Royal College of Pathologists President Dr Michael Osborn speaks to Health Europa about the role of pathology in cancer diagnostic services.
The Royal College of Pathologists (RCPath), a professional membership organisation with more than 11,000 members within the field of pathology, has cautioned of a growing recruitment gap within the sector which may affect the diagnosis and treatment of cancer – particularly as demand on pathology services is continuing to increase. Health Europa speaks with RCPath President Dr Michael Osborn about the impact of the recruitment gap on cancer diagnostic services.
What role do pathologists play in the detection and diagnosis of cancer? How important is early diagnosis in cancer treatment?
It is important to realise that almost all interactions you have with a medical professional will involve pathology at some point: if you go to the GP and you are diagnosed with a urinary tract infection, that diagnosis stems from a pathology department. If you have a vaccination, pathologists will have helped create the vaccine. You interact with pathology all the time, without even knowing that you do it. In terms of cancer diagnosis, nobody can tell you that you definitely have cancer until they have got a tissue diagnosis from a biopsy or blood sample; and the only way to get a tissue diagnosis is to perform tests based in histology, haematology or other pathology tests.
Once there is a diagnosis of cancer and a patient is in treatment, every blood test which is performed to check for anaemia is a pathology test. The blood tests cancer patients take to check that their kidneys are working, so they can have chemotherapy, are pathology tests. If a patient contracts an infection and their doctor needs to know whether they will have to stop chemotherapy, a pathology test is performed.
Early diagnosis is particularly important in cancer: the earlier you catch it, the more likely you are to treat it successfully. Cancer treatment is stratified into different stages based on how advanced the cancer is. For example colon cancer, one of the most common cancers, most commonly starts off in the form of a polyp, which is quite simple to take out by performing a small operation. This is very different from the cases much further down the road, where the tumour can invade the wall of the bowel and maybe go all the way through the wall of the bowel, from which it can spread to the liver, lungs, or lymph nodes. Patients at this stage are unlikely to be cured by a simple operation: they will need to receive chemotherapy and or radiotherapy; at the end of the spectrum, they may be palliative patients.
Different cancers progress at different speeds; even within the same organ, different types and strains of cancer can progress at different speeds; and those speeds differ between patients. The key with any cancer, though, is that if we can catch it early when we could just perform a limited treatment, the patient is much more likely to make a full recovery than they would be much later on when things have spread – cancer likes to invade; and cancer likes to spread.
Pathology staffing levels have not risen in line with increasing demand; and services often have difficulty recruiting for vacant posts. What are the key factors behind the recruitment gap in pathology?
Any recruitment gap consists of two key issues: the number of people leaving and the number of people coming in. Just because of the demographics of our population, a lot of pathologists around the country are over 55 and many are over 60, so they are moving towards retirement age. Meanwhile, over the last three or four years we have managed to fill our training posts, but prior to that some specialities did have some difficulty filling training posts. In addition, we do not really have enough training posts in some specialities to be able to fill the need for people.
It takes 10 to 15 years to train any consultant; and pathology is no different from any other medical speciality. In the late 1990s there were some problems with balancing the number of trainees that would be needed, which meant that perhaps the speciality was less popular because people were worried that they might not get a job at the end of it. We were not the only speciality in this situation: gynaecology and obstetrics were severely affected, so was orthopaedic surgery; and it was all to do with people calculating the numbers and getting projections slightly wrong – and those were the trainees who would be consultants now.
The other really big problem is that pathology is often a forgotten speciality. If a trust, a hospital or a politician of any persuasion reports that they have recruited 100 new consultant surgeons to cure breast cancer, it sounds like fantastic news – and they are very important – but you still need the pathologist to make the diagnosis; the nurse to look after the patient on the ward; the radiographer to perform the X-rays; the porter to carry the patient; the cleaner to clean the ward; the cook to do the cooking. All of these things, which are somewhat less sexy than the consultant surgeon, cost money; and they don’t look as amazing, so they are perhaps not immediately flagged as a financial priority.
While rates of surgery and treatments are increasing, the field of pathology has not quite expanded at the same rate. We are now taking action to overcome that, but that time lag of 10 to 15 years remains in place, so it is still a big issue. A similar issue is that pathology departments as a whole are not exciting to trusts, stakeholders or policymakers – they do not make for good photo opportunities. This can mean there is less investment in pathology departments, which means when people could be interested in pathology as a speciality their eye is drawn instead to the more exciting, modernised departments rather than pathology, which may not have digital technologies and big investment and so forth. Many of the support specialities are in the same situation: we are paying the price for a lack of investment in pathology over the last 15 or so years, even if it is now being rectified.
The other issue is that there are not really enough training posts at present to fill the need that we have. That is out of our control: we can encourage trusts to invest in proportion; we can advocate for more investment in departments, but we have no power over getting more trainee numbers. Some areas find it much harder to recruit than others – there is a particular difficulty in recruiting to rural areas in every medical speciality, including GPs, because people often want to work in a big, well-resourced centre.
Is the pathology recruitment gap likely to have a significant impact on cancer diagnosis and treatment in the UK?
Absolutely. Workload is increasing for two reasons: firstly, because there are now more systems in place to promote testing and examination for common forms of cancer; and secondly, because treatment is now much better – but that means that the procedures and investigations tend to be more complicated and take more time. A pathologist who was able to report X amount 20 years ago could only report, say, two thirds of X now; because each case takes twice as long as it did before. This is not because pathologists are less efficient, but because instead of just looking at one slide, they now have to look at 30 slides and do another couple of extra tests, because that could alter the treatment. Everything is more complicated and more time consuming, which has exacerbated the issues around the lack of pathologists.
What further action could be taken at a policy level to support the recruitment and retention of pathologists in the UK?
In order to get more pathologists, we need to increase trainee numbers. Meanwhile, to improve the productivity of the pathologists we have, we need a national rollout of solutions like digital pathology, which can streamline meetings and track cases. We need greater investment in laboratories – COVID-19 will have an impact on this, because a lot of investment has happened; and if those resources can be redeployed for other tests, that would be useful. It is important to realise that pathology is a core field, and that it is fundamental to cancer treatment.
Dr Michael Osborn
Royal College of Pathologists