October 2010
Feature Story

Josh Roberts

Pathologists have to prepare for new realities, and instructional webinars running for nearly a year now are putting the nuts and bolts front and center.

The CAP Personalized Health Care Committee created the series of webinars to spread awareness about how broad a swath personalized medicine cuts and the many ways it can affect pathology practice.

“There is so much transformative activity in health care, both from a policy standpoint and a scientific standpoint,” says Louis D. Wright Jr., MD, CAP governor and co-chair of the Personalized Health Care Committee. “We needed to raise the general membership’s acuity about all of this transformation and get them interested and involved.”

There is a general understanding of personalized health care, says committee member Samuel K. Caughron, MD, but “until you understand when people are talking about PHC what exactly is meant, it’s difficult to know how you can fit in to it.”

Dr. Caughron, of MAWD Pathology Group, Kansas City, Mo., sees KRAS as the “poster child” of personalized health care. Thirty-five to 40 percent of colon cancers are associated with the KRAS mutation that affects response to a “novel, potentially useful, but also very expensive drug,” he notes. In his own webinar, presented last December and still online, he talked about KRAS mutation analysis as well as BRAF mutation analysis, CYP2D6 for tamoxifen resistance, and CYP2C19 for Plavix resistance. Though it may still be hard to cost justify setting up a molecular pathology lab, costs are declining, volumes are rising, and assays are getting easier, he told his listeners.

Anyone can sign on for the free hourlong webinars, but pathologists, especially those in community practice, are the key audience for the series, says Jill H. Kaufman, PhD, CAP director of personalized health care initiatives. Laboratory managers, technologists and technicians, and clinical scientists may also find them, and the Q&As that follow, to be helpful.

The increasingly popular webinars will not provide all the answers to all questions about personalized health care, of course, and not all are molecular oriented. They’re more like “mini facets of PHC” as a whole, Dr. Kaufman says, with experts addressing everything from biorepositories and the life cycle of biomarkers to medical DNA sequencing and the medical home. All are recorded and accessible anytime at www.cap.org/institute.

Before joining MAWD Pathology, Dr. Caughron was for two years in Billings, Mont., at Yellowstone Pathology Institute, where he set up a molecular laboratory (owing to the foresight of his colleagues and with the help of talented technologists, he says). In his webinar, he talked about why a pathology group might do so (to attract young talent, meet clinical demand, contain costs, for example); the different levels of testing, with a basic operation consisting only of FDA-approved assays (“where you want to start,” he says); the technology; and the business challenges (for him far trickier than the technological ones). While it may be too early today for many pathologists to integrate molecular testing into their laboratories, every pathologist can be learning about molecular assays and gathering information on the opportunities in personalized health care, he says, and the webinars are one way to do so.

How to triage the myriad requests for new molecular tests is the topic of another webinar, presented in June by Alexis B. Carter, MD, PHC Committee member and director of pathology informatics at Emory University School of Medicine. “Keeping up with molecular diagnostics can be really difficult, even for those of us who practice it on a daily basis,” Dr. Carter, who spent 14 months in private pathology practice before joining Emory, told CAP TODAY. How to know which of the many new tests clinicians ask for are worthwhile and which are not? Check out her “three-step evidence check”—“a quick and dirty way to do a simple analysis on these new molecular tests,” she says—and her suggestion for operationalizing molecular send-out testing.

Howard Robin, MD, medical director of continuing medical education at Sharp HealthCare in San Diego, recently retired as a hospital pathologist and now consults with biotechnology companies. As of August, he had signed on to three PHC webinars, one of which was a presentation in May by Raj Dash, MD, of Duke University Hospital and Health System, and Jim Robb, MD, of the NCI, on setting up a biorepository. “The presentation was relevant to a current project at my hospital and with our collaborator to start a limited-scale tumor bank,” he says. Dr. Robin invited the collaborator to the webinar, and he and others were able to hear from the experts, he says, referring to the “people at Duke who have the greatest experience and probably one of the most sophisticated tumor banks.”

Suresh Amin, MD, logged on in July to view the webinar on “Molecular Darwinism” given by Jennifer Hunt, MD, MEd, associate chief of pathology, Massachusetts General Hospital. Dr. Hunt, who argues that “pathologists have been doing personalized health care forever, since the beginning of pathology,” says in her webinar that pathologists can ask about their biomarkers the same questions Darwin asked about species: Where do they come from, why so many, what makes them successful long term? Colon cancer is her webinar focus, in particular microsatellite instability and BRAF and KRAS mutations, which have “survived the test of time,” and EGFR expression, which “thankfully, for colon cancer, has become extinct,” she tells her audience. Dr. Hunt presented an interesting concept, Dr. Amin, who “liked and learned from the webinar,” told CAP TODAY by e-mail. “The topic was tantalizing,” he wrote.

One viewer of last month’s webinar on endoscopic microscopy (“Bridging the Radiology/Pathology Divide”) described the presentation as “scary and exciting” and added, “We are already talking with our gastroenterologists.”

There is more excitement, or, as a watcher of another webinar described it, more “fan bloody tastic,” to come. On Nov. 9, Philip T. Cagle, MD, director of pulmonary pathology at The Methodist Hospital in Houston, will talk about the role of the community pathologist in personalized health care for lung cancer patients. On Dec. 14, Mark H. Stoler, MD, associate director of surgical pathology and cytopathology at the University of Virginia, will take on “The True Meaning of the Bethesda System: Integrating Cytology and HPV Molecular Testing to Individualize a Woman’s Cancer Risk.” And David G. Hicks, MD, director of the surgical pathology unit at the University of Rochester, will kick off the new year of webinars with one in January 2011 on molecular markers in breast cancer.

The CAP will continue to present webinars, probably with an even broader menu and more emphasis on “changing science and the changing approach to delivery of health care... at least over the next couple of years,” Dr. Wright says.

Next year, for example, there will be a webinar on next-generation sequencing. “The technology is rapidly declining in cost and presents new opportunities for interpretation by a pathologist,” Dr. Kaufman says.

Dr. Caughron points out in his webinar that personalized health care isn’t just molecular, it’s not just cytogenetics/FISH testing, and it’s not going away. Dr. Hunt sounded a similar note of the many biomarkers that surface and stay or fade away: “This is nonstop for us.”

It’s only an hour once per month, Dr. Carter says of the webinars. “It may seem like a lot of time, especially when you’re in a busy practice, but I think it’s well worth the time. It’s really important that in every practice there is somebody who is responsible for becoming familiar and keeping up with personalized health care.” If not, she adds, “your practice could be left in the dark ages.”