Caution for Cancer Care

A 12-year study presenting global trends in cancer survival showed a marked gap between the five-year survival rate of patients in China and those treated in the US and Australia (1). There are many reasons for this disparity, but, in my opinion, the most critical is the low-end level of pathological diagnosis of cancer in China.

One reason for this lies in a severe shortage of pathologists in China. There are around 10,000 licensed pathologists in the country, of which 70 percent work in tertiary hospitals within large cities (2). This mis-distribution – combined with the shortfall of around 90,000 to 110,000 pathologists – puts patients at risk of unsatisfactory care. A former colleague, who is now the pathology director in a large Beijing hospital, continues to personally handle specimens and perform tasks usually reserved for pathologists’ assistants, residents, and fellows in other countries.

Many grassroots hospitals have only one or two pathologists, who are overwhelmed with pathological specimens and diagnostic reports, making it impossible to effectively manage workloads. Many of these individuals also lack formal training – having inadequate foundational knowledge and diagnostic skills – which leads to failings in precision and increased risk of diagnostic errors.

Some Chinese hospitals have no pathologists at all, and specimens removed during surgery are often discarded! My mother-in-law recently experienced this from a patient's perspective: after discovering skin nodules, a biopsy confirmed adenocarcinoma, which later metastasized in the brain. After receiving a call from relatives in China, I immediately arranged for a full-body examination. Besides multiple metastases in the liver and lungs, no primary lesions were found in various systems. Her medical history highlighted gallbladder removal a year prior and, after inquiring about the pathology results, I was informed that there was no pathological examination – it had been thrown into the trash during surgery! I was especially shocked because this was a reputable hospital affiliated to my mother-in-law's provincial medical school and the surgeon was one of her students – the head of the department of surgery no less!

Another bottleneck in pathology in China is the low quality of education and training, with no systematic, comprehensive, and standardized training system – in contrast to the four-year residency and one/two years of fellowship in the US. Instead, students are primarily taught via an apprenticeship model. Many pathological practitioners are self-taught with no unified assessment standards, leading to substantial discrepancies in standards and levels between institutions. Naturally, the skills of students can vary widely.

One of my Chinese medical school alumni once asked me to consult about her father’s tumor biopsy and pleural fluid cytology slides along with corresponding immunohistochemical staining. It was evident that it was a lung adenocarcinoma metastasizing to the abdominal cavity, forming metastatic tumor masses. However, it was misdiagnosed as "gastric adenocarcinoma metastasizing to the lung” and all immunohistochemical stains were interpreted incorrectly. Surprisingly, this report was issued by her classmate from our medical school – a pathology professor with 30 years of experience at a prominent hospital with 10 thousand beds, and more than 200,000 surgical specimens.

Even in top-tier hospitals in major cities, such as Beijing, Shanghai, and Guangzhou, irregularities in pathological diagnosis reports are extremely common. Over the years of conducting consultations in China, I have encountered numerous late-stage cancer cases sent by friends or acquaintances to well-known hospitals, including the five most prestigious cancer hospitals in the mainland, top military hospitals, and provincial cancer hospitals. Following the requirements of the College of American Pathologists (CAP), I can confidently say that almost none of those reports were qualified! When we train residents in the US, by the end of the first year they understand how to write a complete tumor pathology report summary (synoptic report) and would not issue reports lacking detailed descriptions or precise tumor staging (pTNM).

This disparity in reporting standards is encapsulated in another personal experience. When my father had surgery for colon cancer in China, I was shocked to see the pathology report comprised only two sentences: “Adenocarcinoma of colon in a 15 cm rectosigmoid colon, moderately differentiated, with five benign lymph nodes”. No tumor invasion depth and no pTNM!

Of course, there’s always hope for advancement, so long as deficiencies are recognized and the pathologist in question is willing to learn and improve. What is frightening is the widespread environment of low standards, especially in major institutions in Beijing and Shanghai.

One area that I and other professionals in the US find alarming is the surge of gene testing diagnostic companies in China pursuing high standards and precision medicine, while many pathology departments in the country don’t work in controlled environments when completing routine immunohistochemical staining. This is a situation I’ve encountered on numerous occasions when consulting on pathology materials from renowned institutions in China – some colleagues from large institutions admitted that this is common practice! How can this be “precision medicine?”

Firstly, we need to ensure quality control of the most commonly used immunohistochemical staining, which is both affordable and leads to effective treatment for patients. While more flashy, gene testing and precision medicine are a superficial leap forward and the modern medical industry won’t advance if the most basic and crucial tasks are not up to standard! It is estimated that over 300 gene testing companies reside in China, while only a handful in the US are FDA-approved.

I’ve previously faced criticism for discussing, on an online forum, problems with using intraoperative frozen diagnosis of breast cancer. This practice – that was replaced in the US 20–30 years ago by preoperative image-guided fine-needle aspiration biopsy (3,4) – is still used to guide surgeries in China, despite its high misdiagnosis rate. Another discussion on the forum concerned gastric cancer treatment following the release of the US NCCN Guidelines (5). With most of the data coming from Japan, South Korea, and Western Countries – and no mention of the 200,000 to 300,000 cases of gastric cancer in mainland China – this raises the question: who should feel ashamed? I believe it’s not just China’s oncologists, but all pathologists worldwide.

Pathologists, honored in the West as "the doctor's doctor," bear the crucial responsibility of "guiding the surgeon’s hands." Seeing the case reports I consult and the papers published by Zhao Chengquan at the University of Pittsburgh discussing remote pathology consultations between the US and China (where diagnostic discrepancies occurred in more than 30 percent of cases) (6), how can the current pathological "chip" level in mainland China improve the treatment standards of surgical oncology, medical oncology, and radiation oncology?

Our ancestors said, "Know shame and then strive for courage," and "Know yourself and your enemy, and you will never be defeated." Chinese clinical medicine must address the serious key issue of pathology shortsightedness early on; otherwise, the gap in oncology outcomes will only widen, leading to catastrophic consequences on clinical treatment! I hope that the following years will show some improvement in medical discrepancies, for our patients’ sake.