and
08:52 --> 08:55having formed a differential diagnosis
08:55 --> 08:57or consideration of what's possible
08:57 --> 09:00before we order those tests.
09:00 --> 09:01On that issue,
09:01 --> 09:03so once having established a
09:03 --> 09:05diagnosis of malignancy,
09:05 --> 09:08then the next step is to decide and this
09:08 --> 09:11is so important for prostate cancer,
09:11 --> 09:12how aggressive is it?
09:12 --> 09:15Because it turns out most men who
09:15 --> 09:17have prostate cancer will die
09:17 --> 09:19with it rather than of it.
09:19 --> 09:22So there are a large number of
09:22 --> 09:24prostate cancers that can grow
09:24 --> 09:26very slowly and may not affect
09:26 --> 09:29the man during his lifetime,
09:29 --> 09:31yet it turns out that
09:31 --> 09:34prostate cancer is the second most
09:34 --> 09:36lethal cancer amongst American men
09:36 --> 09:38by total numbers
09:38 --> 09:40trailing only lung cancer.
09:40 --> 09:43So those are the cancers we want
09:43 --> 09:45to specifically separate out from
09:45 --> 09:47the more slowly growing ones.
09:47 --> 09:49And we do that under the microscope
09:49 --> 09:52using a very powerful approach
09:52 --> 09:54that is grade, as you suggest.
09:54 --> 09:56So what is grade?
09:56 --> 09:59It's basically the way the cells
09:59 --> 10:01grow within the prostate once
10:01 --> 10:04we've identified them as cancer cells,
10:04 --> 10:06so we can look under the microscope
10:06 --> 10:07and in their patterns
10:07 --> 10:09there are specific patterns that
10:09 --> 10:12are known to correlate with the
10:12 --> 10:14outcome for the patient,
10:14 --> 10:17and so we have various tiers,
10:17 --> 10:20various numbers we can apply
10:20 --> 10:22and the most simple one that we
10:22 --> 10:24use right now is grade group and
10:24 --> 10:26that ranges from one to five.
10:26 --> 10:29One being the best outcome,
10:29 --> 10:31and those patients are managed
10:31 --> 10:32very differently from
10:32 --> 10:34those who have a grade group
10:34 --> 10:36five out of five,
10:36 --> 10:37but there's everything in between,
10:37 --> 10:39so it's really a spectrum.
10:39 --> 10:41And therein lies again
10:41 --> 10:46judgment as far as deciphering as you note,
10:46 --> 10:48the detective work deciphering
10:48 --> 10:51out the patterns that can help
10:51 --> 10:53us assign a grade that
10:53 --> 10:54indicates aggressiveness of
10:54 --> 10:56that prostate cancer.
10:57 --> 11:00One of the questions
11:00 --> 11:01that I think always comes up is
11:01 --> 11:04that it seems to be a little bit
11:04 --> 11:06of art and a little bit of science.
11:06 --> 11:09Looking at these patterns
11:09 --> 11:11and trying to decipher is this
11:11 --> 11:13lower grade?
11:13 --> 11:14Is this a higher grade?
11:14 --> 11:18How much of it is art,
11:18 --> 11:20and how much of it is science
11:20 --> 11:24and how sure are you at any given
11:24 --> 11:26time of your diagnosis being correct?
11:27 --> 11:30Interpretation of slides
11:30 --> 11:33under the microscope is most definitely
11:33 --> 11:36both art and science, so there's
11:36 --> 11:38much experience that one must have
11:38 --> 11:41in order to recognize these patterns.
11:41 --> 11:44The science part is that we can use
11:44 --> 11:47antibodies to help identify specific cells.
11:48 --> 11:49The grading part remains, though,
11:49 --> 11:52very much art and pattern recognition
11:52 --> 11:54going forward in the future,
11:54 --> 11:55and this has already started.
11:55 --> 11:59We have tools that can help us recognize
11:59 --> 12:02patterns even better and more quantitatively,
12:02 --> 12:05and that's through the use of artificial
12:05 --> 12:08intelligence and machine learning.
12:08 --> 12:10So all of that work has just started,
12:10 --> 12:12but already I've had the opportunity
12:12 --> 12:14to work in on a couple different
12:14 --> 12:17projects and it turns out that the
12:17 --> 12:19computer with specific algorithms
12:19 --> 12:20can identify,
12:20 --> 12:22can diagnose and grade prostate
12:22 --> 12:25cancers just as well as a number
12:25 --> 12:27of us who specialize in sub
12:27 --> 12:30specializing in that particular area.
12:30 --> 12:33I can't wait to learn more about that,
12:33 --> 12:35but first we need to take a
12:35 --> 12:36short break for medical minute.
12:36 --> 12:39Please stay tuned to learn more about
12:39 --> 12:41prostate cancer diagnosis and prognosis
12:41 --> 12:43with my guest doctor Peter Humphrey.
12:44 --> 12:46Funding for Yale Cancer Answers
12:46 --> 12:48comes from AstraZeneca, dedicated
12:48 --> 12:50to advancing options and providing
12:50 --> 12:52hope for people living with cancer.
12:52 --> 12:53More information at
12:55 --> 12:57astrazeneca-us.com.
12:57 --> 13:00The American Cancer Society
13:00 --> 13:02estimates that nearly 150,000 people
13:02 --> 13:05in the US will be diagnosed with
13:05 --> 13:07colorectal cancer this year alone.
13:07 --> 13:08When detected early, colorectal
13:08 --> 13:11cancer is easily treated and highly
13:11 --> 13:12curable and men and women over
13:12 --> 13:15the age of 45 should have regular
13:15 --> 13:17colonoscopies to screen for the disease.
13:17 --> 13:19Patients with colorectal cancer
13:19 --> 13:21have more hope than ever before,
13:21 --> 13:24thanks to increased access to advanced
13:24 --> 13:26therapies and specialized care.
13:26 --> 13:27Clinical trials are currently
13:27 --> 13:29underway at federally designated
13:29 --> 13:31Comprehensive Cancer Centers.
13:31 --> 13:33Such as Yale Cancer Center and
13:33 --> 13:35at Smilow Cancer Hospital to
13:35 --> 13:37test innovative new treatments
13:37 --> 13:38for colorectal cancer. Tumor
13:38 --> 13:41gene analysis has helped improve
13:41 --> 13:43management of colorectal cancer
13:43 --> 13:45by identifying the patients most
13:45 --> 13:47likely to benefit from chemotherapy
13:47 --> 13:49and newer targeted agents,
13:49 --> 13:52resulting in more patient specific treatment.
13:52 --> 13:55More information is available at
13:55 --> 13:56yalecancercenter.org. You're listening
13:56 --> 13:58to Connecticut Public Radio.
13:59 --> 14:01Welcome back to Yale Cancer Answers.
14:01 --> 14:04This is doctor Anees Chagpar and I'm joined
14:04 --> 14:06tonight by my guest doctor Peter Humphrey.
14:06 --> 14:08We're talking about prostate
14:08 --> 14:10cancer diagnosis and prognosis,
14:10 --> 14:13and right before the break we were
14:13 --> 14:15talking about this magic that
14:15 --> 14:18happens in the pathology lab.
14:18 --> 14:20At least, it seems like magic to those of
14:20 --> 14:22us who send them biopsies and magically
14:22 --> 14:25get back a diagnosis that we then
14:25 --> 14:27use to treat our patients and Doctor
14:27 --> 14:29Humphrey was telling us that this is
14:29 --> 14:30in part art,
14:30 --> 14:33but it is in part science and
14:33 --> 14:35that you're able to use antibodies
14:35 --> 14:39and so on to help you in making
14:39 --> 14:41that diagnosis and right
14:41 --> 14:44before the break you started to talk
14:44 --> 14:47Doctor Humphrey about artificial
14:47 --> 14:50intelligence and how this might actually
14:50 --> 14:55help us in making a diagnosis now,
14:55 --> 14:56so that the computers might
14:56 --> 14:59be able to make a diagnosis
14:59 --> 15:01almost as well as an experienced pathologist.
15:01 --> 15:04Tell us a little bit more about that.
15:04 --> 15:09So we are in the very early pilot stage
15:09 --> 15:11I would say as far as
15:11 --> 15:13development of this tool,
15:13 --> 15:15but I think it will be an important
15:15 --> 15:18tool that can assist the pathologist
15:18 --> 15:19and actually artificial intelligence
15:19 --> 15:21is being developed in many
15:21 --> 15:23branches of medicine and
15:23 --> 15:25radiology too, so it turns out
15:25 --> 15:28that those parts of medicine that
15:28 --> 15:30deal with diagnostic images like
15:30 --> 15:32radiology and pathology are areas
15:32 --> 15:35where there could be great benefit.
15:35 --> 15:39From more standardization, I would say,
15:39 --> 15:41and perhaps even quantitation,
15:41 --> 15:44using computer assisted methods,
15:44 --> 15:46so that's already happening and
15:46 --> 15:47actually happening very quickly
15:47 --> 15:50as far as the research into this.
15:50 --> 15:53And the use of computers and
15:53 --> 15:54artificial intelligence.
15:54 --> 15:58To develop algorithms, ways in which
15:58 --> 16:02the computer can diagnose and
16:02 --> 16:04even grade prostate cancer.
16:04 --> 16:07So I've been fortunate enough to have
16:07 --> 16:09been involved in a couple of these
16:09 --> 16:11research studies and a number of us
16:11 --> 16:12from around the world who
16:12 --> 16:14are interested in prostate cancer
16:14 --> 16:16and are genitourinary pathologists,
16:16 --> 16:18and we've looked at hundreds of slides,
16:18 --> 16:20all online,
16:20 --> 16:23so these are all images diagnosable
16:23 --> 16:24on our computer.
16:24 --> 16:27And then we tested the algorithm and then
16:30 --> 16:33the algorithm was tested against our
16:33 --> 16:35diagnosis in grade versus collections
16:35 --> 16:38of pathologists who were
16:38 --> 16:40not sub specialized in
16:40 --> 16:43prostate cancer diagnosis and the
16:43 --> 16:46computer was actually just as good
16:46 --> 16:49as our diagnosis and grading.
16:49 --> 16:51So what does this mean for the future?
16:51 --> 16:53Well, there are actually a lot of challenges.
16:55 --> 16:56There are several algorithms that
16:56 --> 16:58have already been published.
16:58 --> 17:00Methods that the computer uses,
17:00 --> 17:03and there's a lot of standardization
17:03 --> 17:06and validation that needs to occur
17:06 --> 17:07so that a computer can use
17:07 --> 17:10images from a particular laboratory
17:10 --> 17:13and one particular hospital as far
17:13 --> 17:15as the scanners they use to make
17:15 --> 17:18those images and the way the slides
17:18 --> 17:20are prepared that all of those
17:20 --> 17:23factors can have a huge impact on the
17:23 --> 17:25success or failure of the algorithms.
17:25 --> 17:28My hope is that as far as standardization,
17:28 --> 17:31it can be used as a tool to help
17:31 --> 17:33hospitals where there may not be ready
17:33 --> 17:36access to a genitourinary pathologist.
17:36 --> 17:38And also I think for those of
17:38 --> 17:39us who have high volumes
17:39 --> 17:42and have a special sub specialized group
17:42 --> 17:45of Geo pathologist as we do here at Yale,
17:45 --> 17:46I think it might actually
17:46 --> 17:48help us screen cases.
17:48 --> 17:50So that the computer could actually help
17:50 --> 17:53us identify through all these slides,
17:53 --> 17:56identify the ones that need particular
17:56 --> 17:58attention or standardized grading.
17:58 --> 18:00So there may be,
18:00 --> 18:01for example,
18:01 --> 18:03a difference of opinion about the
18:03 --> 18:05grade of a specific cancer and
18:05 --> 18:07the way we currently address this,
18:07 --> 18:08and this is very important actually
18:08 --> 18:10when there's a difficult case,
18:10 --> 18:12we'll have a consensus conference,
18:12 --> 18:15meaning that up to seven of us
18:15 --> 18:17who are sub specialized in
18:17 --> 18:19genitourinary pathology at Yale will meet
18:19 --> 18:21around the microscope or in this area,
18:21 --> 18:23from our computers and look
18:23 --> 18:26at the images together to try
18:26 --> 18:27to agree on a particular grade.
18:27 --> 18:30In a difficult case or where it's a
18:30 --> 18:32borderline case between grades for example.
18:32 --> 18:35So maybe the computer could also
18:35 --> 18:38provide help in standardizing those.
18:38 --> 18:40Those sorts of assessments when
18:40 --> 18:42it's a difficult or borderline case,
18:43 --> 18:46so it sounds like this is really exciting
18:46 --> 18:49technology that might be able to provide
18:49 --> 18:53a second opinion. But for right now,
18:53 --> 18:56if you're a patient and you might not
18:56 --> 19:00be at or near a large academic center,
19:00 --> 19:02and you get a prostate biopsy,
19:02 --> 19:05for example, how important is it for
19:05 --> 19:08you to get a second opinion on that
19:08 --> 19:11biopsy from another human pathologist
19:11 --> 19:13if a computer isn't readily available?
19:14 --> 19:16That's a really critical question,
19:16 --> 19:19and I think it's important to
19:19 --> 19:21know in discussions with your
19:21 --> 19:24physician whether a genitourinary pathologist
19:24 --> 19:27has reviewed the slides and it's
19:27 --> 19:29true that around the country there
19:29 --> 19:32are just varying degrees of practice
19:32 --> 19:34and varying volumes of practice,
19:34 --> 19:36and so at a smaller hospital,
19:36 --> 19:39maybe only a few prostate biopsies might
19:39 --> 19:41be seen over a long period of time,
19:41 --> 19:44and particularly in those cases where the
19:44 --> 19:47pathologists may not feel as comfortable,
19:47 --> 19:50or the treating physician may not
19:50 --> 19:53feel as as comfortable, it's
19:53 --> 19:55I think a useful step to seek
19:55 --> 19:57a second opinion,
19:57 --> 20:00and we see slides for second opinions
20:00 --> 20:02all the time here from everyone.
20:02 --> 20:05Actually from patients from treating
20:05 --> 20:07physicians and from pathologists themselves,
20:07 --> 20:10and this is an important quality
20:10 --> 20:12to all these second opinions.
20:12 --> 20:14And again we very commonly almost
20:14 --> 20:18on a daily basis share cases here at
20:18 --> 20:20Yale amongst our group of seven genitourinary
20:20 --> 20:22pathologists
20:22 --> 20:25And so are these second opinions when
20:25 --> 20:28you go and you have your
20:28 --> 20:30slides reviewed by somebody else?
20:30 --> 20:33Or maybe the pathologists themselves sends
20:33 --> 20:35it to another center to get reviewed
20:35 --> 20:37if they're not quite sure
20:37 --> 20:38about the diagnosis,
20:38 --> 20:40is that covered by your insurance?
20:41 --> 20:43Usually it is.
20:43 --> 20:46So at least the cases that we
20:46 --> 20:49receive here for second opinions.
20:49 --> 20:52That's good to know.
20:52 --> 20:55Is it ever the case where even
20:55 --> 20:57if you go to a large academic
20:57 --> 20:59center that it's worthwhile
20:59 --> 21:01getting your slides reviewed by
21:01 --> 21:03another large academic center?
21:03 --> 21:05I mean, how much heterogeneity
21:05 --> 21:07is there between experienced
21:07 --> 21:09genitourinary pathologists for example?
21:10 --> 21:12So since diagnosis
21:12 --> 21:15and grading are still art,
21:15 --> 21:18there can be differences of opinion amongst
21:18 --> 21:22even expert and experienced genitourinary
21:22 --> 21:24pathologists and these tend to be the
21:24 --> 21:27rarer or more borderline cases.
21:28 --> 21:30There's been a lot of research looking at
21:31 --> 21:34variations or differences of opinion
21:34 --> 21:38between pathologists and even between genitourinary
21:38 --> 21:39pathologists,
21:39 --> 21:42and even did a study where I looked
21:42 --> 21:45at agreement with myself so I
21:45 --> 21:47diagnosed and graded some slides and
21:47 --> 21:49then came back sometime later
21:49 --> 21:52to see if the diagnosis and grading
21:52 --> 21:54were the same so the agreement is
21:54 --> 21:56pretty good amongst genitourinary pathologists,
21:56 --> 21:59but one should not hesitate in
21:59 --> 22:01seeking a second opinion at another
22:01 --> 22:03center with an established
22:03 --> 22:05group of pathologists,
22:05 --> 22:07but as we
22:07 --> 22:09talk about that variability,
22:09 --> 22:11all of these pathologists are looking
22:11 --> 22:14at the same slides and I know that in
22:14 --> 22:17other cancers we've talked on this show
22:17 --> 22:19about this concept of
22:19 --> 22:21heterogeneity that you might have a
22:21 --> 22:24cancer that looks kind of different in
22:24 --> 22:28one part than another and so I wonder,
22:28 --> 22:30when you get these biopsies,
22:30 --> 22:32we often
22:32 --> 22:34send a core biopsy so
22:34 --> 22:37a sampling of this tumor,
22:37 --> 22:38how representative is that,
22:38 --> 22:40and is it ever the case where
22:40 --> 22:42you look at this and you
22:42 --> 22:44kind of say
22:44 --> 22:46I don't know that this is representative?
22:46 --> 22:48We need to get more tissue or
22:48 --> 22:50are you usually pretty happy
22:50 --> 22:53with the sample that you get?
22:53 --> 22:57So that's such a key question and
22:57 --> 23:00really the practice of the biopsy
23:00 --> 23:03as far as the prostate has changed so
23:03 --> 23:06remarkably since when I was a resident.
23:06 --> 23:07So back in the olden days,
23:07 --> 23:10it was usually just one needle biopsy,
23:10 --> 23:12digitally directed towards a palpable
23:12 --> 23:15mass in the prostate by the examining
23:15 --> 23:18physician and one single core was taken.
23:18 --> 23:20So prostate cancer,
23:20 --> 23:22heterogeneous concept of heterogeneity,
23:22 --> 23:24and different areas of the prostate
23:24 --> 23:27being actually of different grades
23:27 --> 23:28and different aggressiveness
23:28 --> 23:30is actually characteristic of
23:30 --> 23:32prostate cancer and prostate
23:32 --> 23:35cancer also tends to have multiple
23:35 --> 23:37nodules within the same gland,
23:37 --> 23:38so what's been a real advantage
23:38 --> 23:41is medical advances in radiology,
23:41 --> 23:44and there are expert radiologists here who have
23:44 --> 23:46actually helped develop this technique,
23:46 --> 23:50and that's a special type of MRI.
23:50 --> 23:53Magnetic resonance imaging that's used
23:53 --> 23:57with ultrasound to guide the
23:57 --> 23:59needle placement within the prostate.
23:59 --> 24:02So now rather than one needle core,
24:02 --> 24:07we often receive anywhere from 20 to even
24:07 --> 24:1130 individual needle cores per patient.
24:11 --> 24:14And the reason is that the radiologist
24:14 --> 24:17now can identify areas where they're
24:17 --> 24:19suspicious of cancer and can specifically
24:19 --> 24:22say based on their grading scheme,
24:22 --> 24:25whether they think it's a lower
24:25 --> 24:28risk or a higher risk case so
24:28 --> 24:32I do feel good about the
24:32 --> 24:34representation for most patients and when
24:34 --> 24:38the patients have undergone this
24:38 --> 24:41type of imaging by the radiologists.
24:42 --> 24:44Even though multiple needle cores
24:44 --> 24:45are placed in a single nodule,
24:45 --> 24:49it's still possible that maybe
24:49 --> 24:52a smaller high grade area was missed.
24:52 --> 24:54Warning signs would be,
24:54 --> 24:57what if the patient has a really high
24:57 --> 25:00serum PSA prostate specific antigen level?
25:00 --> 25:02Or what if this is radiologically
25:02 --> 25:04a very aggressive looking lesion,
25:04 --> 25:06but we don't see that under the microscope?
25:06 --> 25:10Then I would worry about
25:10 --> 25:12the needle maybe not sampling
25:12 --> 25:13the worst of the cancer.
25:13 --> 25:15Yeah, it goes back to that
25:15 --> 25:17concept of being a bit of a
25:17 --> 25:19detective that we talked about before
25:19 --> 25:22the break and the fact that the
25:22 --> 25:24pathologist is really a key part
25:24 --> 25:26of this multidisciplinary team that
25:26 --> 25:28you need to get information from.
25:28 --> 25:30From the radiologist,
25:30 --> 25:31from the surgeon.
25:31 --> 25:32from the other physicians.
25:32 --> 25:34who are involved
25:34 --> 25:36in the case to kind of put all
25:36 --> 25:38of the pieces together to make
25:38 --> 25:39sure that it all makes sense.
25:40 --> 25:42That's what I love about
25:42 --> 25:44working here is working with so many
25:44 --> 25:47bright and experienced physicians
25:47 --> 25:49who are passionate about providing the
25:49 --> 25:53highest level care and talking with
25:53 --> 25:55them about what their perspective
25:55 --> 25:58and view is on a specific patient.
25:59 --> 26:02For example, if there
26:02 --> 26:06is not a link made between pathology
26:06 --> 26:08and what we see in the clinical setting
26:08 --> 26:12that sort of correlation is
26:12 --> 26:13clinicopathologic correlation and
26:13 --> 26:15is so vital.
26:15 --> 26:18Going back to that patient with pain in the rib.
26:18 --> 26:21It was absolutely essential to know that
26:21 --> 26:23the patient had a history of cancer
26:23 --> 26:2510 years ago to establish firmly that
26:25 --> 26:27cancer scene and what we would
26:27 --> 26:29do is compare slides.
26:29 --> 26:31That cancer in the rib biopsy
26:31 --> 26:34was the same as the cancer in the
26:34 --> 26:35salivary gland,
26:35 --> 26:38so we do that commonly to look
26:38 --> 26:40back at old slides to see if
26:40 --> 26:42if cancer has come back and
26:42 --> 26:44we think a cancer might
26:44 --> 26:47have come back or spread so that
26:47 --> 26:49comparison is a really important part
26:49 --> 26:51of the detective work we do.
26:51 --> 26:54And I think the other piece
26:54 --> 26:57that's so important is that it's so
26:57 --> 26:59critical in terms of what you do,
26:59 --> 27:01especially in prostate cancer,
27:01 --> 27:03to really nail down how
27:03 --> 27:05aggressive this is because it is
27:05 --> 27:08the difference these days between having
27:08 --> 27:11more aggressive surgery
27:11 --> 27:14or radiation versus watchful waiting.
27:14 --> 27:17Tell us a little bit more about how your
27:17 --> 27:20decisions impact treatment and prognosis?
27:20 --> 27:22After establishing a
27:22 --> 27:24diagnosis of prostate cancer,
27:24 --> 27:28we assign the Gleason grade or score
27:28 --> 27:31and that is a grade number we give
27:31 --> 27:33for every single prostate cancer
27:33 --> 27:37needle core in every case and a great
27:37 --> 27:40group for that particular biopsy.
27:40 --> 27:42So if a patient had 10 positive
27:42 --> 27:44cores with cancer in each one,
27:44 --> 27:47we would assign an individual
27:47 --> 27:49grade to each one,
27:49 --> 27:51and actually I just gave a
27:51 --> 27:53lecture this morning to the pathology
27:53 --> 27:55residents on grading and staging.
27:55 --> 27:59So it is one of the most critical
27:59 --> 28:02things we do because grade is such
28:02 --> 28:05a dominant prognostic indicator for us.
28:05 --> 28:07For the patients physician,
28:07 --> 28:08for everyone,
28:08 --> 28:11and the patient themselves.
28:12 --> 28:15For example, a grade Group One in a patient
28:15 --> 28:18with a lower PSA might consider
28:18 --> 28:20along with their physician,
28:20 --> 28:22the physician might consider active
28:22 --> 28:24surveillance or careful monitoring of
28:24 --> 28:27that cancer compared to a grade Group
28:27 --> 28:295 where everyone would agree this
28:29 --> 28:31patient definitely needs active therapy.
28:32 --> 28:35Doctor Peter Humphrey is a professor of
28:35 --> 28:37pathology at the Yale School of Medicine.
28:37 --> 28:39If you have questions,
28:39 --> 28:41the address is cancer answers at
28:41 --> 28:43yale.edu and past editions of the
28:43 --> 28:45program are available in audio and
28:45 --> 28:48written form at Yale Cancer Center Org.
28:48 --> 28:50We hope you'll join us next week to
28:50 --> 28:52learn more about the fight against
28:52 --> 28:53cancer here on Connecticut Public
28:53 --> 28:55radio funding for Yale Cancer
28:55 --> 28:57Answers is provided by Smilow
28:57 --> 28:59Cancer Hospital and AstraZeneca.

Information

Prostate Cancer Diagnosis and Prognosis: Histopathology with guest Dr. Peter Humphrey September 19, 2021 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095