Pathology – perspectives for the next 10 years

Årsmøtet DNP 17-18 mars 2011 Inger Nina Farstad, Department of pathology, Oslo university hospital

Ca 2500 employees (incl research activities)

What questions were asked when we organized Department of Pathology?

•  How can we descrive the Department to doctors, cooperative partners, the Hospital in general? (4 hospital departments, additional molecular lab)

•  How can responsibility be handled; information, decisions, implementing change

•  How can we visualize our activities

•  Is the organizational chart also a tool to achieve strategic plans? –  Laboratories with similar acitivties colocalize –  Subspecialization of pathologists; 9 diagnostic groups –  Integrate science and diagnostic pathology as much as possible

Avdeling for patologi

Avdelingsleder Inger Nina Farstad

Seksjon for diagnostiske faggrupper

Seksjon for hemato-patologi

Seksjon for hist og obd

Seksjon for spesial-

laboratorier

Seksjon for kvalitet

Seksjon for driftsrelatert

støtte

Seksjon for eksperiment.

patologi

Enhet for Gastro, HPB

Enhet for Hjerte, Nyre, Lunge

Enhet for Hud, Øye

Enhet for Nevropatologi

Enhet for ØNH, Ben, Bløtvev,

Barnesvulster Enhet for

Gynekologisk- og mammapatologi

Enhet for Urogenital patologi

Enhet for Perinatal, sv. skaps-

relatert – og obd patologi

Enhet forMolekylær-lab

Non-hematopat

Enhet for FLOW (lab)

Enhet for Hematopatologi

(Leger og forskere) Enhet for

Molekylær-lab Hematopat

Enhet for Histologi Ullevål

Enhet for Obduksjon

Enhet for Histologi

RH/Radium Enhet for Histologi

Aker

Enhet for Cytologi

US inkl immuncyt

Enhet for Cytologi RH/Radium

Enhet for Immun/FISH felles

Enhet for Elektronmikroskopi

(RH/US)

Enhet for Kontor, Ekspedisjon

Enhet for Adm. støtte,

Sakarkiv, Økonomi

Seksjon for forsknings

støtte/kjerne fasiliteter

Enhet for Biobank Vevshåndtering for eksterne oppdrag

Enhet for Avansert mikroskopi

Enhet for Lab for

forskningsstøtte (immun,

vevsmatriser,)

Adm konsulent Adm rådgiver

Kval råd

LIS

For gr JMN

For gr BD

For gr ZS

For gr QP

For gr VF

For gr RH

For gr HH

For gr OPC

For gr FJ

For gr FPR

For gr IHM

For gr GH

For gr JM For gr BR

For gr TS

Strategiråd/”Faculty”

Aker utestasjon Frsyesnitt, møter med klinikere, løpende relevant diagnostikk

Ullevål Perinatal- og obduksjonspatologi Gastro-HPB-patologi Lungepatologi Ikke-malign gyn og mammapatologi Cytologi (inkl lav-terskel poliklinikk Lab: Histologi, immuncyt, obduksjon

Rikshospitalet Hjerte-nyre-lungepat Hudpatologi Gastro-HPB-patologi Nevropatologi ØNH-patologi Cytologi Lab: EM, histologi, immun

Radiumhospitalet Hematopatologi Ben-og bløtvevspatologi Uropatologi Gyn- og mammapatologi Thyreoideapatologi Cytologi Lab: Molekylær, flow, histologi

Gastrokirurgiske og medisinske preparater 1 overlege, 1 LIS, 1 bioingeniør, 1 sekretær fra Aker til UUS *

Uropatologi, thyreoidapat, 1 overlege, 1 LIS, 1 bioingeniør fra Aker til Dnr *

Eksterne gastroprøver (fra Lovisenberg) 1 overlege, 1 bioingeniør, 1 assistent fra Aker til RH

Hematopatologisk diagnostikk, gyn kreft, 1.5 overleger. 1 LIS fra UUS til Dnr

Elektronmikroskopi, nyrediagnostikk, deler av hud-diagnostikk 2 overleger fra UUS til RH

Avd leder, adm rådgiver, obduksjon? Kvalitetsråd fra RH til Ullevål

Flyttinger internt

Avdeling for patologi

2011

* * Det settes opp en turnus der overleger og bioing fra Ullevål og Rad vil betjene utestasjonen på Aker

Challenges/possibilities for the future •  Influence from the clinic

–  Requests for molecular tests increase –  Diagnostic accuracy – standardized reports with many details,

large sections for many surgical samples –  Protocols for clinical trials –  ”Subspecialization” by pathologists is requested –  Digitalization –  Integration of different modalities

•  Sentralization –  Consequence of using specialized techniques demanding

particular equipment and skills (flow cytometry, molecular testing, electron microscopy)

–  ”Networking”?

The important questions •  Will clinicians continue to admit samples to

pathology departments, or will other modalities take over (high throughput sequencing, PET-CT, and so on?)

•  What will be the role of autopsy?

•  How, or why, should pathologists continue to represent ”the hidden science behind clinical decision-making”?

What do we learn from Dnp’s yearly reports of pathology activity in Norway?

•  Number of samples continue to increase, but not dramatically

•  Number of blocks and slides increase much more •  (Large sections increase due to clinical protocols; in former

RiksRadium by ca 25% per year)

•  Supplementary tests increase; especially immunohistochemistry and other

•  Cytology by pathologists (punksjoner) increases (?)

Example: Molecular tests

Example: flow cytometry

2010: 4150 samples

2010-11: Increasing no of samples from external doctors/institutions

Challenges cont’d … •  Economy, economy, economy

•  Lack of pathologists to meet increasing prevalence of people living with cancer –  But Norway is lucky; ca 200 pathologists for a

population of 5 mill (1/2500 people) –  Many European countries have much fewer

pathologists and struggle to recruit younger collegues

•  Hazardous chemicals –  Formalin and xylene, and many others

European perspective (EAPCP training programme)

- The pathologist of the future can only be a key player in the field of molecular diagnosis if s/he is well aware of new therapies, and actively involved in health care systems

- To have more time for the increasingly complex diagnostic processes, the pathologist has to consider leaving the simpler diagnostic work to paramedically trained personnel (pathologist-assistants)

- Pathologists will play an increasingly important role in the field of quality assurance

EAPCP cont’d - Digitalisation and microscopical evaluation from the screen

instead of through the microscope will have an impact on internal reporting and external consultation. A potential danger of this development is “outsourcing” of diagnostic work to commercial companies, resulting in less direct communication between the clinicians and the pathologist. This ‘results-only’ service could also have an adverse impact on training

- New imaging techniques as RAMAN and OCT could possibly replace histopathological diagnosis in some settings. More accurate imaging techniques will follow

So what? •  The pathology department: a strong diagnostic unit at low

cost (?) –  Patient perspective: correct diagnosis from pathologist

improves clinical decision making

–  Only 1 out of 4 cancer patients benefit from chemotherapy, but all experience adverse effects (Smeland, several lectures)!

–  Contribution from science and method/procedure improvement: survival impoves significantly (examples: lymphoma, sarcoma, lung cancer)

•  Who do we want to be? –  The visible science providing optimised clinical decision-

making …pathology is cheap compared to treatment regimes; especially those that will not work …

Department of pathology OUS; Vision 2010-2015

•  Digitalize diagnostic pathology

•  Diagnoses are documented by photos (macro and micro) and by standardized reports

•  Formalin is exchanged with another fixative (??)

•  We have state-of-the-art supplementary methods to support diagnoses – particular focus on molecular techniques

•  We have PhD programs for residents and for basic science students combining basic science and diagnostic challenges

•  As a basis for these PhD programs we accomodate research groups who define their projects independently of the Department

•  We are assembled at one, or at most two, geographical sites (maybe with ”satellites”)

How can we achieve this? •  Appeal to the Board of Pathology specialty: reduce the

requested no of autopsies to giv more room for specialised techniques – molecular pathology in particular

•  Recruit the people we want –  Clear goals (vision) –  PhD programmes –  Research facilities –  Transparent H&R policy –  Career paths

•  Speed up education and training of young pathologists; employ ”pathologist assistants”

How … •  Organize the infrastructure well

–  Pathologists close to ”their” labs –  Persons responsible for methods identified –  Educational programs for technicians (master degree)

•  Establish and pursue diagnostic groups –  (g-i,-, uro-, skin-, etc pathology) to meet clinicians demands

for suspecialization (”spisset kompetanse”) –  research integrated within these groups; leaders responsible

for this activity

•  Cooperation with pathology departments in Health Region South East –  Temporary positions (hospitering) –  Research projects