Peer-to-Peer, Featuring Fátima Carneiro

Fátima Carneiro is Professor of Pathology at the Medical Faculty of Porto University and a senior staff member at one of the University’s scientific Institutes, Instituto de Patologia e Imunologia Molecular da Universidade do Porto – better known around the world as IPATIMUP. Internationally, she is renowned for her contributions to gastrointestinal pathology, including research on the molecular pathology of sporadic gastric cancer and hereditary gastric cancer syndromes. In Europe, she is also known for her many leadership roles in the European Society of Pathology (ESP), for which she gave numerous seminars, actively collaborated on the European School of Pathology, and served as its President. Most recently, she was co-editor of the latest edition of the World Health Organization (WHO)’s Blue Book on gastrointestinal pathology, helping diagnostic professionals around the world recognize and diagnose diseases of the digestive system. She was also voted #1 in our 2018 Power List, nominated by multiple colleagues and lauded for her work by our expert panel of judges.

Throughout her four-decade career in medicine, Fátima Carneiro has learned a lot about pathology, both within and outside her specialty. Now, she shares some of those lessons.

How did you decide to become a pathologist?

I made the decision after graduating from medicine. Until that point, my dream had been to become a pediatrician – quite a different discipline! So what happened to change my mind? It was 1978 and I had just finished the medical course at Porto University. At the end of my final academic year, my professor of cell biology invited me to become a monitor on his team! It was an unexpected invitation – but, after briefly hesitating, I told him that I thought cell biology was a bit too a quiet for me and did not meet my career expectations. It was his turn to be taken by surprise; such invitations are rare and I should have considered it a high compliment. He asked me about my expectations, which were very clear in my mind. I wanted to participate in clinical activities in the hospital; to participate in teaching, which I had loved ever since I had taken my first clinical medical course; and to do research. After I told my professor all of this, he told me I should go into pathology. I had never thought about the possibility before, but his proposal sounded good, so I went to the Department of Pathology to speak to the professors there – Daniel Serrão and Manuel Sobrinho-Simões. The latter, well-known for his affability, replied with a fair degree of curiosity that I could begin working with him the next day. That day turned out to be the first of a lifelong experience.

When I entered the discipline, pathology was quite popular – at least in the School of Medicine/Hospital São João, where I studied. Candidates were recruited from among the best students, who were attracted by the opportunity to combine professional medicine with a research career. Today, the scenario is different. The recruitment system is solely based on the ranking candidates obtain in a national examination; professors and department heads have no input into student selection. And unfortunately – but completely understandably – candidates nowadays make their choices according to their expectations for a future in well-paid employment, an area in which other specialties are much more competitive than pathology.

Why did you focus on gastrointestinal pathology?

I began by working in thyroid pathology with Manuel Sobrinho-Simões. Along the way, he decided to redirect some of his students to gastric cancer research, because the disease is so prevalent in Portugal (and because, as a result, it attracts much more funding). Luckily, I was one of those students, because I quickly got interested in gastric carcinogenesis. Later, as a second-year resident, I added liver pathology to my interests. Ultimately, I was able to complete an internship in digestive pathology in Leuven, Belgium, with Valeer Desmet and Karel Geboes, which played a conclusive role in my attraction to the field of GI and liver pathology.

I have been fortunate enough to have had the opportunity to make numerous contributions to that field over the years. In my opinion, the most important of these is my work on hereditary cancers affecting the stomach. I worked with the International Gastric Cancer Linkage Consortium (IGCLC) and, early on, I began studying the pathology of hereditary diffuse gastric cancer (HDGC). More recently, I had a similar experience in the characterizing the histological profile of GAPPS (gastric adenocarcinoma and proximal polyposis of the stomach) syndrome with Xiaogang Wen. Together, we spent countless hours studying the full length of the gastric mucosa in stomachs removed from carriers of germline mutations of the CDH1 gene, as well as hundreds of digital images of GAPPS. But the work was worth it to improve the lives of patients with these diseases.

It was also a privilege to work on the WHO book, “Tumors of the Digestive System” (4th Edition, 2010). Fred Bosman (to whom I express my gratitude for this experience) invited me to act as a co-editor for the sections concerning the upper GI tract. The hardest parts, in my opinion, were complying with the deadlines and dealing with the differing opinions of the contributors who attended our consensus meetings. Each of them was chosen for their contributions to the field and thus deservedly considered an authority in their subject. How do you challenge the opinion of a world expert? How do you come to a consensus on controversial topics? It was not easy, but the four editors – Fred Bosman, Neil Theise, Ralph Hruban, and I – worked well as a team. We got the work done!

Tell us about your work with the European Society of Pathology…

The ESP presidency was probably the most demanding period of my professional career. The motto of my presidency was “Education in Pathology,” so I focused on the following three areas: 

1. Reinforcing the role of the ESP in the field of pathology education, which included: a) developing e-learning initiatives and maintaining and expanding courses in the framework of the European School of Pathology (EScoP) and tutorials at ESP headquarters in Brussels, b) supporting residents and trainees with bursaries for participation in ESP congresses, and c) supporting the maintenance of progress tests at the European level as a tool to harmonize graduate education in pathology.
2. Reinforcing internationalization and linking pathology with other international organizations in laboratory medicine, and in medicine in general. Under my presidency, the ESP also revised its rules and statutes and joined the Alliance for Biomedical Research in Europe.
3. Reinforcing links with national pathology societies in Europe. ESP provides scientific and financial support to numerous national societies for educational activities and academic development.

Filling the position of President gave me a “go-for-it” approach to problems and challenges while maintaining my professionalism. It helped me to improve the society’s management approach so that we could better deliver advances in science, achievements in basic and advanced education, and good quality diagnostic services for the benefit of patients.

According to a recent survey of national pathology societies in Europe, the burning issues affecting us today are:

• insufficient recruitment of young doctors, resulting in a critical shortage of pathologists and excessive workloads,
• low salaries in many countries without higher pay for higher performance, and
• loss of motivation and “brain drain.”

This scenario is not good at all, but I think we should view these challenges as opportunities. The ESP may be able to help bridge the gap between academic (research-driven) and clinical (service-oriented) pathology. With such a wide remit, though, there is no “one-size-fits-all” solution because our specialty has developed so heterogeneously across Europe. Many countries have adequate pathology services. Unfortunately, some more realistically qualify as precarious – they need major, immediate action to improve the health of their pathology services. The ESP does what it can, but sadly lacks the power to make all of the necessary changes in each country.

The society’s mission is “to promote high quality diagnostic practice, applied and translational research, and under- and post-graduate education in the field of human pathology.” The current leadership, President Dina Tiniakos and Director-General Raed Al Dieri, is discussing the ESP strategy for the near future. Two recently launched initiatives deserve to be highlighted: the ESP Alfonso Giordano Fellowships, which promote advanced training for young pathologists in selected centers of excellence throughout Europe, and the newly launched ESP Junior Academy, whose goal is to stimulate the development of future pathologist-scientists.

What do you consider your greatest achievement to date?

I am proud of my involvement in pre- and post-graduate teaching in histopathology and molecular diagnostics. But beyond that, I am proud of two things. One is my seniority in my main field of interest – gastric cancer – reflected in collaborations with several scientific societies, about 200 papers on gastric cancer (and over 350 peer-reviewed publications in total), and authorship of chapters of multiple well-known and well-loved gastrointestinal pathology textbooks. The other is my international networking through teaching, research, and professional initiatives. I have collaborations on four continents – North and South America, Africa, Asia, and Australia – as well as my work in Europe.

What advice do you have for our younger colleagues?

The pathologist of the future must be able to understand the mechanisms of disease and to translate new knowledge to patient care. That is a question of education and learning; you must envision pathology as both a profession and an integrative discipline. Pathology is an amazing discipline, and one that plays a pivotal role in clinical medicine and in all of our efforts to better understand disease.

Fátima Carneiro is Professor of Anatomic Pathology at the Medical Faculty of Porto, Head of Anatomic Pathology at Centro Hospitalar São João, and Senior Investigator at IPATIMUP, Porto, Portugal.

Ivan Damjanov is Professor of Pathology at the University of Kansas School of Medicine, Kansas City, USA.