When it comes to diagnosing cancer, radiologists examine digital images and pathologists scrutinize slides. Only occasionally do the two collaborate prior to meetings of the tumor board or multidisciplinary team (MDT). Wouldn’t it better serve all parties involved—oncologists, surgeons and, first and foremost, patients—to unite the two main diagnosticians in a common, speedy workflow that launches the moment each sits down to interpret his or her respective visuals?
For sure and we are on the path, says Daniel du Plessis, MD, of Salford Royal Hospital NHS Foundation Trust, a 728-bed hospital in Salford, U.K., and one of the sites that has piloted a digital pathology system in development by Sectra. Du Plessis specializes in neuropathology and leads the institution’s Department of Cellular Pathology. He and a colleague were part of a 6-month pilot utilizing the Sectra solution.
“There are some things for which the microscope will always be my fallback tool, but, as a first port of call, the digital images are vivid and, in many ways, superior,” says du Plessis.
Enabling better cancer care
Making things better for pathology and radiology is a Sectra objective. “Our vision is to provide a diagnostic solution where the pathologist does not need to use the microscope and he or she can easily share and take part of findings with radiology and other specialties,” says Simon Häger, Sectra’s digital pathology product manager. “Cancer care providers should be able to access all relevant imaging and information for patients in one system to create a more accurate diagnosis in much less time. It will be a big improvement over today, where we have totally different departments and very limited exchange of information.”
Häger has helped lead the charge as Sectra has developed and now launched a digital pathology system built on the same platform as Sectra’s radiology PACS. By reducing or eliminating the cumbersome handling of glass slides, the solution frees up pathologists to compare many slides at once while remaining in an upright, ergonomic position. Undistracted by discomfort, poring over high-resolution scans of slides on computer monitors—much like radiologists viewing imaging scans—they navigate sections of stains easier, compare stains faster and combine efforts with radiologists sooner.
The improved teamwork, he says, will allow early cross-specialty review of not only reports but also of images, the end result being better accuracy, efficiency and service to the interventional members of the cancer care team.
A must for the MDT
It becomes apparent the success of the coming “rad-path” alliance rests on the willingness of pathology to embrace Digital Age capabilities.
Häger is convinced that, once pathologists get a taste of the new way, the technology will make a lot of new friends.
As things tend to work right now, attendees of MDT meetings look at radiology images projected from a PACS. In striking contrast, most pathology departments haven’t gone digital yet, Häger points out. “Because digital pathology images are so large, pathologists have not been given the opportunity until now to utilize PACS technology with high performance. The available and most common way has until now been to carry in their microscopes and project their slides onto the wall where sometimes the other physicians in the room have to wait. This can be very time-consuming,” and, considering the attendees, “the MDT meeting is probably the most expensive meeting in the hospital.”
And that’s just at the MDT meeting. Pathologists’ preparation often means assigning staff to identify and pull slides for patient cases to be reviewed at the meeting, then navigating the relevant slides for key sections. It’s not hard to imagine how all of this is much less laborious using a computer and an ergonomic interaction device rather than a microscope and slides. So it is that the digital system facilitates both MDT preparation and MDT presentation.
“One of the best parts of preparing with the digital solution is the capability to make comments and mark noteworthy features right over the images,” says Häger. “With physical slides, this is so time-consuming that a lot of pathologists end up doing it on their own time, after work hours.”
Mitigating the fatigue factor
Du Plessis is one neuropathologist who can relate. Ease of handling is just one of many benefits he reports enjoying with the Sectra system. “What stood out to me was the confidence I felt in navigating the slide, knowing that I was seeing everything I needed to see,” he says. “I’m not sure everyone can appreciate this, although I’m sure radiologists can: You have a big, complex image. You know that you have to cover that whole image to interpret it. You might be only focusing on certain features.”
Even working with a glass slide, du Plessis continues, it’s possible to miss certain microscopic findings. Fatigue is always a factor, especially toward the end of the workday. With that can come less rigor when it comes to assimilating the image in its entirety.
“I found that the digital pathology image on a nice big screen in front of me held my attention better and longer,” he says. “I felt far more in command of the slide with the digital system than with my microscope. I found that I could rip through many cases with high attention and excellent image navigation before fatigue crept in. It really is a better way.” Perseverance and attention also was aided by much-improved workbench ergonomics.
Du Plessis also applauds the cost-savings potential of the digital way. In the U.K., he notes, slides are eventually archived offsite in commercial storage facilities. These businesses charge for retrieval as well as storage, and the costs add up fast. “We saw that all of this can be addressed and solved with a digitized pathology system,” he says. “Everything is at your fingertips. The pathologist can do all the retrieval work him- or herself. There’s no need to dedicate staff to those kinds of logistical processes. That’s a massive benefit.”
Thinking forward, du Plessis imagines the day when scans of slides—which can be much larger in file size than radiology images—will be sent out for second opinions digitally. This, he is quick to point out, will represent a speedy sprint past the present system of mail or courier services toting around stained glass slides. It also will facilitate local networking, permitting quicker double reporting and obtaining quick informal opinions. It also will allow for more robust cross cover in subspeciality fields scarce in staff numbers.
Tools of teamwork
Häger maintains that the single most game-changing advantage of digital pathology is its ability to bring together radiologists and pathologists. One plus one equals a “huge reduction in turnaround times,” he says.
“You can bring in specialized pathologists sooner. You can give the pathologist digital capabilities for image analysis, cell counting, mitosis counting, area calculations, tumor percentage calculations—all those time-consuming tasks that can be automated with digital techniques. In summary, you reduce the waiting time for the patient to get a diagnosis,” says Häger. “This leads to better cancer treatment, faster.”
As for why Sectra chose to build its digital pathology solution on top of it radiology platform rather than parallel to it, Häger uses one word: integration. “You will have a unified user experience,” he says. “This is crucial, because you have the ability to readily synchronize radiology images with pathology studies. It provides opportunities to detect any discordances in the findings.”
As digital pathology finds a foothold and grows from there, some resistance will likely arise from corners of both pathology and radiology, Häger acknowledges, as human nature so often tends toward defending “turf” rather than sharing space. He believes the objections will yield to cooperation first in MDT meetings.
“When all the doctors are gathered together, describing the findings each physician has made, and discussing and concluding diagnosis and treatment, we will have given them the tools they need to have an efficient, very productive discussion,” he says. “Each will come away with a broader, more holistic view of the patient”—and of patient care. Häger also points out that a key component in creating a successful solution for digital pathology is to learn from the digitization journey radiology began 15 to 20 years ago, but it is also crucial to be humble in realizing that there are significant differences that only pathologists can help us with.