Role of Pathology in Cancer

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers
00:02 --> 00:05is provided by Smilow Cancer
00:05 --> 00:07Hospital and AstraZeneca.
00:07 --> 00:09Welcome to Yale Cancer Answers with
00:09 --> 00:11your host doctor Anees Chagpar.
00:11 --> 00:13Yale Cancer Answers features the
00:13 --> 00:15latest information on cancer care by
00:15 --> 00:17welcoming oncologists and specialists
00:17 --> 00:19who are on the forefront of the
00:19 --> 00:21battle to fight cancer. This week,
00:21 --> 00:23it's a conversation about the
00:23 --> 00:25role of pathology and cancer
00:25 --> 00:26with Doctor Angelique Levi.
00:26 --> 00:28Dr. Levi is an associate professor of
00:28 --> 00:31pathology at the Yale School of Medicine,
00:31 --> 00:33where Doctor Chagpar is a
00:33 --> 00:34professor of surgical oncology.
00:36 --> 00:37Angelique, maybe we can start off
00:37 --> 00:39by you telling us a little bit about
00:39 --> 00:41yourself and what it is you do.
00:41 --> 00:44So as a pathologist I am anatomic
00:44 --> 00:46and clinical pathology trained
00:46 --> 00:50so a PCP for short and
00:50 --> 00:52have received fellowship training
00:52 --> 00:54and in Cytopathology,
00:54 --> 00:57a subspecialty of the discipline.
00:57 --> 01:00I have also received some extra
01:00 --> 01:04training and expertise in GU pathology,
01:04 --> 01:06all of which I did
01:06 --> 01:09way back at Hopkins and
01:09 --> 01:12it's a combined program.
01:12 --> 01:14If you do both anatomic
01:14 --> 01:15and clinical pathology
01:15 --> 01:17it used to be five years and now is
01:17 --> 01:204 but you can do one of the two
01:20 --> 01:22disciplines for a little less time now.
01:22 --> 01:26And the anatomic focuses
01:26 --> 01:29mostly on the study of tissue
01:29 --> 01:31and working with a microscope,
01:31 --> 01:33fluids and cells,
01:33 --> 01:35whereas the clinical pathology focuses
01:35 --> 01:38a bit more on laboratory testing,
01:38 --> 01:41blood tests for example.
01:41 --> 01:43So let's dive a little bit more into that.
01:43 --> 01:46I mean, when we think about the role
01:46 --> 01:49of pathology and cancer automatically,
01:49 --> 01:51our brain kind of goes to, Oh yeah,
01:51 --> 01:53it's the pathologists who kind
01:53 --> 01:55of look at the biopsy and tell
01:55 --> 01:57me whether or not I have cancer.
01:57 --> 01:59Can you flesh out a little bit
01:59 --> 02:01more about what it is you do and
02:01 --> 02:02how you come up with that answer?
02:02 --> 02:06I mean everything hinges on what you say,
02:06 --> 02:08how much pressure is that,
02:08 --> 02:09and how do you actually come
02:09 --> 02:11up with the correct diagnosis?
02:12 --> 02:14It's certainly a team
02:14 --> 02:16from the very beginning,
02:16 --> 02:19patients will go to either a hospital
02:19 --> 02:22or a physician office and will have
02:22 --> 02:25a procedure done so the procedure
02:25 --> 02:28could be either a Pap test,
02:28 --> 02:30screening test for cervical cancer,
02:30 --> 02:32it could be a fine needle
02:32 --> 02:33aspiration of a breast mass,
02:33 --> 02:36or it could be a surgical procedure
02:36 --> 02:39in the operating room where
02:39 --> 02:42a tumor or an organ is removed, so
02:42 --> 02:46all of those tissues come to the lab from
02:46 --> 02:50those scenarios and in the lab, the
02:50 --> 02:54histology component is where that
02:54 --> 02:58tissue is transformed into a medium
02:58 --> 03:03where it is put onto a glass slide and
03:03 --> 03:06that process itself is quite intense.
03:06 --> 03:08We have pathology assistants who help
03:08 --> 03:11in the gross examination of these
03:11 --> 03:14tissues when they come to the lab,
03:14 --> 03:17especially the larger ones where they
03:17 --> 03:21may note sizes of lesions they may sample.
03:21 --> 03:23Areas that are critical,
03:23 --> 03:24close to margins, etc.
03:24 --> 03:27And those sections are then
03:27 --> 03:30submitted in cassettes and processed,
03:30 --> 03:33in an automated lab in a way that
03:33 --> 03:36they are sliced and stained and put
03:36 --> 03:39on glass slides for pathologists
03:39 --> 03:42to then review at the time of a
03:42 --> 03:45case review and in community practice,
03:45 --> 03:47often it is just a pathologist,
03:47 --> 03:50but here at academic centers we
03:50 --> 03:52have trainees, residents,
03:52 --> 03:54who are involved in that process.
03:54 --> 03:57We have many sets of eyes that
03:57 --> 03:59we call preview slides and then
03:59 --> 04:01the pathologist sits down at a
04:01 --> 04:03microscope to sign out.
04:03 --> 04:05And that's actually transforming as well.
04:05 --> 04:06Soon we might say we don't sit
04:06 --> 04:09down at a microscope to sign out,
04:09 --> 04:12but we may sit at a computer screen
04:12 --> 04:16if we transform into the digital era,
04:16 --> 04:18but we're not quite there yet.
04:22 --> 04:26Then with a microscope is where we
04:26 --> 04:28really do what we were trained to do,
04:28 --> 04:31and you use your trained eye to look
04:31 --> 04:34at the morphology of the tissue and
04:34 --> 04:37see where it differs from what you
04:37 --> 04:40have trained yourself to know what's normal.
04:40 --> 04:43So identifying what's abnormal
04:43 --> 04:46disease and in that then deciding
04:46 --> 04:48whether it's cancer or not.
04:48 --> 04:50So not every disease is cancer,
04:50 --> 04:52and it's important in some cases
04:52 --> 04:54where the presumption clinically
04:54 --> 04:56might be a mass because of cancer,
04:56 --> 04:58it's a really important piece to
04:58 --> 05:01be able to say this isn't cancer,
05:01 --> 05:03and so therefore no treatment is necessary.
05:03 --> 05:05But at a Cancer Center,
05:05 --> 05:10many of the referrals that come here often
05:10 --> 05:12perhaps already with a preliminary
05:12 --> 05:15diagnosis on a small biopsy of
05:15 --> 05:17cancer and then our job sometimes,
05:17 --> 05:19as pathologists, in a larger procedure, or a
05:19 --> 05:24resection is to then go ahead and stage that,
05:24 --> 05:26which means assign some more
05:26 --> 05:28parameters around that diagnosis.
05:28 --> 05:31So not only is it cancer,
05:31 --> 05:33but it's a type of cancer that
05:33 --> 05:36you want to kind of classify.
05:36 --> 05:40It's given a grade as we call it,
05:40 --> 05:42well differentiated, poorly differentiated.
05:42 --> 05:45It might be given certain
05:45 --> 05:49other parameters regarding size or margin.
05:49 --> 05:50Different cancers have different
05:50 --> 05:52parameters that are important,
05:52 --> 05:55and all of those details are important
05:55 --> 05:58in prognosis prediction and then
05:58 --> 06:00treatment and usually
06:00 --> 06:02associated then with outcome.
06:03 --> 06:05So I want to pick up on a few
06:05 --> 06:06things that you said there.
06:06 --> 06:09So one was this whole process
06:09 --> 06:11that really goes on that
06:11 --> 06:14many people who have never stepped into a
06:14 --> 06:17pathology lab might not know about which is
06:17 --> 06:20when you have a biopsy done
06:20 --> 06:23and your surgeon, your radiologist,
06:23 --> 06:25whoever has done the biopsy,
06:25 --> 06:27sends that specimen away.
06:27 --> 06:29Oftentimes, it's the greatest
06:29 --> 06:31amount of patient anxiety waiting
06:31 --> 06:33for that result to come back.
06:33 --> 06:36And sometimes it can take a few days,
06:36 --> 06:38but there is all of this
06:38 --> 06:41preprocessing that needs to go on.
06:41 --> 06:44Can you give us a sense of how long
06:44 --> 06:47these biopsy results can sometimes take,
06:47 --> 06:50and why it's important to really be
06:50 --> 06:52patient and wait for your pathologist
06:52 --> 06:54to give you the right answer because
06:54 --> 06:57as you say so much of treatment really
06:57 --> 06:59rests on what the pathologist says.
07:00 --> 07:02Absolutely, that pre-analytical phase
07:02 --> 07:05that you're talking about is a big part
07:05 --> 07:07of our processing in the lab and
07:07 --> 07:10that's kind of a traditional laboratory
07:10 --> 07:12setting where you know pathologists when
07:12 --> 07:14we talk about where do you work,
07:14 --> 07:16you work in the lab, well no,
07:16 --> 07:17we actually work mostly in our offices,
07:17 --> 07:19but much of what's happening
07:19 --> 07:20before we even see that glass slide.
07:29 --> 07:32An Accessioner is the first person in the
07:32 --> 07:34laboratory that basically does the
07:34 --> 07:38patient registration that assigns that
07:38 --> 07:39specimen a unique number.
07:39 --> 07:42Every specimen in pathology is assigned a
07:42 --> 07:44unique number and that's how we identify it.
07:45 --> 07:46The patient information,
07:46 --> 07:48clinical identifiers are then entered,
07:48 --> 07:51and that's a really important step in
07:51 --> 07:53terms of specimens being identified
07:53 --> 07:57properly and assigned to the right person.
07:57 --> 08:00That is the first thing that happens and
08:00 --> 08:04the next step is it goes to the gross
08:04 --> 08:08Histology bench and so for small biopsies
08:08 --> 08:11that are cores or maybe liquid,
08:11 --> 08:12or a pap smear,
08:12 --> 08:13just single cells,
08:13 --> 08:15fixation is something that
08:15 --> 08:17doesn't take as long,
08:17 --> 08:20so fixation is something that
08:20 --> 08:23happens in different chemicals,
08:23 --> 08:26alcohol and or formalin.
08:26 --> 08:28Now when these tissues are larger,
08:28 --> 08:31as in the case of a large tumor
08:31 --> 08:33or resection or a large organ,
08:33 --> 08:36that fixation process can
08:36 --> 08:39happen over a 12 hour period.
08:39 --> 08:39Sometimes overnight,
08:39 --> 08:40so for example,
08:40 --> 08:44a prostate that is removed whole
08:44 --> 08:47or a large breast excision,
08:47 --> 08:49those are examples of tissues that
08:49 --> 08:52take a long time to fix in formalin.
08:52 --> 08:54So before those sections can even be
08:54 --> 08:57taken to embed in those paraffin blocks,
08:57 --> 08:59that process has to happen,
08:59 --> 09:00and it's critically important for
09:00 --> 09:03that process to happen
09:03 --> 09:05because these tissues need to be
09:05 --> 09:07able to be examined in sections
09:07 --> 09:09in a way where the margins
09:09 --> 09:12and all of those distinctions
09:12 --> 09:14between things that are critically
09:14 --> 09:15important for patient care,
09:15 --> 09:17whether the person gets radiation
09:17 --> 09:20or not is the margin positive.
09:20 --> 09:22Those delineations are critically
09:22 --> 09:25dependent on that fixation step,
09:25 --> 09:28and that step is where we really
09:28 --> 09:30need to wait, and we can't rush it.
09:30 --> 09:33So we have some technologies,
09:33 --> 09:35microwave assistance and other things,
09:35 --> 09:38but in that process there
09:38 --> 09:40are still very manual
09:40 --> 09:43pieces that take time and then
09:43 --> 09:46by the time that slide comes out,
09:46 --> 09:48if the surgery was on a Monday,
09:48 --> 09:51that glass slide may not even
09:51 --> 09:54come to a pathologist's desk until
09:54 --> 09:56the following afternoon.
09:56 --> 09:57And if that following afternoon
09:57 --> 09:59is the first time a pathologist
09:59 --> 10:01is looking at a cancer,
10:01 --> 10:04whether it's a complicated case or even
10:06 --> 10:08a standard morphologic diagnosis of,
10:08 --> 10:11let's say, breast cancer, there are still
10:11 --> 10:13additional tests that will have to get done,
10:13 --> 10:16and so those tests will include
10:16 --> 10:18immunostains and other markers
10:18 --> 10:20that are all very important that
10:20 --> 10:23need to be included in the report.
10:24 --> 10:27So a lot of those those markers are
10:27 --> 10:30things that we have to then order,
10:30 --> 10:32and again it's another day
10:32 --> 10:33or overnight processing,
10:33 --> 10:36and so each of these steps
10:36 --> 10:39requires kind of another decision
10:39 --> 10:41and potentially another test
10:41 --> 10:44or stain or molecular marker, for example.
10:45 --> 10:47So important for people not
10:47 --> 10:49to rush the pathologist because as
10:49 --> 10:53I tell my patients,
10:53 --> 10:55everything rests on what they say.
10:55 --> 10:57But having said that,
10:57 --> 11:00many people nowadays are
11:00 --> 11:02talking about second opinions,
11:02 --> 11:04either a second opinion
11:04 --> 11:05from their clinician,
11:05 --> 11:07but also getting their pathology that
11:07 --> 11:10may have been reviewed at one institution
11:10 --> 11:12re-reviewed at another institution.
11:12 --> 11:13So for example,
11:13 --> 11:14if they get a second opinion,
11:14 --> 11:18their outside pathology is often re reviewed.
11:18 --> 11:21So can you talk about the importance of
11:21 --> 11:24that and how often do pathologists disagree?
11:24 --> 11:25I mean, are these diagnoses
11:25 --> 11:27things that are black and white?
11:27 --> 11:29That is pretty crystal clear when
11:29 --> 11:31you see a cancer that it's a cancer.
11:31 --> 11:34Or are there some nuances that
11:34 --> 11:36allow for some variability in
11:36 --> 11:38terms of pathologic opinion?
11:38 --> 11:42I'll start by saying second opinions within
11:42 --> 11:45any scenario are always a good thing.
11:45 --> 11:48I think for another set of eyes to
11:48 --> 11:53take a look at a cancer case is
11:53 --> 11:57always good and in the vast majority of
11:57 --> 12:00cases a confirmation is what you'll find.
12:00 --> 12:03The confirmation of the original diagnosis.
12:03 --> 12:06It becomes more important in certain
12:06 --> 12:10scenarios, so certain cancers
12:10 --> 12:12have required subspecialty training
12:12 --> 12:15that not all pathologists have,
12:15 --> 12:18where you practice,
12:18 --> 12:19where you've trained,
12:19 --> 12:21and what you've become an expert
12:21 --> 12:24in really does matter and standards
12:24 --> 12:26are different for different places.
12:26 --> 12:28In the community setting,
12:28 --> 12:30while there's very high
12:30 --> 12:31standards of care there,
12:31 --> 12:35they may not always see all of the unique
12:35 --> 12:40rare tumors that we might have in a tertiary
12:40 --> 12:41academic center.
12:41 --> 12:44Whereas in an academic center like Yale
12:44 --> 12:48we would be able to kind of explain a bit
12:48 --> 12:51more if there are nuances to a tumor.
12:51 --> 12:52So black and white,
12:52 --> 12:54yes cancer or not,
12:54 --> 12:56in the vast majority of cases.
12:56 --> 12:58But for challenging cases,
12:58 --> 13:01I think second opinions are definitely
13:01 --> 13:04helpful with expert review and consensus.
13:04 --> 13:06Daily Conference is something
13:06 --> 13:09that is part of our routine,
13:09 --> 13:11not always in all practices.
13:11 --> 13:14So it's important to kind of
13:14 --> 13:16understand the nuances of pathology.
13:16 --> 13:18We're going to pick up this
13:18 --> 13:20conversation right after we take a
13:20 --> 13:21short break for a medical minute.
13:21 --> 13:23Please stay tuned to learn more about
13:23 --> 13:25the role of pathology in cancer
13:25 --> 13:27with my guest Dr. Angelique Levi.
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14:46 --> 14:48Welcome back to Yale Cancer Answers.
14:48 --> 14:50This is doctor Anees Chagpar
14:50 --> 14:52and I'm joined tonight by my
14:52 --> 14:53guest doctor Angelique Levi.
14:53 --> 14:56We're talking about the role of
14:56 --> 14:58pathology in cancer and Angelique,
14:58 --> 15:00you know one of the things that you
15:00 --> 15:01mentioned before the break that I
15:01 --> 15:03was interested in is that you said
15:03 --> 15:05we are getting close to a
15:05 --> 15:08time when pathologists might not be
15:08 --> 15:10looking down the microscope anymore.
15:10 --> 15:13They might be looking at a computer
15:13 --> 15:15screen and that brought to mind
15:15 --> 15:17this whole concept of digital
15:17 --> 15:20pathology and potentially the role
15:20 --> 15:22of artificial intelligence in helping
15:22 --> 15:25pathologists make that diagnosis.
15:25 --> 15:27You talked a little bit before the
15:27 --> 15:29break about some of the nuances.
15:29 --> 15:31Can you talk a little bit about
15:31 --> 15:34where you see digital pathology and
15:34 --> 15:37the role of AI kind of playing
15:37 --> 15:39into pathology as we move forward?
15:39 --> 15:44Absolutely, the landscape is already
15:44 --> 15:50changing and the field is rapidly evolving.
15:50 --> 15:53And pathologists, I think are
15:53 --> 15:57definitely stepping up and wanting to
15:57 --> 16:03not just join this era of digital and
16:03 --> 16:05artificial intelligence as you say,
16:05 --> 16:07machine learning, but hopefully
16:07 --> 16:11also take a role in leading that
16:11 --> 16:13charge and for pathology there are
16:13 --> 16:16so many potential applications as
16:16 --> 16:19with everything AI is everywhere.
16:19 --> 16:20We don't necessarily appreciate
16:20 --> 16:23it from our phones and our apps,
16:23 --> 16:26or for many the interfaces we do each day,
16:26 --> 16:29but it's a tool no different
16:29 --> 16:31than for pathology,
16:31 --> 16:33maybe an immunostain and
16:33 --> 16:35molecular marker or genetic
16:35 --> 16:38profile and how we use that tool
16:38 --> 16:42is largely dependent on
16:42 --> 16:44what help or guidance a particular
16:44 --> 16:47practice might be looking for.
16:47 --> 16:50One example of AI and pathology as
16:50 --> 16:53you mentioned or alluded to would be,
16:53 --> 16:55helping to make a diagnosis
16:55 --> 16:59or grading a tumor.
16:59 --> 17:03So an area of study that I
17:03 --> 17:06have pursued in GU pathology
17:06 --> 17:07and in prostate cancer
17:07 --> 17:10this is a common application now
17:10 --> 17:15and there are already software
17:15 --> 17:18companies that are promoting
17:18 --> 17:22AI programs and software that can
17:22 --> 17:25reliably help predict grades or
17:25 --> 17:28Gleason scoring of prostate cancer.
17:28 --> 17:33But it's not that simple.
17:33 --> 17:38Depending on the cancers that might be
17:38 --> 17:40seen in a given institution,
17:40 --> 17:42whether it's more common,
17:42 --> 17:46lower grade, or in a tertiary care center,
17:46 --> 17:47much more complicated,
17:47 --> 17:49higher grade,
17:49 --> 17:52algorithms are kind of taught to
17:52 --> 17:55answer a specific question or grade.
17:55 --> 17:58So if you're looking for well differentiated
17:58 --> 18:01prostate cancer 3 + 3 Gleason score,
18:01 --> 18:03that might be one training set,
18:03 --> 18:06whereas if you're looking for
18:06 --> 18:09high grade prostate cancer,
18:09 --> 18:11that is
18:11 --> 18:13amenable not to resection,
18:13 --> 18:14but further treatment,
18:14 --> 18:16that might be another training
18:16 --> 18:18software kind of algorithm,
18:18 --> 18:20so much depends on
18:20 --> 18:21the question being asked,
18:21 --> 18:24and it's not just help in grading,
18:24 --> 18:27but it could also just be help in detection,
18:27 --> 18:30so different programs can be
18:30 --> 18:34taught how to do different tasks,
18:34 --> 18:36and another program might be in
18:36 --> 18:38a better setting for community
18:38 --> 18:41practice not to miss cancer
18:41 --> 18:43as much as
18:43 --> 18:46focusing on the grade because
18:46 --> 18:48detection and preventing false
18:48 --> 18:52negatives would really be the key
18:52 --> 18:54perhaps in a Community setting
18:54 --> 18:56with a lower cancer rate,
18:56 --> 18:58whereas at the tertiary setting something
18:58 --> 19:03that would be more helpful is perhaps
19:03 --> 19:05an AI software algorithm that not
19:05 --> 19:08just helps with detection or grade,
19:08 --> 19:10but maybe with prognosis.
19:10 --> 19:12And that's really the key,
19:12 --> 19:15trying to discern what this AI can help
19:15 --> 19:18with and how we'd like to apply it,
19:21 --> 19:22tailoring the solution to the problem.
19:22 --> 19:25But one of the questions is this.
19:25 --> 19:28Are these technologies in use now?
19:28 --> 19:30And is there a way for patients to
19:30 --> 19:32know whether a particular pathology
19:32 --> 19:35department is using that or not?
19:35 --> 19:36For example,
19:36 --> 19:39if I just had a biopsy at my
19:39 --> 19:41Community Hospital and I want to make
19:41 --> 19:44sure that they didn't miss a cancer,
19:44 --> 19:47should I expect that they have that kind of
19:47 --> 19:50technology that can help the pathologists?
19:50 --> 19:52And if I'm not sure,
19:52 --> 19:53is there a way to find out?
19:53 --> 19:55There's always a way to find
19:55 --> 19:57out and certainly just calling that
19:57 --> 19:59pathologist on the bottom of the
19:59 --> 20:01report would be the first step.
20:04 --> 20:07Or wherever those procedures are done would
20:07 --> 20:09certainly know within the department,
20:09 --> 20:12I would say we're still on the cusp.
20:18 --> 20:21I think right now in tertiary care centers,
20:21 --> 20:25there are many kinds of testing and
20:25 --> 20:27research scenarios and these
20:27 --> 20:30are all kind of sprouting
20:30 --> 20:33up now and it's not to
20:33 --> 20:35be expected I would say because
20:35 --> 20:39it requires so much investment and
20:39 --> 20:43infrastructure.
20:46 --> 20:50Whether it's cloud based
20:50 --> 20:54memory or machine or human time,
20:54 --> 20:57we can't expect that to all be there.
20:57 --> 21:01Now I would say you know,
21:01 --> 21:03in the future 5 to 10 years,
21:03 --> 21:0510 to 15 years, I think
21:05 --> 21:07then we can start
21:07 --> 21:09to see where these
21:09 --> 21:12applications are best suited,
21:12 --> 21:16and imagine with all of this investment
21:16 --> 21:21it would probably be helpful as a QC measure.
21:21 --> 21:24You know there are always reimbursement
21:24 --> 21:26codes for things that are additive,
21:26 --> 21:28whether it's a stain or
21:28 --> 21:30whether it's AI assisted.
21:30 --> 21:33So I imagine in the future it would also be
21:33 --> 21:36part of a report and so you know we're not
21:36 --> 21:40there yet, but it does take a lot of time,
21:40 --> 21:40infrastructure,
21:40 --> 21:42and money frankly,
21:42 --> 21:44and so until those costs come
21:44 --> 21:46down or those partnerships are
21:46 --> 21:48established, things
21:48 --> 21:50may be commercially available
21:53 --> 21:56at a price that is affordable for you.
22:03 --> 22:07The other thing that is here now
22:07 --> 22:10more and more in the cancer world is
22:10 --> 22:12this whole concept of personalized
22:12 --> 22:15medicine and so many clinicians are
22:15 --> 22:17really now trying to unlock and
22:17 --> 22:19understand the genomics of cancers.
22:19 --> 22:22And we've certainly had guests on this
22:22 --> 22:24show who talk about doing stains that
22:24 --> 22:27look at a number of different
22:27 --> 22:31genetic and genomic mutations that
22:31 --> 22:34actually help in figuring out how
22:34 --> 22:37a particular tumor may be treated.
22:37 --> 22:40Is that done at the local pathology lab?
22:40 --> 22:43What's the role of the pathologist in that?
22:43 --> 22:45How do you decide which of these
22:45 --> 22:48markers really needs to be done?
22:48 --> 22:50What's the cost and is that standard
22:50 --> 22:53of care or is that something that
22:53 --> 22:55patients need to really individualize?
22:56 --> 22:59So at the local level I don't
22:59 --> 23:03think it's necessarily standard of care.
23:03 --> 23:05Certainly immunostains,
23:08 --> 23:11certain markers that are common
23:11 --> 23:14to lay folks would be,
23:14 --> 23:16we talk about estrogen and progesterone
23:16 --> 23:18receptors for breast cancer.
23:18 --> 23:19For example, ER,
23:19 --> 23:22PR and certain molecular markers.
23:22 --> 23:24I think in Community practice
23:24 --> 23:27the idea is
23:27 --> 23:29to partner often with
23:29 --> 23:30another lab.
23:30 --> 23:33Whether it's a tertiary center,
23:33 --> 23:36a commercial lab that offers those
23:36 --> 23:39tests because they are not able to
23:39 --> 23:42have access to all of that in house,
23:42 --> 23:45and so a lab like
23:45 --> 23:47ours comes into play,
23:47 --> 23:50where if we have something to offer,
23:50 --> 23:53we can partner with other network hospitals,
23:53 --> 23:54community hospitals,
23:54 --> 23:57even other labs that might not have
23:57 --> 24:00the same volume we do in a Cancer
24:00 --> 24:02Center to provide all of these highly
24:02 --> 24:05specialized tests that without a certain
24:05 --> 24:07volume it's not affordable to run.
24:07 --> 24:12So I think the same thing holds for
24:12 --> 24:14additional molecular assays.
24:14 --> 24:19Panel genetic profiling those are highly
24:19 --> 24:23specialized areas and fields that
24:23 --> 24:25without partnering with another kind
24:25 --> 24:29of tertiary care center or larger
24:29 --> 24:31lab specifically geared towards that,
24:31 --> 24:33I think it's not
24:33 --> 24:35expected at the local level.
24:36 --> 24:38So are the decisions about what
24:38 --> 24:40additional tests need to be done,
24:40 --> 24:42so additional molecular
24:42 --> 24:44tests and so on, EGFR VEGF,
24:44 --> 24:46various mutational panels
24:46 --> 24:49and so on are those decisions
24:49 --> 24:53made by the pathologist, by the
24:53 --> 24:55treating clinician, by a group?
24:55 --> 24:57How are those decided?
24:57 --> 25:00I think in the Community level
25:00 --> 25:03the oncologist drives a lot of that because
25:03 --> 25:06the oncologist sees on that leading edge
25:06 --> 25:09what the potential drugs that are
25:09 --> 25:13available that are targeted to a
25:13 --> 25:16particular molecular change, and so in
25:16 --> 25:19the Community setting,
25:19 --> 25:21I think the oncologist takes that
25:21 --> 25:25role more so in asking a pathologist,
25:25 --> 25:28hey, there's a new drug and it targets
25:28 --> 25:29this molecular marker.
25:29 --> 25:32Is that something you do in your lab?
25:33 --> 25:35Or is it something we can send out for?
25:35 --> 25:36And then you know,
25:36 --> 25:38the pathologist facilitates that.
25:38 --> 25:40And so that I think happens
25:40 --> 25:41more on the Community side,
25:41 --> 25:44whereas I think in the tertiary care setting,
25:44 --> 25:45like here,
25:45 --> 25:48I think it is a bit more of a
25:48 --> 25:50collaborative effort because there
25:50 --> 25:53are there are the pathologists
25:53 --> 25:56here who are doing those genetic tests
25:56 --> 25:59and so we also have our tumor boards
25:59 --> 26:01that while they have been outside
26:01 --> 26:03at the Community level as well,
26:03 --> 26:04I think in a Cancer Center,
26:04 --> 26:06the tumor boards really are
26:06 --> 26:08putting everyone at the table.
26:08 --> 26:11Who has that subspecialty expertise?
26:11 --> 26:13And so I think it's a bit more
26:13 --> 26:15of a collaborative effort.
26:15 --> 26:18And if there's something that is
26:18 --> 26:20clinically warranted or a new drug,
26:20 --> 26:24I think the pathologists here in a
26:24 --> 26:28tertiary center are able to create
26:28 --> 26:30these answers to some of
26:30 --> 26:32those questions or research them,
26:32 --> 26:35or they're already a line of research here
26:35 --> 26:39in the department or collectively.
26:40 --> 26:43Which segues nicely into you,
26:43 --> 26:44know, one of my last questions,
26:44 --> 26:47which is what are the exciting areas of
26:47 --> 26:50research in pathology and cancer?
26:50 --> 26:52I mean, it seems like pathology
26:52 --> 26:55is so central to what we do.
26:55 --> 26:57Are there some exciting developments
26:57 --> 27:00that you see coming down the Pike
27:00 --> 27:02in terms of pathology and cancer?
27:03 --> 27:06Well, I definitely think the
27:06 --> 27:08digital pathology component and
27:08 --> 27:10the artificial intelligence piece
27:10 --> 27:12is very exciting.
27:13 --> 27:15It's entirely a new platform
27:15 --> 27:18and revolution, so to speak.
27:18 --> 27:20It's something that can be applied
27:20 --> 27:22to all of the tools that we have
27:22 --> 27:25and then it's a tool on its own.
27:25 --> 27:29So what I mean by that is the
27:29 --> 27:32ability to work with digital images,
27:32 --> 27:35whether it's radiology or
27:35 --> 27:38scanned pathology slide and
27:38 --> 27:44with that scan slide use metrics or
27:44 --> 27:47segmentation to detect changes
27:47 --> 27:50that maybe even the human eye can't.
27:50 --> 27:52And maybe it's not just about morphology,
27:52 --> 27:55it's just a whole other level
27:55 --> 27:58of detection
27:58 --> 28:00in addition to our molecular
28:00 --> 28:03assays and genetic profiles,
28:03 --> 28:05is something that can on its own be
28:05 --> 28:08additive and the exciting pieces when it
28:08 --> 28:12is also its own prognostic indicator,
28:12 --> 28:14and so we're always interested in
28:14 --> 28:17knowing more about the meaning of
28:17 --> 28:19the cancer and what effect
28:19 --> 28:21that has on outcome and prognosis,
28:21 --> 28:23and AI really has the potential
28:23 --> 28:28to help each of these special
28:28 --> 28:30techniques that we use and the
28:30 --> 28:31ability to stand on its own.
28:32 --> 28:34Doctor Angelique Levi is an
28:34 --> 28:35associate professor of pathology
28:35 --> 28:38at the Yale School of Medicine.
28:38 --> 28:39If you have questions,
28:39 --> 28:40the address is cancer
28:40 --> 28:43Answers at yale.edu and past editions of
28:43 --> 28:46the program are available in audio and
28:46 --> 28:48written form at yalecancercenter.org.
28:48 --> 28:50We hope you'll join us next week to
28:50 --> 28:52learn more about the fight against
28:52 --> 28:54cancer here on Connecticut Public Radio.
28:54 --> 28:55Funding for Yale Cancer
28:55 --> 28:57Answers is provided by Smilow
28:57 --> 29:00Cancer Hospital and AstraZeneca.

Information

Role of Pathology in Cancer with guest Dr. Angelique Levi October 10, 2021 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095