Closing the Gap

Closing the Gap

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Head and neck cancer and the role of the pathologist

Head and neck cancer and the role of the pathologist

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The treatment of head and neck cancers can have devastating effects on the way a person eats, speaks, swallows or the way they see and hear. So, what causes them and what role does the pathologist have in the treatment process?

The news that one of Australia’s most beloved per­form­ers, John Farn­ham, had under­gone surgery in August 2022 to remove a can­cer­ous tumour in his mouth brought head and neck can­cers into the pub­lic spot­light like nev­er before.

Pro­fes­sor Ruta Gup­ta sat down with RCPA Pres­i­dent Dr Lawrie Bott to dis­cuss the role of the pathol­o­gist in head and neck can­cers for an episode of the College’s pod­cast series, “The Pathol­o­gists Cut”.

Prof Gup­ta holds many posi­tions, includ­ing as senior staff spe­cial­ist at NSW Health Pathology’s Roy­al Prince Alfred Hos­pi­tal Lab­o­ra­to­ry, and as lead pathol­o­gist with the Head and Neck Oncol­o­gy and Thy­roid Mul­ti­dis­ci­pli­nary team at Chris O’Brien Life­house Can­cer Centre.

“Because of the area of the body that head and neck can­cers affect, they can have very sig­nif­i­cant effects on the way a per­son eats or speaks, the way they swal­low or the way they see and hear. Head and neck can­cers are a very diverse range of can­cers caused by a vari­ety of rea­sons and risk fac­tors, which are all grouped togeth­er because of their loca­tion on the body,” she said.

“Tra­di­tion­al­ly, the most fre­quent cause of head and neck can­cer is smok­ing and drink­ing alco­hol. How­ev­er, in Aus­tralia, the rate of smok­ing is going down which means that we are see­ing a decline in smok­ing asso­ci­at­ed head and neck cancers.

“Cur­rent­ly, we are see­ing an increase in head and neck can­cers caused by virus­es such as human papil­lo­mavirus (HPV), which caus­es can­cer of the orophar­ynx, or Epstein Barr Virus (EBV), which caus­es nasopha­ryn­geal cancer.

“Head and neck can­cers asso­ci­at­ed with smok­ing or alco­hol are gen­er­al­ly seen in old­er peo­ple and are much more com­mon in men who have had a life­time habit with alco­hol or smoking.

“On the oth­er hand, head and neck can­cers caused by virus­es tend to occur in much younger people.

“These patients tend to be in their ear­ly 40s to mid 50s and gen­er­al­ly do not have life­time expo­sure to tobac­co. More recent­ly, we are also see­ing mouth can­cers in young women, the rea­sons for which we don’t know cur­rent­ly,” said Prof Gupta.

HPV is a com­mon virus that affects both males and females and there are more than 100 strains of HPV.

Most types of HPV are harm­less, do not cause any symp­toms, and go away on their own.

A small pro­por­tion of peo­ple, both men and women, will not clear HPV from their sys­tems – these peo­ple are at high­er risk of devel­op­ing can­cers, either of the head and neck, or in the case of women, can­cer of the cervix.

“Because head and neck can­cers that arise from HPV are gen­er­al­ly hid­den in the fold of the ton­sils or right at the back of the throat, they can be very dif­fi­cult to see. Sur­geons will use an endo­scope to look and take biop­sies from the ton­sils or the back of the tongue. These biop­sies are then sent to the pathol­o­gist who will look under the micro­scope and make a can­cer diag­no­sis. If can­cer is present, there are cer­tain tests we can do to see if it is relat­ed to HPV,” said Prof Gupta.

“Once a diag­no­sis of can­cer is made, the patient then under­goes surgery. For head and neck can­cer this is not just the removal of tis­sue with can­cer. It is not just tak­ing out the tongue, the jaw, or the ton­sils, we also need to take out lymph glands from the patient’s neck.

“These are big sur­gi­cal pro­ce­dures and can require ICU care and long hos­pi­tal admis­sions whilst the patient recov­ers. The diag­no­sis of head and neck can­cer is a crit­i­cal step to start the patient’s can­cer journey.

“The pathol­o­gists exam­ine the tis­sues removed dur­ing surgery to deter­mine whether all of the can­cer was removed or whether micro­scop­ic amounts is left behind or whether the can­cer has invad­ed blood ves­sels and nerves. If this has hap­pened addi­tion­al treat­ment with radio­ther­a­py or chemother­a­py may be need­ed. Thus, it is the pathol­o­gist that informs every step of a patient’s can­cer man­age­ment,” said Prof Gupta.

You can lis­ten to Prof Gupta’s pod­cast episode here: https://www.rcpa.edu.au/Library/Publications/The-Pathologists-Cut-Podcast

Genetic detectives on the case

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NSW Health Pathology is a national leader in genome sequencing and its expertise came to the fore during the COVID-19 pandemic. Within two weeks our Westmead laboratory had developed an in-house whole genome sequencing process for the COVID-19 virus.

When the coro­n­avirus SARS-CoV­‑2 first land­ed on Aus­tralian shores in Jan­u­ary 2020, it car­ried with it a genet­ic passport.

Each case of the virus had its own pass­port with a genet­ic stamp show­ing how the nucleotides inside it were ordered.

As with many virus­es, as SARS-CoV­‑2 spread it evolved and mutat­ed, chang­ing the type and order­ing of these nucleotides ever so slightly.

This may sound sin­is­ter, but it is in fact a very use­ful development.

Under­stand­ing how the virus was spread­ing was going to be key to its con­tain­ment. Pro­fes­sor Vitali Sintchenko, lead pathol­o­gist for the Micro­bial Genomics Lab­o­ra­to­ry at NSW Health Pathology’s ICPMR-West­mead, describes nucleotides with­in an RNA genome as the build­ing blocks of a virus.

“In order to under­stand trans­mis­sion path­ways of the pathogen, you must first under­stand the order of these build­ing blocks. You can then iden­ti­fy any pres­ence or absence of changes in the build­ing blocks,” Prof Sintchenko said.

“With whole genome sequenc­ing we cap­ture the sequence of these build­ing blocks very accu­rate­ly and we employ com­plex instru­ments to do it quick­ly and in high volumes.

“Rapid sequenc­ing tech­niques allow us to gain a whole genome wide view of the pathogen very quick­ly and pre­dict or under­stand behav­iours of the virus.

“When we look at nucleotides, we can iden­ti­fy with high accu­ra­cy any vari­ance with­in the virus genet­ic sequence.

“We com­pare virus­es from patients at dif­fer­ent stages of the dis­ease or with a dif­fer­ent his­to­ry of dis­ease and look for poten­tial rela­tion­ships between cases.

“From this we can infer, from genom­ic data, poten­tial trans­mis­sion pat­terns or path­ways that can help track how it has spread through a com­mu­ni­ty and beyond,” Prof Sintchenko said.

Through whole genome sequenc­ing, experts can match new cas­es to clus­ters, or iden­ti­fy the ori­gin of, and rela­tion­ships between COVID-19 cas­es, pro­vid­ing a deep­er under­stand­ing of the spread of the disease.

Whole genome sequenc­ing offers anoth­er line of evi­dence to sup­port con­tact trac­ing by fill­ing in gaps where peo­ple have not or can­not pro­vide all nec­es­sary details to help trace the source.

With­in two weeks NSW Heath Pathology’s West­mead lab­o­ra­to­ry had devel­oped an in-house whole genome sequenc­ing process for the COVID-19 virus, in col­lab­o­ra­tion with aca­d­e­mics from the Uni­ver­si­ty of Syd­ney, soon fol­lowed by NSW Health Pathology’s lab­o­ra­to­ries at Randwick.

In eight months, the team at West­mead suc­cess­ful­ly sequenced more than 1,000 cas­es and dis­cov­ered 51 genom­ic clusters.

Sequences are also uploaded to an inter­na­tion­al virus sequence data­base to assist epi­demi­ol­o­gists and researchers around the world.

Prof Sintchenko says the appli­ca­tion of whole genome sequenc­ing to the inves­ti­ga­tion of COVID-19 has been trans­for­ma­tion­al and the num­ber of genomes uploaded to the inter­na­tion­al data­base has been unprecedented.

“NSW Health Pathol­o­gy is a nation­al leader in genome sequenc­ing, and we have made a sig­nif­i­cant con­tri­bu­tion to data shar­ing to inter­na­tion­al research teams,” Prof Sintchenko said.

“We have very well-devel­oped trans­la­tion­al research col­lab­o­ra­tion between clin­i­cians, sci­en­tists and researchers that has enabled us to achieve what we have in a very short timeframe.”

NSW Health Pathol­o­gy con­tin­ues to work close­ly with Health Pro­tec­tion NSW, pro­vid­ing whole genome sequenc­ing data and report­ing to sup­port their cen­tralised con­tact trac­ing and epi­demi­ol­o­gy teams.

This work is crit­i­cal to iden­ti­fy peo­ple at risk of COVID-19 and min­imise fur­ther spread of the virus in the com­mu­ni­ty and among the most vulnerable.

“The evo­lu­tion and spread of the virus around the globe and in Aus­tralia is fas­ci­nat­ing but com­plex,” Prof Sintchenko said.

“It is like detec­tive work, and we are part of the NSW Health COVID-19 response team.”

Culturally safe and sensitive care when life’s journey ends

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First Nations people are over-represented in the coronial system and NSW Health Pathology’s Forensic Medicine Service is working in partnership with the Aboriginal community to ensure all deceased persons are given the respect, dignity and care they deserve.

The Foren­sic Med­i­cine ser­vice is com­mit­ted to pro­vid­ing cul­tur­al­ly safe and sen­si­tive sup­port for Abo­rig­i­nal and Tor­res Strait Islander fam­i­lies whose loved ones have been referred to the Coro­ner fol­low­ing an unex­pect­ed or unex­plained death.

Recent­ly, the ser­vice wel­comed Abo­rig­i­nal Liai­son Offi­cers from Local Health Dis­tricts across NSW to its New­cas­tle facil­i­ty for an after­noon of lis­ten­ing and sharing.

Senior Foren­sic Med­i­cine Social Work­er Dan­ny Nugus said it was an oppor­tu­ni­ty to show how the ser­vice oper­ates and its com­mit­ment to sup­port­ing the Indige­nous community.

“The Foren­sic Med­i­cine ser­vice is acute­ly aware of the over­rep­re­sen­ta­tion of First Nations peo­ple in the coro­nial sys­tem as a result of the impacts of coloni­sa­tion and inter­gen­er­a­tional grief, loss and trau­ma,” said Mr Nugus.

“Dis­tress­ing­ly, many of these fam­i­lies encounter the coro­nial process and our ser­vice mul­ti­ple times.

“Much is mis­un­der­stood about the coro­nial refer­ral and post-mortem process, par­tic­u­lar­ly in region­al areas.

“Work­ing in part­ner­ship with com­mu­ni­ty and part­ner agen­cies can help demys­ti­fy the work of the Foren­sic Med­i­cine Ser­vice and the organ­i­sa­tion wel­comes oppor­tu­ni­ties to talk about how respect, dig­ni­ty and care for deceased per­sons, and their fam­i­lies, is cen­tral to every­thing that they do at Foren­sic Medicine.

“Cul­tur­al­ly com­pe­tent prac­tice and build­ing rela­tion­ships is at the heart of rec­on­cil­i­a­tion and that there can nev­er be a ‘one-size fits all’ approach.

“By ask­ing peo­ple what their needs are – indi­vid­u­al­ly, cul­tur­al­ly, spir­i­tu­al­ly, as a fam­i­ly, and as a com­mu­ni­ty – we can do their best to be responsive.

“For exam­ple, we will sup­port a family’s request for a view­ing, mem­o­ry col­la­tion such as hand prints, a smok­ing cer­e­mo­ny, or oth­er cul­tur­al rit­u­als includ­ing paint­ing,” he said.

The ser­vice also sup­ports the leav­ing of arte­facts such as pho­tographs, ani­mal skins, clap sticks or gum leaves with a deceased per­son who is in the care of Foren­sic Medicine.

Dur­ing the recent vis­it, staff were hum­bled to hear one of the Abo­rig­i­nal Liai­son Offi­cer col­leagues say, ‘I’m going to tell my fam­i­lies they don’t need to be afraid. Every­one here is kind and will take good care of your loved ones’.

‘Path in Boots’ clinic delivering care to remote communities

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An award-winning project in northern NSW is delivering truly connected care and helping to close the gap for remote Indigenous communities. The mobile diabetes clinic, known as ‘Path in Boots’, takes pathology staff, GPs, Aboriginal health workers, dietitians and other allied health workers directly into the communities they are serving.

A mul­ti­dis­ci­pli­nary dia­betes clin­ic for Abo­rig­i­nal peo­ple has been on the road and deliv­er­ing care direct to patients in north­ern NSW since 2005.

Sci­en­tif­ic staff from NSW Health Pathology’s Lis­more Lab­o­ra­to­ry, Karen Kennedy, Steve Alvarez and Trish Law, are part of the Goorie Dia­betes Com­pli­ca­tion Assess­ment Clin­ics, tar­get­ing Abo­rig­i­nal clients aged 15 and over who have Type 2 Diabetes.

Rather than get patients from dis­tant Abo­rig­i­nal com­mu­ni­ties to come to Lis­more, a team of health pro­fes­sion­als trav­el to them.

They pack a ‘mobile lab’ of equip­ment into the boot of a car, referred to as ‘Path in Boots’.

The team returns to the same Abo­rig­i­nal com­mu­ni­ties reg­u­lar­ly to build rap­port and trust.

“The main thing with this ser­vice is the clients get every­thing all in one day,” said team mem­ber and senior hos­pi­tal sci­en­tist, Karen Kennedy.

“There are pathol­o­gy staff, a physi­cian, gen­er­al prac­ti­tion­er, dia­bet­ic edu­ca­tor, dietit­ian, phar­ma­cist, podi­a­trist, renal nurse, exer­cise phys­i­ol­o­gist as well as Abo­rig­i­nal health workers.

“We’re pret­ty com­mit­ted. We go on the road every month, although we have missed a few trips due to COVID and bush­fires in recent years.”

The mobile lab is just the first stop for patients attend­ing the clinics.

They give a urine sam­ple and have their bloods col­lect­ed and with­in 20 min­utes, get their results which they take with them in a fold­er to see the oth­er health work­ers who pro­vide lifestyle, diet and med­ica­tion advice.

When the clin­ics fin­ish, our staff join the oth­er health work­ers in case con­fer­ences ensur­ing patients receive the high­est lev­el of indi­vid­ual atten­tion and care.

The team won the 2020 NSW Health Pathol­o­gy Staff Award for Deliv­er­ing Tru­ly Con­nect­ed Care.

The ini­tia­tive is a past win­ner of the NSW Health Abo­rig­i­nal Health Awards for Excel­lence in Ser­vice Deliv­ery as a team.

A fond farewell to pathology after 48 years

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A successful career in pathology came to an end recently for Shan Tredinnick, a hospital scientist at NSW Health Pathology’s Orange Laboratory. She has retired after 48 years in the health sector, including 35 years with NSWHP, leaving a lasting legacy for those she has helped to train over the decades.

After 48 years work­ing in the health sec­tor, hos­pi­tal sci­en­tist Shan Tredin­nick has hung up her lab coat and cel­e­brat­ed her retire­ment with col­leagues at NSW Health Pathology’s Orange Laboratory.

She began her career at Orange Base Hos­pi­tal in Cen­tral West NSW in 1974.

Shan says she did­n’t real­ly know what the job would be but loved it from the moment she set foot in the laboratory.

Over the years, she has worked in the pri­vate sec­tor in var­i­ous loca­tions, Shoal­haven Dis­trict Hos­pi­tal in Nowra, Grif­fith, Bathurst and then return­ing to Orange where she has worked for the last 12 years.

As a mul­ti-skilled sci­en­tist, Shan has worked in all depart­ments from Haema­tol­ogy to Chem­istry, Trans­fu­sion, and Microbiology.

“In lat­er years my pas­sion was Haema­tol­ogy Mor­phol­o­gy,” she said.

“I loved train­ing mem­bers of staff in the review of blood films.

“It gave me great sat­is­fac­tion to see my staff grow in con­fi­dence as they improved their skills.”

She also served as chair­per­son of the South West divi­sion of the Aus­tralian Insti­tute of Med­ical and Clin­i­cal Sci­en­tists (AIMS) from 2004 to 2016, coor­di­nat­ing con­fer­ences each year and net­work­ing with com­pa­nies, speak­ers and lab staff from across NSW.

Shan is now hop­ing to find time to trav­el, get back to the gym and swim­ming pool, and indulge in crafts like lead­light­ing, knit­ting, sewing, and quilting.

We wish her all the best for her retirement!

Forensic Medical Imaging

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The role of CT scanning in helping to determine cause of death.

Images pro­duced by CT scan­ners pro­vide valu­able sup­port to Foren­sic Pathol­o­gists as they inves­ti­gate the clin­i­cal caus­es of deaths referred to the NSW Coroner.

Under the NSW Coro­ners Act, post-mortem exam­i­na­tions must be con­duct­ed using the least inva­sive meth­ods and the work of foren­sic radi­og­ra­phers and radi­ol­o­gists may, in some cas­es, reveal the cause of death with­out the need for more inva­sive procedures.

In this video, foren­sic pathol­o­gist Dr Allan Cala and foren­sic radi­og­ra­ph­er Tony Bux­ton dis­cuss the val­ue of CT scan­ning for foren­sic medicine.

#foren­sicmedi­cial­imag­ing #foren­sicmed­i­cine #CTscan #post­morte­mex­am­i­na­tion

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NSW Health Pathology acknowledges the Traditional Custodians of the land across NSW whose cultures and customs have nurtured and continue to nurture this land. We would like to pay our respects to the Elders past, present and emerging, for they hold the memories, the traditions, the culture and hopes of Aboriginal and Torres Strait Islander peoples across the state.

Aboriginal Workforce Development Closing the Gap

NSW Health Pathology acknowledges the Traditional Custodians of the land across NSW whose cultures and customs have nurtured and continue to nurture this land. We would like to pay our respects to the Elders past, present and emerging, for they hold the memories, the traditions, the culture and hopes of Aboriginal and Torres Strait Islander peoples across the state.

Aboriginal Workforce Development Closing the Gap
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