Future of Pathology

Jared N. Schwartz, MD, PhD FCAPPresident, College of American Pathologists

Digital Pathology Solutions ConferenceOctober 2007 · San Diego, CA

PATHOLOGYVISIONS2

007

The struggle of today, is not altogether for today—it is for a

vast future also.

The struggle of today, is not altogether for today—it is for a

vast future also.

~ Abraham Lincoln

Technology is transforming the delivery of patient care

Clinical transformationis occurring

Time

Episodic

Treatment of

Disease

Reactive Care

Personalized

Medicine; Disease

Prevention

Proactive Health

Management

Variation

Between Styles

Chaotic Flux

Medicine

Why now?

Tumor

Cell

Chromosome

Proteins

Genes

DNA

Tumor

Cell

Chromosome

Proteins

Genes

DNA

Dramatic technology advancements provide new insight and the ability to answer the vital questions that drive diagnosis, and prognosis and therapy

• What disease/condition do I have?• Which drug should I use• How much drug do I need?• Is the drug working?• Is my disease gone?

• Minimally invasive/incision-less surgery

• Tissue characterization and imaging (virtual histology; microendoscopy)

• Molecular medicine

• Tumor-specific in vivo biomarkers

• Proteomics

• Virtual colonoscopy

• Integrated information systems

• HPV and other vaccines

What happens if there is What happens if there is no tissue to look at?no tissue to look at?

And this transformation has implications for pathology

Digital imaging has already progressed on the technology adoption curve

SaferInvestment

Market-ShapingOpportunity

High-Risk Investment

InnovatorsEarly

AdoptersConsensus

AdoptersCautiousAdopters

LateAdopters

1 2 3 4 5

Very SafeInvestment

SaferInvestment

Market-ShapingOpportunity

High-Risk Investment

InnovatorsEarly

AdoptersConsensus

AdoptersCautiousAdopters

LateAdopters

1 2 3 4 5

Very SafeInvestment

Market-ShapingOpportunity

High-Risk Investment

InnovatorsEarly

AdoptersConsensus

AdoptersCautiousAdopters

LateAdopters

1 2 3 4 5

Very SafeInvestment

Beta and early production models available; not FDA approved

Devices available & FDA approved; reimbursement not wide spread. Trials focused on patient mgmt

Becoming standard of care; patient guidelines established and applied. Reimbursement established with major players

Accepted Standard

Pro

bab

ilit

y o

f A

do

pti

on

in

to C

lin

ical

Us

e

0Pre-Clinical

3Consensus Adopters

2Early

Adopters

1Innovators

5Late

Adopters

4Cautious Adopters

Pyrosequencing

Proteomics for cancer screening

POCT PLT fn testing

Pharmacogenetics for DMEs

Microwave tissue processors

Laser capture microdissection

Lab automation

Intraoperative PCR

InVivo Histology

HR HPV PAP adjunct

HPV vaccine

Genetic risk assessment

Continuous monitoring

Comparative genomic

hybridization

Companion DxWaived CBC test

Circulating tumor cell

assay

CAD for Pathology

Digital imaging for path

Screening virtual colonscopy

Sample to answer PCR

Gene expression assays

Positive Impact

Magnitude of Impact--UNSURE

Tech Curve Position-- UNSURE

Color Key

Technology Curve

Imaging for tissue characterization

Robotic telepathology

Its impact on pathology will increase

Accelerators• Decreased cost with ongoing product enhancement• Clinical demand for pathologist sub-specialization• Patient demand for reduced TAT for rapid,

advanced diagnostics• Demand for complete EMR, including multimedia

Dx data• Hospital demand for rapid TAT and value

enhancement for differentiation

It is just a matter of time

Barriers• High equipment costs and

work flow change• Parallel technology

developments• Automation• Image acquisition• Standards agreements• Data storage• Communication and clinical

applications

40-sec20x scan

20-second40x multi-angle

scan

20-sec20x scan

Multispectral imaging

Subspecialistwork flow

triage

Rapidsecondary

consultations

Computer-aided detection

Pathology PACS

Enterprise image management

100 PetabytesPetabytes100 Terabytes

Computer-aided diagnosis

Ima

gin

gS

tora

ge

Ap

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2007 2012 2017

* Source: Sg2 T3 Virtual Slide Imaging

Each pathologist and organization has a place on the Tech Curve

Early Adopters—target for leadership and

resource committees

Innovators—target for foundation grants

Consensus Adopters—Primary target for education and accreditation products

Late Adopters—Members at the

sunset of their careers

Cautious Adopters—Target for technology education

1 2 3 4 5

Early Adopters—target for leadership and

resource committees

Innovators—target for foundation grants

Consensus Adopters—Primary target for education and accreditation products

Late Adopters—Members at the

sunset of their careers

Cautious Adopters—Target for technology education

1 2 3 4 5

Where is the specialty of pathology?

“Never, ever, think outside the box.”

If pathologists don’t step up, others will battle over the turf

The Battle of the Barbers and Surgeons, 18th c. caricature

Clinical care has a history of conflict

A reluctance to train in new technologies opens the door to others to seize the opportunity.Pathology is no exceptionPathology is no exception

ABR Board exams address pathologyDiagnostic radiology now encompasses a variety of diagnostic and image-guided therapeutic techniques, including all aspects of radiological diagnosis, nuclear radiology, …molecular diagnostics and morphology…Integrating pathologic assessment into your radiology reports requires effective management of pathology technicians and adequate quality control. New Board exams address the technical and management skills needed.

ABR Board exams address pathologyDiagnostic radiology now encompasses a variety of diagnostic and image-guided therapeutic techniques, including all aspects of radiological diagnosis, nuclear radiology, …molecular diagnostics and morphology…Integrating pathologic assessment into your radiology reports requires effective management of pathology technicians and adequate quality control. New Board exams address the technical and management skills needed.

Reluctance to train in new technologies opens the door to others to seize the opportunity

Main Topic at ACR’s 2007 ForumLeadership in Radiology

…Forum attendees worked to pinpoint ways in which the ACR and its partners can better identify, cultivate, and empower a new generation of radiology leaders in these increasingly turbulent times…

Could it happen?

Myths and rumors about the future may be inhibiting action

• Pathology is merging with radiology

• There is too much to learn; I don’t have time

• Emerging technologies won’t impact my practice

• Besides nobody will pay for it

• We are turning into dinosaurs

• Etc., etc. etc…

Opportunity exists for pathologists that are ready

“Opportunity paged me, beeped me, linked me, emailed me, faxed me, and spammed me. But I

was expecting it to knock!”

ImagingImaging

Prognosis & TreatmentPrognosis & Treatment

Predisposition, Signs, SymptomsPredisposition,

Signs, Symptoms

The value of traditional pathology has not diminished.

It is simply no longer sufficient.

Pathologist

Gene ExpressionPharmacogenomics

Gene ExpressionPharmacogenomics

BiomarkersBiomarkers

TraditionalPathologyTraditionalPathology

Pathologists can generate test results…

OR

provide answers that guide the treatment team with diagnosis and therapy

Pathologists are physicians…

…take an active role in patient care, utilizing all available tools to integrate and interpret diagnostic information to provide an accurate diagnosis of disease.

Pathologists work closely with other members of the medical team to assess the patient condition and prognosis in order to determine optimum therapy alternatives.

Pathologists are not defined by the tools they use, but the

knowledge they share

Pathologists are not defined by the tools they use, but the

knowledge they share

…so, what can you do?

• Acknowledge market forces driving changes in practice of pathology

• Re-assess your tool kit—all diagnostic tools are available to you

• Engage the change—integrate new concepts and technologies

• Be life long learners; don’t use the certification exam as the guidepost

• Expand beyond the tissue on the slide

“I’ll be happy to give you innovative thinking. What

are the guidelines?”

So, what’s it going to take?

Get back to being a physician!

Get back to being a physician!

“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”

~ Charles Darwin