Maggie McKay (Host): When you are a patient, the role pathology plays in your treatment and diagnosis may not be top of mind during your healthcare journey, but it is an integral part of the process. So today, Dr. Mark Fowler, a pathologist from Community Memorial Healthcare with an additional specialty in surgical pathology and cytopathology will break it down for us.

Host: Welcome to Wise and Well presented by Community Memorial Healthcare. I'm your host, Maggie McKay. So nice to have you here, Dr. Fowler. First off, would you please explain the role of a pathologist in a patient's healthcare journey?

Dr Mark Fowler: Thank you. It's good to be here. The role of a pathologist in a patient's health journey, many people ask me what a pathologist does, and as a hospital pathologist, I characterize what I do as diagnostic and laboratory medicine. Now, what exactly does that mean? Well, any patient specimen, for example, tissue or body fluid, is sent to the laboratory for processing and diagnostic testing.

For my part, I spend greater than 95% of my time practicing surgical pathology. So making diagnoses on patient tissue specimens that are collected in clinic or perhaps in the operating room. And cytopathology, which is making the diagnoses on cell specimens, for example, cervical Pap specimens, thyroid fine-needle aspirations for thyroid nodules and cells that are found within certain body fluids like urine. A diagnosis or differential diagnoses are really the fulcrum upon which the course of patient care and management is determined. And it's not only the pathologist's job to make a diagnosis. But once I make a diagnosis, it's my job to provide the clinician, be it the primary care provider, the surgeon or oncologist, all the pertinent prognostic information, that is then used and incorporated into a personalized care approach for each and every single patient.

Host: So, what you do actually empowers and arms other specialists, physicians and nurses to do the best job possible for a patient.

Dr Mark Fowler: Yes.

Host: Should a patient get to know the pathologist and better understand how they'll contribute to their diagnosis and treatment recommendations?

Dr Mark Fowler: So, I feel that patients should know about the pathologist's role as a diagnostician. They should know that there is a chain of custody and stewardship from the time the patient sample is collected and a diagnosis is rendered, or a laboratory value is resulted. It is essential that clinicians know their pathologists because having a relationship of collaboration and being able to correlate the clinical, the radiological or imaging, the laboratory and the pathology findings is really invaluable in achieving the optimum standard of patient care.

I myself, I have an open door policy here at the hospital, and I'm always happy to sit with clinicians, students, be they medical students or residents or patients alike, to look at and discuss their pathology findings. And I'm usually on the phone multiple times each week to alert clinicians as to unsuspected cancer diagnoses or to give a preliminary diagnosis to assist with decision-making and the care process for our admitted patients in the hospital.

Host: That's got to be reassuring to the patient to, you know, have access to you. So, pathology plays a crucial role in cancer diagnosis and treatment. Could you discuss the role of pathology in cancer care? And also, how can pathology determine various care paths?

Dr Mark Fowler: I feel this would be best described or illustrated by sharing two examples that I see on a weekly basis, and I'll start with the breast biopsy specimen. So, female who goes in for screening mammogram or notices a palpable mass in her breast, comes in and has imaging done, usually mammography and ultrasound and that imaging can be very helpful in telling the likelihood or suspicion for a cancer of the breast. Though there's a lot of gray area and a lot of times it's unsure whether it's cancer or something benign, so that breast mass or lump will get a core biopsy. So, a fine needle is inserted into the mass and tissue core is gathered and then sent to pathology to the laboratory where that tissue is processed. And then, I get it on my desk and look at it under the microscope. And depending on what I see, if I don't see any cancer, perhaps it was a mimic or something else causing a mass or nodule in the breast, then that patient can be reassured through the pathology report that there is no cancer in that biopsy.

Alternatively though, if I find cancer, then that's not the end of what it's my job to do. My next step is I will again gather that prognostic information. I'll perform hormone marker studies for estrogen receptor, progesterone receptor, HER2. And based on the findings of those studies will largely determine the prognosis for the patient, looking at how the cancer will behave and what possible treatment markers there are, if it is hormone receptor-positive. And so, this will direct the patient's treatment course moving forward in regards to their breast cancer.

Another example is we get lung biopsies frequently. And lung cancer comes in a variety of types. There's the non-small cell lung cancer, which really encompasses squamous cell carcinoma and adenocarcinoma. There's small cell carcinoma. And I've seen a few examples where we've had lung biopsies for suspected carcinoma, but the final pathology is a diffuse large B-cell lymphoma. And each of these types of cancers are treated differently. So after I've been able to make the diagnosis based on tissue and cancer morphology, what it looks like, then it's my responsibility to start gathering additional information. If it's a squamous cell carcinoma, is it PD-L1 positive, which would be a potential tumor marker or marker of treatment? If it's an adenocarcinoma, looking at molecular markers for EGFR, ALK, ROS1, for example. If it's a small cell carcinoma, these are very sensitive to chemotherapy and typically are not amenable to resection as oftentimes they're metastatic at the time of diagnosis, unlike squamous cell carcinoma and adenocarcinoma, which would prompt the next step in treatment, being a surgical resection if possible for cure. And so, these are two examples of two different tissue types, where really depending on the pathology diagnosis determines the treatment course and the next steps in care for the patient.

Host: And how does a pathologist collaborate with other healthcare professionals like surgeons, oncologists, radiologists, for example? How does this multidisciplinary approach benefit patient care?

Dr Mark Fowler: Well, as I previous alluded to, this is so important for patient care for meeting the optimal standard of patient care. So, collaboration between healthcare professionals having that multidisciplinary approach is optimal, and this collaboration sometimes occurs in formal settings. There is a weekly tumor board that we have here at Community Memorial Healthcare in which oncologists, so think of those as your doctors who treat cancer; surgeons, radiologists and pathologists and other specialty healthcare personnel, we all come together to address challenging cases to collaborate and take a multidisciplinary approach to better optimize and tailor patient care and treatment to the individual.

A lot of the collaboration I do is just day to day over the phone. And the pathology findings as they're communicated to the clinician, surgeon, oncologist really help drive and direct that patient management and care. For an example, I had a recent breast resection specimen for cancer. So, the patient went in; had the operation, a partial mastectomy or lumpectomy. And when I got the surgical specimen, there was a positive tumor margin for invasive cancer. And so, the goal, of course, is to have a clean margin to achieve cure, complete excision, removal of the cancer and cure. So, I was able to communicate this in the pathology report and to the surgeon, and they went back and did an additional re-excision procedure, which resulted in clean tissue margins for that patient. And now, they're able to continue on with additional oversight and management in their treatment course.

As a pathologist, we also give real-time intraprocedure feedback. As a cytopathologist, I often will go on site for procedures with pulmonologists where they are taking fine-needle aspiration specimens of lymph nodes and cancer staging or for diagnosis of lung cancer. And if they find cancer in a particular site, I'm able to tell them that, "Hey, we got diagnostic tissue. We can collect additional from that site and we can finish the procedure. We have adequate material." And so, this can drastically shorten the time that the patient spends in a procedure under anesthesia and makes the procedure more efficient for the patient and assuring that we have diagnostic material.

As a surgical pathologist, I routinely perform intraoperative frozen consultations. And so, a surgeon in the OR will send a piece of tissue. Most commonly, it's to evaluate for tissue margins to make sure that they resected the cancer entirely, and I can provide real-time intraoperative feedback to the surgeon, to let them know that their margin is clean of cancer or that they need to go back and take more. And so, these are many ways in which, you know, the pathologist is collaborating with and working with other healthcare professionals on a daily basis.

Host: Thank you so much for sharing your expertise about pathology. It's very encouraging, all the things you see in the future and what's going on just right now compared to maybe 10 years ago, and all that's involved for the patient when it comes to pathology. We appreciate your time.

Dr Mark Fowler: Thank you for having me.

Host: Again, that's Dr. Mark Fowler. If you'd like to find out more, please visit mycmh.org/findadoctor/mark-fowler-md. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is Wise and Well, presented by Community Memorial Healthcare. Thank you for listening.