Pathology navigators bring molecular test efficiencies

Valerie Neff Newitt

November 2023—Few things in the laboratory can do so much at once: boost histotechnologist productivity, safeguard tissue, offer a career path and help retain staff, keep watch on test utilization, and reduce the number of calls to pathologists and turnaround time, all while advocating for the patient.

That’s what having the precision pathology navigator position at South Carolina’s Spartanburg Regional Healthcare System achieves.

“The navigators handle all aspects of ordering, tracking, and resulting in molecular testing on pathology samples,” including some liquid biopsies, says Amy Ferea, precision medicine supervisor. She became a pathology navigator in 2019 and supervisor early this year.

Pathologist Rosanna Lapham, MD, of Carolinas Pathology Group and Spartanburg, developed and oversees the navigator program, which now consists of Ferea and two navigators who report to Ferea. Dr. Lapham says it was a gap analysis that revealed the need.

“Historically, you would have oncologists, nurses, and patient navigators trying to order these tests, but they didn’t have any idea how much tissue we had or what was appropriate testing. And pathologists would try to reflex test,” she says, despite knowing little about the patient’s clinical situation and what order was required. “We realized we needed clinical support between the pathologist and oncologist.”

First they tried to develop guidelines and train oncology nurses and patient navigators on what should be ordered and how. “But it was too much work and that was not their area of expertise. They don’t know what’s going on with the tissue,” Dr. Lapham says. She and others developed the pathology navigator program to centralize the information and communication in the lab. “And it has worked great,” she says.

She uses an airplane analogy (for which she credits a colleague) to explain the need.

“There are all sorts of people checking you in, getting you to your flight and your destination. The luggage takes an entirely different path to get on the plane, and no one would expect the people handling the luggage to also navigate the passenger to their seat. There are two different journeys, so we need two different navigators—one for the passenger, one for the luggage.”

The pathology navigators handle the “luggage,” which is the tissue, she says. “When you reach your destination, your luggage—your tissue or your diagnosis or your genomic findings—is there for the oncologist.” It’s the “journey” of the tissue that the pathology navigator steers.

The navigator receives all accompanying paperwork, all relevant pathology reports, clinic notes, insurance details, and sometimes ICD codes, Ferea says. “We get a specimen selected by pathologists. A flag indicates which block is adequate for molecular testing. We get the tissue ready; sometimes we can send out the block, and sometimes we have to get unstained slides. The specimen, with all paperwork, is sent out after we create the case, with a new accession number just for that test, in the electronic medical record.” They track each order, and have a list of all molecular testing that’s out at any given point.

“Our histotechnologists love the relief this program provides,” Dr. Lapham says. “They used to say, ‘We do our histotech job all day, then after we finish all that we have to figure out all the send-outs.’ No more. It’s been phenomenal, and our pathologists love it too.”

Previously, “there was a huge gap in trying to bring it all together,” says Marie Gilliland, MLT, precision medicine manager.

“Histotechs didn’t even have time to make sure they were sending out the appropriate test. It was a matter of just trying to get a test out the door and get back to cutting. The pathologists would get a lot of calls from oncologists to check on testing and ask where it was. Then they would have to track someone down to find out.” Now? “They don’t get calls like pathologists typically do.

The lab assistants and staff with associate degrees who move into the navigator positions are trained on the job, Gilliland says.

“We start with having them send out something simple, like IHC or FISH testing. That way they learn the lingo.” They’re encouraged to attend tumor conferences “to hear more of the oncology side and learn to connect it to the pathology side.” They prep for tumor conferences by gathering reports and slides. “I stress to navigators that they are the stewards of that tissue,” she says. “Some people enjoy that responsibility.” Though there is no patient contact, “they are advocates all the way.”

Ferea says training takes six to 12 months. “Dr. Lapham is wonderful in teaching navigators about biomarkers and helping them get comfortable with the process.” The learning never stops, Ferea says. “All the recommendations and requirements are changing.”

The navigators evaluate the insurance and turn it over to a billing specialist for preauthorization. Ultimately, the specimen, patient history, and pertinent prior testing information is sent to the reference laboratory. “And it’s ready to run,” Gilliland says, adding, “It saves several days.”

“Some reference labs have tried to teach our process to their clients.”

The oncologists are fans too. “It’s a good connector. They’re constantly updated. We even have a Teams page where we put what we’ve sent out, so it lists every day what we sent for the day. As we get the results back, we scan them into the LIS” and the oncologists are notified. All have access—the oncologists, oncology navigators, and oncology nurses.

A pathology navigator with a strong pathology background can recognize when an order is inappropriate, and when they do, they bring it to the attention of a pathologist. “It helps if you have people who are specialized in sending out this testing because they recognize when a test isn’t the correct test”—sometimes the order is nothing more than an error—and money is saved, thanks to the navigator’s gatekeeping.

“The hospital is really invested in this, and they’re giving us the support we need,” Gilliland says.

Steering committees of pathologists and other physicians help determine what testing should be done, and they vet a reference lab, its test, and its validation if an oncologist proposes using a lab that’s new to Spartanburg, Dr. Lapham says. “Another place we centralize all that information.”

The American Society for Clinical Pathology is developing a feasibility pilot for a cancer biomarker testing navigator, and Gilliland hopes it eventually gives the navigator role the exposure it warrants.

Dr. Lapham underscores the need to develop such programs and to “put money toward having the right people who can do this work.” Spartanburg is providing assistance to the ASCP on order sets and other tools, “but it’s all a work in progress,” she says, and “first you have to have the people in place to do the work.”

“We have to get it into the lexicon,” she adds, “so we can start building these programs and so C-suites can understand the advantages.”

At Spartanburg, the advantages are many, in addition to simply “allowing histotechs to do histotech work and pathologists to do the work they need to do,” Dr. Lapham says.

“Now that we have all these processes in place,” she says of the department, “they’re going to start bringing in more molecular testing. It’s bringing a lot of opportunity.”

For staff too: “It’s a place for people to develop a career path and move up in roles. A lot of places lose staff to research or other areas of the hospital, and this way we’ve been able to retain staff.” Moving into the role from accession is common.

Says Gilliland, “The big win is patient care.”

Valerie Neff Newitt is a writer in Audubon, Pa.