Critical role of pathology and laboratory medicine in the conversation surrounding access to healthcare.

Pathology and laboratory medicine are a key component of a patient's healthcare. From academic care centres, community hospitals, to clinics across the country, pathology data are a crucial component of patient care. But for much of the modern era, pathology and laboratory medicine have been absent from health policy conversations. Though select members in the field have advocated for an enhanced presence of these specialists in policy conversations, little work has been done to thoroughly evaluate the moral and ethical obligations of the pathologist and the role they play in healthcare justice and access to care. In order to make any substantive improvements in access to care, pathology and laboratory medicine must have a seat at the table. Specifically, pathologists and laboratorians can assist in bringing about change through improving clinician test choice, continuing laboratory improvement programmes, promoting just advanced diagnostic distribution, triage testing and be good stewards of healthcare dollars, and recruiting a more robust laboratory workforce. In order to get to that point, much work has to be done in pathology education and the laboratory personnel training pipeline but there also needs to be adjustments at the system level to better involve this invaluable group of specialists in these policy conversations.

Knowledge, Practice, and Skills in Cytology-Based Cervical Cancer Screening: Impact Assessment of Training Workshop for the Pathologists.

There is a paucity of trained cytopathologists in low-resource settings for effective cervical cancer screening. There has been no documented report of the impact of a dedicated training program in cervical cytology on pathologists' knowledge and skill in this field. The present study aimed to evaluate the efficacy of the regularly conducted training workshops on the attending pathologists' knowledge, practice, and skills in cervicovaginal smear reporting. Our institute, a premier cancer research institute, has conducted 10 cytology-based cervical cancer screening workshops for pathologists with pre- and post-training evaluation using sets of digital images and a questionnaire (knowledge score). Additionally, feedback on diagnostic skills was taken at a 1-month and 6-month interval post-workshop using a separate set of digital images of cervical lesions. A Google form-based questionnaire was designed to seek the participants' feedback on the perceived improvement in knowledge and skills. All the data thus collected were analyzed to assess the efficacy of these workshops in imparting the desired knowledge and skills. A total of 350 participants were enrolled in these workshops. The average knowledge score improved from 10.56 (± 3.23) in the pre-training questionnaire to 21.17 (± 2.41) in the post-training evaluation, making a 100.5% increase (P < 0.001). Similarly, the diagnostic accuracy on digital images was enhanced from 8.6 (± 2.12) to 19.5 (± 4.28) immediately post-training and was maintained at 17.6 (± 3.87) at 1-month and 16.4 (± 4.26) at a 6-month interval (P < 0.001). The majority of the participants reported fair to a marked improvement in their knowledge, practice, and confidence in reporting cervical cytology in the response to form-based questionnaire. One-fifth of the responders also acknowledged the assistance of the knowledge gained during the workshop in refinement or initiation of cervical cytology at their set-up. Our experience of conducting these regular workshops demonstrates the utility of such training programs in human resource development in the field of cervical cytology for enhancement of cervical cancer screening in resource-constrained settings.

Harmonization of training, training program requirements, board certification, and the practice of cytopathology: data from the American Board of Pathology surveys.

INTRODUCTION: The American Board of Pathology (ABPath) has ongoing efforts to better align certification with graduate medical education, training program requirements, and pathology practice. The present study focused on the subspecialty of cytopathology. We evaluated the current content and scope of fellowship programs, practice patterns and needs of diplomates, and program director (PD) and diplomate perceptions of the ABPath certification examination to identify gaps and provide an evidence base to guide harmonization in these areas. METHODS: Two surveys were administered: one directed to PDs of all 93 Accreditation Council for Graduate Medical Education (ACGME) cytopathology fellowship programs and the other to cytopathology diplomates submitting continuing certification reporting to the ABPath. RESULTS: Most (86%) cytopathology diplomates work in smaller groups. Only 11% do >50% cytopathology in practice. Diplomates' cytopathology-related practice tasks varied, as did their perception of the content of fellowship training aligning with practice needs. In fellowship training programs, the specimen types, volumes, techniques of specimen acquisition, and graduated responsibility varied significantly. We identified areas in which current training and certification requirements are challenging for some programs. Diplomates and PDs had differing perceptions of the cytopathology examination; diplomates regarded image-based and microscopic glass slide questions as the best assessment of their knowledge. CONCLUSIONS: First, fellowship training programs could benefit from shared resources and should provide more graduated responsibility for fellows. Second, the ACGME Review Committee could consider this data in future program requirement revisions. Finally, information from these surveys will be useful as the ABPath adjusts certification examination content and delivery.

A Curriculum for Genomic Education of Molecular Genetic Pathology Fellows: A Report of the Association for Molecular Pathology Training and Education Committee.

Molecular genetic pathology (MGP) is a subspecialty of pathology and medical genetics and genomics. Genomic testing, which is defined as that which generates large data sets and interrogates large segments of the genome in a single assay, is increasingly recognized as essential for optimal patient care through precision medicine. The most common genomic testing technologies in clinical laboratories are next-generation sequencing and microarray. It is essential to train in these methods and to consider the data generated in the context of the diagnosis, medical history, and other clinical findings of individual patients. Accordingly, updating the MGP fellowship curriculum to include genomics is timely, important, and challenging. At the completion of training, an MGP fellow should be capable of independently interpreting and signing out results of a wide range of genomic assays and, given the appropriate context and institutional support, of developing and validating new assays in compliance with applicable regulations. The Genomics Task Force of the MGP Program Directors, a working group of the Association for Molecular Pathology Training and Education Committee, has developed a genomics curriculum framework and recommendations specific to the MGP fellowship. These recommendations are presented for consideration and implementation by MGP fellowship programs with the understanding that MGP programs exist in a diversity of clinical practice environments with a spectrum of available resources.

Best practices of handling, processing, and interpretation of small intestinal biopsies for the diagnosis and management of celiac disease: A joint consensus of Indian association of pathologists and microbiologists and Indian society of gastroenterology.

The Indian Association of Pathologists and Microbiologists (IAPM) and Indian Society of Gastroenterology (ISG) decided to make a joint consensus recommendation for handling, processing, and interpretation of SI biopsies for the diagnosis and management of celiac disease (CD) recognizing the inhomogeneous practice of biopsy sampling, orientation, processing, and interpretation. A modified Delphi process was used to develop this consensus document containing a total of 42 statements and recommendations, which were generated by sharing the document draft, incorporating expert's opinion, followed by three cycles of electronic voting as well as a full-day face-to-face virtual ZOOM meeting and review of supporting literature. Of the 42 statements, 7 statements are on small intestinal (SI) biopsy in suspected patients of CD, site and the number of biopsies; 7 on handling, fixative, orientation, processing, and sectioning in pathology laboratories; 2 on histological orientation; 13 statements on histological interpretation and histological grading; 3 on the assessment of follow-up biopsies; 2 statements on gluten-free diet (GFD)-nonresponsive CD; 4 on challenges in the diagnosis of CD; 2 statements each on pathology reporting protocol and training and infrastructure in this area. The goal of this guideline document is to formulate a uniform protocol agreed upon both by the experienced pathologists and gastroenterologists to standardize the practice, improve the yield of small bowel biopsy interpretation, patients' compliance, overall management in CD, and generate unified data for patient care and research in the related field.

Impact of education on institutional and faculty rates of atypical squamous cells.

INTRODUCTION: Papanicolaou test quality metrics include the ASC rate, ASC:SIL ratio, and ASC HPV+ rate. What a laboratory should do when metrics show a worrisome trend is not well defined. In 2015, our laboratory noted a worrisome trend in our quality metrics and decided to implement a systemic education program in 2016; we monitored the effectiveness of our program. METHODS: An educational intervention was designed for March/April 2016. Cytotechnologist education consisted of: group meeting on March 10 to discuss metrics, lecture, and written materials on ASC-US criteria, a quiz on challenging ASC-US cases, encouragement to seek consultation, and each cytotechnologist received quarterly individual metrics. The cytopathologist education consisted of: group meeting on April 16 to discuss metrics, encouragement to bring borderline cases to consensus conference, and each faculty received quarterly individual metrics. The ASC rate, ASC:SIL ratio, and ASC HPV+ rate was collected for the institution and each individual faculty in 2016 for January to March (pre-interventions, Q1), April to June (post-interventions, Q2), and July to September (post-interventions, Q3). ASC-H was included in the calculation of ASC %, ASC:SIL, and ASC HPV+ rates. RESULTS: There was a substantial decline in the lab ASC rate and ASC:SIL ratio, and the ASC HPV+ rate increased. Individual faculty changes in ASC:SIL ratio and ASC HPV+ rate also improved. CONCLUSIONS: In our institution, an educational program has been very effective in improving Papanicolaou test metrics. It is helpful to perform re-education at all levels within the department.

To whom the specimen goes: a look at how touch preparations and core needle biopsies are handled in different practices and the effect on fellowship education.

INTRODUCTION: Core needle biopsies (CNBs) have proven to be an excellent source of tissue for diagnosis and ancillary testing in the era of personalized medicine, commonly yielding sufficient material for testing via a relatively minimally invasive technique. Thus, there has been an increase in touch preparations (TPs) evaluated with rapid onsite evaluation (ROSE) of these small biopsies either in isolation or with concurrent fine needle aspiration (FNA). This in turn has forced cytopathology practices to make decisions with regard to processing and workflow of CNBs, which affects cytopathology fellowship education substantially. STUDY DESIGN: The present review is based on a review of recent literature and an evaluation of the authors' personal experiences. RESULTS AND CONCLUSIONS: Deciding whether CNBs with associated TPs should be assigned to the cytology service, the subspecialty or general surgical pathology service, or a split between cytopathology and surgical pathology, is complicated. The workflow is variable at different institutions depending on multiple factors. Each of these routes has benefits and disadvantages that can affect patient care and laboratory workflow, in addition to having downstream effects on the quality and type of education our pathology trainees receive. Herein, the advantages and disadvantages of the different approaches for CNB triage are discussed, with an emphasis on the impact upon cytopathology fellowship education.

ACGME Milestones 2.0: why and what's new for cytopathology?

BACKGROUND: Primary stakeholders in the Accreditation Council for Graduate Medical Education (ACGME) Milestones Project are: ACGME, Residency Programs, Residents, Fellowship Programs, Fellows, and Certification Boards. The intent of the Milestones is to describe the educational and professional developmental trajectory of a trainee from the first stages of their postgraduate education through the completion of their clinical training. The Milestones 2.0 project includes changes made based on experience with Milestones 1.0. METHODS: The ACGME solicited volunteers to participate in the development of subspecialty Milestones 2.0. The workgroup was charged with reviewing/making any additions to the four "Harmonized Milestones", developing subspecialty specific milestones for the Patient Care and Medical Knowledge competencies, and creating a supplemental guide. The Milestones were finalized following review of input from an open comment period. RESULTS: The Cytopathology Milestones 2.0 will go into effect July 2021. They include additional subcompetencies in the 4 harmonized competency areas and cytopathology-specific edits to the patient care and medical knowledge subcompetencies. Although the number of subcompetencies has increased from 18 to 21, within each subcompetency, the number of milestone trajectories has decreased. Additionally, within each subcompetency, the wording has been streamlined. A supplemental guide was created and Milestones 1.0 were compared to 2.0; however, curriculum mapping has been left to programs to develop. CONCLUSIONS: The ultimate goal of the Cytopathology Milestones 2.0 is to provide better real-time documentation of the progress of cytopathology fellows. The expected outcome is to produce highly competent cytopathologists, improving the care they provide, regardless of the program at which they trained.

Trends in cytopathology fellowship positions and vacancies over the past decade.

INTRODUCTION: Cytopathology is one of the most sought-after fellowships within pathology, with a lower fellowship vacancy rate compared with most other subspecialties. The Accreditation Council for Graduate Medical Education (ACGME) actively tracks annual program data for cytopathology fellowship programs, and evaluating this longitudinal data looking at trends in programs and positions over the past 10 years could provide insights into the future of cytopathology and its training programs. METHODS: Data obtained from the ACGME was examined in detail for all ACGME-accredited cytopathology fellowship programs over the past decade (2011-2021). Additional responses from program directors (PDs) from a 2021 American Society of Cytopathology (ASC) survey are also included. RESULTS: The total number of ACGME-approved cytopathology training programs and cytopathology fellowship positions remained relatively constant over the past 10 years, but the vacancy rate and number of programs with 1-2 unfilled spots has gradually but steadily risen over the past 6 years. In a 2021 ASC PD survey with 66% response rate, 53% of PDs reported having recruitment problems at least occasionally and 46% reported an increase in unexpected fellowship openings. CONCLUSIONS: Although the number of cytopathology positions has been relatively constant over the past decade, there has been a recent increase in cytopathology fellowship vacancies that may indicate changes in career choices or the job market, with fellows choosing jobs over additional fellowships, and potentially signal a growing shortage of fellowship-trained, Board-certified cytopathologists in the coming years.

Cytopathology fellowship recruitment: Has the time come to consider a unified approach?

INTRODUCTION: Cytopathology (CYP) fellowship training is a critical component of maintaining a skilled group of cytopathologists. For years, the recruitment process for CYP fellowship programs has remained unchanged, with individual programs outlining their own requirements and timeline, and applicants bearing the cost of travel and dealing with the variable processes outlined by individual programs. However, there has been renewed interest in analyzing the recruitment process for CYP fellowships to look for areas of potential improvement and uniformity. METHODS: With the goal of gauging the interest of CYP fellowship program directors (PDs) in a more unified approach to recruitment or a formal match process, the ASC Cytopathology Program Directors Committee (CPDC) surveyed PDs via SurveyMonkey and organized special webinars with polling over a 4-year time frame (2017-2021), and examined Qualtrics survey data collected by the American Board of Pathology (ABPath) in 2020. RESULTS: The response rate for PDs was greatest in a formal survey by the ABPath (66 respondents; 71% of PDs) conducted in 2020, and lower for an ASC survey in 2021 (61 respondents, 66% of PDs) and 2017 (19 respondents; 21% of PDs) and two recent ASC webinars (10 and 26 respondents; 11% and 28% of PDs). Support for a fellowship match process varied from 29% to 77%, respondent uncertainty ranged from 13% to 50%, and a lack of support ranged from 10% to 60%. In aggregate, approximately 56% of respondents would be in favor of a more standardized process. Recently, after hearing about other fellowships experimenting with a standardized process, the interest in a unified approach doubled from approximately 29% to 60%, and the percentage of PDs with uncertainty decreased from 50% to 26%. In the most recent follow up survey, interest reached the highest level of 77% among PDs. CONCLUSIONS: Herein we present several years of feedback from the CYP fellowship PD community regarding a more standardized approach to CYP fellowship recruitment, culminating in the latest survey with 77% of CYP fellowship PDs expressing interest. Thus, details about what a unified timeframe may look like for CYP fellowships is presented to show how this may improve the recruitment process for the mutual benefit for programs and applicants.

Polyclonal PAX8 expression in carcinomas of the biliary tract - Frequent non-specific staining represents a potential diagnostic pitfall.

Paired box protein 8 (PAX8) is a transcription factor that is considered a relatively specific marker of carcinomas of the thyroid, kidney, and Müllerian/Wolffian duct derivatives. Unexpected PAX8 immunoreactivity has occasionally been reported in other tumors. The frequency of PAX8 expression in carcinomas of the biliary tract is not well studied. We evaluated the immunohistochemical expression of PAX8 in 73 cases of biliary tract carcinoma. We found that 28 of 73 (38%) biliary tract carcinomas had variable immunoreactivity for PAX8, assessed by a widely used polyclonal antibody (ProteinTech Group, Chicago, IL). This included 3 (4%) of cases with strong diffuse, and 14 (19%) of cases with strong focal staining. Strong PAX8 expression was more frequent in distal bile duct carcinomas than other biliary sites (p = 0.015), and showed a weak association with advanced T stage (T3-T4 versus T1-T2; p = 0.09). No correlation was observed between PAX8 positivity and age at diagnosis, gender, or lymph node metastasis. The 28 polyclonal PAX8-positive cases were largely negative for monoclonal PAX8 and PAX6 immunostains, with only rare tumor cells with weak immunoreactivity being present in a subset of cases. We show that a substantial fraction of biliary tract carcinomas exhibit immunoreactivity with a widely used polyclonal PAX8 antibody. Pathologists should be aware of this potential pitfall during the diagnostic workup of hepatobiliary lesions to avoid misdiagnosis as a metastasis from a PAX8-positive tumor.

Comparison of quantitative internal and external measures of performance for trainees in cytopathology fellowships.

INTRODUCTION: Cytopathology fellowships need measures to assess performance of fellows. We sought to compare several internal quantitative assessment metrics in our fellowship with external metrics, such as performance on the American Society of Cytopathology (ASC) Progressive Evaluation of Competency (PEC) examination and United States Medical Licensing Examination (USMLE). METHODS: Quantitative parameters generated from our laboratory information system (LIS) on cytopathology fellows were evaluated over 6 years, including case volume and diagnostic discrepancies, in addition to ASC PEC and USMLE scores. For discrepancy reports, interpretations made by the fellow were compared with that of the cytopathologist, and classified as none (concordant), minor (<2-levels) or major (≥2-levels). RESULTS: We evaluated internal and external metrics on 13 fellows over 6 years. The program average diagnostic concordance rate was 89.9%, with an average major discrepancy rate of 1.5%, and an average monthly case volume of 260 cases. More fellows with above-average ASC PEC performance showed above-average concordant diagnoses and lower case volume, while below-average PEC scores were seen more often with higher major discrepancy rates. More fellows with above-average USMLE scores had higher case volumes, while low USMLE scores showed a trend towards higher major discrepancy rates. CONCLUSION: Our fellowship program has used a variety of internal and external measures of performance for cytopathology fellows. Although the findings show no statistically significant finding correlating performance, these quantitative parameters generated from our LIS were helpful to identify areas of improvement, facilitate comparison to peers, and provide case volume documentation.

[Histopathologic grading of breast cancer; large variation with major consequences?] / Histopathologische gradering van het mammacarcinoom.

The pathologist's assessment of tumor tissue plays a critical role in therapeutic decision-making in early-stage invasive breast cancer. In daily practice, however, there appears to be considerable variation in grading between the different Dutch pathology laboratories and between individual pathologists within the same laboratory. This underlines the need to standardize grading by pathologists as much as possible in order to minimize the risk of a worse outcome for patients due to under-treatment and of unnecessary toxicity from over-treatment. Therefore, two initiatives were launched, i.e. laboratory-specific feedback reports and an e-learning module in which pathologists were trained in grading of invasive breast cancer. While these initiatives have yielded encouraging results, the overall variation in grading remains significant. Awareness of this variation, and of the inherent difficulties of subjective grading, among the various clinicians involved in breast cancer management, is therefore of utmost importance to improve clinical decision-making for patients.

Online Training and Self-assessment in the Histopathologic Classification of Endocervical Adenocarcinoma and Diagnosis of Pattern of Invasion: Evaluation of Participant Performance.

Histopathologic classification of endocervical adenocarcinomas (EAC) has recently changed, with the new system based on human papillomavirus (HPV)-related morphologic features being incorporated into the 5th edition of the WHO Blue Book (Classification of Tumours of the Female Genital Tract). There has also been the introduction of a pattern-based classification system to assess invasion in HPV-associated (HPVA) endocervical adenocarcinomas that stratifies tumors into 3 groups with different prognoses. To facilitate the introduction of these changes into routine clinical practice, websites with training sets and test sets of scanned whole slide images were designed to improve diagnostic performance in histotype classification of endocervical adenocarcinoma based on the International Endocervical Adenocarcinoma Criteria and Classification (IECC) and assessment of Silva pattern of invasion in HPVA endocervical adenocarcinomas. We report on the diagnostic results of those who have participated thus far in these educational websites. Our goal was to identify areas where diagnostic performance was suboptimal and future educational efforts could be directed. There was very good ability to distinguish HPVA from HPV-independent adenocarcinomas within the WHO/IECC classification, with some challenges in the diagnosis of HPV-independent subtypes, especially mesonephric carcinoma. Diagnosis of HPVA subtypes was not consistent. For the Silva classification, the main challenge was related to distinction between pattern A and pattern B, with a tendency for participants to overdiagnose pattern B invasion. These observations can serve as the basis for more targeted efforts to improve diagnostic performance.