Pathologists and Oncologists

Re: Pathologists and Oncologists

J G Wray — Thu, 16 Sep 2010 07:43:43 GMT

[quote user="robloxley"]Maybe herein lies much of your answer: the histologist is giving his best opinion on what's going on in a small lump of tissue; the oncologist is able to examine the rest of you, look at the bigger picture of your whole health, as you more questions, get information from other sources etc. to put together a treatment plan?[/quote]

Quite so, but at the time there was a discussion with the oncologist, along the lines of - the pathologist has been presented with an orange, It's orange and looks like an orange and when he cut it up it looked like a cut orange, so why isn't it an orange? (The "orange" is a metaphor for the tumour) - answer, histology isn't definitive (and I'm not talking about poor biopsy technique, margins and all that). That took a bit of "swallowing" by the patient. Unless you've been educated differently to me, then I think there is a general acceptance in Our World of the near definitive nature of histopathology for decision making and pontificating - particularly at PM. We may choose our pathologists, particularly for skin issues, but I'm not so sure we are as discriminating with solid lumps and here I have an oncologist expressing a more universal, I mean national, scepticism than I have heard hitherto. Is this something you've experienced?

JGW

Re: Pathologists and Oncologists

Rob Loxley — Wed, 15 Sep 2010 23:10:51 GMT

[quote user="Jonathan Wray"]I am aware of a similar need for careful consideration of histology from personal experience of oncological services in the NHS where a histologist made a diagnosis, but the oncologist considered some blood test as well and chose not to indulge in a particular therapy. I am grateful for this decision from the perspective of thirteen years of remission.[/quote]

Maybe herein lies much of your answer: the histologist is giving his best opinion on what's going on in a small lump of tissue; the oncologist is able to examine the rest of you, look at the bigger picture of your whole health, as you more questions, get information from other sources etc. to put together a treatment plan?

Re: Pathologists and Oncologists

Rob Loxley — Wed, 15 Sep 2010 23:04:50 GMT

[quote user="Jonathan Wray"]It appears that, in the opinion of oncologists, the patients are not best served by the work of UK pathologists and are keen to get the staining done abroad and even a second opinion on the diagnosis.[/quote]

A few thoughts:

Some pathologists are better than others?; there are plenty of good ones in the UK IMHO. Some labs seem to employ pathologists to do everything from cytology to haematology to histopathology, others have much more experienced 'specialists' in individual areas, some even have 'skin histologists' and 'cancer specialists'.

The oncologist has presumably seen the whole patient, which the pathologist hasn't, and maybe the clinical and histological diagnoses don't line up, hence a second opinion?

Be aware that for some further staining - e.g. Ki67 - different labs may use different methodologies and therefore may report different reference ranges. Have come across this with MCT samples sent to the US for staining.

[quote user="Jonathan Wray"]Has anyone else come across this sort of thing?[/quote]

Yes, we've had cytology/histo reports that we've not been convinced of the diagnosis given or have been demonstrated to be wrong (the lymphoma dog that's still alive too many years down the line, the MCT on FNA that wasn't on histo), and have moved labs to where we feel confident. We have come across many cytologists who won't come off the fence, so have sent samples elsewhere.

There's a lot to be said for confidence in your lab, and a good working relationship to discuss those not so clearcut cases, and maybe this is what your finding with you oncologist and their 'favourite' lab?

[quote user="Jonathan Wray"]But, for a GP, how can I tell?[/quote]

Why not ask your oncologist where they would like the biopsy sent and send it there?

Re: Pathologists and Oncologists

Laurence Webb — Wed, 15 Sep 2010 19:11:13 GMT

I'm certain that there must be differences between pathologists/histopathlogists. I have been unhappy with the quality of interpretation of blood work from some labs (notably IDEXX) when even an amateur like me can tell that a report telling me an anaemic dog is non-regenerative is rubbish if the smear exam has loads of reticulocytes. I don't like the 'push a button' type interpretations and you often get the impression that the lab isn't interpreting the results as a whole ("this cat has high urea. Urine exam including SG may be useful" written below the urine SG) I now generally use them for their non-interpreted profiles only (cheap) and if I want interpretation then send it elsewhere.

It is more difficult to quantify the quality of histopath reports as there is no ready way of comparing the interpretation unless you send samples from 1 case to a selection of labs and see which agree the most. Certainly the grading of mast cell tumours on histology is very dependant on the individual histopathologist, but this is where immunostaining (eg Ki67) comes in as it is less dependant on an individuals interpretation. I believe that lots labs forward their immunostaining on to other places although the histology is normally done in-house.

When I discuss cases with our oncologist he'll normally ask who did the histology as he seems to view some labs and individuals within labs as better than others. As I result I've ended up using his preferred lab in the UK for most samples and I certainly feel happier about the quality of interpretation of histology as well as bloods and cytology.

Re: Pathologists and Oncologists

Niall Taylor — Wed, 15 Sep 2010 18:58:34 GMT

[quote user="Michael Woodhouse"]I loathe it when I spend a clients money and they are non-committal and I am no further on.[/quote]

I am less enthusiastic about fine needle aspirates than I once was for that very reason.

Niall

Re: Pathologists and Oncologists

Niall Taylor — Wed, 15 Sep 2010 18:57:16 GMT

[quote user="Jonathan Wray"]There appears to be a scepticism about the quality of pathology and subsequent processing - immunohistochem etc. and crucially interpretation, when performed by UK labs[/quote]

Our oncologist doesn't seem to have problems with UK pathologists per-se but I'll check next time I see him.

[quote user="Jonathan Wray"]The oncologist is, by extension, not entirely impressed by GPs who indulge in cytotoxic treatments relying on what they see as sub-standard information.[/quote]

Is that sub-standard information from UK pathologists or sub-standard information as in non-specialists' failure to keep up with leading edge oncological diagnostics, therapies and risk/benefits?

Niall

Re: Pathologists and Oncologists

Michael Woodhouse — Wed, 15 Sep 2010 18:33:17 GMT

If these further tests stop the pathologists sitting on the fence and not committing themselves I would be happy. I loathe it when I spend a clients money and they are non-committal and I am no further on.

If we send all the histo abroad then we'll lose the expertise here. Maybe badger Idexx et al for these tests?

Re: Pathologists and Oncologists

J G Wray — Wed, 15 Sep 2010 14:41:26 GMT

[quote user="Niall Taylor"]An oncologist we work with here will frequently ask for additional tests including immunohistochemistry, gene-markers etc but he seems to work with the pathologists he deals with quite happily and I'm not aware he sends tests abroad, though I imagine some of the labs may do such tests as referral tests themselves. Very, very occasionally he will ask for slides to be sent to other labs for second opinions but then different pathologists are going to have different areas of expertise surely?[/quote]

What I'm reporting is something more fundamental than an occasional issue caused by less familiarity with particular conditions. There appears to be a scepticism about the quality of pathology and subsequent processing - immunohistochem etc. and crucially interpretation, when performed by UK labs, because of the implications of a poor premise for the deployment of subsequent cytotoxic therapies. The oncologist is , by extension, not entirely impressed by GPs who indulge in cytotoxic treatments relying on what they see as sub-standard information.

I'm just asking whether this is part of a more widespread scepticism, because I've got some thinking to do if I'm making judgements for therapy (not cytotoxic) based on opinion from histologists which might not be quite of the quality I might want for my patients.

I am aware of a similar need for careful consideration of histology from personal experience of oncological services in the NHS where a histologist made a diagnosis, but the oncologist considered some blood test as well and chose not to indulge in a particular therapy. I am grateful for this decision from the perspective of thirteen years of remission. I didn't have to undergo therapeutic unpleasantness and now that this issue appears to be cropping up in our world as we catch up with some of the sophistication that has been available to doctors for twenty years I am keen to improve my input for my cases. However, if this is an idiosyncratic view of our oncologist then I'd like to know that also, hence the posting.

JGW

Re: Pathologists and Oncologists

Tim Cheyne — Wed, 15 Sep 2010 13:41:44 GMT

I have worked quite closely with some local medical pathologists/oncologists and I know that occasionally material is sent elsewhere either because the recipient is carrying out research on such material or the test needed is so rarely used, unstable and expensive that it is not economic for the laboratory to hold a stock of the reagents. Could that be the case here?

Tim.

Re: Pathologists and Oncologists

Niall Taylor — Wed, 15 Sep 2010 08:19:11 GMT

An oncologist we work with here will frequently ask for additional tests including immunohistochemistry, gene-markers etc but he seems to work with the pathologists he deals with quite happily and I'm not aware he sends tests abroad, though I imagine some of the labs may do such tests as referral tests themselves. Very, very occasionally he will ask for slides to be sent to other labs for second opinions but then different pathologists are going to have different areas of expertise surely?

I'm not sure what there is for your pathologist to be getting upset about - if they don't provide a test a clinicial wants what's wrong with asking elsewhere, not that much different from a general practitioner referring a case to another vet with more specialist expertise?

Niall