I want to talk about an essay I wrote with @NathanPaulsonMD and John Sinard in @ArchivesPath. It's about the potential destruction of the "pathology commons." That sounds esoteric, but it affects all doctors and patients. Read on for more... (article free) https://archivesofpathology.org/doi/pdf/10.5858/arpa.2020-0022-ED

Let's start with what pathology is. It's a medical specialty, but it's also the foundation of all medical knowledge. The observations of pathologists, first through gross anatomy and microscopes, and now through advanced laboratory and genetic testing, drive medical innovation.

It's easy for pathologists to glamorize pathology (well, someone had to do it). In truth, we are forever indebted to our patients. They are the real fuel of innovation. I hope we help them out with our diagnoses, but I'm not sure it's always a fair bargain.

You see, when a patient gets a biopsy or surgery, in exchange for the diagnosis they receive from a pathologist, which they pay for, patients also make an in-kind donation to medical science: their tissue and slides are stored in pathology archives for a decade or even forever.

What do pathologists do with tissue and slides? They perform research, learning the causes of disease and how to better diagnose and treat them. They also train the next generation of pathologists. I have learned from patients in front of me and from those treated 50 years ago.

Tissue is power in medical science. Whoever has more of it can generate more research, especially about rare diseases. This means big, old cancer centers and departments that receive many consults control the largest archives.

This monopoly has a chance to be disrupted, an opening of pathology archives around the world. Where once physical proximity dictated access, proponents of digital pathology promised easier access and more collaboration. But the opposite could easily become true.

The problem, as usual, is money. Digital pathology systems are expensive (technology + labor). There's currently no special reimbursement for all of this work, so costs need to be recouped. Archives are also valuable, and hospitals can easily see the value in monetizing them.

Instead of sharing their digital archives with the world, hospitals could instead cash in and sell access. This reached the mainstream when MSKCC made the NY Times for potentially offering a sweetheart exclusive deal to a startup affiliated with execs. https://www.nytimes.com/2018/09/20/health/memorial-sloan-kettering-cancer-paige-ai.html

The second risk to pathology knowledge comes from digital pathology vendors. Glass slides are an open format - they can be viewed on any microscope. Digitizing slides suddenly offers the potential for vendors to lock customers into proprietary image formats.

Many pathologists advocate for an open slide image format based off DICOM, but so far vendors don't universally utilize this format as the primary archive storage method. Glass slides are easily shipped around the world. Digital slides could ironically be harder to share.

The third risk to pathology knowledge comes from the rise of artificial intelligence/machine learning. The diagnostic algorithms pathologists use are open. They are shared in the scholarly literature without patents or trade secrets. Anyone can Gleason grade or stage a tumor.

ML/AI is different. It's often a "black box" producing a diagnostic answer using opaque algorithms. Of course, the code and methods COULD be shared, but there's increasing private funding going toward these endeavors. It'll be easy to keep digital diagnoses a trade secret.

What does this mean for day-to-day practice? It could mean pathologists have to buy proprietary technology or pay a royalty every time they want to diagnose or grade a cancer. It could mean only patients with access to wealthy healthcare systems get the best diagnoses.

Doctors and patients need to speak up. Demand 3 things:

1. Don't sell off access to patient tissue to the highest bidder. Give as many people access as possible.

2. Don't use any whole-slide imaging tech that isn't a fully open image format.

3. ML/AI algorithms must be open.

The first counter-argument to these proposals will be that pathologists and hospitals and startups are leaving money on the table. There won't be any incentive to innovate. There's some truth to that.

But remember where tissue archives come from: our patients, who usually don't even know they are donating pieces of their body to medical science and education. In fact, patients pay us - not the other way around.

We must do what's right by them.

Read our article for more! :)