I don’t think many of us were shocked to hear the news that the NHS cancer testing service is under enormous strain. According to a report by Cancer Research UK:
- Demand for cancer pathology services has been increasing year on year
- Staffing levels are not increasing fast enough to keep up
Interestingly, the Department of Health has responded to this news by reiterating that the UK government has invested more than £2.5bn in improving pathology services across the NHS. While more investment in the NHS is desperately needed and the attempt is laudable, there is little indication that core staffing issues can be quickly resolved in this case – the number of graduates who could fill new positions is simply too small to satisfy the need for larger numbers, and anyway it takes so long to qualify that growing the pool of practitioners is really a generational level goal.
If not through recruitment of more pathologists, how can we improve pathology?
Fundamentally, the pathology lab examines samples taken from a patient to assess for cancerous tissue. These services are required throughout a cancer patient’s journey. During initial diagnosis they are essential to confirm whether a suspect area of tissue is cancerous or not. During treatment they help physicians target the right area and help surgeons be confident that they have got the whole tumour. And in post-treatment monitoring they reveal whether the tumour has responded or returned. While, typically, stakeholders focus on the burden of initially diagnosing the condition, we should not be underestimating the impact that ongoing testing – post and during treatment – has on pathology services.
Rather than simply increasing capacity in the system we have, we need to be examining each of these stages in the care pathway for cancer and looking for ways to supplement the path lab.
Despite all of the pharmacological products available today, surgery remains one of the primary tools in treating cancer. If we can, our preferred treatment option is still to cut out the tumour. During resection surgery the surgeon uses their best judgement, informed by preoperative scans to make sure they get the whole tumour. The sample removed is then sent to the path lab to be examined and the ‘margins’ – the layers of healthy tissue taken out around the tumour – are tested. If the margins are intact, the surgeon (and patient) can be confident they got it all. If not, then there is a good chance that some bad cells were left in the patient and could grow anew. Given the challenges highlighted by Cancer Research UK, that testing of the margins can take more than 60 days. Imagine the stress that can cause the patient. Let alone the cost of further treatment to the hospital and NHS if the margins aren’t good and the tumour regrows while waiting for the results.
Now imagine if the surgeon could SEE the cancerous tissue, in real time while doing the surgery. If they could easily tell the difference between cancerous and normal tissue reliably, their confidence in their resection becomes much stronger and the role of the path lab goes from diagnosis to confirmation. In that scenario a delay in the pathology results is far more acceptable. There is also a side benefit that the repeat treatment rate – and hence cost to the hospital and stress for the patient – drops significantly.
This is not science fiction. This technology in many different forms is in development and being built into commercial surgical platforms today. The core technologies include approaches such as OCT, hyper-spectral imaging, and Raman spectroscopy. These technologies all help with localising tumours, by allowing a surgeon to tell the difference between cancerous and healthy tissue in real time during surgery (or biopsy). Such improvement in the surgeon’s toolkit will mean:
- The success rate and efficiency of surgical treatment is likely to be improved
- The number of repeat procedures with be reduced
- The cases requiring urgent pathology services will drop
Of course disease progression and monitoring will still be needed but, by integrating these systems into biopsy and inspection devices (such as endoscopes), we can even reduce short-term reliance on rapid path lab responses in these stages of the care pathway.
Change the approach to initial diagnosis and postoperative workflow
Another technology which is very likely to release the load of path labs is liquid biopsy (LB). More specifically, it will disrupt the initial diagnosis and post-treatment/intervention requirement for pathology services. Its minimally invasive nature means that in the near future LBs will be:
- Carried out by people who are not path lab experts
- A fast and yet efficient way of getting results, even in primary care settings
- Reduce the number of path lab tests required for monitoring the disease state of a patient
- Reduce the number of path lab tests for monitoring the effectiveness of prescribed treatments
Although still in its infancy, LB has the potential to transfer the efficiencies of path lab testing to the point of care or point of need.
The core technologies to enable these visions exist and can have a dramatic short-term impact on not just our path labs’ capacities but also our effectiveness in treating cancer, the cost of care and the patient experience. Given the UK government’s recently announced investment to boost R&D and make the UK the ‘global place to go’ for innovation, shouldn’t we be prioritising investment to fast track some of these approaches to help both our patients and our path labs?