The Department of Pathology at City of Hope is recognized worldwide for its diagnostic excellence. Laboratories lead by renowned investigators and equipped with highly sophisticated technologies enable us to provide physicians and their patients with accurate diagnoses of even the most elusive diseases.
Pathology and radiology form the core of cancer diagnosis, yet most patients never see the Pathologist. With the enormous technological advances currently occurring in both fields, the opportunity has emerged to develop an integrated diagnostic reporting system that supports both specialties and, therefore, improves the overall quality of patient care.
Listen as Sophia Apple, MD discusses the relationship between the Radiologist and the Pathologist and how the teams at City of Hope work together to give patients the best standard of care to assure a proper diagnosis.
The Pathology of Breast Cancer
Featured Speaker:
After more than 20 years at UCLA (15 as director of breast pathology), Dr. Apple came to City of Hope to expand her clinical and research work with breast cancer, in search of better treatments for her patients.
Dr. Apple studied biochemistry at New York University, received her medical degree from Wright State University in Dayton, Ohio, and completed her pathology residency and fellowship at UCLA.
Dr. Apple literally “wrote the book” on combining breast imaging and pathology, co-authoring a definitive textbook on the subject and published more than 70 peer-reviewed journal articles related to breast diseases.
She’s grateful and loves America for the opportunities given for her to fulfill her dreams.
Learn more about Sophia Apple, MD
Sophia Apple, MD
Born in Korea, Sophia Apple, M.D. survived a childhood bout with polio which left her with a slight limp and a determination to become a physician. In her second year of medical school she became fascinated with pathology, which she calls “the brain of medicine.”After more than 20 years at UCLA (15 as director of breast pathology), Dr. Apple came to City of Hope to expand her clinical and research work with breast cancer, in search of better treatments for her patients.
Dr. Apple studied biochemistry at New York University, received her medical degree from Wright State University in Dayton, Ohio, and completed her pathology residency and fellowship at UCLA.
Dr. Apple literally “wrote the book” on combining breast imaging and pathology, co-authoring a definitive textbook on the subject and published more than 70 peer-reviewed journal articles related to breast diseases.
She’s grateful and loves America for the opportunities given for her to fulfill her dreams.
Learn more about Sophia Apple, MD
Transcription:
The Pathology of Breast Cancer
Melanie Cole (Host): Led by pathologist renowned for diagnostic excellence, the Department of Pathology at City of Hope combined state of the art laboratories equipped with the latest diagnostic techniques and advanced instrumentation with superior investigative skills to accurately and rapidly identify even the rarest and most complex diseases. My guest today is Dr. Sophia Apple. She's a clinical professor in the division of anatomic pathology in the Department of Pathology at City of Hope. Welcome to the show, Dr. Apple. Today we're going to talk about breast cancer and specifically combining breast imaging and pathology. So, will you first start by please explaining what a pathologist even does?
Dr. Sophia Apple (Guest): Pathologists are subspecialty people who are mostly responsible for providing final diagnosis on any diseases, either benign or malignancy.
Melanie Cole: So, if we're talking specifically about breast cancer, when would you be brought into a woman's diagnosis?
Dr. Apple: A woman with any breast abnormality or even after age 40, when the diagnostic screening mammogram is done then they will get the mammogram or ultrasound or sometimes the MRI, and if the radiologist finds any abnormality or any concerns or suspected lesion they would target that with the core needle biopsy. Those core needle biopsy gets into the pathology department and we fix the tissue and make a slide and then we look at the slide and provide a final diagnosis.
Melanie Cole: Is a pathologist somebody that the patient would actually meet?
Dr. Apple: No, we are behind a curtain but I would say that we are the brain of the entire medicine because if we provide the diagnosis wrong, then everybody will go into the wrong route. So, we're critically important because we provide the final diagnosis of any diseases. We are behind the scene and sometimes the patients’ mention, “Who are these pathologist who gave us the bills and what are they doing?” but we actually are the critical doctors, medical doctors, who provide the diagnosis for individual patients.
Melanie Cole: You're kind of steering the ship as it was. So, please speak about the benefits of a collaborative working relationship between pathologists and the radiologists that have done the stereotactic or whichever kind of biopsy they did?
Dr. Apple: Yes. So, the radiologist and pathologist they both provide diagnoses but the radiologists look at the shadow of the disease whereas a pathologist actually look at the tissue of the material that they've provided. We have to work together. If the radiologist thought that the lesion was very suspicious and the pathologist called it “benign” then it doesn't match. So, we do like to do correlation between clinical imaging, clinical findings, and a pathologist findings. That's called “triple test” because clinical is one, imaging is another, and the pathologist are third. They all have to match together to provide an accurate diagnosis. For instance, if clinically or imagingly suspicious lesion was targeted and the core needle biopsy was performed but if I called it benign that means there's a probability or possibility that radiologist did not get the lesion. So, if the triple test failed then the radiologist would have to bring the patient back, either redo the core needle biopsy or wait for three months or six months and then retarget that lesion again.
Melanie Cole: Speak about some of the critical components of a radiology/pathology integration and how that for the patient as you're the one sort of steering the ship and really making that final diagnosis and giving the histologic type pictures, then what would be some of the most critical components that you would want the patient to know about the importance of this relationship.
Dr. Apple: Let's say the patient is worried about a mass lesion and she goes to imaging or radiologist and the radiologist targeted that lesion and perform the core needle biopsy and if I called it benign or the benign entity explains the mass that the woman is experiencing, then since the final diagnosis was benign, she does not have to worry about it; whereas, on the other side of the coin, if the radiologist looked at the mass lesion and if the pathologist called it “malignant”, she has a diagnosis and she has to act on it, such as surgical removal and if the surgical removal is a breast cancer with hormonal findings, the estrogen receptor, the progesterone receptors, if those are positive, then the oncologist will treat the patient with endocrine therapy. If HER2 is positive, then the receptor therapy is generated. So, pathology provides an incredibly significant role in diagnosing women with cancer.
Melanie Cole: Do you think that the widespread adoption of electronic health records or improving health information technology is going to help to remove some of the barriers between pathology and radiology?
Dr. Apple: Yes, I really hope so. In the future, I hope to see patients because the pathologist does provide incredible critical information to the patient and, therefore, I hope that one day the curtain will be removed and we have a face to face interaction because once they see the slides of their own cancer cells and they can picture that in their mind what that tumor cells look like, then they could target that in their brain image. It's a very powerful way to look at your own cancer and think about that and fight over that emotionally. I've seen a patient a couple of times when they came to a pathology office and they wanted to actually see the visual image of their own tumor and it really helped them to fight emotionally. So, I think in the future maybe pathologist perhaps should come out of the curtain and actually see the patient and help them.
Melanie Cole: And, you think that this can really add value to improve patient outcomes and that's the main goal, isn't it?
Dr. Apple: Yes. Many people do not see pathologists and they don't really see their slides. It's a visually very different image if you have a malignancy versus a benign. It's actually not that difficult to identify which one is abnormal and which one is normal. So, when a patient gets to see that I think it will be helpful for them, as sometimes they are suspicious of whether “Do I really have a breast cancer or can anybody else say that it's not cancer?”. They do have that speculation sometimes but when they see the actual image of a pathology slide they may be able to trust medical professionals a little more.
Melanie Cole: Do they get to see the actual image of the slides?
Dr. Apple: No, they don't. Sometimes the radiologist will show them ultrasound findings and mammogram findings, and they can show there is a mass lesion or there's this speculation, suspicious calcification. They have opportunities to show it to patients but not pathologists.
Melanie Cole: Would you like to see that change?
Dr. Apple: I do.
Melanie Cole: Where do you see it going in the future in the field of pathology and wrap it up for us, Dr. Apple, and what you would like to see, in your own opinion, happen in the field of pathology with this integration with radiology?
Dr. Apple: First of all, pathologist and radiologists have to work together very well to serve the patients with the most accurate diagnoses together. Radiologists cannot work independently and pathologists also cannot work independently because of possible sampling error and sampling issues. For the benefit of the patient, for the best patient care we can possibly provide in City of Hope. I like to have a pathology and the radiologist work together and go over all the core needle biopsies that they ever perform, first of all. And the second thing, I would like to have a pathologist come out of the curtain and see the patients so the patient can see the pathologist is actually a medical doctor who provides the final diagnosis. In the future, I'd really like to see patients with pathologists and, hopefully, get reimbursement for the time that we're spending with the patient in explaining what the disease actually is. So, that's what I'd like to see happening in the future.
Melanie Cole: Thank you so much, it's a really fascinating topic. Thank you so much, Dr. Apple, for being with us today. You're listening to City of Hope Radio. For more information you can go to www.cityofhope.org. That's www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.
The Pathology of Breast Cancer
Melanie Cole (Host): Led by pathologist renowned for diagnostic excellence, the Department of Pathology at City of Hope combined state of the art laboratories equipped with the latest diagnostic techniques and advanced instrumentation with superior investigative skills to accurately and rapidly identify even the rarest and most complex diseases. My guest today is Dr. Sophia Apple. She's a clinical professor in the division of anatomic pathology in the Department of Pathology at City of Hope. Welcome to the show, Dr. Apple. Today we're going to talk about breast cancer and specifically combining breast imaging and pathology. So, will you first start by please explaining what a pathologist even does?
Dr. Sophia Apple (Guest): Pathologists are subspecialty people who are mostly responsible for providing final diagnosis on any diseases, either benign or malignancy.
Melanie Cole: So, if we're talking specifically about breast cancer, when would you be brought into a woman's diagnosis?
Dr. Apple: A woman with any breast abnormality or even after age 40, when the diagnostic screening mammogram is done then they will get the mammogram or ultrasound or sometimes the MRI, and if the radiologist finds any abnormality or any concerns or suspected lesion they would target that with the core needle biopsy. Those core needle biopsy gets into the pathology department and we fix the tissue and make a slide and then we look at the slide and provide a final diagnosis.
Melanie Cole: Is a pathologist somebody that the patient would actually meet?
Dr. Apple: No, we are behind a curtain but I would say that we are the brain of the entire medicine because if we provide the diagnosis wrong, then everybody will go into the wrong route. So, we're critically important because we provide the final diagnosis of any diseases. We are behind the scene and sometimes the patients’ mention, “Who are these pathologist who gave us the bills and what are they doing?” but we actually are the critical doctors, medical doctors, who provide the diagnosis for individual patients.
Melanie Cole: You're kind of steering the ship as it was. So, please speak about the benefits of a collaborative working relationship between pathologists and the radiologists that have done the stereotactic or whichever kind of biopsy they did?
Dr. Apple: Yes. So, the radiologist and pathologist they both provide diagnoses but the radiologists look at the shadow of the disease whereas a pathologist actually look at the tissue of the material that they've provided. We have to work together. If the radiologist thought that the lesion was very suspicious and the pathologist called it “benign” then it doesn't match. So, we do like to do correlation between clinical imaging, clinical findings, and a pathologist findings. That's called “triple test” because clinical is one, imaging is another, and the pathologist are third. They all have to match together to provide an accurate diagnosis. For instance, if clinically or imagingly suspicious lesion was targeted and the core needle biopsy was performed but if I called it benign that means there's a probability or possibility that radiologist did not get the lesion. So, if the triple test failed then the radiologist would have to bring the patient back, either redo the core needle biopsy or wait for three months or six months and then retarget that lesion again.
Melanie Cole: Speak about some of the critical components of a radiology/pathology integration and how that for the patient as you're the one sort of steering the ship and really making that final diagnosis and giving the histologic type pictures, then what would be some of the most critical components that you would want the patient to know about the importance of this relationship.
Dr. Apple: Let's say the patient is worried about a mass lesion and she goes to imaging or radiologist and the radiologist targeted that lesion and perform the core needle biopsy and if I called it benign or the benign entity explains the mass that the woman is experiencing, then since the final diagnosis was benign, she does not have to worry about it; whereas, on the other side of the coin, if the radiologist looked at the mass lesion and if the pathologist called it “malignant”, she has a diagnosis and she has to act on it, such as surgical removal and if the surgical removal is a breast cancer with hormonal findings, the estrogen receptor, the progesterone receptors, if those are positive, then the oncologist will treat the patient with endocrine therapy. If HER2 is positive, then the receptor therapy is generated. So, pathology provides an incredibly significant role in diagnosing women with cancer.
Melanie Cole: Do you think that the widespread adoption of electronic health records or improving health information technology is going to help to remove some of the barriers between pathology and radiology?
Dr. Apple: Yes, I really hope so. In the future, I hope to see patients because the pathologist does provide incredible critical information to the patient and, therefore, I hope that one day the curtain will be removed and we have a face to face interaction because once they see the slides of their own cancer cells and they can picture that in their mind what that tumor cells look like, then they could target that in their brain image. It's a very powerful way to look at your own cancer and think about that and fight over that emotionally. I've seen a patient a couple of times when they came to a pathology office and they wanted to actually see the visual image of their own tumor and it really helped them to fight emotionally. So, I think in the future maybe pathologist perhaps should come out of the curtain and actually see the patient and help them.
Melanie Cole: And, you think that this can really add value to improve patient outcomes and that's the main goal, isn't it?
Dr. Apple: Yes. Many people do not see pathologists and they don't really see their slides. It's a visually very different image if you have a malignancy versus a benign. It's actually not that difficult to identify which one is abnormal and which one is normal. So, when a patient gets to see that I think it will be helpful for them, as sometimes they are suspicious of whether “Do I really have a breast cancer or can anybody else say that it's not cancer?”. They do have that speculation sometimes but when they see the actual image of a pathology slide they may be able to trust medical professionals a little more.
Melanie Cole: Do they get to see the actual image of the slides?
Dr. Apple: No, they don't. Sometimes the radiologist will show them ultrasound findings and mammogram findings, and they can show there is a mass lesion or there's this speculation, suspicious calcification. They have opportunities to show it to patients but not pathologists.
Melanie Cole: Would you like to see that change?
Dr. Apple: I do.
Melanie Cole: Where do you see it going in the future in the field of pathology and wrap it up for us, Dr. Apple, and what you would like to see, in your own opinion, happen in the field of pathology with this integration with radiology?
Dr. Apple: First of all, pathologist and radiologists have to work together very well to serve the patients with the most accurate diagnoses together. Radiologists cannot work independently and pathologists also cannot work independently because of possible sampling error and sampling issues. For the benefit of the patient, for the best patient care we can possibly provide in City of Hope. I like to have a pathology and the radiologist work together and go over all the core needle biopsies that they ever perform, first of all. And the second thing, I would like to have a pathologist come out of the curtain and see the patients so the patient can see the pathologist is actually a medical doctor who provides the final diagnosis. In the future, I'd really like to see patients with pathologists and, hopefully, get reimbursement for the time that we're spending with the patient in explaining what the disease actually is. So, that's what I'd like to see happening in the future.
Melanie Cole: Thank you so much, it's a really fascinating topic. Thank you so much, Dr. Apple, for being with us today. You're listening to City of Hope Radio. For more information you can go to www.cityofhope.org. That's www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.