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Inside the Lab Profession, Training and education, Oncology, Digital and computational pathology

Trial by Fire

How did you find your way to pathology and tumor classification?

Initially, I wanted to become a surgeon, but after a brief stint in surgery, I realized I’d be bored pretty rapidly. Broadly speaking, I think you can classify physicians into those interested in curing disease and those interested in understanding it – and I realized that I was more interested in the latter. And by chance, when I decided that surgery wasn’t the career for me, a position opened in pathology. I’d never thought about pathology, but it was love at first sight. I’ve never regretted it for one moment.

Tumor pathology has always been one of my major interests. The striking variety of different tumors is a big puzzle, and I’ve had a lifelong interest in walking the thin line between experimental pathology and diagnostic pathology to try to solve it. Recently, I’ve been lucky enough to get involved as a series editor of the World Health Organization’s tumor classification series – one of the most influential things I’ve done, and a real pleasure. We’re recording the transition from pure morphology to molecular classifications that impact the way patients are treated.

Pathologists have always looked at patterns of gene expression as they are reflected in morphology – but for a long time, we didn’t know which genes were involved. When I became a pathologist, morphology was the endpoint of what we could contribute to disease diagnosis. Now that we have a better understanding of genetics, it’s only the beginning. Morphology allows us to use microscopic tissue analysis to select which samples and tests to use, while molecular analysis allows us to understand tumor pathways and heterogeneity. So I don’t think the morphological dimension of our work will disappear; rather, it has become the foundation upon which the molecular dimension is built. And that’s not just something for a happy few; it will impact the way every diagnostic pathologist works.

It will impact the way every diagnostic pathologist works.

Can you talk about your work in resource-poor communities? How have digital tools helped?

I’ve always perceived myself as a global citizen. Although I’m Dutch, I spent my boyhood in South Africa, which gave me a head start on feeling comfortable wherever I am in the world. In all of my leadership positions, I’ve actively looked for a partner institution in a resource-poor country to assist with pathology development. One reason for this is because the first position I held as a young pathologist was in Suriname, where I was confronted with a totally different pattern of disease and a significant lack of infrastructure. It was trial by fire! So I’ve spent my career trying to help others in similar positions – from Cuba to Cameroon.

Digital tools haven’t changed the way pathologists look at tissue – but they have enormously facilitated things like training and long-distance consultation. At the moment, I spend about a month each year educating medical students in Nepal and supporting pathologists there. Virtual microscopy has allowed them to team up with expert pathologists all over the world much more easily. Pathology is pretty much the same everywhere, and Nepalese pathologists are well-trained. They’re familiar with the sophisticated approaches of cutting-edge pathology, but they don’t have the infrastructure to use many of them – not even ones we take for granted, like immunohistochemistry – so they lack the information we use to diagnose and classify disease.

What are the biggest challenges currently facing pathology?

Most pathologists are still mainly interested in what they can do with a microscope. But if the people involved in day-to-day diagnostics remain attached to their microscopes, they’ll miss out on the molecular revolution. I think that’s the main challenge in pathology right now: to reshape the discipline in such a way that pathology remains a key element in understanding disease, and goes beyond tissue samples to offer a molecular understanding of disease and therapy.

It’s also important to get the public eye on pathology. It’s not a very flashy discipline; a surgeon who has done some spectacular interventions with immediate success is much better perceived than a pathologist who is quietly sitting in his office, looking through a microscope. But pathologists can change that. We should be much more actively engaged in interaction with the public, teaching them who we are and showing them the importance of what we do.

What’s the most interesting thing you’ve learned in your career?

The importance of education. This ties in with one of the main challenges in pathology, the lack of public awareness and the need to send the message that it’s in an absolutely fascinating new phase of its development. The impact of a serious effort at any level of education, is absolutely crucial – and not only in terms of conveying factual information, but also in being a role model. It’s not only about classroom teaching; it’s a more holistic vision on the role of an educator. I’ve enjoyed research, but over time, I realized that the cited half-life of a good paper is only a few years. The half-life of a good educational effort is a generation – a pathologist’s entire career.

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