Beyond the microscope: expanding the role of cytopathologists

From the CAP Cytopathology Committee;
Jordan Paul Reynolds, MD, Derek B. Allison, MD, Editors

Varsha Manucha, MD
Martin J. Magers, MD

January 2025—The traditional image of a pathologist is often that of a scientist working in a laboratory, handling chemical solutions, or peering through a microscope. Over the past decade, pathologists, including those specializing in cytopathology, have increasingly moved beyond those confines, taking on more prominent roles in patient-facing care. This article explores the various ways cytopathologists are expanding their roles, engaging directly with patients and physicians and positioning themselves at the forefront of the management team.

Fine-needle aspiration. Fine-needle aspiration is a minimally invasive, cost-effective method that enables rapid diagnosis of lesions that might otherwise be challenging to access. Clinicians and radiologists perform FNAs frequently, but studies have demonstrated that tissue adequacy and diagnostic accuracy are highest when a pathologist performs the procedure.

Traditionally, pathologists performed FNAs using palpation guidance for superficial, palpable lesions. However, there is a growing trend toward cytopathologists performing ultrasound-guided FNAs. Cytopathologists acquire the skill set during training and fellowships or through hands-on courses offered by organizations such as the CAP, American Society of Cytopathology, and American Society for Clinical Pathology.

The pathologist’s role in FNA encompasses gathering patient history, performing focused physical exams, evaluating patient risk factors, conducting the FNA, and providing on-site adequacy evaluations. Their comprehensive involvement ensures safety, adequate sample collection, higher diagnostic rates, and prompt preliminary diagnoses, enabling rapid patient management. In settings such as one-stop clinics, where clinical, radiological, and morphological examinations are integrated, the direct participation of cytopathologists enhances patient care and reinforces their position as indispensable members of the health care team. FNA is an opportunity for practice development, fostering greater patient-pathologist interactions and expanding the use of pathology services.

Pathology consultation clinics. Traditionally, the training of pathologists has been centered on microscopic diagnosis aided by immunohistochemistry and molecular tests. It is precisely this training that uniquely positions the pathologist to explain to patients the why and how of a diagnosis. The patient-pathologist consultation program is designed to educate patients about the pathology of their disease, equipping, enabling, and empowering them to make informed decisions about their health and treatment. This concept holds even greater significance today in the era of personalized medicine, which requires patient engagement in decision-making, facilitated by a better understanding of the disease process.

In pathology consultation clinics, pathologists meet with patients in an outpatient setting to review pathology findings using clear, nontechnical language. This approach helps patients understand their conditions, alleviates anxiety, and improves treatment compliance. Furthermore, the direct interaction with the pathologist serves to dispel misinformation that the patient may have encountered through social media and internet searches. A multisite quality improvement study showed that patients reported personalized clinical encounters with pathologists improved their understanding of their health condition and their satisfaction with their care experience. These interactions can be highly rewarding for pathologists, serving as a reminder of their motivation to become physicians.

The concept of a pathology consultation clinic, the first of which was implemented in 2017 in Massachusetts, has gained attention and received endorsements from national societies like the CAP and ASCP. Cytopathologists, owing to their direct involvement in FNA procedures, are uniquely positioned to offer similar consultations. By being present during clinical FNAs to provide rapid on-site evaluations, cytopathologists not only enhance diagnostic accuracy but also can offer consultations to their clinical colleagues, thereby strengthening interdisciplinary communication and improving patient care.

See, Test & Treat. See, Test & Treat is a pathologist-led initiative for free cancer screening and health education programs funded by the CAP Foundation. The goal of the program is to bring the power of diagnostic medicine to medically underserved and vulnerable populations. Initially, the program focused on providing Pap tests and screening mammograms with same-day results, but its success has led several participating institutions to extend cancer screening to other organ systems, including oral, skin, and lung. See, Test & Treat is a collaborative effort of several medical specialties, but it is primarily driven by pathologists, offering them a unique opportunity to take a leadership role in cancer care while increasing their visibility among hospital leadership.

Tumor boards. Tumor boards consist of multidisciplinary team members who discuss complex cases, enhance diagnostic accuracy, and collaboratively formulate treatment plans. The traditional role of the pathologist at these conferences is to present the salient gross and microscopic features of the tumor and provide the pathology staging. With the rise of personalized medicine, the pathologist’s responsibilities are expanding to include preclinical drug testing, assessment of prognostic markers, tissue triage for molecular testing, consultation on the feasibility of such testing, and interpretation of companion biomarkers. As personalized therapies become more prevalent, treatment decisions increasingly rely on diagnoses from small biopsies and FNA. This shift has elevated the importance of cytopathologists, who are often responsible not only for making the diagnosis but also for ensuring that sufficient tissue or cells are available for molecular and ancillary testing. Participation in tumor boards offers pathologists and cytopathologists a valuable opportunity to broaden their roles in treatment planning and decision-making.

Social media. Social media has become a powerful tool for pathologists to share knowledge and educate a wide audience, including other pathologists, health care workers, students, and patients. Platforms such as X and Instagram enable pathologists to efficiently share case studies, diagnostic challenges, research findings, and expert opinions. Pathologists often share on social media images of pathology slides with accompanying educational discussions, allowing others to comment on and learn from real-life cases. Educational initiatives, such as “tweetorials” and pathology-focused hashtags (e.g. #PathTwitter), have emerged as accessible resources for trainees and established professionals. The interactive nature of social media fosters collaborative learning and networking within the pathology community. Social media enhances specialized medical education and bridges the gap between expert knowledge and the general public.

Conclusion. The cytopathologist’s role has been evolving, shifting from primarily one as a diagnostician to one that is an integral part of the patient care continuum. Through procedures like FNA, engagement in consultation clinics, participation in See, Test & Treat, and active involvement in tumor boards, cytopathologists are expanding their expertise far beyond the microscope. This evolution not only enhances patient care but also underscores the vital contributions of cytopathologists in the modern health care landscape.

Additional reading

1. Grohs HK. Starting out: the interventional cytopathologist: a new clinician/pathologist hybrid. Am J Clin Pathol. 1988;90(3):351–354.
2. Suciu V, El Chamieh C, Soufan R, et al. Real-world diagnostic accuracy of the on-site cytopathology advance report (OSCAR) procedure performed in a multidisciplinary one-stop breast clinic. Cancers (Basel). 2023;15(20):4967.
3. Villar-Zarra K, Balassanian R, Vielh P. Unleash your potential: inside interventional pathology. Cytopathology. Published online July 9, 2024. doi:10.1111/cyt.13417
4. Booth AL, Katz MS, Misialek MJ, Allen TC, Joseph L. “Please help me see the dragon I am slaying”: implementation of a novel patient-pathologist consultation program and survey of patient experience. Arch Pathol Lab Med. 2019;143(7):852–858.
5. Jug R, Booth AL, Buckley AF, et al. Multisite quality improvement study of a patient-pathologist consultation program. Am J Clin Pathol. 2021;155(6):887–894.
6. Lapedis CJ, Horowitz JK, Brown L, Tolle BE, Smith LB, Owens SR. The patient-pathologist consultation program: a mixed-methods study of interest and motivations in cancer patients. Arch Pathol Lab Med. 2020;144(4):490–496.
7. Joseph L. Your doctor, the pathologist, will see you now. Am J Clin Pathol. 2021;156(6):939–940.
8. Green EA. Steps to start a patient-pathologist consultation program. College of American Pathologists. Oct. 31, 2019. https://www.cap.org/member-resources/articles/steps-to-start-a-patient-pathologist-consultation-program
9. Shachar E, Hasson SP, Fayngor R, Wolf I, Hershkovitz D. Pathology consultation clinic for patients with cancer: meeting the clinician behind the microscope. JCO Oncol Pract. 2021;17(10):e1559-e1566.
10. Magnani B, Harubin B, Katz JF, Zuckerman AL, Strohsnitter WC. See, Test & Treat: a 5-year experience of pathologists driving cervical and breast cancer screening to underserved and underinsured populations. Arch Pathol Lab Med. 2016;​140(12):1411–1422.
11. Williams MS, Wells J, Duhé RJ, et al. The College of American Pathologists Foundation’s See, Test & Treat program: an evaluation of a one-day cancer screening program implemented in Mississippi. J Cancer Educ. 2022;37(6):1912–1917.
12. Deeken AH, Mukhopadhyay S, Jiang XS. Social media in academics and research: 21st-century tools to turbocharge education, collaboration, and dissemination of research findings. Histopathology. 2020;77(5):688–699.

Dr. Manucha is professor, Department of Pathology, University of Mississippi Medical Center, Jackson. Dr. Magers is staff pathologist, Trinity Health IHA Pathology and Laboratory Management, Ypsilanti, Mich. Both are members of the CAP Cytopathology Committee.