Heme/Onc and Pathology

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Did any of you in Heme/Onc initially consider going into pathology? It seems like a pretty large conceptual overlap in that pathology tends to diagnose most of the conditions that Heme/Onc treats. Do any of you ever wish that you were on the other side, signing out the biopsies and looking at the marrows?

Originally Posted by Enkidu

Did any of you in Heme/Onc initially consider going into pathology? It seems like a pretty large conceptual overlap in that pathology tends to diagnose most of the conditions that Heme/Onc treats. Do any of you ever wish that you were on the other side, signing out the biopsies and looking at the marrows?

Yes, I thought about Path. No, I'm not upset that I'm not signing out cases and here's why:

1. I like the patient contact and continuity.
2. I still look at a lot of smears, marrows and biopsies, but its for my own edification and education...the buck doesn't stop with me on that front.
3. As an oncologist, I won't have any trouble finding a job when I finish training. As a path resident, I'd be looking at 1-3 more years of fellowship with minimal hope of a job.

Originally Posted by gutonc

Yes, I thought about Path. No, I'm not upset that I'm not signing out cases and here's why:

1. I like the patient contact and continuity.
2. I still look at a lot of smears, marrows and biopsies, but its for my own edification and education...the buck doesn't stop with me on that front.
3. As an oncologist, I won't have any trouble finding a job when I finish training. As a path resident, I'd be looking at 1-3 more years of fellowship with minimal hope of a job.

Interesting. But to be fair, you are already doing 3 years of fellowship to do heme/onc.

I was thinking that oncology might be frustrating because oncologists don't really diagnose their patients and chemotherapy seems to be very empirical (in that there are only a few targeted therapies like Gleevec).

Well, the job market for pathology is not that good, but statistically nearly all pathologists find a job... just not necessarily in the location that they wanted.

I guess it is still pretty edifying to look at a slide even though you are not responsible for signing it out. I guess that most clinicians routinely look at their imaging studies, but maybe only heme/onc regularly looks at slides/smears.

Isn't the patient contact in oncology pretty dark? I would think that it would be pretty emotionally draining. Maybe I'm just not that much of a people person, but it seems to me that oncology is very heavy on the emotional interaction with dying patients. Don't you ever wish to just be on the purely scientific unemotional side of the equation? Maybe I'm just not appreciating the draw of this type of patient interaction.

Originally Posted by Enkidu

Interesting. But to be fair, you are already doing 3 years of fellowship to do heme/onc.

Actually, I'm doing 4! But I only did 2 years of IM and I get 3 full years of research time. But that's beside the point.

I was thinking that oncology might be frustrating because oncologists don't really diagnose their patients and chemotherapy seems to be very empirical (in that there are only a few targeted therapies like Gleevac).

It is clear that you misunderstand the role and practice of oncologists (this is my polite way of saying you're talking out of your *****).

About half of inpatient consults go like this "I have a guy with a (insert organ/anatomical site) mass on CT, can you come figure out what he has and how to treat him?" The other half are from surgeons asking you to figure out why a patient with an INR of 5 and platelets of 12 is having post-op bleeding.

At that point it's kind of semantic as to who "diagnoses" the patient. You're going to write a note stating what the most likely dx is (and you're probably already warming up your favorite treatment cocktail). The radiologist who read the CT scan probably already said "suspicious for X-inoma." Then a surgeon, GI, pulm or radiologist will get a hunk of that tissues. Then the pathologist will look at it under the scope, maybe run an IHC or two (or 12 if they have good insurance) and pronounce it to be "definitely X-inoma." Of the 3-5 people who laid their hands on that case, who "made the diagnosis?" Who cares?

As for targeted therapies...rituximab, sorafenib, sunitinib, cetuximab, panitumumab, pazopanib, ipilimumab, erlotinib, trastuzumab, bevacizumab...let me know if you want me to stop.

Well, the job market for pathology is not that good, but statistically nearly all pathologists find a job... just not necessarily in the location that they wanted.

That's a generous interpretation of the path job market but not completely off the mark.

I guess it is still pretty edifying to look at a slide even though you are not responsible for signing it out. I guess that most clinicians routinely look at their imaging studies, but maybe only heme/onc regularly looks at slides/smears.

I think oncologists probably spend more time looking at slides and films than any other specialty besides radiology (and maybe surgery) because many of our treatments (and nearly all of our clinical trials) are dependent on how things look on CT. I probably look at 2 studies for every patient I see. And while I don't routinely look at all slides, if there's something interesting or unusual about the case I will...I also look at all of my own smears.

Isn't the patient contact in oncology pretty dark? I would think that it would be pretty emotionally draining. Maybe I'm just not that much of a people person, but it seems to me that oncology is very heavy on the emotional interaction with dying patients

.

It can be tough, sure, but it can also be quite edifying both to help cure people (which happens although not as often as we'd like) as well as to help people have a good death. But yes, you need to have some people skills and a fair amount empathy in order to do it. I'm probably the wrong person to ask about this though because my clinical and research focus are on advanced and metastatic GI malignancies so I probably have a different perspective and tolerance for this part of the job.

Don't you ever wish to just be on the purely scientific unemotional side of the equation? Maybe I'm just not appreciating the draw of this type of patient interaction.

I am...4 days a week. On the real scientific side...the research side.

I went through this same thought process when I was finishing up grad school and headed back to med school. Lots of people that I respected (including my PhD advisor and a close collaborator) told me I should do path since it would be the fastest route back to the lab. But I like the patient interaction too much to give it up.

Interesting points. I guess that my perspective on oncology is based on my experience in pathology. Thanks for being polite about my talking out of my ****, I admit that I never considered going into oncology. My interest is secondary to my interest in path.

The majority of cancers don't have targeted therapies, though. Isn't that right? That's the impression I got from medical school, at least.

Based on your characterization it seems like you consider pathology to be tantamount to a laboratory test confirming your clinical impressions. How accurate are your clinical impressions when it comes to classifying a tumor?

Originally Posted by Enkidu

Interesting points. I guess that my perspective on oncology is based on my experience in pathology. Thanks for being polite about my talking out of my ****, I admit that I never considered going into oncology. My interest is secondary to my interest in path.

The majority of cancers don't have targeted therapies, though. Isn't that right? That's the impression I got from medical school, at least.

Based on your characterization it seems like you consider pathology to be tantamount to a laboratory test confirming your clinical impressions. How accurate are your clinical impressions when it comes to classifying a tumor?

Pathology should be compared with radiology/radiation oncology etc (fields with no patient contact).....Onc is a field full of pt contact which is fun (People in other field think Onc pt encounter is depressing, but thats not true). pt exposure with Onc pt is the most diverse/fun experience to me. You see a young 19 yr old with Hodgkin going for ABVD to 90 yr old grandpa with prostate cancer on casodez

Originally Posted by asprin81

Pathology should be compared with radiology/radiation oncology etc (fields with no patient contact).....Onc is a field full of pt contact which is fun (People in other field think Onc pt encounter is depressing, but thats not true). pt exposure with Onc pt is the most diverse/fun experience to me. You see a young 19 yr old with Hodgkin going for ABVD to 90 yr old grandpa with prostate cancer on casodez

Radonc has plenty of patient contact. They plan the radiotherapy, oversee the delivery, and manage the side effects and complications. Hard to do that without talking to a patient. Their relationship to the patient is more like a surgeons, in that they are called in to evaluate a patient and perform a specific procedure, including the follow-up.

Originally Posted by asprin81

Pathology should be compared with radiology/radiation oncology etc (fields with no patient contact).....

Are you kidding? Rad Onc spends as much time (or more) with the patients as Med Onc does. At our institution, Rad Onc gets 90-120 min new pt appts (not including simming and treatment planning). Their H&Ps are epic and they see patients weekly during treatment.

Now...they do often have minimal follow-up once they're done zapping...that usually gets left to us. But getting them re-involved is easy.

Originally Posted by gutonc

Are you kidding? Rad Onc spends as much time (or more) with the patients as Med Onc does. At our institution, Rad Onc gets 90-120 min new pt appts (not including simming and treatment planning). Their H&Ps are epic and they see patients weekly during treatment.

Now...they do often have minimal follow-up once they're done zapping...that usually gets left to us. But getting them re-involved is easy.

True to some extent, But I see their role as helping guest in life of cancer pt...Agree with 1 1/2 hr consult for radiation planning....Pathologist may say they get pt encounter when they come for frozen section in OR and they spend time with pt's tissue (if they consider that encounter)....But comparing radiologist pt encounter to med Onc doc will not be fair...Oncolgist role is different...In radiation dept, pts time is spent with machine and tech.....MD see them at start and end of treatment

Well, the amount of patient contact is pretty irrelevant to this question. Pathology delivers the definitive diagnosis of cancer and oncology provides the medical treatment. That is the link between them. My question is whether many oncologists wish they were signing out the tissue rather than providing the chemotherapy and emotional support.

I don't know of many pathologists that desire patient encounters, because they get the satisfaction of having the final say in the patients diagnosis. Maybe oncologists are the same in that they don't mind relying on a diagnosis from pathology because they get to treat the patient and have those patient encounters.

As for there being a semantic ambiguity in the question of who makes the diagnosis, to be honest I don't see it that strongly. Regardless of the clinical impression, the final diagnosis is made based on the tissue. If the oncologist is proved right by pathology, then I suppose they can feel pretty good about their clinical acumen, but ultimately the patient is treated for what the pathologist diagnosed him with. At least that's what I think. Would some oncologists ignore a tissue diagnosis and instead treat the patient based on their clinical impression?

Originally Posted by Enkidu

As for there being a semantic ambiguity in the question of who makes the diagnosis, to be honest I don't see it that strongly. Regardless of the clinical impression, the final diagnosis is made based on the tissue. If the oncologist is proved right by pathology, then I suppose they can feel pretty good about their clinical acumen, but ultimately the patient is treated for what the pathologist diagnosed him with. At least that's what I think. Would some oncologists ignore a tissue diagnosis and instead treat the patient based on their clinical impression?

Wow. You went from semantic to pedantic in a hurry there. Look, I never said pathologists weren't important, and no...obviously I don't treat without a tissue diagnosis (usually talk to the pathologist directly too). But, again, who cares? If being the one to "make the diagnosis" gives you such a chub, then, by all means, go into whatever specialty you think does that.

If you had just said at the beginning that all you wanted to do was start an irrelevant fight over this non-issue, we could have ended this much more quickly and you could have gotten back to masturbating furiously to Robbins while the rest of us got on with our lives.

Originally Posted by gutonc

Wow. You went from semantic to pedantic in a hurry there. Look, I never said pathologists weren't important, and no...obviously I don't treat without a tissue diagnosis (usually talk to the pathologist directly too). But, again, who cares? If being the one to "make the diagnosis" gives you such a chub, then, by all means, go into whatever specialty you think does that.

If you had just said at the beginning that all you wanted to do was start an irrelevant fight over this non-issue, we could have ended this much more quickly and you could have gotten back to masturbating furiously to Robbins while the rest of us got on with our lives.

Hi, I think you've misunderstood me. My interest is in pathology, and my intent in this thread was to get a sense of how oncologists view pathologists. Specifically I wanted to know if oncologists are mostly fulfilled by their patient interaction or whether they sometimes envy being able to diagnose and characterize cancer on a morphologic/molecular level.

My impression from this thread was that oncologists don't consider that pathologists necessarily diagnose cancer any more than they do, and that pathology can't even be compared to oncology because pathologists don't have patient contact. I guess that this surprised me.

After you took issue with my characterization of pathology as "diagnosing" cancer, I switched my usage to "definitive" or "final" diagnosis of cancer. I guess I'm not really sure how to specify the role of pathology any more clearly.

Originally Posted by Enkidu

Hi, I think you've misunderstood me. My interest is in pathology, and my intent in this thread was to get a sense of how oncologists view pathologists. Specifically I wanted to know if oncologists are mostly fulfilled by their patient interaction or whether they sometimes envy being able to diagnose and characterize cancer on a morphologic/molecular level.

My impression from this thread was that oncologists don't consider that pathologists necessarily diagnose cancer any more than they do, and that pathology can't even be compared to oncology because pathologists don't have patient contact. I guess that this surprised me.

After you took issue with my characterization of pathology as "diagnosing" cancer, I switched my usage to "definitive" or "final" diagnosis of cancer. I guess I'm not really sure how to specify the role of pathology any more clearly.

To answer your question, no, most oncologists do not with they were doing pathology. They are two very different fields and probably attract different personalities.

Originally Posted by gutonc

Actually, I'm doing 4! But I only did 2 years of IM

As for targeted therapies...rituximab, sorafenib, sunitinib, cetuximab, panitumumab, pazopanib, ipilimumab, erlotinib, trastuzumab, bevacizumab...let me know if you want me to stop.

To be fair, these 'targeted therapies', though better than cytotoxics, aren't really cancer specific like say antibiotics are bacteria-specific. Shutting down VEGF is like turning off the plumbing to fix a leak (except the leak is an evolving expanding mass full of plumbing encroaching on your rooms!). Imatinib was the first truly specific, and thus exciting biologic, at least in my eyes.

Originally Posted by Raygun77

To be fair, these 'targeted therapies', though better than cytotoxics, aren't really cancer specific like say antibiotics are bacteria-specific. Shutting down VEGF is like turning off the plumbing to fix a leak (except the leak is an evolving expanding mass full of plumbing encroaching on your rooms!). Imatinib was the first truly specific, and thus exciting biologic, at least in my eyes.

I assume you're aware of the huge # of tyrosine kinases that imatinib inhibits (in normal and disease states), correct? While it does in fact inhibit abl like a charm (unless it doesn't), it also hits a bunch of other things.

That's why I actually tend to use the phrase "biologic therapies" because they're not targeted.

Originally Posted by gutonc

I assume you're aware of the huge # of tyrosine kinases that imatinib inhibits (in normal and disease states), correct? While it does in fact inhibit abl like a charm (unless it doesn't), it also hits a bunch of other things.

That's why I actually tend to use the phrase "biologic therapies" because they're not targeted.

yeah, but i like how it truly does 'target' the tumours primary source of success- bcr-abl. Likewise, i'd call traztuzumab, rituxumab successful 'targetted therapies' as well. But i dont know about the rest!

Originally Posted by gutonc

wow. You went from semantic to pedantic in a hurry there. Look, i never said pathologists weren't important, and no...obviously i don't treat without a tissue diagnosis (usually talk to the pathologist directly too). But, again, who cares? If being the one to "make the diagnosis" gives you such a chub, then, by all means, go into whatever specialty you think does that.

If you had just said at the beginning that all you wanted to do was start an irrelevant fight over this non-issue, we could have ended this much more quickly and you could have gotten back to masturbating furiously to robbins while the rest of us got on with our lives.

Roar!

I'm glad I found this thread. I'm doing the PSF program right now, and am interested in heading towards IM then Heme/Onc. I enjoyed the Heme Path rotation, but I'm starting to miss seeing people...Maybe third year will make me miss NOT seeing people though.

Originally Posted by Raygun77

To be fair, these 'targeted therapies', though better than cytotoxics, aren't really cancer specific

Targeted therapies are better than cytoxics? Hey, I'll take my weekly paclitaxel over 400 bid sorafenib anyday. Easier on my monthly budget too. I think TKI side effects can be nastier than chemo, depending on the drug/dose. Their toxicity profile is different, not necessarily better. I will agree that monoclonal abs or antibody-drug conjugates are well tolerated.