If you’ve been diagnosed with cancer, you will interact with a number of different members of the health care team at various times during treatment. When you walk into a doctor’s office, hospital, or cancer center, you may encounter nurses, physician assistants, social workers, doctors—the list goes on. In this series, we talk with some of these health care professionals to learn more about their jobs and the role they play in providing high-quality cancer care.
A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. Although you might never meet your pathologist, he or she plays a vital role in your diagnosis and treatment planning.
To find out what goes on behind the scenes and in the laboratory, I talked with Carey August, MD, Director of Anatomic Pathology at Advocate Illinois Masonic Medical Center, and Chanjuan Shi, MD, PhD, an associate professor in the Department of Pathology, Microbiology, and Immunology at Vanderbilt University Medical Center.
Q: How would you describe the role of pathologists in the cancer care team?
Dr. Chanjuan Shi (CS): Pathologists are indispensable to the cancer care team. We provide a comprehensive and final diagnosis to enable clinicians to develop definitive cancer treatments and sometimes estimate the likely course of a cancer. In addition, pathologists are now able to detect genetic changes in most cancers, allowing oncologists to recommend and/or prioritize new targeted cancer therapies for patients.
Dr. Carey August (CA): Since no two people with cancer are alike, treatment plans demand very detailed information in order to apply evidence-based guidelines. Pathologists must ensure that all of these details are accurately addressed. As physicians who are laboratory professionals, we develop and implement newer and better ways to provide diagnoses and the information necessary for cancer care. Laboratories are held to rigorous standards, and pathologists make sure that these are met.
Our role in patient care doesn't end with a diagnosis. We collaborate with other members of the cancer care team to find the most effective ways to evaluate people with cancer and, at the same time, the least costly to the patient in terms of discomfort, time, and money. Our goal, as key members of the cancer care team, is to share our expertise in formulating the best plan possible for each patient.
Q: What are some of the most important things you do on a daily basis?
CS: As a surgical pathologist, part of my job is to examine by microscope thinly sliced tissue from biopsies and resection specimens to diagnose cancer. A biopsy is the removal of a small piece of tissue from a lesion or tumor. We use a biopsy to determine if the lesion is a tumor, and if so, whether it is benign (not cancerous) or malignant (cancerous). In addition, we provide details about the type of cancer and if possible, its differentiation (how similar the cancer cells are to healthy cells). Resection is the surgical removal of a tumor and all or part of the organ/tissue/structure where the tumor is located. We use a resection specimen to assess the level of cancer invasion, number of lymph nodes with and without cancer that has spread from the original site, and completeness of the surgical resection. As a molecular pathologist, I perform molecular testing on tumor samples to identify gene mutations or other changes in cancer cells.
CA: Pathologists care deeply and personally about our patients, even if we don't interact directly with them on a regular basis. Every day I focus on treating every slide and sample as though it was from a family member or close friend. Because of the nature of my practice, I don't often get to meet my patients face to face. But knowing that every slide and sample represents the life of someone's spouse, someone's parent, someone's child, or someone's friend, I treat each one as I would want the people important to me to be treated.
On a daily basis, making diagnoses is the number one priority. However, there are other things that form crucial parts of my day. Participating in multidisciplinary tumor board discussions allows me to have input into how a patient is evaluated and treated. In the laboratory, I oversee activities to ensure that our results are accurate and timely. Multiple times a day, I am asked to solve small problems regarding patient specimens. I usually find that one brief phone call can save a lot of aggravation for patients and their physicians!
Q: Why did you become a pathologist?
CA: Frankly, I became a pathologist because I thought that it was a field of medicine where there is always a black or white answer and that the care I gave would have nothing to do with any personal interactions. What I have learned is that, like all fields of medicine, pathology isn't always black or white. However, it is still very satisfying to strive for the best possible answer in each case. And I have learned that my personal interactions enable me to engage the other members of the cancer care team in finding the best ways to evaluate and treat patients.
CS: I trained to be a colorectal surgeon in China and served as an attending colorectal surgeon for more than two years. Then, to pursue dedicated scientific training, I moved to Canada. After completing my PhD in Pharmacology, I moved to the United States. I became a research fellow in the Department of Pathology at Johns Hopkins where I worked in cancer research. One of the research projects focused on the early detection of cancer. Additionally, I gained valuable molecular pathology experience. My extensive clinical knowledge and years in cancer research provided a good foundation to become a pathologist. Currently, I am an academic pathologist serving as a surgical pathologist, molecular pathologist, and researcher at Vanderbilt University Medical Center.
Q: What are the best or most rewarding parts of your job?
CA: The most rewarding parts of my job involve those conversations, formal or informal, with other care team members in determining the best course of action for each patient. Working through a case is like solving a difficult puzzle, and getting the satisfaction of making an accurate diagnosis for a patient is very satisfying. Every day I see and learn something new. It doesn't get better than this.
CS: Tissue diagnosis of cancer can be very challenging. In addition to studying the structure and arrangement of tumor cells as seen through the microscope, pathologists may gather detailed clinical histories, perform special studies, and search medical literature in order to logically analyze all of the information needed to make an accurate diagnosis. I really like being able to provide the final and definitive diagnosis of a case that was perplexing at the start. I also like the moment when I’m able to determine a cancer that is sensitive to a certain targeted therapy. Some patients have advanced disease, and targeted therapy might be their only option for treatment.
Q: Do you have any tips to help people better understand their pathology reports?
CA: ASCO is collaborating with the College of American Pathologists to create a document for patients called How to Read Your Pathology Report. It will explain how the report was generated, why it gives all the information it gives, and how the cancer care team uses the report to treat an individual patient. Generally, the patient's treating physician will review the pathology report with the patient, and most doctors involved in cancer care are knowledgeable about the components of a pathology report. But, patients shouldn't be afraid to ask questions, and it may be helpful for a patient to speak directly with their pathologist.
Q: Is there anything else people should know?
CS: Those of us in medical research continue to look for better treatments. Many research projects require the use of patient tissue samples. As opportunities arise, I strongly encourage patients to donate tissue, often at the time of surgery, and to participate in other research projects.
Dr. August and Dr. Shi talk more about the role of pathologists in cancer care in the following podcast.