Hidden expert – the breast cancer pathologist

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By prof. JE Martin, president of the royal college of pathologists, and professor of pathology at Queen Mary university of London

EVERY day, millions of patients are treated in the health services, and behind the scenes there are thousands of highly skilled experts, you don’t know, you don’t see, but they are looking after you…

Breast cancer patient: Florence

Florence goes to a screening appointment and a small shadow is seen on the X-ray. She is given an appointment at the local breast clinic. She is examined and an ultrasound scan is done that finds a lump. Using a technique called fine needle aspiration, a hollow needle attached to a syringe is used to withdraw a small amount of tissue from the suspicious area.  This is done gently and carefully by the cytologist, Dr X, who then analyses the sample to find out whether there are cancer cells in it. Dr X is an expert in looking at isolated cells under the microscope…

As well as being qualified as a doctor, he has undergone five years of extra training. He knows how cells look normally and how they look when they are inflamed or if they are from a cancer. If he decides these cells are from a tumour then the patient will have surgery to remove the lump, or may need a mastectomy. Getting this right is crucial.

On interpreting the cells, some look benign, but a very small clump of cells at one end of the slide look worrying. Dr X can’t make a definite diagnosis from this small clump so he decides a biopsy is needed, and discusses this with the surgeon looking after Florence.

Florence’s surgeon takes a biopsy, a core of tissue, from the lump, and sends it to the pathology laboratory. Here, the tissue is first looked at by a scientist or doctor, before being specially prepared by a biomedical scientist. After preparation, very thin slices of the specimen are placed on glass slides and dipped into a series of stains or dyes to change the colour of the tissue; this makes cells easier to see under a microscope.

Decision

The slides are picked up by Prof Y. Prof Y is a specialist breast histopathologist, a doctor who has an additional five-year pathology training in how cells and tissue react to disease. Prof Y has also done research training and she has a PhD in breast pathology. The PhD took three years. Prof Y only looks at breast samples in her job, and is one of the world’s leading experts in the pathology of breast cancer. Prof Y also has a research team looking into how breast cancer spreads. Prof Y looks at the first slide and the decision is clear: cancer…

Prof Y feels for Florence; she knows from her biopsy form that they are a similar age, and Prof Y knows it is difficult to be told that you have cancer. The Professor and all her colleagues in histopathology never forget that every sample is from a patient…

Treatments for cancer are chosen depending on where in the body the tumour started, the type of cancer, how big it is and whether it has spread. Cancers also have different genetic changes and there may be a treatment that targets the particular gene change. This ‘personalisation’ of treatment is becoming more and more important in cancer treatment as doctors carry out very specific tests on cancers to find out which changes there are inside the cancer cells.  The biopsy will also be tested to see if certain proteins are present; this will determine how the breast cancer progresses, as well as how it will respond to particular treatments.

Treatment

The treatment that Florence will be offered depends on the advice from Prof Y, based on the results of these tests. Prof Y will meet other breast pathology consultants and trainees, the radiologist, the surgeon and the oncologist in a ‘multidisciplinary team meeting’. These experts will discuss Florence’s case and agree the best course of action. Prof Y shows slides of the tumour to the team. Florence’s tumour has high levels of hormone receptor, meaning that she can be offered a chemotherapy treatment that targets these receptors, followed by surgery…this is good news for Florence.

Florence has a family history of breast cancer. Her sister has also had breast cancer, and Florence is worried whether her daughter might be at risk. Experts in genetics work alongside Florence and the clinical teams to explain to her the benefits and risks of gene screening. Florence decides that she would like the test, and Dr Z, the clinical geneticist, takes a blood sample, which goes to the molecular pathology lab for the DNA to be extracted for analysis. The DNA is looked at for a panel of specific gene changes, including some of the family breast cancer genes such as BRCA. The laboratory results are through and Dr Z reviews the data.

The whole genome has about 3 billion letters in, and one change in a cancer gene can lead to disease. The genetics scientists and doctors know their way around this forest of data, but Dr Z, who spent an extra six  years learning clinical genetics after qualifying as a doctor, can also help give expert advice about the implications of a gene change for Florence. Any gene change may also affect the family, who may share the gene change but may not know…..Dr Z reviews the traces…..no evidence of a family cancer gene change. Cautious relief. Not all family cancer genes are  known yet, but the test has ruled out the most likely.

Florence has her chemotherapy. During treatment her blood is monitored, and Florence has to be careful of infection, since sometimes chemotherapy can affect the immune system. Blood test results are all overseen by experts in blood sciences, including haematologists. If Florence does get a fever, blood cultures will be taken to check her blood for bacteria, and microbiologists (specialists in infection with five years’ specialist post-qualification training) will advise on what the bacteria is, and the best way to treat it.

Florence does well, and her treatment is successful.

Pink Ribbon says. Thanks, Jo. NB, the royal college of pathologists will be conducting a separate session on pathology, with an international flavor, at next year’s breast cancer forum

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Pink Ribbon is the growing international network of doctors, researchers, charities and other campaigners, interested in bringing forward the date where breast cancer-related deaths are a thing of the past. It focuses on events and information provision, including website bulletins, conferences and awards (being planned for 2018). It is led by publisher Gerard Dugdill.

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