On June 27, I interviewed Dr. John Crary, a neuropathologist at Columbia University. Dr. Crary spends 80% of his time researching neurodegenerative diseases and the other 20% looking at brain biopsies. Every week he attends a tumor board consisting of neurosurgeons, neuroradiologists, neurologists, neuro-oncologists, and neuropathologists.
The first time a neuropathologist comes into play is when the patient is in the operating room. The neurosurgeon will call the neuropathologist to come do what they call a frozen section. In this process, small pieces of tissue are given to the neuropathologist and they quickly cut slides of the tissue under the microscope. It is during the frozen section that the neuropathologist can tell the neurosurgeon if it is a benign or malignant region.
Over the next few days, they will look at the tissue under a microscope. It is advised that you get an actual neuropathologist to do this, not a hospital generalist. The hospital generalist, although they may be an expert in pathology, may not be an expert in the brain. And always, if there is any question, you can always request that the slides be read by a second neuropathologist. Also, whenever you have a biopsy always ask if it can be reviewed at a major center. You may get a get a different wording, from different styles and customs, and pretty much a different diagnosis, but the treatment is often the same.
Dr. Crary explained to me how understanding the pathology of the tumor dictates the treatment:
“Pathology is all about estimating the prognosis. Pathologists are labelers, they’re namers. The neuropathologist will do his or her best attach a label to every tumor that comes through the laboratory. But these labels are somewhat artificial and can be confusing - what the patients and treating physicians really care about is the prognosis. For example, if there’s a patient with a brain tumor, and we know that patients with similar tumors generally live for about two years – which is information that the neuropathologist can provide – this is extremely valuable when considering treatments. Alternatively, should another patient have a different tumor type with different features that we know are associated with much longer survival, we can pass that information onto the neurologist and neuro-oncologis. In turn, they will be better able to balance the side effects of the treatment versus the extension of life. So they know that the treatment will extend life a certain number of years on average based on previous clinical research. So it’s all about us prognosticating on what the chances of living and being cured are.”
Towards the end of the interview, I asked Dr. Crary what was most rewarding about his job. He told me that the research he does and the opportunity of making a lasting difference is what keeps him going. But he also enlightened me with a classic story of the tumor board. A neuropathologist shows up at the tumor board. The previous week they had done a tricky frozen section. The neuropathologist said that it didn’t look right. The neurosurgeon thought it was one type of tumor but the neuropathologist said, and proved, that it wasn’t. He went home patting himself on the back and very proud of himself. The next week at the tumor board, everyone had a new watch. The neuropathologist asked why they all had new watches. One person said “Well you remember that guy last week who was a really tough case? He owns a watch store and gave us all new watches because we cured him.” And the neuropathologist said, “Does anyone want to give me their watch?” And nobody did.
The key here is that no one really knows about the neuropathologists. They get satisfaction from helping people, but it’s never directed from the patients. In the words of Dr. John Crary: “it’s knowing that you’re doing science that’s the most important thing. Because your impact could potentially be beyond what you’re doing that that moment. It has the potential to reverberate to change care across the whole country. And that is a great feeling.”
*If you would like to read the full story regarding the neuropathologist and the watch, go to the Links.
**If you would like to read the full transcribed interview, to to interviews.