A candid discussion on the challenges and realized benefits of Digital Pathology with three leaders from Leeds Teaching Hospitals NHS Trust, United Kingdom

Dr. Bethany Williams

Lead for Training, Education and Public/Patient Involvement at the National Pathology Imaging Co-operative

Dr. Daljeet Bansal

Operations Director of the National Pathology Imaging Co-operative

Dr. Rebecca Millican-Slater

Consultant Pathologist with a specialist interest in breast and tumour pathology

I’d like to emphasize the amazing impact that digital pathology has had on education…

…not just in continuing to provide clinical services, but in continuing to train and educate the next generation of pathologists. – BW

Discussion chaired by Jonathon Tunstall, CEO, Pathology News – September 2022

Published – March 2023


JT – Hello and welcome to Pathology News and our roundtable discussion on Digital pathology: its challenges and realized benefits. My name is Jonathon Tunstall and I’m pleased to welcome my three distinguished guests today who have each been intimately involved with the adoption of digital pathology at the Leeds Teaching Hospitals NHS Trust, situated at Leeds in the UK.

Our digital pathology experts, in no particular order, are Dr. Bethany Williams, Lead for Training, Education, and Public Patient Involvement at National Pathology Imaging Co-Operative. Bethany has been closely involved with the evolution, implementation, and validation of digital pathology at Leeds and is also the author of the Leeds Guides to Digital Pathology, Volumes 1 & 2, which we will hear more about later.

Dr. Rebecca (Becky) Millican-Slater is a Consultant Pathologist at Leeds with a specialist interest in breast and tumour pathology, digital pathology, and AI. Becky is also a fervent supporter of on-screen diagnosis of the application of AI to aid diagnosis, and a strong advocate of going digital and never turning back.

Dr. Daljeet (Dal) Bansal is Operations Director of the National Pathology Imaging Co-Operative. She has been responsible for the scaling and integration of digital pathology across several hospitals in the North of England, a project which has now expanded to two national networks. Dal leads research and innovation opportunities through the application of artificial intelligence tools to help improve the diagnosis of cancer and other diseases.

Bethany, I’d like to start with you, as I know you have been involved with the adoption of digital pathology for many years now. How has your role evolved over the years?

BW – My involvement with digital pathology goes back to around 2015 when I started a Future Leaders fellowship project in digital pathology at Leeds. That was a pilot to try out digital pathology for primary breast diagnosis back in the days when we just had one scanner, myself, and one other person in the lab trying to run everything! That one-year project has developed into a full-time career. After that, I went on to take on a research role and, completed a PhD in the patient safety aspects of digital pathology and helped to implement our 100% digitization of the Leeds laboratory. Since then, the Leeds digital pathology project has evolved into the National Pathology Imaging Cooperative (NPIC), where I’m now the lead for training, education, and patient and public participation.

Digital pathology really is at the crossroads of clinical work, technology, innovation, research, and education. One of the new challenges I find the most stimulating is being able to involve patients and the public more in our work and trying to do our best to incorporate their perspectives into the work we’re doing, especially now we’re looking at some of the more research and innovation-oriented projects that Dal is drumming up for us.

JT – Thank you Bethany. This certainly is an exciting field. What has been your experience Dal? When did digital pathology come into play for you, and what are the innovation-oriented projects that you are “drumming up” for Leeds:

DB – I’d, say that digital pathology came into play before the beginning of my role in NPIC because I remember feeling slightly envious when one of my colleagues had the opportunity to take on a PhD in digital pathology, which was after I had worked for many hours and days using a microscope. I could see that it might be a game changer, if I pursued, at that stage, a career in digital pathology and I was quite pleased and fortunate that the opportunity rose again to lead digital transformation.

When I took this role as the operations director at NPIC, it was, at that time, a program to focus on the northern region of the UK. I was fortunate that in my previous capacity I was involved in a regional image sharing platform which was aligned with the 100,000 Genomes Project.  That meant I was getting more involved in new challenges and opportunities in terms of digital transformation, and I was acquainted with the leadership and expertise at Leeds. One thing led to another, and I was fortunate enough to become part of the team at Leeds supporting the aims of the program.

Initially, the aim of the program was to consider deploying digital pathology across the northern region and that meant, across the 6 hospitals in West Yorkshire hospitals, serving 3 million people alongside that, there was a parallel aim of supporting research and artificial intelligence projects. Very early on, it might have been in my first week, I was given the opportunity to co-create the plans to scale our aims and NPIC went from Northern to National and has been my focus since 2020.

JT – Thank you Dal. Turning to Becky now; Becky, as a consultant pathologist, dealing with patients daily, how did you first hear about the digital pathology transition at Leeds and what was your initial reaction?

RMS – I was first introduced to digital pathology and using a digital microscope as part of some research studies many years ago. When the time came for a group to pilot digital pathology in routine practice, we (the breast group) were approached as a few of us had shown interest in these early research studies. We were also based in a different building to the main laboratory and there was often a significant delay between the slides being ready for reporting and physically arriving with us. Moving to a digital way of working was a good solution to the difficult logistics of transporting slides back and forth in a timely fashion.

JT – Bethany, turning to you again. If I could ask you to reflect on what is a huge and momentous transition at Leeds from analogue to digital pathology, what would you say have been the biggest challenges that you and your team have faced with the implementation of such a new technology?

BW – That’s a very interesting question. When I first started out in this role, I was very worried about the technology side of it, because I was on the human side of the human-computer interaction, and I didn’t have a computer science background in any way. In reality, at least from my point of view, the biggest challenges have been more about people, rather than technology. I’ve found that a lot of my work has focused on doing engagement work both in laboratories and with pathologists and other stakeholders, as well as doing a lot of the training and validation that needs to be put in place. I think it’s easy to underestimate the importance and the magnitude of the challenge there.

There is still a real mix of opinions amongst the pathology community about digital pathology. I think there are more and more people that are super enthusiastic, cheerleaders for digital, but there are still those that are unsure about their abilities to use digital or implement it in the laboratories. They are sceptical about delivering these types of projects. So, it’s very, very important to make sure that you are engaging with all these groups of people and not just deploying for the technophiles and tech enthusiasts that are found in every department. You’ve really got to think about how you bring along those that are more sceptical and that’s why it’s so important to have them involved in your plans, even if that makes for some quite uncomfortable meetings at times. Having your vocal and articulative sceptics present to pour cold water on some of your ideas is really, helpful. I think that once you know where there is resistance and you understand what might be causing that resistance, you can really start to objectively look at whether these are real problems that exist in the project.

I think sometimes it’s very easy to just go and talk to pathologists and find out how they’re feeling about digital, and we make the mistake of concentrating on the diagnostic end of the process, thereby neglecting our colleagues in the laboratory, which is where a lot of the real heavy lifting is going to be done in terms of the change management of the project. We’ve benefited greatly from having some fantastic colleagues in the laboratory and several of our biomedical scientists have taken on management and leadership posts in the project over the years. They have really brought so much value to the team. So, the big challenge is bringing together your laboratory scientists and pathologists and working with them together from as early as possible in the process.

JT – Do you find there is an age profile to the scepticism? Is it perhaps caused by many years of using a microscope and being reluctant to change, for example?

BW – Initially there was a little more scepticism in some of our more experienced pathologists. I think that is only natural when you think that they’re comparing maybe 10, 20, 30 years of use of the light microscope as an extension of themselves for diagnosis with their use of brand-new technology. More recently, however, we have found that some of our more experienced pathologists are the most excited by the opportunities of digital pathology, largely because they see it as factoring into their peri-retirement job planning. A lot of them are very interested in starting to work remotely or doing parts of their work remotely or from different sites.

JT –That’s great to hear! Turning to you Becky, I’d like to get a feel for the scope of this transition from the perspective of a clinician. You’re obviously handling breast cancer digitally, but I’d like to get a feel for what other types of cancers you are you running on the digital pathology systems at Leeds. What would you say are the pros and cons of dealing with multiple disciplines through a digital approach?

RMS – We are scanning all slides produced in our lab and have been for several years. This encompasses the disciplines of skin, soft tissue, GI, neurology, urology, gynaecology, head and neck, thoracic, renal, liver and paediatrics, and includes all tumour types within these specialties. Whilst it made sense to limit the use of digital pathology to just a few groups in the initial stages when everything was completely new to the department, scanning all slides is ultimately easier for the laboratory as they don’t need to run different workstreams for different groups. Most pathology departments in the country have pathologists who report more than one specialty, including many of us in Leeds, so it also does not make sense on a practical level to be doing some of your work digitally and some not.  As a result of scanning all slides, we are building up a complete digital archive of reported cases rather than just a subset of cases, which will be of huge benefit in the years to come when reviewing past cases. It is also of huge benefit for trainee pathologists now as they can review large numbers of cases across all disciplines in preparation for their exams. The cons are that it obviously takes up more laboratory staff time if scanning all slides than if just scanning, say 20% of slides. However, this time cost will hopefully even out in the years to come with the reduced requirement for the lab to be retrieving  archived slides for us from files.

JT – Bethany, turning your thoughts to the digitization process which you’ve been intimately involved with yourself, perhaps you could tell us what recommendations and advice you would have for a laboratory team who are setting out to embark on the path to digital pathology.

BW – Number one, do your research and don’t try and reinvent the wheel. There are lots and lots of resources out there for you to look at like the Leeds Guides to Digital Pathology, Volumes 1 and 2, for example. None of these materials are pretending to present a perfect solution or a perfect way of deploying digital but reading accounts from other institutions can really give you a taste of some of the challenges that you’re going to be putting yourself up against. I would encourage you to have a look at as many of those resources as possible and glean what you can from them.

JT – Becky, I imagine that this type of innovation can also bring with it some trepidation for the clinicians. Is there any advice that you would give to those labs that are not yet convinced that digital pathology should replace the microscope?

RMS – Adopting digital pathology in a laboratory constitutes a major change to pathways and workflows that have been in place for decades. It does, however, bring major advantages not just to the reporting pathologist, but also ultimately to the pathology laboratory, the multidisciplinary teams (MDT) and our patients. It is well worth the short-term pain for the longer-term gains.

JT – And as a follow-on question for you Becky, I wonder how you as a pathologist have handled what is a huge transition of going one hundred percent digital? There must have been quite an adjustment period, and I wonder if there was a point when you knew for certain that you would never go back to the microscope.

RMS – Despite being the pilot group in the department for transitioning to digital pathology and therefore having to deal with more challenges than others that have followed, it was still apparent quite early in the process that this was going to be a change that brought many advantages and was going to replace the use of the light microscope permanently.

JT – Dal, we can certainly say that the recent pandemic has been a major driver of digitization in pathology. How would you say Covid has impacted operations at NPIC?

DB – I think that in all programs, particularly those that are trying to drive transformational change, there has been a significant impact. For us, the pandemic impacted our original aims, our plans, and the deployment. From a research point there’s certainly been a drive to accelerate the plans and we’ve experienced an uptake locally in terms of going digital, even if it is just supporting home remote working versus getting connected and involved in the laboratory.  We have also seen that, because of needing to keep up with the pace and the demand of the industry, we have increased resources, and appointed more staff.  Our team, since lockdown, has certainly expanded or perhaps tripled from where we were before lockdown.

We now have a significantly stronger workforce that are supporting both digital pathology deployment and research. This has meant that what may have been a plan for about the next five to seven years has been compressed and everybody’s wanting the solution here and now. We’ve obviously been working to best manage those demands and expectations. It’s also meant we have a new opportunity, more than just a challenge, because it has meant that each of these new sites has become interested in going digital and now lends itself to the opportunity of becoming part our national solution. Our funding to support 20 to 30 hospitals, a larger footprint, will mean many hospitals will benefit and be further on with their digital journey.

As a result (and I’d say it probably is linked), there has also been a drive to secure funding in other regions for them to go digital.  We have received a growing number of enquiries from sites and programs wanting to be a part of NPIC. It’s been, and still is, very much non-stop work, as we have been through multiple lockdowns and recovery phases.

JT – So how many people are on the NPIC team now?

DB – We keep counting. We are in the realms of 30 to 40 or so that are one hundred percent dedicated to NPIC but that’s just on the program itself. We have over 30 partners across academia, Industry, and other NHS sites as part of the consortium. As a result of the funding, each of those partner organizations has also appointed staff to meet demands and to support its own program so the NPIC workforce is somewhat significant.

JT –Obviously, you’ve mentioned already that NPIC has now expanded quite dramatically beyond its base in Yorkshire and the north of England. I’m guessing that wasn’t just a COVID story. How did you go from being a single site to a national network?

DB – We were fortunate in that NPIC at Leeds was already established and considered to be world-leading. Historically, that was strengthened by the Leeds-Leica Biosystems partnership and from then on, Leeds became world-renowned as the place to visit when you were even thinking about going on a digital journey.

You would come and speak to my colleagues and the NPIC team first, so that naturally evolved and made it easier to have those discussions at a higher level (even at a government level), and for us to say that there needs to be more significant investment in digital pathology right now, to future proof against an increase in cancer wait times and targets. Obviously, this occurred before COVID and was already a part of the NHS’s long-term plans, back then we were already on a track to future-proof digital pathology.

We were also one of five Centres of Excellence funded by the Industrial Strategy Challenge Fund. That meant, when there was an opportunity and a dialogue with funders about where they wanted to consider a further 50-million-pound initiative for funding investment, which put us in a very good place to apply for that funding. And it was a unique opportunity, because, as you can imagine, we were already on a trajectory to deploy digital pathology across the North of England.  Now, in parallel, we would have this opportunity to scale up our ambitions and to secure further funding. This funding has driven a change in our description from Northern to National, making us not just the largest regional deployer of digital pathology, but also the largest deployer of digital pathology in the country, if not world.

We obviously had a significant number of partners and we have had the opportunity to support the modernization of laboratories in 20 to 30 hospitals. Also, we have now aligned with the Great Ormond Street Hospital and the Royal National Orthopaedic Hospital. By coincidence, we had already established two national networks with those units, in line with the work that they were doing with Genomics England (i.e., analysing sequenced genomes for the NHS and then equips researchers to use data to help find the cause of disease). In some ways, we piggybacked onto those existing relationships to support those hospitals and the hospitals in their networks on their digital journey. By default, which has meant that we can now provide not just digital pathology, but also increased scanning capacity aligning with the national genomics plans.

JT – Bethany, turning to you again. During this conversation, we’re hearing that Leeds has become a major hub not just for the expansion of the technology nationally, but also internationally. I know we mentioned your Leeds guides to pathology earlier on, so, could you tell us something about the genesis of that idea and perhaps about the message that you look to impart by creating these guides and making them available globally?

BW – Yes, of course. I think this is one of the most exciting parts of my work over the last few years. I very much see these Leeds guides as my second and third children I’d say. So, right from the very start, we made it our self-appointed mission, here at Leeds, to try and make digital pathology mainstream, and palatable for general pathologists, and all those working in laboratories delivering pathology services. I’d characterize my research work over the last few years as some of the least glamorous topics you could possibly be looking at. There’s nothing that’s ever going to make the front page of Nature, but lots and lots of really, really, important pragmatic questions about how we can safely and effectively deploy digital pathology in busy clinical settings.

Questions like, where should I put the scanners in my laboratory? How can I train a pathologist to accurately review and screen samples digitally? And more questions like that. So, we started out by running these workshops as we were scaling up our own deployment. We would invite people from around the world to come along and attend; to come and see the laboratory, see the scanners in action, and talk with some of our pathologists that were using digital in their work. They were able to learn a little bit about our approach to training and validation and understand some of the practicalities of deploying the infrastructure necessary for digitization.

Although these events were successful, and it was great to see people face to face, we still thought that we needed to spread that message a bit further. So, we were very fortunate to have the support of Leica Biosystems in creating the original Leeds Guide to Digital Pathology. This included everything which we considered would really help laboratories that were making their first steps towards digital. That included some of our validation protocols, considerations when you’re trying to choose a scanner, and the considerations for workflow. That guide has been phenomenally successful. I think it’s now been translated into 10, 11 or 12 different languages. Everywhere I go now, when I try and force volume 1 of the guide on people, they say, “we’ve already got it!”

We were very lucky to be able to go ahead this year and come out with volume 2 of the Leeds Guide. That is an expansion where we try to bring everybody up to date with what’s been going on at Leeds since the 100% digitisation. We also include the latest information on the regional and national projects, some of the AI work, and a discussion of some of the more pressing topics of the day like remote reporting using digital pathology, multi-site networking, and some of the developments in artificial intelligence and image analysis. What’s nice is that we’ve been able to pull out some of the individual stories around different members of our team; our biomedical scientists, some of our pathologists, and some of our NPIC team members. This also includes some of our surgeons and clinicians at the Leeds teaching hospitals, just to find a little bit more about their experiences with using and deploying digital, and how that’s changed patient services at Leeds. I just can’t emphasize how excited I am that we’re able to share this information with everybody now. It’s been a team effort from NPIC and it’s a lovely document.

JT – That’s fantastic! Do you make the guides available for free?

BW – Yes, we have worked in partnership with Leica Biosystems to offer complimentary guides. I think it’s particularly important in a field like digital pathology where everyone around the world is trying to do the best they can with the resources available. I think it’s crucial that those that are moving ahead with digitization share their experiences; and I mean the successes, as well as the failures.

JT – Thank you. I have just one final question for each of our experts. Perhaps you could tell me briefly and from your own perspective what are, in your opinion, the true realized benefits of digital pathology? Bethany, we’ll start with you.

BW – Well, I think I’d like to emphasize the amazing impact that digital pathology has had on education in pathology. If you think about the difficulties that many departments had during the recent COVID-19 pandemic, it was not just in continuing to provide clinical services, but in continuing to train and educate the next generation of pathologists. We were extremely fortunate that we’d already deployed digital at Leeds, our consultants were able to continue to deliver teaching, and that they were able to provide feedback to trainees using screen-sharing technology and digital slides. That is something that they wouldn’t be able to replicate using the old double-headed microscope which was the staple of my own training. So, digital pathology has really helped to level the playing field for training in allowing all trainees, regardless of whether they were shielding at home, looking after their children, or coming into the department, the ability to access high-quality training materials and get live feedback from their trainers.

The other big benefit would be the ease with which our trainees and consultants are now able to initiate and conduct research and audit projects. After just a few searches of the archive, you can instantly draw together hundreds of relevant, high-quality clinical images in a digital archive if you’re setting up, for example, a breast cancer or a lymphoma project. Often, the most laborious part of any pathology audit or research project, as a trainee, used to be to go down to the basement, pull out all the glass, and try to find which slides were still there. Now, you can access all that material instantly.

JT – Well, that sounds like an epitaph for the microscope. Dal, same question to you, what are the realized benefits of digital pathology from your perspective in operations at NPIC?

DB – I think it must be about being a part of something that will impact and benefit patients. Obviously, digital pathology, is allowing easier access to data, enabling the sharing of images within a hospital and across different hospital sites. It also enables that accessibility and the sharing of images amongst clinicians in multi-disciplinary team meetings. For example, as part of supporting the paediatric network, we hear cases where there are a few specialists in the country. Historically, that has meant the glass slides being shipped to another hospital and now just by having digital pathology available, one clinician can share that case with one or multiple colleagues to gain a second opinion.

Although patients might not be seeing that direct impact, digital pathology very much supports their journey in terms of enabling access to digital pathology and AI, and accelerating participation of patients into some of the larger scale research projects. For example, it is a bit of a postcode lottery having accessibility to some of these research projects and clinical trials. We’ve been fortunate at NPIC that we already support several hospital sites, so it makes it quite easy for us to work with colleagues across the country. If we are speaking to, a potential AI developer to see what benefits a particular technology will bring to their patient population or cohort, we can broker a collaboration and even facilitate a multi-site study.

Also, at NPIC, the leadership team have established a ‘patient public’ advisory group, which allows us to bring patients into some of the discussions on the research projects and provides an environment to create those opportunities together.

JT – Thank you Dal! Becky, turning to you with that same final question. what are your own views, as a consultant pathologist, on the realized benefits of digital pathology?

RBS – From the point of view of a reporting pathologist, there are many benefits that are already realized. I have found that I am significantly quicker reporting cases (biopsies and excisions) using a digital system rather than glass slides and a light microscope, mainly due to the speed in which you can move from slide to slide and the ease in which you can make measurement. I also find it ergonomically more comfortable so I can manage longer reporting periods. I have instantaneous access to previous cases and no longer wait for a few days waiting for a biopsy slide to be retrieved from file if I need to review it when reporting the corresponding excision. It is much more convenient to get interdepartmental second opinions on cases and review of cases for MDT meetings no longer requires tracking down glass slides from various offices and desks.

JT – Well thank you Becky. That brings us to the end of our discussion on the on the challenges and realized benefits of Digital Pathology I’d like to thank our three experts today, Bethany Williams, Daljeet Bansal, and Rebecca Millican-Slater, for their time and to say how much I’ve enjoyed speaking with you. It’s clear that the Leeds and NPIC team are at the forefront of innovation in Pathology, driving excellence in digital processes and lighting the road to digital pathology for scores of labs around the world. We look forward to hearing much more from this exciting group in the future.

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