Transcriber: Madina Juarez Reviewer: P B
My story began almost twenty years ago
when I sat with a patient at the Princess Margaret Hospital,
middle aged woman who's been referred because she had
metastatic fibroid cancer in her bone.
Her tumor had spread to the bone.
As the pathologist,
who was responsible for fibroid pathology at the hospital,
I had reviewed her biopsy,
and confirmed that indeed the diagnosis was correct.
I also had the opportunity to review a different specimen.
This patient had had her thyroid removed 5 years earlier.
And had been told that her thyroid was benign,
meaning that it was not going to spread.
When I reviewed the pathology it was obviously malignant.
The sad part of this patient's story is that if the diagnosis
has been made correctly on the initial specimen,
if the doctors have known that her thyroid had a malignancy,
she could've been treated with a very targeted drug,
radioactive iodine, that would've cured her.
Now that the tumor had spread to her bone
the chance of successful cure was very small.
This story made me stand back and question
how do pathologists do what they do,
how could my colleague have missed the diagnosis of malignancy,
which I recognized.
What was about the discipline, and in the way we practice,
that allowed an error like this to happen?
Some of you may know that there had been
many headlines in Canada over the last few years
about errors in pathology.
Pathology, the word comes from the Greek pathos,
meaning feeling or suffering, and logia, the study of.
It's the study of disease, and pathologists examine
organs, tissues, body fluids, cells
to understand what is wrong with the patient.
In today's world, most patients don't know their pathologists.
The pathologist is the physician's doctor.
We speak to other doctors who see patients,
and we examine parts of patients
to help the doctors understand what's wrong with them.
It's the pathologist's responsibility
to ensure that the patient has the right diagnosis.
What is the disease? What's wrong with this patient?
We also have learned over many years to understand
what is the patient's prognosis.
Is this the disease that's likely to resolve by itself?
Is it something that will progress? And if it will progress,
is it going to progress slowly, or quickly?
And with all the new technology and new tools that we have in medicine,
pathologists are now able to analyze the patient's specimen
and predict what is the right drug,
what is the right treatment for this patient.
Much of what we do as pathologists is looking at body fluids,
like blood or urine, and measuring chemicals or counting cells.
You can see in this photograph a large laboratory,
where we automate most of the testing.
We have an ability to do a lot of quality assurance testing
on our machines and with our reagents.
And the answers that come out are usually correct.
And they are usually are very clear, they are a number.
What's your white blood cell count? What's your blood glucose?
There is very little room for error in this kind of automated pathology.
But there is another part of pathology,
which is what we call an interpretive morphology.
If a patient has a lump or a bump, a physician can feel it, they do a biopsy.
If you have a radiologic test, like a mammogram,
something is found, it's biopsy. That biopsy goes to the pathologist.
If the tissue is removed at the time of surgery,
what the surgeon removes goes to the pathologist.
The pathologist is responsible to examine the specimen,
to measure something, to weigh it, to feel it,
and ultimately what we do
is we usually examine it in a microscope.
Pathologists get tissue.
We cut up the relevant parts of the tissue that we need to analyze in a microscope.
We fix the tissue so that it's permanent, it will not decay.
We embed small pieces of this tissue,
the parts that we need to examine
in wax blocks that become a permanent way of storing the material.
Those blocks are cut up into very very thin slices,
that are mounted on glass slides.
The glass slides are then stained with dyes,
that allow us to recognize patterns in the tissue,
that will allow us to recognize the disease process.
Pathology is a very interesting field,
because it's based primarily on pattern recognition.
We learn to recognize the images that we see in a microscope.
I can tell you that by looking at this slide,
this is an inflammatory process.
And I can also tell you whether it's infectious or not.
Other patterns will tell us that this is a tumor.
And we recognize whether it's a benign or a malignant tumor.
We have technologies that allow us to localize specific proteins in cells,
things like HER2, a target for Herceptin therapy in breast cancer.
We can tell whether a biopsy from a patient is a tumor
that should be treated with this drug or not,
based on a stain like this one.
And of course, now in the genomic era, we are able to look at the genes of cells,
we are able to look at chromosomes,
and recognize whether there are genetic changes
that changed the behavior, or the response to therapy of a given disease.
My patient's story led me to ask the question,
who is the right pathologist to look at a specimen?
Pathologists are physicians who are very well trained.
We go through medical school, we do our residency,
which is usually 4 or 5 years,
further training after medical school.
We learn to recognize many many patterns in the microscope.
Most pathologists work in an environment,
where they are in a laboratory, either in a clinic or in a hospital.
And all of the samples, all the biopsies,
all of the surgical specimens from that institution come to the laboratory
and the group of pathologists share the work,
they grade the slide, they issue reports.
But is this the right way of practicing pathology?
Medicine has grown so much in the last 15 to 20 years.
Our knowledge has been increasing at an exponential pace.
No pathologist can know everything about every disease.
So I ask the question,
Can we do pathology in a different way?
Where pathologists are no longer jack of all trades
and master of none.
Can we create groups of pathologists who are experts in certain diseases?
Who can know more about that specific disease,
recognize the pattern faster, see the more subtle changes that,
maybe, other colleagues don't see?
Become integrated into clinical care teams,
so we understand better which drugs can be used for this patient.
How do we know what's the right marker?
To tell whether a patient should be treated
with a certain drug or a certain surgical procedure.
In the year 2000, I was given an opportunity to try and come up
with a different model.
I was asked to take over as a Pathologist-in-Chief
at University Health Network in Toronto.
At the time, University Health Network was comprised of three hospitals,
the Toronto General Hospital, the Princess Margaret Hospital,
and Toronto Western Hospital.
Each hospital had its own department of pathology.
I convinced both the pathologists and the organizations
that we would be better served by creating
a single large department of pathology,
where we had enough critical mass, enough pathologists,
that we could actually start to create a dream team,
a team composed of pathologists, who knew everything about breast.
Another group who knew things about other parts of the body.
There is a long list of sub-specialty areas in pathology,
that we would need to make sure could be covered by our dream team.
What does this mean to you, to your family, to your relatives?
Well, basically, if your sister had a breast biopsy,
you could be sure that breast biopsy was read by an expert in breast.
And if your brother had a prostate biopsy,
that biopsy would be read by a pathologist who knows
all about prostate disease.
We also need to make sure that we have experts
in all kind of different technologies.
Because all of these specimens are handled
through a number of different laboratories
with different technical ways of handling material.
At the end of the day, our dream team was able
to ensure that the patients at our institution
had the right pathologist for the right patient at the right time.
We had a bit of a challenge though. There are some areas in pathology,
that are not as common,
and there were some teams that had only one person.
And it was a difficult situation.
If that person had to go away to a conference somewhere,
or take vacation, which we actually do sometimes.
What would happen to the patient, whose biopsy came in if I was away,
and I was the only person on the team?
Fortunately, the problem was solved by partnerships.
There were hospitals across the provinces of Ontario
that needed pathologists,
and who saw what we were doing at the University Health Network,
and they elected to join us.
Some of these hospitals were as far away as 400 miles.
Some of them were closer.
But all of them had a capacity for pathologists,
that allowed to grow our team, and develop all of the expertise
that we needed.
It did create a different challenge though.
One of scenarios where pathologists are very important
is during a surgical procedure.
When a surgeon is doing a procedure, and removes a piece of tissue,
there are situations in which the surgeon needs the pathologist right away,
to look at that tissue, examine it in a microscope,
and give an answer.
"Is it benign or malignant?"
"Should I take it all out?"
Or if they are taking out something malignant they'll ask,
"Did I get it all out? Are there sections, margins,
or edges of the specimen free of tumor?"
To be able to provide intraoperative consultations
to those hospitals in the north
we had to have pathologists on the ground, at all times.
And it wasn't always, exactly, the right pathologist.
In addition, we were sending glass slides all around the provinces of Ontario.
Granted, all three are very secure courier systems,
so there was not much risk of any information loss,
but still causing some delays to the patients,
and creating a potential risk of some loss, or a breach of privacy
in an event of an accident.
When our three hospitals merged, and we created our dream team,
we had to find one place where
all the pathologists could work together as a team.
And that place was the Toronto General Hospital.
If a surgeon at the Princess Margaret Hospital across the street needed us,
it was an easy run across the street
to provide that intraoperative consultation.
But when a pathologist had to be available
at the Toronto Western Hospital a mile away,
they had to go and sit there and spend some time,
which was not always the most productive way of spending their day.
So we had initiated some investigations
into novel ways of doing pathology at a distance,
what we called telepathology.
The first thing we tried was a robotic system,
remote controlled microscopy.
In these two photographs, you see two stellar members of my team,
Suganthi Illaalagan, and Dr. Andrew Evans,
two people that really pioneered the use of this brand new technology,
where we can have a pathologist sitting in the Toronto General Hospital,
remotely controlling a microscope, that a technologist
at the Western Hospital had prepared with the slide ready for the examination.
This was a great way of doing it.
Then, there was a real game changer.
Some new technology that was about to change
the way pathology would be forever.
There were companies that had created whole-slide imaging.
A way of taking a glass slide and digitizing it at very high resolution,
so you can see the finest details that a pathologist sees in a microscope,
and being able to transmit this through computer networks,
to a computer at a distance.
Dr. Evans was the man who really pioneered this for us.
And as soon as it was implemented our team took this on
with real vengeance.
This was going to change the way we practice pathology.
We started to provide intraoperative support for pathology consultations
at the Toronto Western Hospital.
In an environment where if there ever was a problem
we can just get in a taxi and get over there,
and do what we had to do.
After several years of great experience, we were quite comfortable
that we could support people 400 miles away with this technology.
Digital pathology is a disruptive technology.
It changes everything.
I love this quote from Eric Hoffer,
"In a time of drastic change, it is the learners who inherit the future.
The learned usually find themselves equipped to live in a world
that no longer exists."
Most of my colleagues in pathology said,
"Digital pathology, great for teaching students,
but it hasn't really matured to the stage where we could use it yet."
Well, the new pathology is very different from the old pathology.
We now have worked with companies that make digital scanners.
We have worked with computer companies that make laboratory information systems
that we use to track our cases, and generate the reports.
We've worked together to integrate the new pathology with digital imaging
to allow us to provide reports to patients across this province,
and anywhere else that might be interested in our services.
It's faster than the old way of doing things.
In the old days if a pathologist in a smaller hospital didn't know
what a case was,
they would have to wrap up those slides and send them to an expert somewhere.
That takes time.
The expert doesn't know the case, doesn't know the story,
until the right answer comes in it can be a matter of weeks.
If I were a patient I would want my report much faster that that.
It's better, because we are now ensuring that every patient within our system
has the right pathologist,
the expert who really knows their disease.
And in Canada, Ontario, this is a public health care system.
We have to leading the way in providing better value for money.
And this system is cheaper.
There is one pathologist for every case.
We have a team.
If there is a question, if it's a difficult case,
the team works together to generate the right answer immediately.
It gets our there.
We don't pay to send cases around for multiple opinions.
And the patients are treated faster, so their stay in the hospital is shorter.
In the end, I would argue that what we've done
is we've been innovative
to provide a much better pathology service for our patients.
We are not going to stop there.
We now are looking at new ways of using all of this wonderful new technology.
Having slides digitized,
means that we can look at a computer-assisted diagnostics.
We can get much more accurate measurements.
We can do better counts of features that we see.
We can use pattern recognition algorithms,
that software developers can write with us
to try and identify the things that we might just miss
if we are having a bad day, which we sometimes do.
All of these tools are going to give us a much better outcome,
and are going to make pathology much better.
Faster. Better. Cheaper.
Our vision is that pathology is really the heart of diagnosis.
A pathologist can now sit at a computer cockpit,
and integrate information that we get from the clinical patient's chart.
We can see the radiologic images that are on the file.
We have all of the biochemistry, and the hematology,
in many departments like ours we have molecular data.
We can sequence mutations and tumors.
We can look at all the genetic aberrations,
that happened in the tumors of the patients with cancer.
We can sequence patient's blood to determine what changes they have
that will determine how they will metabolize a specific drug,
what would their response be to a drug.
We can show a patient the visual image of their disease.
We can integrate all of this information, and ultimately,
make pathology the center of personalized medicine.
We are very proud of what we have accomplished here in Toronto.
We are the leaders in sub-specialty diagnosis.
We've been world leaders in digital diagnosis in digital pathology.
And how appropriate is it that pathology in Toronto is leading the world?
Over a hundred years ago,
another very famous Canadian physician, Sir William Osler said,
"As is your pathology, so goes you clinical care."
Thank you.
(Applause)