CEO SUMMARY: Digital pathology holds the promise of interconnecting pathologists around the globe in ways that advance diagnostic accuracy and improve patient outcomes. One pioneering digital pathology collaboration involves the pathology departments at the medical schools of the University of California, Los Angeles (UCLA) and Zhejiang University in Hangzhou, China.
PART ONE OF A SERIES
DIGITAL PATHOLOGY WILL BE BOTH disruptive and transformational to the profession of anatomic pathology. The good news is that early signs point to a transformation that will be beneficial to the profession at large and most pathologists individually.
Over the past 36 months, clients and regular readers of THE DARK REPORT have read our briefings about the experiences of first-mover pathologists who have acquired digital pathology systems and now use this technology in unique and innovative ways. In almost every case, these pioneering pathologists will candidly acknowledge the specific limitations of the technology at this point in its development.
At the same time, most pathologists who are hands-on users of digital pathology systems will then enthusiastically make the case for how and why digital pathology systems expand their capabilities as physicians and help them to practice a higher level of laboratory medicine.
Here in part one of a series on the disruptive and transformational potential of digital pathology, I am writing in the first person in order to better communicate to you the way histopathology’s innovators are using digital pathology to forge new paths in more accurate diagnosis. These applications are consistent with personalized medicine and the expanding field of companion diagnostics.
In particular, I will focus on the unique and ground-breaking relationship between the Department of Pathology and Laboratory Medicine at the University of California at Los Angeles (UCLA) School of Medicine and the Department of Pathology at the 2nd Affiliated Hospital of Zhejiang University (SAHZU) School of Medicine, located in Hangzhou, China.
The anchor to this international histopathology collaboration is a digital pathology system. Via digital pathology, for the past 18 months, pathologists at the two academic center hospitals on each side of the Pacific Ocean have been able to share cases and work together to provide subspecialty pathology expertise in a way that advances patient care.
In October, 2011, I had the opportunity to travel to Hangzhou, China, to speak at the 17th Congress of the Chinese Society of Pathology and the 1st Annual Meeting of Chinese Pathologists. My presentation, travel and some pathology laboratory site visits were arranged by the Anatomic Pathology Group at Thermo Fischer Scientific.
I mention this because, in China, it is the pathology vendors who act as primary agents in fostering an exchange of knowledge that benefits pathologists, clinical chemists, and laboratory scientists. Further, this is a country where personal relationships matter greatly in business and medicine.
Some of you have read my impressions gained at the pathology congress, which were published at DarkDaily.com. (See “Anatomic Pathology in China Is a Booming Growth Industry,” October 24, 2011.) While in Hangzhou, I visited the pathology department at SAHZU.
This gave me a first-hand look at the Chinese lab side of the digital pathology collaboration between UCLA and SAHZU. Prior to my departure for China, I spoke with Scott Binder, M.D., who is the Senior Vice Chair of Pathology and Laboratory Medicine, Geffen/UCLA School of Medicine.
Managing the Collaboration
Binder coordinates the pathology collaboration between his department and the pathology department of SAHZU. This arrangement has been active since the beginning of 2010. The digital pathology system used at both laboratory sites is manufactured by Aperio Technologies, Inc., of Vista, California. While in Hangzhou, Aperio’s representatives were most helpful in the arrangements for the site visit to the SAHZU histopathology laboratory.
The digital pathology arrangement between SAHZU and UCLA developed as a result of a larger collaboration agreement between the two universities that was instituted about eight years ago. Under this master agreement, the medical schools of the two universities have been cooperating in a number of faculty exchanges and training programs. (See sidebar below.)
These basic facts were confirmed during my site visit to the pathology department at SAHZU in Hangzhou. By the standards of the United States, this is a large hospital. It has 1,750 beds, which is more than any single hospital site here in this country.
Each year, the 2nd Affiliated Hospital services an average of 38,000 inpatients and 1,300,000 outpatients (that includes ER visits). The Zhejiang University Medical School involves a total of six hospitals with 7,700 beds and handles 238,000 inpatients and 8.8 million outpatients annually. Revenue is almost US $1 billion per year.
More Demand for Healthcare
During my site visit, I met with Li-Rong Chen, M.D., Ph.D., Director, Professor, Chief Doctor, Department of Pathology, at SAHZU. He provided a concise overview of his pathology laboratory. The first point he emphasized is that the demand for healthcare by China’s middle class is increasing at a steady pace.
“In the Hangzhou metro, there are 6 million residents,” he noted. “In this province live 47 million people and we are only about 130 miles from Shanghai, which is in a province of 22 million residents. These population numbers indicate why the demand for quality health services is increasing.”
There are 16 pathologists, including residents, in Chen’s histopathology department at SAHZU. “We process about 500 tissue blocks daily and diagnose about 43,000 surgical cases annually,” said Chen. “We also handle approximately 30,000 cytology cases per year.”
The digital pathology arrangement with UCLA has brought important benefits to the anatomic pathologists in Hangzhou. “Here in China, there is an urgency to bring the practice of medicine up to the standards of care common in Europe and the United States,” observed Chen. “Pathologists have the opportunity to contribute by improving the accuracy of the diagnosis. In specific cases, we are also involved in helping physicians select the most effective therapies.”
Not surprisingly, the digital pathology arrangement between SAHZU and UCLA has quickly centered upon tumor support. “We are using the digital pathology system to share images of specific cases with the subspecialist-pathologists at UCLA,” stated Chen. “This regular interaction between our two groups of pathologists is part of the mission to advance the training and skills of pathologists in this country.”
As part of my site visit, I was introduced to G. “Jenny” Wang, M.D., Ph.D., who is a chief pathologist at SAHZU. She handles the digital pathology system and creates the digital images that are shared between her lab and the pathology department at UCLA.
“Like any technology, we’ve had to work through some challenges,” she commented. “The basic functions of scanning glass slides, archiving the images, and viewing digital pathology images were rather easy to master.
Transmitting Digital Images
“Once the glass slides for a case are digitized, these images can be transmitted to the pathologists at UCLA for a second opinion or a sub-specialist consultation,” noted Wang. “At this time, we are referring between 10 and 15 cases per week and the number of case referrals is increasing.”
Wang stated that live sessions between the SAHZU and UCLA pathologists are evolving into something similar to the tumor boards conducted regularly at many hospitals. “By video conference—supported by the digital pathology images— pathologists at both laboratories are able to discuss the case and interact,” she said.
“Such close interaction is one way our pathologists can gain subspecialty skills and expertise without having to travel and study abroad,” she explained. “The sharing of this knowledge is helping us with patients here at our hospital.”
Wang noted that pathologists do meet regularly with patients to discuss their diagnosis, and—for certain types of cancers— explain what types of therapies might be appropriate. “Patients in China want to choose a hospital that is known for quality healthcare,” observed Wang. “They do understand the role of pathology in improving the accuracy of their diagnosis.
Second Pathology Opinion
“In fact, patients here can have the choice of a second pathology opinion,” she added. “That can happen in one of three ways. One, our clinic’s physicians can recommend that a pathology second opinion be obtained.
“Two, our pathologists may recommend referral of the case for a pathology second opinion,” Wang said. “Third, we have times when a patient will request that we obtain a pathology second opinion.”
Patient engagement is a feature of healthcare in China. As noted earlier, the growing middle class is interested in purchasing top quality healthcare. For that reason, hospitals are taking steps to establish their reputations as the provider of first-rank healthcare.
In fact, this was one reason for the collaboration agreement between the medical schools of Zhejiang University and UCLA. In China, the “UCLA brand” is recognized by consumers and Zhejiang University wants to leverage that brand recognition. For the same reason, the UCLA affiliation is valued by the pathologists at SAHZU.
“We are sending pathologists to Los Angeles to train at UCLA,” observed Chen. “This gives them access to all the innovations happening in laboratory medicine today, particularly in molecular diagnostics and genetic testing. Pathologists from UCLA are also coming here to Hangzhou to conduct lectures and provide training to our laboratory staff.”
Vision of Pathology in China
Chen has his own vision for the future of his pathology department. “I would like to use our capability in digital pathology to establish a digital pathology network that links us to hospitals in our region,” he said. “It is a way that we can help with the primary diagnosis of patients.”
Chen is referring to the shortage of pathologists and lab scientists in his country. China’s Ministry of Health provides a number of 14,000 public hospitals, plus 5,700 private hospitals in China, served by only about 20,000 pathologists. Thus, unlike in North America and Europe, where nearly every critical care hospital has pathologists on site, there are hospitals in China that lack an in-house anatomic pathologist.
For Chen, this is the opportunity for his pathology department to engage with other hospitals and provide help in establishing the primary diagnosis. The enabling tool for this service will be the use of digital pathology systems.
“It is part of our vision that our pathology department can use digital pathology systems to provide clinical services to other hospitals in our region.”
The glass slides processed at the community hospital can be digitally scanned at that site and transmitted to the pathology department at SAHZU. The pathologists in Chen’s department can read these slides and consult with the referring physicians via videoconferencing and other methods.
“It is part of our vision that our pathology department can use digital pathology systems to provide clinical services to other hospitals in our region,” continued Chen. “The clinical service model is feasible and would be similar to how pathologists here at SAHZU and UCLA are now working together.
“Further, ongoing improvements in information technology and digital pathology systems will make it easier for us to establish and operate this type of diagnostic service,” emphasized Chen. “In our country, the need for quality anatomic pathology services is great. It is why we think that a pathology network would be utilized by physicians and hospitals in communities around Hangzhou.”
Lots of Enthusiasm
During my site visit to the Department of Pathology at the 2nd Affiliated Hospital of Zhejiang University, the enthusiasm and commitment of Dr. Chen, Dr. Wang, and the other pathologists was quite evident.
At a time when demand for healthcare services is growing very fast, the pathologists at SAHZU have a vision for how they can position themselves to provide top quality diagnostic services. To achieve that vision, they are incorporating the use of digital whole slide images and digital pathology systems into educational programs and clinical consultations.
In so doing, the SAHZU pathologists, via their collaboration with the UCLA pathologists, are demonstrating how use of digital pathology systems will bring closer integration of pathology, even across international borders.
In part two of this series about digital pathology, THE DARK REPORT will provide information about the American side of this China–U.S.A. digital pathology collaboration. Pathologists at the UCLA School of Medicine will share the lessons learned from this trans-Pacific anatomic pathology relationship and its ground-breaking use of digital pathology technologies.
Pathology Collaboration Part of Existing Agreement
HOW THE TWO PATHOLOGY DEPARTMENTS in Hangzhou and Los Angeles came together is part of a larger story. For almost a decade, UCLA and Zhejiang University have had an agreement to “promote, exchange, and collaborate in research, technology, and professional training.”
This agreement extends to the medical schools at both universities. An interesting aspect of the relationship between the two medical schools is recognition of the importance of an accurate diagnosis. “All the treatments, remedies, and therapies start from the diagnosis,” noted Chen Gongxiang, Ph.D., Director of SAHZU’s Center for Clinical Laboratories. “If you have a correct diagnosis, then you can have better treatment. For the Chinese doctors, they’ll have more opportunities to learn U.S. ways, U.S. systems, and they can change their habits of working and improve their skills.”
Chen was quoted in a UCLA newsletter, which also highlighted the development of a “joint diagnostic center” between the two institutions that emphasizes tissue-based laboratory diagnostics. This is the initiative that utilizes digital pathology to link pathologists on both sides of the Pacific Ocean.
“It was the ongoing advances in Internet technology, informatics, and digital pathology systems that allowed us to develop a more active pathology consultation service between the two medical centers,” he continued. “Both laboratories have the Aperio digital pathology system and are using it to create whole slide images that can be simultaneously viewed by pathologists at 2nd Affiliated Hospital and here at the UCLA Medical Center.”