Piloting Progress

The UK’s Independent Cancer Taskforce has a radical new goal: to allow an additional 30,000 patients every year to become 10-year survivors of cancer by 2020 (1). That’s no small number – it’s nearly 10 percent of all cancers diagnosed in the UK, or nearly one-fifth of all UK cancer deaths (2). But it’s not an impossible goal; in fact, we could achieve more than one-third of it – 11,000 patients – by simply diagnosing them sooner. It seems clear that early diagnosis is an area worthy of more attention, and new plans to take action against cancer have sparked a national ambition to spot and stop the disease as early as possible.

Backed by National Health Service (NHS) England chief Simon Stevens, the taskforce’s plans call for significantly increased diagnostic capacity in the NHS. The aim is for 95 percent of patients to receive their results within four weeks, and to provide general practitioners with direct access to key investigative tests. But numbers alone will not be enough to deliver the increased diagnostic capability needed to make these ambitions reality. And when it comes to pathology – a key player in cancer diagnosis – many of the processes and practices in the NHS remain largely unchanged since the birth of modern pathology in the 19th century. The discipline has also been facing diminishing capacity and now battles with the serious challenge of attracting younger people, many of whom don’t relish the idea of decades at a microscope. So how can the NHS deliver the diagnostics needed to make it a reality?

A move toward modernization

The first step into modernizing pathology is a big one – we need significant and immediate action to provide pathology departments with the technology that more and more pathologists want. The attraction of sharing expertise and findings with clinical colleagues, no longer needing to handle (or fear losing) hundreds of slides, and rapid reporting is clear. And all of this is achievable with digitization, a move that’s already having an impact on improved diagnoses and timely cancer care in other parts of the world. Put simply, the microscope can no longer be a pathologist’s only tool if a health service wants to increase its lifesaving abilities by tens of thousands of lives every year.

The good news is that pioneering parts of the NHS are already changing the status quo. Salford Royal NHS Foundation Trust has become a pioneer in the north of England by piloting a digital pathology system that has shown immediate benefits for speedy and connected pathology reporting. In this pilot program, the trust chose neuropathology for digitization due to the pathologists’ familiarity with digital images – and it seems to have paid off. Despite initial hesitations, the pathologists became very enthusiastic very quickly, declaring the system intuitive and easy to use. Though they still had microscopes, they rapidly moved to a primarily digital method of reporting and now insist that they don’t want to go back to their old systems. They’re pleased to be able to compare multiple slides at once on the same screen, with extremely high standards of image quality. They’re noticing the ability to report much more quickly and effectively, no longer having to keep manually changing slides. And, crucially, reception in multidisciplinary team meetings has been very strong; images and specific areas of samples can be shown quickly on screen, eliminating the time-consuming processes of preparing and loading slides to share with clinical colleagues. Thanks to these simplified processes, turnaround times have decreased considerably with the introduction of digital imaging.

Salford Royal’s pathologists have noticed less tangible benefits, too. “You feel more in command of the case,” explained Daniel du Plessis, a consultant neuropathologist and clinical lead in the department. He highlights the ability of an efficient system to help him maintain focus and momentum, and adds that the system’s ease of use offered an incentive to tackle even non-urgent cases quickly. He and his colleagues all report different benefits of their new methods – comparing multiple stains on a single screen, rapid access to archived images, easier communication with other specialists, better teaching and training – and they’re not the only ones interested. The results of the digital pilot have intrigued pathologists and clinical staff both within the trust and at other hospitals throughout the region and beyond. A conference held at Salford Royal this year showed a huge appetite for digitization from pathologists who turned a question-and-answer session into a passionate open discussion on regional collaboration, the potential for “super-labs,” and ways to make digitization into a reality.

Lessons from radiology

As a former NHS radiographer, I have seen the clinical benefits of digitization firsthand. Radiology embarked on the digital journey 15 years ago to eliminate the loss of X-rays in the backs of people’s cars and from the drawers of their desks. At the time, 10 to 15 percent of all images were being mislaid – and you can imagine the impact it had on timely care. Digitizing radiology solved that problem, but the transformation was much broader than that. Hopefully, as a closely related diagnostic discipline, pathology will fare even better as it builds on the technologies already deployed in many hospital radiology departments and learns from what was done in its fellow diagnostic discipline only a decade or two ago.

But when transitioning to digital imaging, radiology had one luxury pathology lacks – central funding. Now, each hospital must find its own way to fund digitization. It isn’t be easy at a time when NHS purse strings are held more tightly than ever, but there are options: large trusts with control over their own budgets can procure pathology solutions and sell them to other hospitals to generate revenue, while hospitals in smaller trusts can collaborate to buy a shared system.

Whether large or small, the challenges of moving to a digital workflow aren’t coming from pathologists, many of whom would like to make the transition sooner, rather than later. There’s a real hunger to shift to digital, which we’ve seen with the Salford Royal pilot program. Clinicians and radiologists in the north of England are eagerly watching what Salford is doing. The only dissatisfaction seems to be impatience: the pathologists who are already using digital systems want to see them everywhere. “If we had this system pan-Manchester, it would revolutionize pathology,” said Anne Yates, the cellular pathology services manager at Salford Royal. It would prevent having to package and send slides from one hospital to another when a patient needs specialized care only available in certain locations. In discussing the potential for a digital neuropathology network, du Plessis echoes Yates’ sentiments. “It would be wonderful to have this system, which has much better quality images, which is much easier to navigate, to provide intraoperative smear cover or to share cases immediately,” he said. “This would allow us to do what we do far more efficiently.”

So what’s holding up digital implementation across the board? The challenges are at the organizational level, not in the clinic. But with an opportunity for cancer outcomes on the NHS to match those of the countries with the highest survival rates, organizational differences simply aren’t a good enough reason not to proceed. In my opinion, the NHS should now prioritize enabling its hospitals to move away from analog approaches to pathology. Only by digitizing can we match growing demand, increase access to specialist expertise, and improve the speed and accuracy of reporting. And when we do those things, we achieve the kind of timely intervention that can save lives.