COVER STORY

PathologyPathology 2025:2025: ImaginingImagining thethe futurefuture

Never has been as Dr Puay Hoon Tan technological advances and be fully involved in and direct new developments, challenging as it is in the 21st Singapore since it is only appropriate that century; and never have the pathologists be the ones to control the opportunities been so great. How will the role of use of novel technology in our discipline to Pathology, as the very foundation of Q. change over the next two decades? improve patient care. medicine, is at the forefront of the revolution and new diagnostic tools A. In many institutions with a research Q. What is your wishlist for pathology and knowledge are taking arm, anatomical pathologists are already over the next 20 years? pathologists into broader roles of serving as the bridge between basic research and correlating diagnoses science and clinical medicine, and are A. I hope for sufficient pathologists to for clinicians. therefore poised to become effective perform the closely integrated duties of leaders in the research arena. I believe diagnostic service, teaching and research. Yet, despite the challenges and pathology will be increasingly called upon Pathology is the foundation of medicine, opportunities, there remains a to take a leadership or at least a and is by nature an academic discipline. It shortage of pathologists which adds prominent supportive role in research in is sad that pathologists have been to the pressures to this crucial the coming years. sometimes relegated to a less important branch of medicine. So, what does It is hard to clearly imagine what role in the medical profession. The goal as the future hold for pathology in advances in information and other an anatomical pathologist is to provide as best a diagnosis on submitted tissues, and 2025? PathWay asked five leading technology will have exploded into our lives by 2025. It is difficult to use to be an effective member of the pathologists from across the globe pathology of 20 years ago as historical managing team of clinicians in solving the to share their vision for the future, comparison with pathology today, and problems of patients. In order to achieve with some fascinating and extrapolate the advances over the past 20 these aims, pathologists should constantly surprising results. years to the future two decades, as the add value to their work by actively pace of development and change will be participating in teaching and research, as distinctly more rapid in the future. these are efficient means of learning, Hopefully, pathologists in 2025 will not be understanding and self-improvement. This merely “tissue samplers. Pathologists wish can only be realised when there are need to keep pace with current enough pathologists on board.

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I truly hope that pathology can be re- Sir James Underwood as exciting as forensic death established as the basis of all medical investigations. disciplines, and regain the respect, United Kingdom Research in pathology should be relevance and profile within the medical valued by its benefit to human health and community. It is also important that more Q. Which scientific/technological/ welfare rather than by the size of the young medical professionals should medical developments will have the consider pathology as a viable career most impact on pathology in the research grant or the impact factor of the option, as that will be the start of coming years? journal in which it is published. alleviating the current shortage of When given death certificates, pathologists. There is a great need for A. Advances in genetics, information bereaved relatives should ask certifying pathologists with passion for the technology and digital imaging are already discipline. transforming histopathology and many doctors how they can be so confident Technological advances should be other pathology specialties. This will about the cause of death when research harnessed to continually improve the continue. In histopathology, for example, I shows that up to 30% of certificates are discipline, with the pathologist in charge. predict that much interpretive reporting will significantly wrong or incomplete? How be done from flat screens rather than about an ? through microscope eyepieces. Q. Where would you like to see Pathology services should cease to be research focused over the next 20 years? In my specialty of histopathology, I forecast that molecular pathology will regarded as a ‘cost’ or ‘overhead’ in A. I would like to see research focused develop alongside diagnostic macroscopy healthcare organisations. on cancer prognostic markers and cancer and microscopy and as an adjunct, rather Pathology investigations should be than as a substitute. cures via targeted therapies. Advances in evidence-based in order to reduce molecular taxonomy will be an important unnecessary tests and iatrogenic anaemia adjunct to histologic diagnoses. How will the role of pathology Q. (resulting from excessive haematological Development of dedicated tissue banks, change over the next two decades? construction of tissue microarrays, and biochemical investigations). standardization of processing protocols so A. Pathology will always to be the that paraffinised archival tissue can be scientific basis for medical practice, but it Q. Where would you like to see effectively harnessed for will continue to struggle to get this research focused over the next 20 immunohistochemical and molecular message across to curriculum planners years? research, all occurring within an and to health service managers. established ethical framework that ensures The migration of some pathology A. Rather than suggest topics for moral standards, will be in the future of ‘tests’ from laboratories to the point-of- research, I would argue for a cultural shift research pathology. care will continue, but hopefully with concerns about training, health and safety, in how pathology research is designed, Q. If the current shortage of quality assurance, and results conducted and published. Too many pathologists continues, how will the interpretation fully addressed. This will be papers report small series with numerous profession and the community be best achieved by point-of-care testing variables, such that the study is incapable affected? being part of a locally managed pathology of advancing knowledge with sufficient network. reliability. To give pathology research the A. The profession will not be able to pull Medical graduates (as opposed to status it deserves, we should encourage itself out of the monotony of service work, science graduates) working in pathology studies that are robust, powerful and and will not find time to participate in services will continue to develop a much value added activities such as cutting more patient-centred approach to their demonstrate clinical effectiveness. For edge research, which will be taken over by specialty, with increasing involvement in example, a new classification or grading of non-pathologist scientists. The discipline clinical decisions as members of a particular disease should be researched will be unable to improve and advance. multidisciplinary teams. as a clinical intervention in order to There will be a pervasive low morale which determine the effect on patient outcomes. may cascade into a vicious cycle with Q. What is your wishlist for pathology diminishing numbers of young doctors A new monoclonal antibody for identifying over the next 20 years? being interested in the discipline. It will histogenetic or predictive markers should continue to slip in professional standing in A. Pathology should be restored to its be evaluated for its actual clinical utility. relation to other more glamorous and rightful place in the medical undergraduate Sir James Underwood is Professor of Pathology dynamic medical disciplines. curriculum before widespread ignorance at the University of Sheffield, UK, and and misunderstanding imperils patients, if consultant histopathologist to the Sheffield Dr Puay Hoon Tan is the Senior Consultant and Teaching Hospitals. In 2002, he was elected Head of Histopathology at Singapore General it has not done so already. Hospital and Adjunct Associate Professor President of the Royal College of Pathologists. Departments of Pathology and Anatomy, Television drama producers should He was recently knighted for his services to National University of Singapore. realise that cancer diagnosis can be just medicine.

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COVER STORY

saying this for years and it won’t happen Dr Lee Hilborne Q. If the current shortage of over the next 20 years. I am not sure how USA pathologists continues, how will the fast change will occur. Of course, if the profession and the community be demand for pathologists rises and the affected? Q. Which scientific/technological/ shortage increases, the laws of supply and medical developments will have the demand will necessitate that the cost of A. Pathologists, laboratories and diagnostic activities will be predominantly most impact on pathology in the professional pathology services will located in major population centres with coming years? increase and more individuals will be point of care testing, courier transfer of encouraged to enter the profession. A. Molecular diagnostics, genomics and specimens and electronic communication proteomics will probably have the biggest Current trends have been in the opposite of results. This has already happened with impact because they will continue to direction, but shortages will force a many regional communities no longer redefine disease at the molecular level. reversal of this trend. served by a locally based pathologist. Some of the challenges we face today in Dr Lee Hilborne MD, MPH, DLM (ASCP) is Anthony J Landgren, FRCPA, FACLM, MRACMA, terms of discriminating disease will be Barrister and Solicitor. Tony Landgren is Professor of Pathology and Laboratory eliminated ie: uncertainty will be Chairman of the Department of Anatomical Medicine at the David Geffen School of Pathology at the Royal Melbourne Hospital and decreased and accuracy will be increased. Medicine at UCLA and Deputy Director of a Biotechnology Lawyer. The further development of Global Health for the RAND Corporation in Santa Monica, California. nanotechnologies will also drive change Dr D Sean O’Briain and expedite diagnoses. The other change will be increased automation - more things Dr Anthony Landgren Ireland can be done with greater consistency, less time, and less cost. Australia Q. Which scientific/technological/ medical developments will have the Q. Where would you like to see Q. Which scientific/technological/ most impact on pathology in the research focused over the next 20 years? medical developments will have the coming years? most impact on pathology in the I think research should focus on new A. coming years? A. Medicine is pathology, and as new diagnostic tests, getting those tests with technology steadily changes medicine, promise to market, and work on modifying A. Further development of molecular pathology will change gradually with it. A some diagnostic tests that are only sudden quantum change in medicine, diagnostic tools and point of care available in large clinical laboratories rather than gradual change, is less likely to pathology testing. because of the testing complexity. Highly occur but there are two possible complex testing restricts applications to circumstances of rapid profound change. developed countries and those with Q. How will the role of pathology One is the finding of a silver bullet, a magic resources. Moving to new paradigms for change over the next two decades? cure for a major disease, such as a cure for some diagnostics, particularly for such cancer, that would profoundly change conditions as acute infectious diseases, A. Increased focus on disease much of medicine including pathology; but HIV, diarrheal diseases, acute respiratory prevention and early diagnosis. this is unlikely to be achieved by 2025. The illnesses, can help move those diagnostic second is the emergence of a devastating services to under-served areas of the new disease. We worried about this with What is your wish list for pathology world. Of course, the development of new Q. SARS a few years ago, and within the past diagnostics will require the availability of over the next 20 years? two decades we’ve seen AIDS change the therapeutic techniques for treatment once face of medicine in many poorer regions of the diagnoses have been made. Of A. Short to medium term issues, the world. particularly work force shortages tend to course, I would hope that by the next 20 Extreme regional poverty, years we would have the answer regarding overwhelm consideration of where to in overpopulation and local conflicts with how to effectively attack both the next 20 years. Improved training ensuing malnutrition and infectious diseases malignancies and retroviral infections. opportunities, facility and technology including gastroenteritis, AIDS and investment, improved risk management tuberculosis, will continue to be the major Q. If the current shortage of and error reduction are my current problems in world health but, as now, will pathologists continues, how will the priorities. only have a significant effect on medicine of profession and the community be the developed world if the situation also affected? acts as a pressure cooker for the Q. Where would you like to see emergence of new global pandemics. A. I guess that depends on the other research focused over the next 20 Developed countries may heave a quiet issues. I think the demand for traditional years? collective sigh of relief if 2025 dawns surgical pathologists may decrease if without such a pandemic, but, as now, are molecular diagnostics take over. Many will A. Development of molecular diagnostic unlikely to take effective action to end the argue (and I agree) that people have been tools. threat.

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In the developed world, pathology will still use many of the current techniques but these will be enhanced due to developments predominantly in molecular pathology, information technology and imaging techniques and will be driven by commercialisation of new techniques and better instrumentation.

Q. How will the role of pathology change over the next two decades?

A. The pathologist will continue as diagnostician, but as there will be a wider range of technologies to support and to augment the diagnosis, will take on a larger role in correlating the diagnosis for the clinician. A major challenge to the pathologist will be to master the new technologies and to incorporate them into the pathology diagnosis. The current division of the pathology laboratory into traditional well-defined subsections may be a barrier to change; with expanded dynamic imaging and point of care testing much of current laboratory work will occur at the bedside while the laboratory will offer a new profile of tests that may require a realignment of diagnostic disciplines and subspecialties. Enhanced decision support programmes will be a major component of useful in making diagnoses, and to guide molecular biology. But the causes of clinical care and the pathologist will format and monitor therapy. A general wishlist cardiovascular and degenerative cerebral results to feed laboratory information into includes more rapid access to the disease remain tantalisingly out of reach these hospital systems. This will simplify specimen, increasingly better tests and and will require a substantial research the diagnosis and care of well-defined prompt communication of the results to effort at a more basic level. diseases and will allow the pathologist to the clinician. These will be achieved by a focus on diseases where the diagnosis is variety of developments in test ordering, obscure. These will be the subject of Q. If the current shortage of point of care testing, specimen transport, hospital multidisciplinary conferences pathologists continues, how will the with enhanced laboratory information where the pathologist will have a major profession and the community be systems connecting with more developed role in defining the implications of complex affected? electronic patient records, and new laboratory results. instrumentation providing better, faster A. Pathology, like any other occupation, New therapies will change the profile of tests. follows the law of supply and demand. diseases, and some now-fatal diseases Shortages are likely to be temporary and will be curable; but just as infectious Q. Where would you like to see regional. Medical graduates are unusually diseases did not go away when antibiotics research focused over the next 20 years? mobile and will move to the areas of were developed, diseases such as cancer opportunity. Pathologists will improve the will develop new forms of resistance to A. Research should be focused where it profile of the discipline and present it more therapy and complications from the new is it likely to do most good, either on attractively to medical students who will treatments. New laboratory-based diseases causing widespread morbidity or respond to the increased career approaches to these problems will where a breakthrough seems intuitively opportunities by filling any vacancies. continue to emerge. likely. The major areas include infectious diseases that involve the developing world, Dr D Sean O’Briain MB, MRCPath, FFPath, What is your wishlist for pathology cancer, cardiovascular disease and FRCPI is the Dean, Faculty of Pathology, Royal Q. College of Physicians of Ireland, Associate over the next 20 years? degenerative cerebral disease. We are Professor of Pathology, Trinity College Dublin likely to see a huge return on money and the Consultant Histopathologist and Head A. The role of the pathology laboratory invested in research on infectious disease of Department, St James’ Hospital, Dublin, Ireland. is to use blood, fluid or tissue to provide and cancer, based on application of accurate, timely and relevant information

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