I recently ran across a wide-ranging blog, “Getting More From Les,” written by suburban Chicago pathologist Lester Raff, MD.
I was amused by his tongue-in-cheek take on pathologists like him “giving (prostate) cancer” to patients. Actually, giving them prostate cancer diagnoses.
I wrote a fan note to Raff and told him there was another prostate cancer blogger in town. We started an email exchange, which I will share shortly.
We look at the pathology slide from different vantage points. Me with a Gleason 6 diagnosed by a pathologist like him. He as the expert using the art and science of pathology to diagnose cancer as lab director for UroPartners, a large urology group in the Chicago area. (He stresses in his blog and in his conversation with me that he is expressing his own opinions, not those of UroPartners.)
It turns out we had more in common. When he graduated from eighth grade, he had his eye on journalism. He wanted to attend the highly regarded Medill School of Journalism where, as it happens, I have taught in the grad school over the past 10 years.
But he took a radical turn and became a pathologist. Medicine’s gain has been journalism’s loss, though Les keeps a hand in journalism through his blog.
I had some questions from the patient point of view and solicited others from patient advocates Mike Scott, founder of Prostate Cancer International and Rick Davis, founder of Answer Cancer Foundation.
Here is my Q & A with Raff.
Wolinsky: “Do you often speak with men to whom you ‘give’ prostate cancer.”
Raff: “It is very interesting to me to see your perspective. As a pathologist I rarely talk with patients, other than friends and relatives whose biopsies I often wind up reading. I would enjoy talking with more patients, but only a few ever give me a call, even though my name and phone number are on our reports.
When I speak with patients, I try to restrict myself to the diagnosis of the prostate cancer and to the prognostic markers that can be obtained from the biopsy specimen.
I do not claim to be an expert on the varying, and expanding, armamentarium of treatments now available.”
Wolinsky: “It is my experience that many physicians refuse to have PSA screening because they see little value in it. What do you think about the value of PSAs?”
Raff: “I do believe in PSA screening and the use of prostate biopsies. On a personal level, I lost my dad to prostate cancer, and on a professional level I have seen a real (though anecdotal — I don’t have a full data analysis) increase in high-grade prostate cancer since the decline of PSA testing. I realize PSA testing grabs a lot of men (such as you) in its net that may not need therapy, but it also finds the men who have potentially aggressive disease and will benefit from earlier therapy.”
Wolinsky: “In the same vein, many men in active surveillance programs are rebelling against biopsies because they think they can rely on multi-parameter MRIs. (My urologist, Brian Helfand, MD, PhD, is not one. He sees biopsies as essential for active surveillance, the ‘gold standard.’). What do you think?”
Raff: “My experience with MRI at this time is that it is sub-optimal, with many false positives. I cannot speak to the false negative rate — if the men don’t get biopsied, I have no way of knowing whether or not disease is present.”
Wolinsky: “We know that different pathologists may grade slides differently … but what do you do to optimize the chances that you are ‘right’ as often as possible? For example, if you have a sense of difficulty in deciding whether a particular patient has Gleason 3 + 4 or 4 + 3, can you and do you have a colleague take a look at that particular set of slides too, to get a second ‘in-house’ opinion before a report is written up? Should that be noted in the pathology report when it happens?”
Raff: “In my institution, ALL malignant cases are reviewed at a daily quality assurance committee review at a video microscope. We frequently discuss the appropriate grade on a particular slide. All our reports document that a QA review occurred. I also track the opinions of other labs when our slides are sent to other institutions for second opinion, to see if we have any institutional bias toward up or down grading.”
Wolinsky: “Have there been technological improvements in the way prostate cancer pathology is carried out that have improved the ability to ‘see’ critical histopathological information?”
Raff: “There have not been significant changes in diagnostic techniques. There have been changes in patient safety in regards to proper identification of biopsies. We initiated and published an inking technique, and DNA patient identity testing (Know Error) has been embraced by many labs.
The other significant change is in the use of molecular diagnostics for prognostic markers in prostate cancer, as well as to try to identify patients with negative biopsies who may still be at significant risk for prostate cancer.”
Wolinsky: “What do you think about the change in the ways that the pathological findings should be reported: from Gleason patterns and Gleason scores to the new ISUP (International Society of Urological Pathology) scoring system?”
Raff: “These are cosmetic changes. All are still based on pattern recognition by the diagnosing pathologist, who in turn is dependent on receiving slides from properly obtained, processed, sectioned, and stained tissue.”
Wolinsky: “Considering just prostate specimens, what would you say are the most challenging aspects of your work?”
Raff: “It takes skill to translate a two-dimensional appearance to a three-dimensional structure, ignore distractions on the slide and in the laboratory, and to recognize mimics of cancer as well as very bland appearing malignancy.”
Wolinsky: “Why is there significant variation in how different laboratories report pathological data from biopsies? Shouldn’t there be a single standard format for reporting the key data?”
Raff: “Synoptic reporting, which meets your requirements, is required for most malignant specimens. However, it is NOT mandated for prostate biopsies, leaving each lab with freedom to include those elements they see fit, with some resultant anarchy. I believe this will change over the next few years.”