Plus Ça Change!

What led you to gynecological pathology?

As a medical student, I knew that I wanted to be a histopathologist, and undertook an intercalated BSc Hons degree in “Morbid Anatomy”. The Manchester Department of Pathology was one of the best in the country in those days and full of real characters. I was particularly inspired by the reproductive pathologist Professor Harold Fox, who became a good friend, and remains the most amusing lecturer I have encountered in my career.

I then did one year of “house jobs” at Hope Hospital in Salford, including medicine on Professor Leslie (now Lord) Turnberg’s unit. Having worked for him at the beginning of my career, it has been difficult to be more impressed by anyone else. If I had not chosen pathology, I would have been a gastroenterologist.

Following this, I took a Senior House Officer post in clinical pathology at Bristol Royal Infirmary. The following year I became a demonstrator in pathology, and was quickly promoted to Lecturer. After this I moved to a Lecturer’s post in Leeds, and within a month was asked by the head of department, ProfessorColin Bird, if I would like to take a special interest in gynecological pathology, as the National Health Service (NHS) consultant at Leeds Women’s Hospital was approaching retirement. I was seconded to St Mary’s Hospital, Manchester, where I spent three months improving my diagnostic skills.

You’ve been a pathologist for 38 years – how has the profession changed since you started?

I would say there have been two main changes. First, the increased number of hoops we now have to jump through on a regular basis, including accruing CPD/CME points, participating in EQA schemes, annual appraisal and now, of course, revalidation. None of these things are really necessary for dedicated professionals – they are for identifying substandard practice or unprofessional behavior. But in my opinion, the UK’s NHS is singularly hopeless in handling this kind of issue when it does arise.

Second, increasing subspecialization has led to increased numbers of staff, and in some cases, considerable disparities in workloads between consultants. Although subspecialization is beneficial to patient care, it has eroded the collective ethos of cellular pathology departments – often, consultant pathologists will interact more with clinicians than with pathologists in their own department who are pursuing other subspecialties. In academic pathology, the pursuit of research themes has seen pathologists ally themselves with other members of their “theme”, resulting in an institutional diaspora of pathologists.

That said, even after almost 40 years of practice, I still begin my morning or afternoon of work with a pile of slide trays full of glass, which I must shift from one side of the microscope to the other. My essential work has stayed much the same, but all the peripheral aspects have become more complicated, and I never stop for communal morning coffee or afternoon tea as we did in those halcyon days.

How has gynecological pathology changed?

Without a doubt, the single most important advance in my working lifetime has been the introduction of a vaccine against human papillomavirus (HPV), though it will be several more years before its full impact is realized. It represents the culmination of 30 years of HPV research, to which I made a modest contribution.

Another is our growing realization that many serous carcinomas of the pelvis arise not from the ovary but the fimbrial portion of the fallopian tube, particularly in BRCA mutation – related familial cancers. This represents an important change in our understanding, but unfortunately this doesn’t impact greatly on women, who often present with advanced disease.

Molecular diagnostics are increasingly important too, particularly as ancillary investigations in gynecological neoplasms: for example, the identification of FOX-2 mutations in granulosa cell tumors. However, the application of molecular pathology is incremental and, despite claims to the contrary by pundits, is not going to supplant histological diagnosis any time soon.

Diagnostic gynecological pathology itself has changed surprisingly little. The mainstay is still the H&E stained section. Immunohistochemistry has obviously had an important effect, although in my opinion many pathologists use it somewhat indiscriminately. There have been regular, often unnecessary changes in terminology in the spurious belief that by engaging in such activity the subject is being advanced.

Gestational trophoblastic disease is rare and doesn’t receive much attention – what do you think pathologists need to know about the disease?

There are three crucial things to bear in mind: do not attempt to make a diagnosis without knowledge of the clinical history, the serum ßHCG level and the imaging findings. This is particularly true for a tumor as rare as placental site trophoblastic tumor or epithelioid trophoblastic tumor – one can be easily misled by exuberant but physiologically invasive normal trophoblast. Also, appreciate the more subtle histological appearances of “early” complete hydatidiform mole, a diagnosis now greatly facilitated by the use of p57 immunohistochemistry. Finally, always be aware of your limitations, and seek help from someone with greater experience in the field.

What have been some of the highlights of your leadership work?

I have been President the British Gynecological Cancer Society (BGCS), the International Society of Gynecological Pathologist (ISGyP), the European Society of Pathology (ESP) and the British Division of the International Academy of Pathology (BDIAP). In the limited time I had available, I tried with each society to make a difference. But I consider myself a diplomat rather than a politician – I only had influence, not power! 

I have tried to bring groups together; for example I brought the Pathological Society of Great Britain and Ireland and the ESP together, culminating in the hugely successful joint European Congress of Pathology in London in 2014. I also brought the International Academy of Pathology and the ESP together, and there will be a joint European Congress in Cologne next year.

I found my three years as vice president of the Royal College of Pathologists an enjoyable challenge, too. I introduced digital pathology into the College, enhanced its influence in the rest of Europe, and fostered the increased inclusion of molecular pathology in the cellular pathology curriculum.

One of my last achievements, during my time at the University of Sheffield, was to introduce a new course in basic pathology for medical undergraduates, which included 30 pieces of essential knowledge. My consultant colleagues were very enthusiastic, and the course was well received by students.

You started the first UK Pathology Summer School for medical students – what was the motivation, and what were the outcomes?

This was my major initiative as President of the BDIAP. I wasn’t alone in noticing that we do not attract enough of the brightest medical graduates to pathology, as a result of the erosion of pathology in the medical undergraduate curriculum, and the steady demise of academic pathology. The first Pathology Summer School was held in London in 2014, and was enjoyed by the participants and faculty alike. It is too soon to talk of “outcomes”, but I guess the most gratifying early outcome is that the second Summer School was held earlier this year in Oxford, and the proportion of those considering a career in pathology has increased.

What tips do you have for pathologists trying to encourage trainees into the field, or for those considering a career in pathology?

To pathologists educating trainees, I’d say there is simply no substitute for conveying enthusiasm for your chosen discipline, combined with sound knowledge. To those considering pathology, I’d say that diagnostic cellular pathology is a scholarly discipline, because if you don’t know about rarities, you’ll never diagnose them. It remains an intellectually challenging specialty, particularly if you strive to understand the biology of what you’re observing down the microscope, rather than simply being a “pattern recognizer”. And despite what some might think, it is essential for pathologists to have good verbal and written communication skills.

What do you think lies ahead for gynecological pathology, and pathology in general?

I am a cup half full (rather than half empty) character, and I’m therefore optimistic about the future of both my specialty and subspecialty. The major challenge we face is to attract more bright young doctors. Cellular pathologists in all subspecialties (including gynecological pathology) must embrace the burgeoning developments in molecular pathology, and be responsible for integrating molecular diagnostic information into their cellular pathology reports.

If you could travel back in time, what would you tell yourself at the start of your career?

When I was interviewed for my Chair in Sheffield, I said that I had tried to advance on the three fronts of diagnosis, teaching and research, and that I had never regarded one aspect as more important than another. It made a good impression at the time but, regrettably, is an increasingly anachronistic approach. I have had a wonderfully enjoyable career that has taken me round the world with more than 400 invitations in 58 countries, and I realize that I could never have been a full-time researcher – I would always have questioned why I had a medical degree. Nevertheless, it is a brutal fact that academic careers flourish because of research performance. Teaching and diagnostic work actually count for little in terms of academic advancement, and I think it’s now impossible to do all three well.

With that in mind, I would tell myself to be more ruthlessly calculating about the career steps I take, particularly in relation to research. The longest period of full-time research I ever had was six months at the University of Nice, where I published three papers on reproductive immunology. I never held a research fellowship with, for example, the Cancer Research Campaign (now CRUK), the Wellcome Trust or the Medical Research Council. I was promoted too quickly, too young, but I suppose it all came out in the wash. Now I’m happily working part-time in Leeds, where I started 35 years ago. Plus ça change, plus c'est la même chose!

You’ve achieved a lot in your career to date. What are you most proud of?

Sure, it’s been a great career, but my biggest source of pride? I’d have to say my children.