Pushing Pathologists to Pursue Research

And we certainly do live in interesting times. The explosive expansion of our understanding of cancer biology, coupled with the availability of hundreds of “targeted” cancer drugs, has created enormous excitement amongst oncologists, researchers and patients. As the key medical professionals tasked with extracting clinically actionable information from diagnostic tissue samples, pathologists find themselves with an enviable opportunity to improve the lives of cancer patients by expediting the clinical implementation of new concepts and technologies. However, as implied by the apocryphal Confucian curse, “interesting times” present challenges as well as opportunities. Here, we discuss some of our own tried and tested approaches for ensuring that both new and existing pathologists grow familiar with these novel concepts and technologies, allowing them to expand their molecular repertoire.

Connecting and coordinating

The Ontario Molecular Pathology Research Network (OMPRN) was established in the spring of 2016 as a program of the Ontario Institute for Cancer Research (OICR) to increase the involvement of practicing, hospital-based pathologists in high-quality applied cancer research. This investment of almost CA$4 million over four years reflects recognition by the OICR of the important role that pathologists can – and should – play in connecting and coordinating diverse cancer research activities across the province. For example, pathologists can contribute to the design and undertaking of biomarker research associated with clinical trials and, importantly, pursue their own research questions in a manner informed and augmented by transdisciplinary collaboration. At the same time, they can help basic and clinical scientists gain appropriate access to high-quality biospecimens.

In deciding how to deploy resources to maximal effect, organizations must consider the multiple roadblocks that prevent practicing pathologists from becoming fully involved drivers of research. These include limited time available for research pursuits, limited training in research design or techniques, limited access to specialized technical resources, and the extremely competitive nature of the current research funding environment. With these issues in mind, we elected to provide targeted funding for pathologist-led, transdisciplinary research projects. In addition, because education represents a cost-effective and feasible means of guiding and encouraging the adoption of new concepts and methods in research and practice, we also prioritized the education of pathologists and pathology trainees.

Education, education, education

One way we address this educational priority is by requiring both transdisciplinary collaboration and active participation by a pathology trainee in the research projects we fund. That helps us to broaden the experience and career options of trainees and incentivize collaboration across interdisciplinary boundaries. The fact that trainees self-select or are nominated for involvement in research projects helps direct our investment to motivated individuals. Trainees and early-career pathologists who obtain funding through the grants program also automatically join OICR’s Pathology Club, whose members meet quarterly to report on the progress of their projects and obtain advice from peers and experienced researchers. The Pathology Club complements the grants program and contributes to the development of a peer group of motivated young pathology investigators.

Connecting and coordinating

The Ontario Molecular Pathology Research Network (OMPRN) was established in the spring of 2016 as a program of the Ontario Institute for Cancer Research (OICR) to increase the involvement of practicing, hospital-based pathologists in high-quality applied cancer research. This investment of almost CA$4 million over four years reflects recognition by the OICR of the important role that pathologists can – and should – play in connecting and coordinating diverse cancer research activities across the province. For example, pathologists can contribute to the design and undertaking of biomarker research associated with clinical trials and, importantly, pursue their own research questions in a manner informed and augmented by transdisciplinary collaboration. At the same time, they can help basic and clinical scientists gain appropriate access to high-quality biospecimens.

In deciding how to deploy resources to maximal effect, organizations must consider the multiple roadblocks that prevent practicing pathologists from becoming fully involved drivers of research. These include limited time available for research pursuits, limited training in research design or techniques, limited access to specialized technical resources, and the extremely competitive nature of the current research funding environment. With these issues in mind, we elected to provide targeted funding for pathologist-led, transdisciplinary research projects. In addition, because education represents a cost-effective and feasible means of guiding and encouraging the adoption of new concepts and methods in research and practice, we also prioritized the education of pathologists and pathology trainees.

Education, education, education

One way we address this educational priority is by requiring both transdisciplinary collaboration and active participation by a pathology trainee in the research projects we fund. That helps us to broaden the experience and career options of trainees and incentivize collaboration across interdisciplinary boundaries. The fact that trainees self-select or are nominated for involvement in research projects helps direct our investment to motivated individuals. Trainees and early-career pathologists who obtain funding through the grants program also automatically join OICR’s Pathology Club, whose members meet quarterly to report on the progress of their projects and obtain advice from peers and experienced researchers. The Pathology Club complements the grants program and contributes to the development of a peer group of motivated young pathology investigators.

The OMPRN also facilitates access to a series of workshops that help pathologists and trainees acquire skills applicable to pathologist-driven research. Workshops that have already taken place or will take place in the near future include sessions on gene expression profiling, fluorescence in situ hybridization, PCR-based analyses, next generation DNA sequencing, bioinformatics, biostatistics, computer-assisted image analysis, and the design and conduct of clinical trials. We develop and host some workshops in-house, and in other instances we encourage pathologists to attend workshops run by other organizations (for which we cover the associated costs). In considering the content of these workshops, we intend to complement the educational opportunities available to pathologists and trainees at their home institutions. In our experience, initiatives like these can help both trainees and working pathologists to update their knowledge and stay current.

The rise of molecular methods

Until recently, Canadian pathology training programs have devoted a relatively small portion of their curricula to molecular concepts and techniques. This is despite the fact that clinicians are already relying on molecular data to guide their decision-making. Well-known examples include the use of mRNA-based gene expression analyses and EGFR gene sequencing in breast cancer and non-small cell lung cancer, respectively. Mid-career pathologists are already adapting their practices to incorporate molecular methods – so pathology training programs, both in Canada and around the world, must prepare their trainees accordingly.

Collaboration is the key. We are working with pathology representatives at the Royal College of Physicians and Surgeons of Canada (RCPSC) to inform the evolution of pathology training curricula not just in Ontario, but across Canada. Our goal is to work with the existing governing bodies to ensure that all “freshly-minted” pathologists can practice competently in the molecular era.

With this in mind, an important near-term challenge for all educators is to decide which molecular concepts and competencies are likely to be of most use to practicing pathologists – and to ensure that they are introduced during training.

Worthy candidates include (1):

• theoretical knowledge about genomics, epigenetics, gene regulation, protein structure and function,
• applied knowledge pertaining to the indications for molecular testing,
• pre-analytical variables that may affect testing results, and
• the interpretation and clinical implications of results.

Once identified, these priorities can inform recommendations for modifications to residency training programs. We expect that revised residency curricula will use a combination of didactic instruction, “on-the-job” training during subspecialty rotations, independent reading or computer-assisted instruction, and, when specialized resources are required, off-site workshops sponsored by the OMPRN or others. We began this process by convening an Education Committee that includes researchers in pathology and diagnostic molecular genetics. The Committee reviewed current literature, considered what Canadian residency training programs are already doing to incorporate molecular content into their curricula, and generated a draft list of molecular competencies. Then, we initiated a dialogue with the RCPSC Specialty Committee in Anatomical Pathology. At the moment, we are looking forward to working with them, pathologist educators and other stakeholders in the Canadian oncology community to modernize pathology residency training.

Evolve to survive

Many people equate the medical specialty of pathology exclusively with histopathology. As our colleagues will know, this is a simplistic view – it ignores the important evolutionary changes of the last several decades that have required pathologists to incorporate molecular assays into routine diagnostic practice. However, it remains largely true that pathologists themselves still tend to consider conventional histology their primary diagnostic approach and typically refer to molecular techniques as ancillary at best.

But the technical and intellectual landscape in oncology is changing rapidly. To stay current – and to improve the experiences and outcomes of patients – pathologists, laboratory-based clinical scientists, clinical oncologists and colleagues must work together seamlessly, and perhaps even reconsider the boundaries that have historically defined their respective disciplines. We hope that our own efforts in this area can provide inspiration to other pathology organizations seeking to embrace the latest developments in molecular science.

David LeBrun is Network Leader of the Ontario Molecular Pathology Research Network and Principal Investigator in the Cancer Biology and Genetics Division of the Cancer Research Institute, Queen’s University at Kingston, Canada.

John Bartlett is Education Lead of the Ontario Molecular Pathology Research Network and Program Director of Diagnostic Development at the Ontario Institute for Cancer Research, Canada.

We thank Rebecca Tamarchak for her insightful comments on the manuscript.