CEO Summary: It is one of the first clinical collaborations of this type to be anchored by use of digital pathology. Pathologists at the medical schools of the Second Affiliated Hospital of Zhejiang University in Hangzhou, China, and the University of California Los Angeles (UCLA) are exchanging cases and sharing knowledge. During the first 18 months of this unique relationship, the volume of cases shared via digital pathology has grown steadily.
PART TWO OF A SERIES
EDITOR’S NOTE: Perhaps nowhere in the world is digital pathology more transformational than it is right now in the People’s republic of China. At the forefront of these developments is a unique digital pathology relationship that spans the Pacific ocean and connects pathologists in the United States with pathologists in China.
Partners in this digital pathology collaboration are the pathology departments of the David Geffen School of Medicine at the University of California Los Angeles (UCLA), and 2nd Affiliated Hospital of Zhejiang University (SAHZU) School of Medicine, in Hangzhou, China.
Part one of our coverage presented the digital pathology relationship from the perspective of the Chinese pathologists. It was based on interviews conducted by THE DARK REPORT during its site visit to the pathology laboratory in Hangzhou, China.
Part two, presented here, tells the story as viewed by an American pathologist. It is an interview with Scott Binder, M.D., Senior Vice Chair, Pathology and Laboratory Medicine at UCLA. He is actively involved in the collaboration with the SAHZU pathologists and had just returned from a trip to China.
EDITOR: First, I must tell our readers that all the pathologists engaged in this clinical and teaching collaboration that is anchored by digital pathology—whether in China or in the United States—are quite enthusiastic about the exchange of knowledge.
BINDER: There is a reason for this enthusiasm. Pathologists at these two institutions are using digital pathology to work collaboratively to improve the practice of pathology in dramatic and startling ways.
EDITOR: That has been my impression as well. During my site visit to SAHZU in October 2011, I visited both the clinical laboratory and the anatomic pathology department. This is a 1,500-bed hospital and each laboratory was well-equipped with the latest lab analyzers and automated systems. But I could see that the volume of testing performed at this hospital is noticeably less than what would be typical in the United States. Could you comment on that?
BINDER: These Chinese hospitals have some of the best laboratory equipment in the world. However, keep in mind that China’s rapid economic development only started a couple of decades ago. This is a healthcare system that is modernizing at an astounding rate.
EDITOR: What the pathologists in China told me is that economic growth is moving large numbers of people into the middle class. As this happens, these people want the best healthcare their money can buy.
BINDER: That is correct. In turn, it is why the medical schools in China are motivated to train new doctors to deliver state-of-the-art medicine. Professors of pathology and laboratory medicine must themselves acquire these advanced skills across the entire spectrum of laboratory medicine—then teach these skills to their medical students.
EDITOR: You describe a situation where demand for healthcare services in China currently outstrips the supply of pathologists (and other physicians) who are trained in the latest medical techniques.
BINDER: The numbers tell the story. China is a nation of 1.3 billion people. In part one, you shared the statistic from the Chinese Ministry of Health that there are 14,000 public hospitals, plus 5,700 private hospitals in China. Yet there are only about 20,000 pathologists in this nation—hardly one pathologist per hospital! Moreover, most of these pathologists do not have the depth of training in laboratory medicine that is typical in the United States and Northwestern Europe.
EDITOR: Your observations make it easier to understand why there is keen interest in China to train more pathologists. It also explains the motivation for medical schools to upgrade the quality and content of their training programs for young doctors. Isn’t it true that the relationship between the pathology departments at UCLA and SAHZU came about because of earlier agreements between the parent universities?
BINDER: Yes. Almost one decade ago, the original agreement created a nanotechnology institute involving Zhejiang University and UCLA (that included both the university itself and our medical school). From this first initial shared project, a similar exchange developed between the respective medical schools and health systems of the two institutions. It is for these reasons that Zhejiang University is considered our sister university in China.
EDITOR: You emphasize the exchange of knowledge as a cornerstone of this unique, ongoing relationship between the pathologists at SAHZU and the pathologists at UCLA. Could you speak to how digital pathology is used to support this exchange of knowledge?
BINDER: Digital pathology forms the basis for the knowledge exchange because it eliminates the need to ship glass slides back and forth across the Pacific Ocean. It allows pathologists at both sites to view the same images in real time during consultations, tumor boards, and similar interactions.
EDITOR: What digital pathology system is used by each pathology laboratory?
BINDER: We both have the system designed by Aperio Technologies, Inc., of San Diego, California.
EDITOR: What is the best way to understand the ongoing relationship between your two pathology laboratories, how they interact, and the ways in which digital pathology is a tool that supports this activity?
BINDER: At the center of this relationship is the role of UCLA pathologists as the source of second opinions and consultations.
EDITOR: Explain that in more detail, please.
BINDER: Pathologists at SAHZU use us for subspecialist second opinions, mostly on tumor cases. This is also consistent with how the Food & Drug Administration (FDA) wants the digital pathology system to be used for clinical purposes.
EDITOR: Are these second opinion cases discussed at regular sessions?
BINDER: Yes. At least once every month, a tumor board is conducted with the SAHZU pathologists. With the growth in case volume, there are some months when we have two tumor board meetings.
EDITOR: To date, how many cases have been handled using the digital pathology system?
BINDER: It’s been more than 18 months since the digital pathology relationship commenced. Early in this arrangement, it was just a handful of cases, maybe totaling 300 during that first year, or about 25 cases per month. Currently, the volume has grown to about 100 cases per month and we project that, by the end of this year, there will be a total of 1,500 cases handled via digital pathology.
EDITOR: I am curious about one point. During my interview with Li-Rong Chen, M.D., Ph.D., Director, Professor, Chief Doctor, Department of Pathology, at SAHZU, he mentioned that there is a shortage of pathologists in China. Is the emphasis on referring cases to UCLA for second opinions one way that Dr. Chen and his colleagues can expand their capacity to handle a larger volume of cases?
BINDER: That is one benefit for them in having us provide subspecialty expertise. But much more significant is the knowledge exchange and training that happens when their pathologists interact with our pathologists.
EDITOR: You are emphasizing that the knowledge exchange is primary.
BINDER: That is true. Keep in mind, each case was first diagnosed by a Chinese pathologist. Their interest is only in second opinions.
EDITOR: What are some of the benefits for the UCLA department of pathology?
BINDER: First of all, the cases we get from them are extremely interesting and unusual because the diseases are unusual. That means that there is always a teaching element involved, which is critical to everything we do at UCLA.
EDITOR: Is this digital pathology relationship creating other opportunities for your pathology department to do business in China? We always read about the exploding demand for luxury goods and all types of top quality services—including healthcare.
BINDER: Yes, there are other opportunities. I just returned from a trip to China where I met with a number of companies, hospitals, and private medical laboratories. The UCLA brand is strong in China, for reasons I will explain in a moment.
EDITOR: It sounds like there is active development of other collaborations involving UCLA and organizations in China.
BINDER: That is definitely true. Our pathology department is talking to other companies in China about using telepathology as a gateway to doing additional partnerships and creating new business models. This demand and high interest is driven by the tremendous need for esoteric testing in China. There is also a substantial and untapped demand for reliable second-tier testing and for reliable immunohistochemistry and flow cytometry.
EDITOR: All of this seems to be related to the fast growth of the Chinese economy and the demand for sophisticated healthcare services.
BINDER: As you mentioned, many Chinese hospital laboratories have the most expensive and newest lab analyzers and automated systems. But the lab staff lacks the training to run this equipment. For example, they cannot interpret some of the more sophisticated test results or troubleshoot when test results are not as expected. Chinese labs generally don’t have the quality control and quality assurance (QA/QC) of labs in the United States and Europe, for example.
“We are talking to other companies in China about using telepathology as a gateway to doing other partnerships and creating other business models.”
–Scott Binder, M.D.
EDITOR: This is interesting. You are describing that gap between resources and skilled lab scientists that we discussed earlier. There is the money to afford the most sophisticated, latest-generation laboratory analyzers, but there are inadequate numbers of pathologists and clinical laboratory scientists who are trained and able to perform testing at the full potential of these instrument systems.
BINDER: It gets even more interesting. One reason for this situation is that, historically, pathologists have not been held in high esteem. Pathology is a low-pay, low-status profession in that country.
EDITOR: How is that changing, if it is?
BINDER: The status of pathologists, and laboratory medicine in general, is increasing. It is because of the rise of a large middle class and the growth of the upper class. Suddenly, these people realize that they need to get the correct diagnosis. And they find that they cannot get into clinical trials unless they have a correct diagnosis.
EDITOR: That is interesting. You describe a trend where patients are becoming more aware of the importance of having an accurate diagnosis of their medical condition.
BINDER: Most definitely! Once these patients—who have the economic means to pay for quality healthcare—saw these failings, they started to demand that they get a correct diagnosis. That puts pathologists front and center because of their role in performing and interpreting laboratory tests.
EDITOR: Does brand awareness have a role in the growing appreciation that accurate pathology and lab testing is essential to better patient outcomes?
“[In China,] the status of pathologists, and laboratory medicine in general, is increasing… because people realize that they need to get the correct diagnosis.”
–Scott Binder, M.D.
BINDER: Yes, and that brings me back to my comments about the value of the UCLA brand. As you may have seen, Robert, during your trip to China, as a people, the Chinese want quality. For that reason, they are extremely brand-oriented. They want the highest-quality name brands for shoes, purses, clothes, cars, and now medical care.
EDITOR: Thus, your UCLA brand of pathology has high value in China.
BINDER: Yes. In particular, it is why medical schools, hospitals, and private health companies in China want to work with UCLA, Stanford, and Mayo—the best cancer institutes and diagnostic centers. That translates into a strong interest in raising the level of quality in pathology and lab accuracy and in the precision of diagnosis. Also, there is strong interest in correlating the results of pathology testing with appropriate clinical care.
EDITOR: You are pointing out that improved diagnostic accuracy is a major goal for this digital pathology collaboration between UCLA and SAHZU.
BINDER: In dealing with patient cases, that is definitely true. Our subspecialist pathologists provide seamless and relatively rapid, second opinion consults. Our diagnoses can sometimes vary greatly from what the SAHZU pathologists were thinking and how they were working up these cases. This is where a rich learning exchange takes place and that is the ideal for both pathology departments. Their pathologists come here to study. Our pathologists go there to learn what they are doing and to better understand the context of how patients are diagnosed and treated.
EDITOR: One point that will interest pathologists in the United States is how pathologists in China are paid. During my site visit to Second Affiliated Hospital of Zhejiang University (SAHZU) in Hangzhou, I was told that the payment rate is about 100 Chinese yuan per outpatient diagnosis. That would work out to about US$15 per case.
BINDER: $15 per case would be correct.
EDITOR: Was it your impression that in China there was a very clear division between anatomic pathology and what we would call clinical laboratory?
BINDER: Yes, that’s true. And, also, the blood bank is completely separate as well, as it is in Europe.
EDITOR: Can you describe the direct benefits to UCLA over the 18 months of the relationship? What has been positive for you, your department, and your colleagues?
BINDER: First, the most important positives have been the collegial exchange of these cases and the education of the residents regarding these unusual cases. Second, this digital pathology relationship is opening up channels that allow us to discuss larger pathology ventures with other players in China.
“…the most important positives have been the collegial exchange of these cases and the education of the residents regarding these unusual cases.”
–Scott Binder, M.D.
EDITOR: Is there much revenue associated with these cases and relationships?
BINDER: Revenue is a third benefit. This year, we expect to get close to 1,500 specimen consults. That won’t generate a lot of money, but it adds up. More importantly, as UCLA develops its pathology network in China over time, there could be a sizeable amount of income in the future.
EDITOR: Could you discuss the clinical aspects of the digital pathology collaboration in more detail? What are some of the unique types of cases that you see?
BINDER: The keys to this relationship are the educational and research opportunities. The tumor boards give us an opportunity to exchange clinical information with them, and when we do, we find their clinicians are very much up to date.
EDITOR: Scott, as a board-certified dermatopathologist, what do you see happening in that field?
BINDER: I recently spent a day with dermatologists in China. I gained a lot of respect for their clinical acumen, which is similar to that of the clinicians here at UCLA. They are much less interested in cosmetics and lasers and much more interested in medical dermatology. I find the clinical-pathological correlation to be very exciting—in part because they are excellent clinicians and because they have phenomenal cases.
EDITOR: I would assume that, in a country as large as China, that they see a variety of cancers and infectious diseases that reflect their environment and are different from the types of cases seen here.
BINDER: That is a good observation. The cancers are related to their diet and the environment and tend to affect the liver, GI tract, and lungs. They also have breast, ovarian, bone, and brain tumors.
EDITOR: What do you see in the way of infectious disease cases?
BINDER: Interestingly, tuberculosis is still a major disease there. They often see people from rural areas who have deep fungal infections. Leprosy is another infectious disease that we have seen.
EDITOR: Are there types of cancers where the UCLA connection has helped the SAHZU pathologists expand their clinical services?
BINDER: That would involve cases of lymphoma and leukemia, which they have not worked up in the past. The leukemia patients basically are characterized as AML, ALL, and CML. But few laboratories in China are equipped to handle cytogenetic testing, flow cytometry, and the additional studies needed to help guide treatments and prognoses. That makes it very exciting for us to work with them in hematopathology.
EDITOR: Are there other areas where you’ve been able to help them improve the range of pathology services they offer to their referring physicians?
BINDER: The best way to answer that question is that this digital pathology collaboration is really about them. For us, the bottom line is improving the delivery of healthcare, seeing these interesting cases, and teaching the residents.
EDITOR: You are emphasizing that pathologists in both countries are learning a great deal from this relationship.
BINDER: That is true. We bring them world-class expertise in pathology. That is important because so much medicine in China is still that of the second world. Conversely, because of a long-time emphasis on surgery, China has excellent clinicians who are doing lots of transplants and technical surgery.
EDITOR: That reflects uneven development in their healthcare system.
BINDER: In pathology and lab medicine, it might be said that the training and general service levels are stuck in the 1980s. Now, as they acquire 21st century lab analyzers and automation, they need to put these technologies to their best use.
EDITOR: In working to help the SAHZU pathologists advance their skills and acquire more sophisticated knowledge, is there any common learning curve they experience?
“We are consistently impressed with the level of intelligence and commitment of our Chinese colleagues. They care deeply about delivering quality results.”
–Scott Binder, M.D.
BINDER: That is an interesting question. There is a certain step-by-step learning process. Some of their pathologists have spent time in our lab. As well, some of our pathologists have gone there. These are smart pathologists and eager to learn.
EDITOR: Does the learning start with how to order the right tests?
BINDER: That is correct, since, initially, they didn’t know which tests to order for certain cases. We helped them with that. We are teaching them the importance of good technique. It is essential that they know how to interpret results, particularly for the sophisticated cases. One reason is because their practice of pathology is still
BINDER: That is an interesting question. There is a certain step-by-step learning process. Some of their pathologists have spent time in our lab. As well, some of our pathologists have gone there. These are smart pathologists and eager to learn. EDITOR: Does the learning start with how to order the right tests?
BINDER: That is correct, since, initially, they didn’t know which tests to order for certain cases. We helped them with that. We are teaching them the importance of good technique. It is essential that they know how to interpret results, particularly for the sophisticated cases. One reason is because their practice of pathology is still primarily at the H&E (hematoxylin and eosin stain) level.
EDITOR: This probably goes back to the original training that was given to these pathologists.
BINDER: You make a good point and I would like to comment on that. We are consistently impressed with the level of intelligence and commitment of our Chinese colleagues. They care deeply about delivering quality results. They became pathologists because they are interested in the science of pathology and laboratory medicine. It just so happens that, in China, pathology is a low prestige field. The resources were not there during their training.
EDITOR: Traditional Chinese medicine is rooted in a much different philosophy than Western medicine. Would you comment on how that influences the development of “modern medicine” in China, along with the way pathologists are trained in that country?
BINDER: The answer lies in the Chinese culture. The foundation of their traditional medicine had no pathology as we recognize in Western medicine.
EDITOR: Please continue.
BINDER: Traditional medicine in China is centered upon physiology and anatomy. The emphasis is on assessing the yin and the yang, or the humours. The practitioner looks at the body to ensure that it is in balance. But this method of practice is not about pathology as it is defined in Western medical practice. Traditional Chinese medicine never viewed pathology as a central issue. Nor was it made part of their medicine.
EDITOR: Conversely, of course, pathology is the foundation of western medicine. BINDER: Agreed. And the growth of genomics and molecular technology makes pathology even more important in Western medicine. For us, medicine is about the tissue. For traditional Chinese practitioners, medicine was about the balance of energy.
EDITOR: I suspect most readers overlook the role traditional Chinese medicine has had in shaping the thinking of both patients and physicians in that country. Those insights reinforce why the relationship between the pathology departments of UCLA and SAHZU is highly valued by both parties.
BINDER: One cannot ignore the influence of traditional Chinese medicine. On the other hand, it bears repeating that the Chinese people are driving the current revolution in healthcare in their country. That is because they are willing to pay for the best care in pathology.
EDITOR: You are emphasizing that patients are driving this revolution.
BINDER: Of course. Informed patients— with the money to pay for top healthcare—saw that the diagnoses they were getting were not necessarily the best. And, today, it is the patients in China who are willing to pay so that subspecialist pathologists at prominent institutions like UCLA, Stanford, or Mayo will take a second look and provide a consultation. That is the foundation of the economic model that drives this venture.
EDITOR: At the same time, this economic model of the patient who is willing to pay for a second pathology opinion is what creates the foundation for the exchange of clinical knowledge and medical training between the pathology departments at SAHZU and UCLA. It is interesting how economics is always intertwined with clinical practice.
BINDER: That is true. Today, we are simply opening the door to that sleeping giant called China. There is every reason to expect that, as their healthcare system develops, their pathologists will eventually be recognized as world-class. It may take some time for them to catch up to the West, but they have a strong start.
EDITOR: Thank you, Scott, for your insights into the value of digital pathology and UCLA’s collaboration with pathologists in Hangzhou, China.
Chinese Traditional Medicine Was Slow to React To 19th Century Medical Advances in Europe, U.S.
THERE IS AN INTERESTING REASON why pathologists in China traditionally did not get the respect they are now gaining as today’s Chinese patients recognize the importance of an accurate diagnosis.
It is the fact that traditional Chinese medicine—anchored in the philosophy of the balance of energy that would be revealed by assessing the yin and the yang—never incorporated the exciting medical advances of the 19th century into their medical thinking.
During that era, physicians and scientists in the nations of Germany, England, and France developed the foundations of modern medicine. One important figure was Rudolph Virchow who lived in Berlin, Germany. He is the pathologist generally recognized as the father of modern pathology.
Virchow, who lived from 1821 until 1902, described many pathological processes in detail. He also developed appropriate terminology and a classification system.
Virchow’s cellular pathology “destroyed the old humoral pathology and created the doctrine of cell physiology and pathology” that opened a new epoch in medical science, according to an article published last year in the Russian publication, Arkhiv Patologii
For pathologists in China, rapid economic development has brought new opportunities to deliver more value to referring physicians and their patients. In turn, the need to acquire more sophisticated diagnostic skills is the motivation behind several of the international collaborations that have been announced between labs in the U.S. and China.