Cytopathology: Training for a Field of the Future
“Just a seroma," says Professor Joerg Schwock, smiling as he walks from the clinic back to the laboratory. Schwock has just seen a young man who developed a new lump during treatment for cancer. The mass that had the patient, his family and his doctors worried was a mere postoperative fluid collection. “These are the cases that stay in your mind for a while,” says Schwock.
Schwock is a recent graduate of a new cytopathology fellowship at the University of Toronto and a Cytopathologist for University Health Network (UHN) and Lakeridge Health. "Cytopathology is a bit like the emergency room of the pathology department," says Schwock. "Frequently we are the pathologists who get the first glance at a mass and with just a few cells, we can often point patient management in the right direction and prevent more invasive procedures."
Cytopathologists study cells and tiny tissue fragments to determine the nature or cause of disease, in contrast to surgical pathologists, who tend to work with larger tissue samples or entire organs. Often they join clinicians in the procedure room to take samples from almost any site in the body through minimally invasive techniques like image-guided fine-needle aspiration. This collaboration permits quick and unique insights on how to manage a patient’s illness, at a low cost to the health care system and with minimal risk to a patient's life.
Increasingly, cytopathology is a key part of personalized medicine. Cytopathologists suggest targeted therapies based on molecular profiles in melanoma, lung, colorectal and other cancers. Cytopathology also helps clinicians choose molecular treatments for patients with metastatic cancer whose primary tumors are inaccessible via other sampling methods.
Because cytopathologists provide diagnostic information on different types of cancer and on infectious, autoimmune, and other non-cancerous conditions, they need training in many diseases and deep knowledge of each organ system.
Last year, Schwock became the first trainee to complete U of T's fellowship in cytopathology, run by the Department of Laboratory Medicine and Pathobiology (LMP). "The training was very thorough, and it was a pleasure in part because of the variety," says Schwock, who joined LMP as an Assistant Professor after graduating.
"I saw a large number of specimens under the microscope but also had almost daily interactions with surgeons, endoscopists and radiologists right in the procedure room. Also, the team provides a clinic service for palpable lesions where we as pathologists see patients ourselves. Not all cytopathology programs have that level of clinical exposure," he says.
The fellowship offers clinical training at two sites — UHN and Sunnybrook Health Sciences Centre. Schwock says both hospitals have very good cytopathology labs, but because their practices vary slightly he got exposure to different methods of specimen preparation and analysis, which broadened his experience.
The fellowship meets the requirements of a new category of accreditation set up by the Royal College of Physicians and Surgeons of Canada (RCPSC) in 2011. The new standard — called the Areas of Focused Competence (AFC) diploma — recognizes disciplines that are not official medical specialties or subspecialties but still meet an important health need.
"We're at a point that's a bit like the time before medical specialties," says Scott Boerner, an Associate Professor in LMP and the Director of Cytopathology at UHN who chairs U of T’s AFC program in cytopathology. "The Royal College came into existence to recognize specialties that had evolved as medical knowledge and practice became more complex. Recently the college started to recognize subspecialties through the AFC programs as the complexity of medical practice continues to grow."
The RCPSC recognizes 13 disciplines through its AFC program, and cytopathology was the first area in pathology to get AFC status. The U of T fellowship is one of only three other AFC programs in cytopathology in Canada. "It's gratifying to see our program accredited," says Boerner. "It will improve recognition of the field in the medical community and will help raise the quality of cytopathology practice locally and nationally."
Boerner would like to expand Toronto's program so that credentialed cytopathologists are distributed across Canada. He says that while recognition of cytopathology has been a barrier in the past, today a greater challenge to growth is funding. Fellows in AFC programs are not funded by provincial health ministries — unlike most other medical trainees — so universities and hospitals must find funding to run the programs.
But Boerner is optimistic that Toronto's cytopathology program will grow. "In Canada, we've been a bit behind the U.S. and some other countries in providing the training and infrastructure for cytopathology. But there is increasing awareness that this field affects patients in many ways and that it has massive potential to reduce health care costs," he says.
Philippe Stephenson is U of T's current cytopathology fellow. He decided to apply for the program while in the fifth year of pathology residency at the University of Montreal and after he did a week-long observership at UHN, through which he gained exposure to cytopathology techniques in Toronto.
"I've learned new ways to maximize specimen adequacy and make small samples go a long way — diagnostically," says Stephenson. "It's really rewarding to help treat patients quicker and with minimal discomfort."
Stephenson also likes the structure of U of T's fellowship. "There is a clear, competency-based curriculum for a skill set that substantially expands beyond residency training, but there is also latitude to customize," says Stephenson. "I've been able to focus on sample preparation and lab management, with a view to introducing these techniques elsewhere."
Schwock, for his part, says he really likes the daily mix of clinical and lab work, as well as the opportunities to do research, teach cytopathology fellows and technicians, and help structure the university's AFC program in cytopathology. He recalls his training, which began years ago in his native Germany with what he now considers the largest possible pathology specimen: hospital autopsies. Today he works with tiny tissue fragments and cells, and increasingly looks into markers for molecular therapies that shut down cancer without side effects. "It's been quite a journey," says Schwock. "I'm grateful for all the training I've had along the way."
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