Cancer diagnostics

What is the role of pathologists? Histopathology is the diagnosis and study of diseases of tissue, and involves examining tissue and/or cells under a microscope. Histopathologists are responsible for making tissue diagnoses and helping clinicians manage a patient’s care. Histopathologists increasingly have key responsibilities for cancer screening, at the moment for breast, bowel and cervical cancer, with other programmes expected in the near future.

Haematologists are doctors who are experts in blood. These include the blood cells circulating in the blood and those being made in the cell factories of the bone marrow. Haematologists study blood disorders, including blood cancers and diagnose and treat these cancers. Histopathologists and haematologists work closely with molecular pathology and genomic pathology colleagues.

Pathologists are at the heart of cancer prevention through screening, diagnosis, monitoring and treatment. Pathology is the service that handles the blood samples and the cells and tissues removed from suspicious ‘lumps and bumps’. They identify the nature of the abnormality and, if malignant, provide evidence to the clinician on the type of cancer, its grade and, for some cancers, the likely profile of responsiveness to certain treatments.

Challenges in cancer diagnostics

  • There has been a year-on-year increase in demand for pathology services, both in the number and complexity of tests performed.
  • Staffing levels have not risen in line with demand and pathology services are unable to recruit to vacant posts. It can take up to 15 years to train a pathologist.
  • It is anticipated that a third of consultant histopathologists will retire in the next five years. And there are not enough trainee doctors in post to fill this gap.

The NHS target (set out in the Cancer Taskforce strategy report in 2015) is for a definitive cancer diagnosis for 95% of patients within four weeks by 2020. However the pathology workforce is facing increasing pressures.

With an ageing population and a predicted sharp rise in the number of people who will develop cancer at some point in their lives, pressure on already-stretched pathology services will also increase. Cancer Research UK estimates that the yearly number of cancer diagnoses will exceed 400,000 by 2020, climbing from an annual figure of around 357,000 in 2014.

Cancer Research UK’s report Testing Times to come? An evaluation of pathology capacity across the UK, November 2016 highlighted that, year on year, the amount of histopathology requests to laboratories has increased by around 4.5% on average.

The College’s role

The Royal College of Pathologists welcomed the publication of the first stage of the Cancer Workforce Plan by Health Education England in November 2017 which highlighted the need to increase capacity and work on possible solutions. We continue to stress these issues with parliamentarians and policy makers.

Professor Jo Martin, President of The Royal College of Pathologists said:

One in two of us will develop cancer at some point in our lives and more of us will live with the long-term effects of cancer and its treatment. Pathology is the definitive diagnostic service for cancer and plays an important role in cancer prevention, early detection, treatment and monitoring. It is facing a critical stage in recruitment and retention.

‘Earlier detection improves the chance of successful treatment, saves lives and leads to a better quality of life for a person living with cancer, and is more cost-effective for the NHS. Pathologists are key to this.”

Faecal immunochemical test (FIT)

FIT is a type of faecal occult blood test for bowel cancer screening which uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect, and can quantify, the amount of human blood in a single stool sample and is carried out in clinical biochemistry departments. FIT has been shown to have higher participation rates by the population and the switch is expected to increase screening uptake by around seven to eight percentage points in England. Whilst we welcome higher uptake in testing and the benefits for earlier diagnosis, this will increase pathology demand, both as a result of increased initial testing and because positive results lead to further testing.

Human papilloma virus (HPV) testing

The major restructuring of cervical cytology services and wholescale move to primary HPV screening has been expected for some considerable while, but the delay has created uncertainty for staff. The reduction in sites from 54 to approximately 12–13 sites is a major change, and there will be larger distances between centres. The model of service delivery in new centres may well rely more heavily on advanced practitioners, but few of these are in training at the moment. Many of those in practice are over 50, and may not be prepared to travel to the new hubs. In addition not many medical staff currently doing cervical cytology are expected to transfer to the new centres. Once the centres are established there will be more stability, but the intervening period is one of concern, and the College is working with NHS England, NHS Improvement and Public Health England to suggest ways in which potential risks to services can be reduced.

Also on the agenda