Interpersonal Pathology

Publicizing pathology remains one of the discipline’s greatest challenges. Many pathologists agree that it’s important to teach the general public what the “people behind the microscopes” actually do, but fewer seem clear on how to accomplish this. And fewer still are targeting the people for whom this kind of education would be most useful: the patients themselves. With a constantly growing, constantly aging population, pathologists are processing more diagnoses than ever – so why not step out from behind the microscope and speak directly to those patients? Marc Rosenblum, director of neuropathology at Memorial Sloan Kettering Cancer Center, spoke to us about his experiences with patient interaction.

Are your patients aware of pathologists’ important role in their care?

I don’t believe there are many patients who comprehend the extent to which pathologists guide their “hands-on” colleagues in medicine and surgery. To take the area of neoplastic disease as an example, I imagine that few patients realize pathologists are responsible for so many different tasks. We identify tumors, classify them, indicate their biologic potential, determine the extent of disease, assess the adequacy of surgical excision by inspecting tissue margins, and often interpret immunohistochemical, cytogenetic and molecular genomic tests. It’s important for patients to understand that we’re not only involved in the diagnosis and monitoring of disease, but also in prediction and prognosis – some examples include hormone receptor (estrogen, progesterone, HER2) status in mammary carcinoma, or isocitrate dehydrogenase (IDH) and chromosome 1p/19q status in diffuse glioma.

So you feel that pathologists should make themselves available to patients?

Yes. To those who wish to discuss their findings, but I think that a large responsibility for educating the public about pathology also rests with clinicians, and with the medical and administrative personnel who lead their institutions.

When clinicians discuss tissue diagnoses – or any other laboratory-based information – with patients, it’s important to acknowledge the efforts of the pathologists involved. Medical and administrative leadership should ensure that patients have access to written or visual material explaining the roles played by specialists of all disciplines, including pathology, in their care. Accuse me of tribalism if you like – but if you can boast a seasoned pathology staff experienced in the application of state-of-the-art methods to tissue and fluid analysis, why wouldn’t you want to make the public aware of expert pathologists as an integral hospital resource?

Can you give us an example of successful patient contact?

One of my patients had back pain and myelopathic signs secondary to a vertebral tumor compressing their spinal cord. A biopsy of this mass was interpreted (quite understandably, given the histologic picture) as demonstrating a metastatic, mucin-producing adenocarcinoma. But the patient didn’t have a history of neoplastic disease, and extensive radiologic and serologic investigations proved unrevealing. I was asked to review the case in consultation, at which point I suspected that the lesion was a chordoma. Immunohistochemistry confirmed my suspicion, because I was able to demonstrate nuclear brachyury expression in the tumor cells.

The patient contacted me to discuss how I had arrived at my conclusion. I explained that the diagnosis they had initially received was entirely reasonable – but that, over the course of three decades of practice at a busy cancer center, I had become familiar with chordoma in its unusual, as well as typical, morphologic guises. This grateful and generous person actually offered to help disseminate awareness of brachyury as a diagnostic “marker” – as it was then relatively new as a commercially available reagent – and even offered financial assistance if necessary. Since then, the patient has made sure to keep me apprised of their treatment and progress.

You were involved in the treatment of a patient with the melanoma drug vemurafenib, which had a very successful outcome; how did your expertise influence the patient’s care and their personal journey, in particular since the trial the patient was involved in was histology-independent?

Although the patient in question was enrolled in a histology-independent “basket” trial, their eligibility was in fact based on a histologic observation. It fell to me to analyze their neurosurgical specimen and I was struck by certain resemblances between their brain tumor and an uncommon cerebral neoplasm, known as pleomorphic xanthoastrocytoma, that usually presents in childhood or adolescence. That type of tumor often harbors a BRAF V600E mutation. Accordingly, I ran immunohistochemistry for the mutant antigen – and when it turned out positive, I ordered molecular profiling to confirm its presence. That mutation rendered the patient eligible for treatment with vemurafenib, a BRAF inhibitor most commonly used to treat a subset of melanomas. I think it’s noteworthy that this trial demonstrated the non-uniform responses of BRAF V600E-mutant neoplasms to targeted therapy, and found that histology also had an effect on the likelihood of treatment responsiveness.

How has direct involvement with patients benefited you and your patients?

Beyond the personal gratification that I derive when patients express thanks for my services, I find that conversing with them underscores – often dramatically – the stakes involved in what I do as a pathologist. The many discussions I have had with patients and family members convince me that pathologists can help them understand how we arrive at our conclusions, and clarify just what those conclusions mean. At Memorial Sloan Kettering Cancer Center, where I work, this is our way of life as pathologists – and my colleagues and I regard it as a professional responsibility to talk to any patients who want explanations of their findings, or who want to discuss the implications further. Doing so has also helped our relationships with clinicians, who are clearer than ever about the role our assessments play in rational practice.

Direct communication between pathologists and patients is not generally encouraged by healthcare departments – in fact, it’s sometimes actively discouraged. Pathologists in some parts of the United States face regulatory restrictions that bar them entirely from discussing laboratory reports with patients. I think this an unfortunate state of affairs, because direct patient contact can only increase our profession’s visibility and our patients’ understanding of their own health. Open communication brings benefits to us all.