Oncology Care Coordination with In-House Testing

An interview with Michael Vieth

How – and why – do you conduct precision oncology testing at your institution?

When a clinician asks us to perform a specific test, our first step is always to identify the most suitable methods. By carrying out all testing in-house, we can adjust these methods to best suit each individual sample, maintaining regular communication with our clinicians to align testing with clinical needs. This benefits the patient because we can provide an immediate response to the treating oncologist, asking for further samples or information if necessary.

In centralized testing, specimens are sent to an external laboratory, which carries risks – for instance, logistical problems with the transit of material or communication issues because there is no direct contact with a physician. By avoiding these issues, in-house testing saves time and money. The entire diagnostic process comes from one source and we aren’t left waiting for an organization to provide analyses without medical advice.

It’s the rare and complex cases that really benefit from in-house testing, because those who conducted the analysis are available to discuss the results. However, different labs have different needs; to ensure that in-house testing is a sustainable option, there must be enough tests required to make the investment worthwhile.

How do different regional costs affect the choice between in-house and centralized testing?

The price that central labs charge for testing varies between regions and countries. Some labs send specimens abroad to be tested – but passing public money from one health system to another raises ethical concerns. Even if specimens are sent to central labs in the same country, they could be outside the national health system and therefore benefit external stakeholders. Different regional costs can also lead to legal issues. Regulations and side costs vary between countries – and if samples sent elsewhere are cheaper to run, that advantage must make its way back to the patient or healthcare system. If the more expensive local price is paid, then the difference could end up as profit for the central lab, which is illegal.

How does test centralization impact local healthcare?

Driving more testing through central facilities can lead to local laboratories “drying out” as knowledge, tests, patients, and money get drawn into the larger central facilities. The biggest damage that I see from losing routine cases is that you lose the ability to carry out basic science and research, which is crucial for many local facilities. Without a certain number of cases on which to demonstrate a particular testing method, it is impossible to educate people. Routine cases are an important part of the educational services of local institutions that offer medical courses – and, for complex tests that require detailed background knowledge, there’s no way to learn if cases (and pathologists experienced in diagnosing them) are not available.

It’s also easier to maintain tissue blocks if they are kept in-house. We have a strict tumor bank and receive up to 10 requests per day from external researchers for samples – but we always request that they return the samples without stepping down the blocks completely.

How does in-house testing make it easier to coordinate patient care?

We recently received a call from the intensive care unit. The head anesthetist had sent me a sample of bronchoalveolar lavage and told me that they suspected the patient had vaped something with an e-cigarette, so we should look for macrophages and lipid-loaded cells. We were able to react to the situation immediately in a way that would not have been possible had the sample been sent elsewhere, because it’s often difficult to reach people at central labs by phone. A pathologist’s second most important tool – after the microscope – is the phone, which is frequently used to retrieve information missing from cases. I often find that, especially in centrally managed labs, people fail to provide all of the necessary details about a certain case. This can be frustrating and delay diagnosis or treatment, so moving testing in-house means that you can collaborate easily and follow up quickly if any information is missing.

Another benefit comes in the form of turnaround times. Our clinicians often call at midday on a Friday and request an urgent test – for example, to determine whether a patient has a particular virus and shouldn’t be allowed home over the weekend, or whether or not a patient should start immediate chemotherapy. We can usually provide an answer that same day, which wouldn’t be possible if we sent the sample to a central lab via an expensive courier that might not deliver the specimen before the following week. If everything is sent externally, the in-house lab will eventually lose the expertise to carry out these urgent cases. Even if 90 percent of cases are routine, it’s these few urgent ones that really prove the value of in-house testing.

Michael Vieth is Professor of Pathology and Chairman of the Institute of Pathology, Klinikum Bayreuth, Germany.