Letters to the Editor
Subspecialty in Community Pathology Practice To the Editor.— I disagree with Dr Sarewitz1 when he states that ‘‘in the future, most community pathologists will need to practice as subspecialists, and my kind of career path [as a general pathologist] will become obsolete.’’ After almost 40 years of private pathology practice, I see a bright future for pathology that rests in the hands of well-trained, boardcertified anatomic and clinical pathologists. The practice of future pathologists will be based not on subspecialization, but on the same skill set that marks today’s successful general pathologist. This skill set includes current competence, the ability to effectively communicate with colleagues, and (to paraphrase the film character Dirty Harry) a knowledge of their limitations. In our southern California group practice, more than 95% of our cases (breast, gastrointestinal, hematopathology, genitourinary, gynecology, etc) are signed out without the need of a subspecialist. In our metropolitan area, as in more remote practice areas, subspecialty consultation is easily obtained by US mail, messenger, or overnight delivery. Sarewitz states that in the future ‘‘there will be no reason for anyone to look at a brain frozen section except for a network’s neuropathologists.’’ In our practice, neurosurgeons operate late into the evening, and a pathologist is often requested for frozen section. I wonder who in Dr Sarewitz’s neuropathology network will come into the hospital to prepare and interpret a frozen section when requested by the neurosurgeon at 1 o’clock in the morning. I suspect none other than the general pathologist he sees as becoming obsolete. In my opinion, the network he envisions will simply not be necessary. I am optimistic about the future of pathology, competently practiced by board-certified anatomic and clinical pathologists rather than subspecialist pathologists. KENNETH FRANKEL, MD Citrus Pathology Medical Group Arch Pathol Lab Med—Vol 139, June 2015
Pasadena, CA 91105 1. Sarewitz S. Subspecialization in community pathology practice. Arch Pathol Lab Med. 2014; 138(7):871–872.
doi: 10.5858/arpa.2014-0397-LE
In Reply.— Considering the disruptive changes currently affecting many aspects of health care—in technology, the marketplace, reimbursement, and regulation—it is hard to believe that the practice of community pathology will stay the same. Already, a large health care insurer is implementing a program that will require subspecialty pathologist review of certain kinds of cases.1 Whether or not this particular program gains traction, it is a sign of the changes to come. With respect to neuropathology, in the future, there need be no barrier whatever for all brain frozen sections to be examined in real time by a neuropathologist. The local hospital pathologist, or even a pathologist assistant, will be the individual onsite who performs the technical preparation of the frozen section slide. This slide will then be digitized in real time and reviewed microscopically by the neuropathologist on-call for that particular laboratory’s network, wherever he or she may be located. The neuropathologist will be able to review the patient’s imaging studies and medical record electronically and, through videoconferencing, will discuss the case directly with the surgeon. Because the electronic network can include multiple neuropathologists across the country, the on-call schedule would not be unduly burdensome for any single individual. I also am optimistic about the future of community pathology practice. I just think we will need to practice differently. STEPHEN J. SAREWITZ, MD Department of Pathology Valley Medical Center Renton, WA 98055 1. United Healthcare Laboratory Benefit Mana g e m e n t P r o g r a m . h t t p s : / / w w w. u n i t e d healthcareonline.com/b2c/CmaAction. do ? channel Id¼9cc7b96891e22410VgnVCM2000002a4ab10a. Accessed August 29, 2014.
doi: 10.5858/arpa.2014-0472-LE
College of American Pathologists Guidelines for Reporting HER2 Test Results in Gastric Cancer To the Editor.—We read with interest the recently published ‘‘Template for Reporting Results of HER2 (ERBB2) Biomarker Testing of Specimens From Patients With Adenocarcinoma of the Stomach or Esophagogastric Junction’’1 and do appreciate the efforts the College of American Pathologists is taking to standardize reporting of cancer specimens, including the results of biomarker testing. However, we take exception to one point made in the explanatory notes. In the trial of trastuzumab in gastric adenocarcinoma (ToGA), all patients were dual tested (ie, samples underwent both immunohistochemistry [IHC] and fluorescence in situ hybridization [FISH]) and if either was positive, they were eligible for randomization.2 It is true that in the updated survival analysis, when sorted by IHC results, the IHC-negative, FISH-positive cohort did not seem to derive a benefit from trastuzumab.3 However, this result did not reach statistical significance. Additionally, the overall survival of IHC-negative, FISH-positive patients receiving chemotherapy alone was 8.8 months, versus 13.2 months among the IHCpositive patients receiving chemotherapy alone. So perhaps the apparent lack of response to trastuzumab in IHC-negative, FISH-positive patients has nothing to do with trastuzumab but rather reflects a more aggressive tumor biology. No reference was provided for the following statement: ‘‘In the US, the FDA [Food and Drug Administration] has approved trastuzumab in association with chemotherapy for metastatic gastric cancer using the eligibility criteria of the ToGA trial, limited to patients with a score of IHC 3þ or 2þ and ISH [in situ hybridization] positivity.’’1 During our review of the FDA Web site, we found several locations where they caution: ‘‘The study also demonstrated that gene amplification and protein expression (IHC) are not as correlated as with breast cancer, therefore a single method Letters to the Editor 709
Copyright of Archives of Pathology & Laboratory Medicine is the property of College of American Pathologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Subspecialty in Community Pathology Practice To the Editor.— I disagree with Dr Sarewitz1 when he states that ‘‘in the future, most community pathologists will need to practice as subspecialists, and my kind of career path [as a general pathologist] will become obsolete.’’ After almost 40 years of private pathology practice, I see a bright future for pathology that rests in the hands of well-trained, boardcertified anatomic and clinical pathologists. The practice of future pathologists will be based not on subspecialization, but on the same skill set that marks today’s successful general pathologist. This skill set includes current competence, the ability to effectively communicate with colleagues, and (to paraphrase the film character Dirty Harry) a knowledge of their limitations. In our southern California group practice, more than 95% of our cases (breast, gastrointestinal, hematopathology, genitourinary, gynecology, etc) are signed out without the need of a subspecialist. In our metropolitan area, as in more remote practice areas, subspecialty consultation is easily obtained by US mail, messenger, or overnight delivery. Sarewitz states that in the future ‘‘there will be no reason for anyone to look at a brain frozen section except for a network’s neuropathologists.’’ In our practice, neurosurgeons operate late into the evening, and a pathologist is often requested for frozen section. I wonder who in Dr Sarewitz’s neuropathology network will come into the hospital to prepare and interpret a frozen section when requested by the neurosurgeon at 1 o’clock in the morning. I suspect none other than the general pathologist he sees as becoming obsolete. In my opinion, the network he envisions will simply not be necessary. I am optimistic about the future of pathology, competently practiced by board-certified anatomic and clinical pathologists rather than subspecialist pathologists. KENNETH FRANKEL, MD Citrus Pathology Medical Group Arch Pathol Lab Med—Vol 139, June 2015
Pasadena, CA 91105 1. Sarewitz S. Subspecialization in community pathology practice. Arch Pathol Lab Med. 2014; 138(7):871–872.
doi: 10.5858/arpa.2014-0397-LE
In Reply.— Considering the disruptive changes currently affecting many aspects of health care—in technology, the marketplace, reimbursement, and regulation—it is hard to believe that the practice of community pathology will stay the same. Already, a large health care insurer is implementing a program that will require subspecialty pathologist review of certain kinds of cases.1 Whether or not this particular program gains traction, it is a sign of the changes to come. With respect to neuropathology, in the future, there need be no barrier whatever for all brain frozen sections to be examined in real time by a neuropathologist. The local hospital pathologist, or even a pathologist assistant, will be the individual onsite who performs the technical preparation of the frozen section slide. This slide will then be digitized in real time and reviewed microscopically by the neuropathologist on-call for that particular laboratory’s network, wherever he or she may be located. The neuropathologist will be able to review the patient’s imaging studies and medical record electronically and, through videoconferencing, will discuss the case directly with the surgeon. Because the electronic network can include multiple neuropathologists across the country, the on-call schedule would not be unduly burdensome for any single individual. I also am optimistic about the future of community pathology practice. I just think we will need to practice differently. STEPHEN J. SAREWITZ, MD Department of Pathology Valley Medical Center Renton, WA 98055 1. United Healthcare Laboratory Benefit Mana g e m e n t P r o g r a m . h t t p s : / / w w w. u n i t e d healthcareonline.com/b2c/CmaAction. do ? channel Id¼9cc7b96891e22410VgnVCM2000002a4ab10a. Accessed August 29, 2014.
doi: 10.5858/arpa.2014-0472-LE
College of American Pathologists Guidelines for Reporting HER2 Test Results in Gastric Cancer To the Editor.—We read with interest the recently published ‘‘Template for Reporting Results of HER2 (ERBB2) Biomarker Testing of Specimens From Patients With Adenocarcinoma of the Stomach or Esophagogastric Junction’’1 and do appreciate the efforts the College of American Pathologists is taking to standardize reporting of cancer specimens, including the results of biomarker testing. However, we take exception to one point made in the explanatory notes. In the trial of trastuzumab in gastric adenocarcinoma (ToGA), all patients were dual tested (ie, samples underwent both immunohistochemistry [IHC] and fluorescence in situ hybridization [FISH]) and if either was positive, they were eligible for randomization.2 It is true that in the updated survival analysis, when sorted by IHC results, the IHC-negative, FISH-positive cohort did not seem to derive a benefit from trastuzumab.3 However, this result did not reach statistical significance. Additionally, the overall survival of IHC-negative, FISH-positive patients receiving chemotherapy alone was 8.8 months, versus 13.2 months among the IHCpositive patients receiving chemotherapy alone. So perhaps the apparent lack of response to trastuzumab in IHC-negative, FISH-positive patients has nothing to do with trastuzumab but rather reflects a more aggressive tumor biology. No reference was provided for the following statement: ‘‘In the US, the FDA [Food and Drug Administration] has approved trastuzumab in association with chemotherapy for metastatic gastric cancer using the eligibility criteria of the ToGA trial, limited to patients with a score of IHC 3þ or 2þ and ISH [in situ hybridization] positivity.’’1 During our review of the FDA Web site, we found several locations where they caution: ‘‘The study also demonstrated that gene amplification and protein expression (IHC) are not as correlated as with breast cancer, therefore a single method Letters to the Editor 709
Copyright of Archives of Pathology & Laboratory Medicine is the property of College of American Pathologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
