Pathologist helps patients understand complexities of a cancer finding

Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Dr. Rohin Mehta is a pathologist at Upstate who offers consults with patients who are facing a cancer diagnosis because lab reports can be difficult to understand. He'll also be studying the impact of this consult service on the patient's care journey. Dr. Rohin Mehta is an assistant professor of pathology at Upstate and the medical director of pathology and clinical pathology at the community campus, and he's here to explain how this will work, along with Alexandra Tatarian, who's a third year medical student who works with Dr. Mehta Welcome, both of you, to "The Informed Patient."

Rohin Mehta, MD: Hi, good afternoon.

Alexandra Tatarian: Thank you for having us.

Host Amber Smith: It seems like it's becoming more and more common for patients to see the results of blood work or lab tests before their doctors do, and I'd like to ask each of you whether you think this is a good thing.

Dr. Mehta, you can recall a time when patients never saw reports and had to wait until the next appointment with their doctor to learn the results of tests. Have things changed for the better?

Rohin Mehta, MD: So I think with the initiation of MyChart, where patients can, are able to look at the results before seeing their clinician, there's pros and cons to that. On one side, I think it's good because the patients are able to get the information, where it may take some time for the clinician to give it to them, whether it be lab work, et cetera. However, on the flip side, if there is a diagnosis, there may not be a positive one, i.e., a cancer diagnosis. In some senses that may not work to people's benefit because they get it, and then they'll have to wait some time before they see the clinician, and obviously the anxiety that that brings along is not the best thing.

Host Amber Smith: Miss Tatarian, you're of a generation growing up that expects all of this information to be available ASAP. Even though not everyone can make sense of a pathology report, is it helpful to have access to what can be confusing or anxiety-provoking?

Alexandra Tatarian: I think it's certainly important that patients, when they receive all this information instantaneously, have somewhere to go for interpretation, especially if they won't hear from their clinician. And sometimes they may not get a full explanation from their clinician, of what the report actually means. There's a lot of detail that goes with the pathology report. And so, this service offers the opportunity for patients to really sit down and take the time to go through the report line by line if they want, and really understand what is behind just the diagnosis the clinician might share with them.

Host Amber Smith: So this is an interesting project that you're working on here. Are professional pathologist organizations offering solutions or things like this? Are you aware of any efforts that are under way?

Rohin Mehta, MD: Well, it is funny you say that because actually, the president of the College of American Pathologists, which is a renowned organization for pathologists, came across our consultation service on Twitter. So he reached out to us, and he's a big advocate of patients and pathologists being consultants. And he reached out to us after reading (about) our unique program, and he featured our facility in the Archives of Pathology, which is a prestigious journal. And he seems to really want to move forward with having pathologists as consults.

Host Amber Smith: That's interesting. Ms. Tatarian, I want to ask you, with three years of medical school under your belt, do you feel confident that you could decipher any sort of pathology report yourself?

Alexandra Tatarian: I've certainly studied a lot in the last three years. And I didn't realize how much learning medicine would be like learning a foreign language. So I would feel comfortable at least understanding what the words in the paper mean, but in terms of their interpretation for the patient's prognosis and the clinical context of what the treatment plan would be, I think that would be something that would be in my residency where I would figure out the full meaning. So I think it also just goes to show how much training it takes to truly and fully understand the pathology report.

Host Amber Smith: Right. And the importance of what Dr. Mehta began a few years ago. You started offering patients with breast cancer assistance with making sense of pathology reports after they had a biopsy or a surgical procedure. And are you now expanding that to other types of cancer?

Rohin Mehta, MD: Well, we'd like to. We try to put it out there, but you know, during Covid, it kind of halted, because a lot of people were not able to come into the hospital. So, you know, it kind of took a hiatus. And, now with the help of Alex, we are trying to get the word out to all clinicians. Alex has reached out to a lot of the clinicians with emails saying, "we're offering this service; it'd be great to have more people." So just to show them how informative it can be and how helpful it can be. So yes, we would like to offer it to all types of patients, and I think there's a move for pathologists to be seeing patients, because pathologists serve as clinical consultants to all health care professionals, and now we're beginning to do it. It should be expanded to patients and their family to answer specific questions and to help bridge the gap in their understanding of laboratory tests and pathologists diagnosis.

Alexandra Tatarian: And going off that, we've met with a number of oncologists and radiation oncologists at Upstate, as well as even a breast cancer support group and talked to patients directly. And part of what we're trying to figure out is when is the best time to set up this meeting in a patient's treatment course and just kind of get people involved, but at the right time, when they're ready to process the report.

Host Amber Smith: So is this mostly patients who are getting their care from Upstate?

Rohin Mehta, MD: As of this point, it is, but I mean, I wouldn't mind seeing patients from anywhere. Again, the main thing is even if they don't understand the jargon per se of what we're saying, we can try to explain it to them in layman's terms. It's so good for them to see what they're fighting against. And that, to me, is the main thing. Some of the patients we've seen, it's mainly they see it, and then they can wrap their head around it. That's how I like to put it. Some people actually are more informed than you would believe. They get on Google, and they come in here, and they ask me all these terminology, and I'm like, "wow, did you go to med school?" They're like, "no, you know, I just Googled it." So I'm like, wow, that's pretty exciting that they can do that these days.

Host Amber Smith: So I wanted to understand how this works, and I know that Covid changed some things, but ideally you want to work with these people in person, face-to-face, is that right?

Rohin Mehta, MD: Yes, ma'am. I feel that that's the best way to do it. You know, there's something not as personal if you are doing it online or on a TV. I think when they're there and you can see them in the eyes, they can ask questions. And, you know, body mechanics, you can work off of that, sometimes. If you start talking about something and you could sense that they're not really comfortable, you can kind of back off a little bit. And sometimes they can come with their significant others or their family members, and that makes it much easier for them.

Alexandra Tatarian: I was also fortunate to attend one of these sessions with a patient, and it was really powerful for them to just hold the microscope slide in their hands and realize that was the outcome of this biopsy procedure they went through. And kind of see the whole process and then see the slide under the microscope just puts everything together for them.

Host Amber Smith: Now, what are you doing in terms of studying the impact of this service on a cancer patient's journey? Do you have a clinical trial underway?

Rohin Mehta, MD: I'll let Alex answer that one.

Alexandra Tatarian: So we recently received IRB approval to study the impact, and how we're doing that is with a survey afterwards that the patients can fill out -- just questions gauging whether or not they thought it was helpful, whether or not they feel more comfortable with their treatment plan and just understanding their diagnosis. And we're also trying to figure out what cancer severity levels patients might feel more inclined, or less inclined to have this consultation. Because if not as good as a prognosis, it might be something that people don't want to see under the microscope per se, but we're just trying to figure out exactly what patients might find it the most helpful.

Host Amber Smith: And you mentioned IRB. That's the Institutional Review Board. But can you explain to our listeners what that is?

Alexandra Tatarian: Yes. It is an organization at Upstate, and I think most institutions around the country have it. And you basically put in an application saying all the data that you'll be studying because you need permission to go into patient charts to see what diagnoses they have, and just make sure that people are OK with how the research is being done, just making sure it's clear what we're studying, how we're studying it, and what our goals are.

Rohin Mehta, MD: So also making sure that we are, there's a lot of HIPAA regulations and this and that. So collecting their data, we need to make sure that we have their permission and know what and what we cannot look at in their charts. Because a lot of this is kind of gathering information from the charts, educational status, socioeconomic class, all these things. Because it's so novel, it's never been done, maybe there is a certain genre of patients that would be more inclined as Alex was putting it to, to come see us. And some may say, "you know what, I don't want to know." And that's why I think breast cancer patients have this camaraderie that I have not seen. You know, you have all this pink ribbons and these things that a lot of other cancer patients you don't see as much of anymore. I think that pendulum is swinging the other way, and they're starting to do that. But it's good to just gather this information. It may be we can see if there's some sort of trend that we can utilize to get other patients to come in.

Host Amber Smith: And this will help you determine whether this is making a difference for people?

Rohin Mehta, MD: Absolutely. I mean, in the end that's what was our goal to make sure that people are making sense of their pathology report.

Alexandra Tatarian: And just looking at what research is already out there, there's really not that much on this type of service. There's very few programs even around the country that will offer pathology consultations. And when the published papers that we've seen so far have very small patient pools, maybe around 20 or 30 patients, and I know Dr. Mehta has already met with many, many more than that. We're hoping to get even more patients. We're welcoming all patients who want to come review their pathology reports. And the more information we have, the stronger our understanding of this service's impact will be.

Rohin Mehta, MD: Yeah, I think we've seen now about 61 patients thus far, which is according to the president-elect of the College of American Pathology is the most in the country. And now we've sent out these questionnaires to these patients after we had the IRB approval. And, we've gotten a lot of feedback already. And, the president of the C A P said he wants to collaborate with us and put this in a national spectrum to maybe galvanize other pathologists around the country to consider utilizing this as a form of treatment, if you will.

Host Amber Smith: How would you advise someone if they're listening to this and they'd like to connect with a pathologist for some help understanding their report? Do you have a website or a way for them to reach out to you?

Rohin Mehta, MD: We do actually. On the Upstate pathology website. Right now it's just gauged toward breast cancer patients. So you go under "patients" and "patient care." There is a link to us. We also have a pamphlet that we have that was created, and Alex has been kind enough to go around the cancer center and put it around to other clinicians so people can get more exposure to it. I think the thing about it, people would like it if they knew about it, but because it's such a novel thing, nobody really knows that they can see it. And the other thing about it -- we offer this completely free of charge. There's no charge to it. It's mainly for the benefit of the patient.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Upstate pathologist, Dr. Rohin Mehta, and third year medical student Alexandra Tatarian, about how pathologists can help patients understand their pathology reports.

Now, let's simplify if we can, what types of information a patient can expect to find on a pathology report if they went for a tissue biopsy to find out whether they have cancer. What sorts of things would they expect to see on the report?

Rohin Mehta, MD: So depending on the type of neoplasm or non neoplasm we see there can be numerous things that can be on it. So we have a gross description. So let's say for a biopsy, we describe exactly what's coming out of the patient. For instance, if it's just a biopsy of a lesion, it'll say "small piece of tissue," give dimensions and the dimensions of it and the color, the texture. And then from there we have a final diagnosis, what we see under the microscope, whether it be a neoplasm, such as a carcinoma, or whether it's just something benign like chronic inflammation. For big resection specimens, it gets a little bit more complicated. We have describe what the neoplasm is, whether it's a carcinoma or a sarcoma. We describe what it looks like under the microscope, which is called a microscopic description. Then we have what's called a synoptic report, which the oncologist can use to determine margin status, meaning is the tumor completely excised? Is there any residual tumor? We have certain amino histochemical stains that we can use to help us determine how aggressive it can be.

Nowadays there's something called targeted therapy. So certain things we can use for instance, in breast cancer, HER2/neu Herceptin utilization is due to a stain of HER2. So they can gather a lot of information. Some of it is mainly meant for the surgeon and the oncologist, but the patient obviously sees it, so they may have questions on it. So it all depends on what type of neoplasm it is, what part of the body it's from. These reports can actually offer a ton of information.

Host Amber Smith: Now you used the word tumor, and I'm pretty sure that can either be cancerous or not, but what does the word neoplasm mean? Is that a synonym for tumor or...?

Rohin Mehta, MD: It is a synonym for tumor. I mean, neoplasm is something that doesn't really belong there, if you will. Tumor is a growth of tissue.

Host Amber Smith: Are there words that are reassuring that a person might see on their pathology report? I mean, the word "benign." Does that mean you don't have cancer anywhere?

Rohin Mehta, MD: It means you do not have cancer. Benign means benign. It is not a neoplastic, nothing malignant. Other words, such as chronic inflammation, as long as they don't see, and then we will delineate it in our report saying if it is something that's a malignancy, it will be very obvious to the patient.

Host Amber Smith: And you were talking about like with breast cancers, you can tell a lot about whether they're hormonal, if they're fueled by hormones or not. Are you seeing a lot of use of the genetic testing for breast tumors, the oncogene and that type of stuff?

Rohin Mehta, MD: Absolutely. Yes, we do. We do the oncotype score. Foundation Medicine is something we use. Nowadays, with this targeted therapy, you can get the genetics of a tumor, and some of these tumors may express certain receptors that oncologists can utilize to form what's called targeted therapy. And that is going to revolutionize cancer treatment. I think we're just in the infancy of this. And down the line, it's going to be, I think it's going to be the new wave of medicine. You get a piece of tissue, put it into a machine, get the genetics of it, and then we can say how to treat the patient.

Host Amber Smith: But that's a whole another level of confusion for a patient trying to understand, what does that tell me?

Rohin Mehta, MD: Oh, it's confusing for me, not being a molecular pathologist too. That's why I say pathology is great because we have, it's such team work. It's not like one pathologist doesn't do everything. Everyone has their specialty. Here at Upstate, we have a phenomenal cancer center and phenomenal molecular genetics, and everybody here, we work together. And that's why this group approach is why I love this institution. Other institutions, they'll send things out and you'll have other institutions working with the same patient. In our place we have, everyone is in one area. That, I think, is what's great about Upstate.

Host Amber Smith: Now, what if a patient has several samples taken in a single biopsy? I'm thinking about prostate biopsies where they take a bunch of different samples at once, and some of them say "cancerous" and some of them say "benign." How does a patient make sense of all of that collectively?

Rohin Mehta, MD: Specifically with prostate, they take biopsies from different areas of the prostate. If one of them says cancer, then you have cancer. Some areas may not, it may not be as diffuse as it could be, but if there's one or two biopsies in certain parts of the prostate that say it's carcinoma, then you have carcinoma. So you have a malignancy.

Host Amber Smith: Now, what additional kinds of information would a person be looking for if they already had a biopsy that detected cancer, and then they went for surgery to have the mass removed? What sorts of things would they look for on that report?

Rohin Mehta, MD: I think the main thing that they will look for is how high grade or low grade it may be. The main thing for everybody is that make sure that the tumor is completely out, or the carcinoma. That's margin status is the biggest thing. And from there, there's other entities that's put in the report, again, such as hormone receptor status or certain stainings that may indicate that they can utilize a targeted therapy. Those are the main things for a patient that would be important for them to know. Other things like, from a pathology perspective, how proliferating it is, that's nothing that the patient really, in my opinion, wouldn't really doesn't need to know about because they have enough to deal with and know about all these little semantics of it. So, the main thing is, is it out? Is it high grade or low grade? And the biggest thing is, has it metastasized anywhere. And that's a big factor, which most people know about when they think about cancer. Has it mets anywhere, or not? Is it localized, or is it diffuse?

Host Amber Smith: Well, how hard is it to tell whether it has metastasized, because there's not like a full body scan that you can do that'll tell you that the person doesn't have cancer anywhere, is there?

Rohin Mehta, MD: Well actually, there is. So we use what's called the PET (positron emission tomography) scan, and that doesn't necessarily tell you that it's diffused, but if you have a high PET uptake in certain areas in the context of a cancer, then the oncologist or surgeon or interventional radiologist will biopsy those areas to make sure that there is not a metastasis there. But yes, you are correct in the sense it doesn't, it's not a clear cut. The last line of defense or the definitive diagnosis is a tissue. Radiology plays a big role in this. They see a mass that looks very aggressive, that's eating away at the bone cortex, for instance. Then you can pretty much presume that this may be a metastasis. But until you get the biopsy of it and see the tissue under the microscope, you really can't tell.

But there are some imaging studies, and I'm sure in the future there'll be other things now that we'll be able to tell how far ... There's blood tests that you know, you can utilize certain blood tests that can tell you if it's high. Is that an indication that this may be. And that's how they monitor a lot of tumors in patients that are undergoing treatment. They will use blood tests to determine is has this level gone down or has it gone up, in the context of radiation and chemotherapy. So instead of keep putting the patient through biopsies and biopsies, they can utilize blood tests.

Host Amber Smith: Well, it occurs to me that the majority of patients never meet the pathologists who are analyzing their tissue samples. So I wanted to give listeners kind of a description of what a pathologist is and what their training is. Ms. Tatarian, what attracted you to this field?

Alexandra Tatarian: That is correct that many patients do not meet their pathologist, and even as a medical student, when I tell peers who are not in medicine what I'm interested in -- and that's pathology -- they haven't heard of it, which is interesting because pathologists do play such a key role in the hospital, and what I love about the specialty is that you're problem solving all the time. You're coming up with diagnoses, looking under the microscope, seeing exactly what's going on, and you're able to describe that and communicate it to the doctors who will be giving treatments. So I think it's exciting to be able to figure out what's happening, look at the cells directly.

Host Amber Smith: And so you do the four years of medical school and then a pathology residency, and then maybe fellowships on top of that, is that right?

Alexandra Tatarian: That's correct. And typically the pathology residency is three to four years, and then a fellowship and maybe a specific part of the body like breast or hematology. But I think the more once you get past medical school, it becomes more like a job and more learning. But I'm excited because I'll get to do pathology more often as a resident than I get to do it as a medical student, and just really learn in the field that you're interested in.

Rohin Mehta, MD: And pathology is also such a constant growing field, like in the sense that you are always learning, you're always reading and going to tumor boards. Like my specialty, for instance, is GI (gastroenterology) and I enjoy doing breast, but all my colleagues have other specialties and we go together to consensus conferences, and you learn about it a lot. So some people have their love of a certain type of pathology, however, you can always learn more. That's the main thing. I think that pathologists are no longer just a doctor's doctor. I think pathologists should be become more widely recognized as the patient's doctor, and like directly providing information and counseling the patients for their clinical management and well-being.

Host Amber Smith: Well, before we wrap up, let me ask some advice: For someone who's facing testing that has to do with cancer, can they ask their doctor to see pictures of the tissue samples or the tissue sample itself? Will that help in any way?

Rohin Mehta, MD: So, I mean not the pathologist, the actual clinician?

Host Amber Smith: Either, I guess. Although for most patients, they really are not likely to have access to the pathologist, or can they ask to talk to the pathologist if they want to?

Rohin Mehta, MD: Yeah, I mean this is the galvanization of our service because now they're able to ask. I guess they can. I mean, I don't know how comfortable some clinicians may be to point out the histology, having not gone to pathology residency. However, most doctors go through histology and pathology in medical school, so they do have a certain amount of knowledge of it, so they can probably point it out. But I think that pathologists, obviously, do a better job at that, due to our experience.

Host Amber Smith: Do you think that trying to read the report is likely to be helpful or informative, or confusing and frustrating?

Rohin Mehta, MD: You know, that's weird because sometimes I've had patients come in here who have done their due diligence and have done research. That's what they call Google, right? Sometimes Google's not a good thing because what happens is they can go down this rabbit hole, and there's certain times people who have, they go to these forums and people, you know misery loves company. So they'll make it sound so bad, and it's really not as bad as it sometimes is.

So on one hand, it's good because it helps them deal with it. But other hand it could get bad because they're getting these results on My Chart. They haven't seen their clinician yet. They're getting on the internet, Googling all these things, and then their anxiety and cortisol level shoots up because they don't know everything else about until they see their clinicians. So I guess there's pros and cons to that.

Host Amber Smith: How do you see the field expanding? Because it seems like information is just going to become more and more available, more and more immediately. So do you think that services like the one that you're offering are going to become more common?

Rohin Mehta, MD: I hope so. I do hope so, because at least the feedback that we've gotten, me and Alex have gotten, through our questionnaires, it's been nothing but positive. It helps people. Now, the caveat to that, there's some people who do not want to know anything about it. They say, "I have cancer. Let me just get treated. I don't want to know about it. Let's just get it over with." Some people really want to know about it. I guess it all depends on the person, and as Alex has alluded to before, how severe the cancer is. If it's something that's not so bad, maybe they'll have more likely to come and see us or wanting to know about it.

Host Amber Smith: Well, I appreciate both of you making time for this interview. Thank you.

Rohin Mehta, MD: Thank you very much for having us.

Alexandra Tatarian: Thank you.

Host Amber Smith: My guests have been Dr. Rohin Mehta, an assistant professor of pathology at Upstate, and the medical director of pathology and clinical pathology at the community campus, along with third year medical student, Alexandra Tatarian. "The Informed Patient" is a podcast covering health, science, and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.