{"id":7362,"date":"2019-11-14T12:47:26","date_gmt":"2019-11-14T12:47:26","guid":{"rendered":"https:\/\/mybreastmyhealth.com\/?post_type=podcasts&#038;p=7362"},"modified":"2021-08-11T15:39:27","modified_gmt":"2021-08-11T15:39:27","slug":"s1-ep3-breast-cancer-pathology-results","status":"publish","type":"podcasts","link":"https:\/\/mybreastmyhealth.com\/podcasts\/s1-ep3-breast-cancer-pathology-results\/","title":{"rendered":"S1 Ep3: Breast cancer pathology results"},"content":{"rendered":"<p><script src=\"https:\/\/www.buzzsprout.com\/686513\/1925180-breast-cancer-pathology-results.js?player=small\" type=\"text\/javascript\" charset=\"utf-8\"><\/script><\/p>\n\n\n\n<p>If you have been diagnosed with breast cancer, the treatment that has been planned for you almost certainly will be based on a breast cancer pathology report. This would have been produced by a pathologist, who analyses the breast specimen and subject it to different kinds of complex processes, before looking at it through the lens of a microscope.<\/p>\n\n\n\n<p>In this episode, I interview Dr Peter Davis, who is a consultant in breast pathology. <\/p>\n\n\n\n<p>During this conversation, we dissect and unpick the processes that take place from the moment a piece of breast tissue is taken, all the way to the various steps that are needed that allow the specimen to be examined underneath the microscope. The complexity of the process was certainly evident and in this episode, you will find out exactly what it involves.<\/p>\n\n\n\n<p><\/p>\n\n\n\n<p class=\"has-medium-font-size\"><strong>WHAT WILL YOU LEARN?<\/strong><\/p>\n\n\n\n<ul><li>What is the role of a breast pathologist?<\/li><li>How is a breast specimen transported to the lab?<\/li><li>What happens to it when it arrives in the lab? <\/li><li>Why do you embed it in a block of wax?<\/li><li>How does the staining process of specimens help oncologist?<\/li><li>What does cancer look like underneath a microscope?<\/li><li>What does the grading of cancer mean?<\/li><li>What is the difference between invasive cancer and insitu cancer?<\/li><li>How can you tell if breast cancer is ductal or lobular?<\/li><li>What are ER \/ PR and Her2 receptors?<\/li><li>The role of artificial intelligence (AI) in breast cancer pathology<\/li><\/ul>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<h1 class=\"wp-block-heading\">Transcript #003<\/h1>\n\n\n\n<p><em>Note: transcription of episodes are generated using a combination of speech recognition software and human efforts, and as such may contain errors.<\/em><\/p>\n\n\n\n<p><strong>Tasha Gandamihardja<\/strong><br>Welcome to the My Breast My Health podcast. My name is Tasha Gandamihardja, and I\u2019m a breast cancer surgeon with over a decade\u2019s worth of experience. I created this podcast as a place where those who have been affected by breast cancer can connect with each other, share experiences, and learn from each other\u2019s life stories. I will also have conversations with experts in the field of medicine, as well as the health and wellness space. So if you want to learn more about this topic, then this is the place to be. The aim of this podcast is simple, to create a community where everyone feels empowered to help each other and support one another. This is because I truly believe that together we are stronger. I\u2019m really happy to spend this time with you, so let\u2019s start building community.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Hi, and welcome to the podcast. Thank you so much for being here today. If you already subscribed to the show, thank you so much. I\u2019m really, really grateful. And if you\u2019re here for the first time, then make sure you subscribe to the show because that way, you won\u2019t miss any of the future episodes.<\/p>\n\n\n\n<p>Today I\u2019ll be talking to Dr. Peter Davis, who is a breast pathologist. The role of a pathologist is extremely vital in the diagnosis of breast cancer. Have you ever thought how a breast cancer diagnosis is made just by taking a biopsy or sample of breast tissue? You\u2019d be forgiven to think that it simply involves taking the specimen and looking at it down a microscope. In fact, the whole process is actually a little bit more complicated than that. In this conversation, we explore in more detail what happens when the specimen arrives in his lab. The complex steps that need to be taken before that piece of breast tissue is ready to be inspected by him through the lens of a microscope. It was an absolutely fascinating conversation and one that highlights the amount of work that takes place behind the scenes, which we don\u2019t always appreciate. I hope you enjoyed this episode as much as I did interviewing Dr. Peter Davis.<\/p>\n\n\n\n<p>Hi, Peter.<\/p>\n\n\n\n<p><strong>Peter Davis<\/strong><br>Hello, there.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Thank you so much for coming on to the podcast today.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Pleasure.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>You are a consultant pathologist.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>That\u2019s right. Yeah.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>For those who don\u2019t know what a pathologist does, could you explain to us what it is that you do?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Okay, so I\u2019m a doctor medically trained just like all of the doctors. So I have the same training as as other kinds of doctor and then I disappear off into pathology training, which after coming out of medical school is probably a sort of three years of junior doctorship and then another six years of training in histopathology then continually learning as you go along, basically. But what we do is we are particular kinds of pathologists who study disease by looking at tissue, and cells. And there are lots different kinds of pathologists. microbiologist look at infection, haematologist look at blood,<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>We look at tissue and by looking at it down the microscope, we work out what\u2019s going on in a patient\u2019s body. We do that through small samples that might be taken through a narrow needle, or sometimes a punch biopsy from the skin and then also in bigger surgical specimens. And the idea is that we look at tissue, examine it with the naked eye, dissect a specimen, if it\u2019s a big specimen and turn that into something that we can look at down a microscope. And from that, we aim to work out, in essence, what the diagnosis is, and what does it mean. And the what does it mean bit is something that we spend an awful lot more time doing these days. In the past, pathology reports will be quite simple things..<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right now they\u2019re they\u2019re complicated.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Now they\u2019re much more complicated and takes a lot more time. And what we\u2019re trying to do is we\u2019re trying to work out, what is the likely prognosis? What can we tell oncologists and surgeons about what they\u2019ve done? Is a tumour, for example, completely out, does the surgeon need to go back and take a bit more tissue maybe. Does the tumour have features that make it more aggressive? And how likely is the tumour to recur? Increasingly oncologists want to know what sorts of factors there are in a tumour that will guide how it\u2019s likely to respond both to traditional drugs, that they\u2019ve always used \u2026.. chemotherapy, and then some newer agents that are coming online now,<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right. So you play an extremely important role not only in the diagnosis of a disease, and that is essentially anything where a tissue specimen and has been taken from the patient because that is the thing that we send to you for analysis. But also you help us formulate a best treatment plan for the patient because you tell us exactly what we\u2019re dealing with, which will, in turn, help us decide how to treat them. Is that correct?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>That\u2019s right.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So let\u2019s have a scenario. A patient comes to the breast clinic, and they will get assessed they\u2019ll get clinically assess. So in a triple assessment clinic, they get clinically assessed, they have a lump or they have an area of abnormality in the breast which we want to investigate further. So we do a biopsy. This specimen is then put into formalin and sent to the lab. So you can tell me why we need to put that in formalin\u2026 but also, if a patient has a cancer, which we remove in surgery, as you said before, that surgical specimen is then also sent to the lab to you to to look at. Whether that\u2019s a lumpectomy or if it\u2019s a breast, having had a mastectomy all of whatever it is that was removed from a patient was sent to you. What happens to that specimen when it arrives in your lab?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>So yeah, we receive a specimen in formalin, as you say and formalin sort of rather lightly call it pickling fluid is basically the first thing that it does, is it preserves tissue. It\u2019s not like vinegar, it\u2019s horrible to smell. It gets right up your nose. Yes, it is quite nasty stuff. But what it does do is it very, very quickly preserves that tissue. And what we mean in particular, with relevance to breast cancer with fixation is not just preserving the tissue physically, but also fixing or stopping the turning over of living cells.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>I see.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>And when cells are alive, they divide and they grow. And that\u2019s something that normal tissue does, but obviously that\u2019s something that cancer does a lot. Because one of the problems with cancer is that cells grow too quickly,<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So that one of the definitions of cancer, isn\u2019t it, that it continues to multiply and it doesn\u2019t, it doesn\u2019t die.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Yeah, that\u2019s right. So one of the things that we need to know about cancer is how aggressive it is. And to do that, we give it what we call a grade. And a grade is really a measure if you like a reproducible measure, of how aggressive that tumour is. And one of the things that is its aggressiveness is the speed at which is dividing.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay, so the formalin stops that<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It does, it stops those cells dividing quickly. And why we need that to to happen really quickly is because one of the things we look at down a microscope is a thing called a mitosis. And that\u2019s a thing that a cell does that we can see, which is where the chromosomes are actually dividing, to turn one cell into two. So it really helps us to see how many cells in a tumour or sample of the tumour, have a mitosis in them. If we don\u2019t fix a sample quick enough, a lot of those mitosis continue. And then they become invisible.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Even when it\u2019s outside of that body.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Even outside the body, even outside the body, which is a bit of a thing to get your head around isn\u2019t it? What the formalin does is it actually acts almost like a snapshot.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right, so it just freezes it in time?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>So it just freezes that moment in time.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right<\/p>\n\n\n\n<p>We talked about why we put this specimen in formalin<\/p>\n\n\n\n<p>And then I guess the aim is for you to be able to look at these underneath the microscope.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Yeah.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>And to make them into slides.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>That\u2019s right.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So then what happens to the specimens after you\u2019ve taken the out of the formalin?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Sure. So we get them in the in the lab and if there is a core biopsy a very small core breast tissue that we\u2019ve received, then that\u2019s very simple. We just put that into what we call a cassette, which is like a little holder. And what we need to do is we need to be able to cut off that core into a very thin slice. A little bit like a meat slicer at a supermarket deli counter. But of course, it\u2019s very tiny. So we need to have a way that we can hold it. Because you can\u2019t hold it with your fingers because you cut your finger as well.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right Of course. Yeah.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It\u2019s so what we need to do is we need to find some way of holding that tissue firm. And the way we do it is by solidifying it into a block of wax, paraffin wax.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right, that makes sense. So you embed it into the wax.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>So we embed it into the wax. But what we need to make sure is that the wax doesn\u2019t just surround the tissue, but actually goes all the way through it. Because otherwise when we cut it, the tissue jumps out. It\u2019s like trying to embed something like a like a grape in wax. You need to hold it rather than just surrounding it. So we have to go through a chemical process that dehydrates the tissue, impregnate it with wax, and then by the time that\u2019s happened, tissue has actually been a little bit chemically changed in that it\u2019s still the shape that it was. It\u2019s still microscopically made of the same stuff. But it\u2019s chemically changed. So it\u2019s ready to be cut. So it\u2019s dry enough to cut, thoroughly dehydrated. And then it\u2019s ready to stain. Because if you imagine if you cut a very, very thin slice through something delicate, like human tissue, it\u2019s so thin that it\u2019s almost translucent. You can see through. It\u2019s much thinner than a human hair.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Wow, so you slice them that finely. And how many slices would you get from a biopsy?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Well, we have to be careful, we have to make sure that each slice we can\u2019t add value. Because sometimes we need to do more tests on a piece of tissue than we initially think. Usually, we can get at least 16 or so slices as a piece of tissue. It depends how big the core biopsy is, of course. But usually, we can get enough out to do the work we need to do. And keep some in file for future use just in case we need to. So we cut these very thin slices. And they\u2019re the things that we then slide onto a piece of glass called the slide. And the tissue is so thin that it sticks to the glass. But what we need to do is do a few more things to it before we can actually look at it, we need to stain it in some contrasting colours. So we can see the difference between the various bits of tissue that make up breast. And that often looks like various shades of pink and purple. Yeah, it\u2019s nice. It\u2019s nice is that it\u2019s amazing. Actually, the human body is a fascinating thing. And it\u2019s actually quite a beautiful thing too.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So that\u2019s the H and E stain.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>That\u2019s what we call the H and E, which is haemotoxin and eosin which is just the name of the two kinds of ink we use. And then we put another thin piece of glass over the top to protect it. And that\u2019s the slide.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>And how long does that whole process take?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It takes somewhere between 24 and 48 hours. It depends on the size of the piece of tissue that we\u2019ve received. Because the fixing process with the pickling fluid, the formalin takes a little while to get seep through tissue. If it\u2019s a very thin piece of tissue, like a core biopsy will fix very quickly. If we receive a surgical specimen, a big excision, that\u2019s going to take quite some time to pickle.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>And how can you tell whether it\u2019s ready?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Because it\u2019ll feel solid. And it starts to look before we stain it, of course, it starts to look a kind of a homogenous kind of brownish colour. It looks a bit cooked if you like.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay, so a little bit shrivelled up.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Yeah, it shrivels up.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So it\u2019s in formalin, then you embed it in wax. Then you slice them to very finely, to fine slices and then you stain them. And then you put them on slides and then you look at it anything right underneath the microscope. Yeah. And that\u2019s when everything becomes clear for you.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>This is when the magic happens. Yeah, this is well, the misconception I think about pathology is that we are very clever.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>You are<\/p>\n\n\n\n<p>Thank you very much.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>But we\u2019re very clever. We can look at tissue under the microscope and immediately make a diagnosis.<\/p>\n\n\n\n<p>It\u2019s not quite true. For some diagnoses, it is true. Some diagnoses are very characteristic.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>And very straightforward.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Very straightforward. And I can look at it, I can say, this is a malignant tumour. And this is its name. And this is how it\u2019s likely to behave. But often we\u2019re dealing with things that are precursors to cancer, or even precursors to the precursor. So they may be changes that you see in breast that are not quite normal, but aren\u2019t malignant.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay. So there\u2019s bit more complicated than, you know, that we may think.<\/p>\n\n\n\n<p>So, how can you tell whether a cell or you know, a specimen contains cells that are cancerous?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Well, the earliest changes in the cell that are moving towards cancer are probably things we can\u2019t see. They\u2019re probably mutations, that we have ways to pick up through looking at the genetics of the cell. But in terms of daily diagnosis, that\u2019s too small for us to see. So what we\u2019re looking for is changes in the cell that change what the cell actually looks like. And the way it grows. And breast tissue is made up of a number of different components. There\u2019s a fatty stroma, which is essentially the tissue in the background that makes up the bulk of the breast, which is fat. And then within it, it has tubes, what we call ducts. And it has lobules and lobules are the parts that basically produce the milk that goes through the ducts, that<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>goes through the nipple.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Exactly. There are other elements of tissue within the breast, but those are the basic components. And each one of those can develop benign proliferative processes, which is where they grow too much. And then when that growth becomes uncontrolled that\u2019s when cancer can start.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So when you look at them underneath the microscope, there are, you know, certain characteristics that make up the cell like the nucleus and the cytoplasm. These terms come to haunt me from my medical school days, but you can decide whether a cell is I guess, more active than normal by looking at certain things. Is that right?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>That\u2019s right. So the cells individually can start to look wrong. When a cell is growing too fast, it grows from its nucleus because its nucleus provides it with the instructions to grow or not grow. So nuclei tend to become bigger. And they tend to exhibit disorderly growth, which is one of the characteristics of cancer. So the nucleus starts to look irregular, because it\u2019s no longer growing in a tidy, tidy manner. We talked a little bit about mitosis earlier, and we can start to see more mitosis because the cells are dividing more. So on an individual level, there are characteristics that tells me that the cell is growing out of control.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>And you can look and you can see that underneath the microscope? And it\u2019s quite obvious, isn\u2019t it?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It is, it is. But we also see changes in groups of cells. So normally a group of cells will produce a structure. So they will all be growing because their program to grow to form a duct or they may be cells within a lobule that are programmed by genetics to grow a duct. And when they start to go a bit wrong, you can have too many ducts, for example. Or you can have a duct that has too many cells within its wall. So it starts to expand, and it starts to have too many cells piled on top of each other.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So there is a disorganisation of cellular growth, that becomes quite obvious to see underneath the microscope. So that\u2019s how you can tell the difference between a cancer versus a benign specimen. When we give a diagnosis to patients, you know, it contains lots of terms and words that are quite medical, and can be quite confusing. So I thought it might be a good thing to maybe dissect those terminologies a bit more. The first things that we would say to a patient if they had breast cancer would be the type of breast cancer. So it\u2019ll either be, you know, a ductal carcinoma or lobular carcinoma. What are the commonest types of breast cancer that you see and what you know, what are the other non, the other cancers that are not that obvious and not that common? Because they\u2019re quite many.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Yeah, exactly. Well, the main groups in the traditional sort of anatomical way of looking at this are that there are ductal carcinomas, and those are tumours which are derived from the duct. So if we go from having a normal duct growing normally, as it should be, to too much proliferation within the duct, to uncontrolled proliferation within the duct, and if that gets to the point where that\u2019s growing a tumour, it becomes a ductal carcinoma. And ductal carcinoma is a good way of looking at\u2026the other thing people might have heard of is its insitu. So ductal carcinoma insitu means a malignant proliferation within the duct, but it hasn\u2019t yet got the ability to break out of the ducts, because the error in its genetics that grows from a mutation that allows it to do that hasn\u2019t happened yet.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay, so it\u2019s confined within the duct.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It becomes confined within a duct.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay, so that\u2019s a ductal carcinoma, DICS really. Yes.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Now, that\u2019s insitu in that, it\u2019s not broken out into the surrounding breast. But what it does tend to do is creep along the tube..<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right\u2026along the ducts..<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Along the ducts.. so that\u2019s one of the characteristics of DCIS. It tends to be associated with calcification, often, not always, that\u2019s the problem. So that\u2019s can be one of the ways that you guys follow it. Once a ductal carcinoma has moved beyond that, it can develop the ability to invade.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right, that is where a cancer is known to be an invasive cancer or an invasive ductal carcinoma. So you can tell whether a cancer is an invasive cancer by virtue of it going through the ducts, beyond the ducts, or the confines of the ducts..<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Exactly, into the breaking out into that surrounding fatty tissue. Now, lobular carcinoma is a pretty similar process, but it grows its thought from cells within the lobules. So, these two tumours when they\u2019re relatively early stage, they look quite distinctive. And for a long time, they look distinctive, and the way we tell one from the other is by looking for what they seem to be trying to do. Which is looking at what they look like they\u2019ve come from. So an invasive tumour that looks like it\u2019s forming tubes, is probably a ductal carcinoma. Whereas an invasive lobular carcinoma tumor\u2026..a tumour that\u2019s made of lots of little cells that looked like the ones you see in a lobule, is probably a lobular carcinoma. The problem comes, when tumours get more advanced and more aggressive, they can start to look worse and worse down the microscope to the point where it becomes really difficult to work out.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Distinguish between the two\u2026<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Just by eyeball\u2026 to distinguish between the two.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So then what do you do to distinguish between the two? You do other staines?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>We do other stains. Yeah, I mean we have, when we talk about stains, what we\u2019re talking about is the first of all the H and E stain, which shows us morphology. But we have certain things that we can do where we use, we call immunohistochemistry or IHC. All abbreviations for the same thing. And what we\u2019re doing now is we\u2019re using, in essence, an antibody, which has a, an ink on it, or an enzyme on it that activates an ink. Now that antibody people might think of antibodies is something you see in an infection and you might have an antibody to nuts. Which is why you have a nut allergy. So we\u2019re borrowing that reaction and we\u2019re saying we want to know if this unidentified cell that might be ductal might be lobular has a particular protein on it, that\u2019s too small to see with our eyes, even with a microscope. But we want to know if it\u2019s there because if it\u2019s there, it\u2019s more likely to be lobular. So we try an antibody on it. And we\u2019ll try a range of antibodies on it. And the antibody that picks up that particular protein will activate an enzyme which lights up an ink.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right? And then you can tell \u2026<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>that cell changes colour. So we look for the cells that have changed colour. And we say if a certain proportion of them have changed colour, they\u2019re positive for that particular protein. Yeah, yep. And that allows us to say, more likely than not, these particular cells that we\u2019re looking at, have probably come from a lobule rather than a duct.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So that\u2019s extremely helpful for you to decide whether it\u2019s ductal or lobular<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It is, it\u2019s not always as clear cut as that makes it sound because tumours don\u2019t always behave the way the book says they do, which is why sometimes test results aren\u2019t entirely comparable and you have to look at them in the setting of an individual patient.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Sure, or it might change from\u2026 a core biopsy might say something. But then, you know, after the patient\u2019s had an operation and you look at the specimen in its entirety, you might change. Exactly. Because you have more specimen to look at.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>That\u2019s right. I mean, the core is only ever a tiny sample..<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Yeah<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>\u2026of tumour. And the core when you think about it might be 12 millimetres long, one millimetre wide. And the tumour might be 35 millimetres across.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Yeah. So that\u2019s much, you know, sometimes more helpful. Well, it can be. Yeah, and I think.. I also warn my patients that when you get a diagnosis of something, at the time of your core biopsy, looking specifically at grading, for example, we can talk about that in a minute. That grading can change depending on\u2026 it depends on the final histology of that specimen because you are looking at only a small area of that cancer, which is the biopsy. And you might give that a grade 2, for example, but that grading might be upgraded to a grade 3 based on the outcome of that specimen. So we know that there are three grades 1, 2, and 3. What are the differences in those three? And what is a grade I guess?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Sure, yeah, well, a grade is a way of trying to identify some features that we can see down the microscope that allow us to reproducibly identify three different sets of likely outcomes for patients. So we try to identify a group who are likely to do quite well, a group who have a more aggressive tumour and a group that have a more aggressive tumour still. And to do that, it\u2019s a product of a lot of researchers over the years that\u2019s identified features that we can use for this. But what we look at is we look at the degree to which a tumour makes tubes or tubules. And we give that a score. So if the tumour is making lots of tubules, and we give it a one, because it\u2019s a good feature. If it\u2019s not making many tubules we\u2019d give it a three, because it\u2019s a bad feature. So it goes in that direction\u2026one, two, three. We then look at what we call there\u2019s another technical term.. pleomorphism, which is really the irregularity of the nucleus. So nuclei of a tumour as we said before, nuclei of tumours that are quite aggressive tend to be quite irregular. And this is a way of saying one is very nice, neat and tidy, almost like normal. Two is somewhere in the middle and three is nasty, irregular looking, angry nuclei.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So it\u2019s more pleomorphic, right. Okay.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>And then the last thing we look at is mitotic activity. And that is measured by the number of mitoses you see per a fixed area and that requires you to calibrate your microscope. So you know, you\u2019re always measuring a fixed area, so everybody\u2019s range that you use to count is slightly different depending on what kind of microscope you\u2019ve got. But we all calibrate our microscopes so that we measured the same area. And then it\u2019s just a matter of counting the mitosis.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So the more mitosis you see, the more aggressive that tumour type is<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Exactly, so not only mitosis is a one, lots of mitoses is a three.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay. So you look at those three factors.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>And we put those together. And then the number that we get then affects whether you\u2019re in grade one, two, or three. So the higher the number, the higher the grade.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right, and I guess that\u2019s the surrogate to how aggressive a cancer might be.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It is to a degree, it is only\u2026 it is only one way of looking at cancer off course. There are other prognostic scales that look at the mutations that tumours have and use that to put people into different groups, for the likely outcome. There are also scoring systems that involve both pathological factors and things like nodal count\u2026 how many how many nodes the tumour might have spread to. So there are other\u2026<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>other factors that might determine whether a patient\u2019s cancer is more aggressive than somebody else\u2019s. Because of course, we treat patients depending on their cancer. So somebody\u2019s cancer will be very different to another person\u2019s cancer and their treatment will be entirely different.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Yeah, I mean, we\u2019re moving\u2026 we\u2019re moving from an age when cancer therapy was was quite mechanical, it was about digging it out, and then poisoning the person and the tumour. And you kind of hoped that the tumour would, would be killed.. quite quickly. But what we\u2019re moving now is we\u2019ve moved through into much less toxic chemotherapy regimes and specialized treatments\u2026 immunotherapy\u2026new treatments that are coming on<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>..more targeted really.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>they are much, much more targeted\u2026 and they really are targeted at the tumour rather than the tumour and the person.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right, yeah that\u2019s very that\u2019s very true. So, another kind of factor that we look at when we determine how best to treat a patient is whether the cancer expresses hormone receptors. So, you know, a cancer might be what\u2019s called ER-positive which is oestrogen receptor-positive, PR positive, which is progesterone. And there\u2019s another receptor called the HER2 receptor. So can you explain a bit more about these receptors and why they are important?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Yeah, so we know\u2026.we know that a lot of breast cancers are driven by responses to hormones, and they will often but not always expressed estrogen receptors, and progesterone receptors.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>So that\u2019s the ER and PR to abbreviate them<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Those tumours are being fed, if you like by oestrogen and progesterone, which opens the ability to either select use drugs to either selectively block that drive, or actually to modulate the hormonal environment itself. So it opens a therapeutic option for those patients who have enough responsiveness to estrogen and progesterone. So what we have to do as pathologists are we have to use some of those IHC immuno tests to try to identify how positive a tumour is for oestrogen receptors and progesterone receptors. And we have another scoring system that we use for that \u2026. we like scoring systems, giving us reproducible ways of doing things. And so what we\u2019ll do is we\u2019ll look at \u2026 so there is a lot of counting involved as a pathologist. And we\u2019ll look at a sample of cells within that tumour, and we\u2019ll assess how many of them are staining, and to what strength. Now at the moment, that\u2019s all done by the human eye, which means you have to regularly recalibrate yourself and check that you\u2019re scoring reproducibly. And we have to check that we\u2019re scoring against positive and negative controls. So we know what a negative stain looks like and what a positive stain looks like. But what we\u2019re trying to do, and this is a sort of at the forefront of technology is trying to teach computers how to do that.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right\u2026AI<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>AI. And this is this is where actually AI has a lot of possibility within pathology because yeah, I know for a lot of us, we we would probably like to think that a highly trained doctor was assessing your tumour. So would I, but highly trained doctors get tired, and machines don\u2019t get tired.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Yeah, so maybe they perhaps maybe more accurate because fatigue doesn\u2019t come into it.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Exactly, they can be accurate they can be potentially quicker.. now a lot of research is going into this at the moment and the results are actually very, very good. Now if you can be better than a tired human, why wouldn\u2019t you do it? So it\u2019s it\u2019s certainly something which is on the cusp of technologies is where we what we tend to be where we\u2019re going. Obviously, a lot of the decision making and interpretation has to be done by a human, but the actual counting\u2026<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>..kind of the automated tasks that you the pathologists do can be delegated to, to a machine. So how, so we will get you know, an ER score of eight out of eight or seven out of eight or three out of eight or zero out of eight. How do you determine whether you know the oestrogen receptor positivity is eight out of eight versus three versus zero.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>So this is basically counting, and there are a number of different ways of doing it. The quick score or Allred score, it has two names, is that it\u2019s relatively quick. And what it looks at is it looks at the percentage of cells, which stain, weakly, strongly or moderately. And each one of those gets a score. And that score the two together, so you might say, you might score if you have less than 1% of cells staining it scores a one for example.<\/p>\n\n\n\n<p>If you have 100%, it scores four or five anyway, half\u2026 And the other half comes from the intensity. And basically what we do is we check and the intensity of the cell staining and the percentage that are staining combined<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>becomes the score.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Where we set the cutoff is two and three, so two is regarded as negative. Three is regarded as positive. Now three is still very weak staining. So you say you call it weekly positive, or we call it weekly positive. And those are the kinds of cases where there may be some sort of discussion with the oncologists. You know, which which way they think is the best way to proceed. The alternative way of doing it is to look for less than or greater than 1% of staining in any intensity. And that usually aligns with the two three cut off, but not always. So what we do is we tend to get both.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>OK\u2026 talk to me about HER2.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>So HER2 is the human epidermal growth factor receptor. And it is one of the molecules that\u2019s involved in cell growth. And what we do is we test for that in exactly the same way, a very similar way to the way we do Er and PR. It\u2019s still done by immunohistochemistry, but it has a different scoring system. Of course.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Of course, why would it make it any easier?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>So we have we have a zero which is negative. We have a +1, which is negative. We have a +2, which is borderline. And then we have a +3, which is positive.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right. And then we know that if it\u2019s borderline it goes for further testing, which is called the FISH testing.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Which is fluorescence in situ hybridisation.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay, thankfully, it is abbreviated to FISH.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It\u2019s gone fishing, it\u2019s is gone fishing and that FISH.. FISH is one of those other things in histology which looks great. It does actually look like fluorescent dyes, staining different parts of the cell. It is as a result quite technical to report and so we tend to send it out to another specialist lab to do.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>And it does take a while for it to come back.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It does. The problem is at the moment in the UK, there are relatively few labs which are doing it. And of course, lots of patients need it.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right. Okay.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It can mean that there is a little delay in getting it. But I think most of our MDT teams tend to, you know, try to anticipate as much as you can.. how you may manage the patient in different circumstances of how that comes out. Okay. But obviously, it is a problem. As we move forward with technology, what we hope is that we can start to kind of bring a lot of these things in house. FISH itself is likely to be reduced in HER2 in the coming years because actually, the scoring system for immunohistochemistry is likely to change. Which will probably get rid of some of those problems around 2+.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay, so get rid of that ambiguity and become either more binary,<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Probably more binary. That\u2019s right. I mean, the thing is, though, that the more we know about cancer, the more we know about the other mutations. Substances that are involved in the pathway of carcinogenesis, like cancers grow. So just when we think we have less testing to do we discover something else that needs testing for. And that really is the story of pathology because we have gone from really simple reports that say, cancer, completely excised, full stop, to great big, long, complex reports with lots and lots of data fields that take longer to do and the more complex to read, but they, they incorporate much more information that\u2019s relevant to an individual patient.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right. So it\u2019s becoming much more complex than years, you know, long, long time ago. And I think the receptor positivity is extremely important because that, as you said, guides us to, you know, say to a patient well your tumour is this\u2026 these are the characteristics of your tumour. And therefore we think you would benefit from, you know, anti-hormonal treatment like tamoxifen or letrozole or you may greatly benefit from chemotherapy, if you have, for example, a triple-negative cancer. So, you know, it is an extremely important part of the cancer treatment.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Well, this is where we talked earlier about an anatomical view of breast cancer. And that was the traditional view for a long time. You either had a ductal carcinoma or you had a lobular carcinoma or one of the other kinds that\u2019s driven by where it\u2019s come from. But now, of course, increasingly, we look at what is the receptor status of that tumour? Or what is it actually doing? Yes,<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>the biology of the tumour. That\u2019s right.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>And that has become all-important because a lot of the decisions that are now made are based on the individual patients\u2019 tumour biology.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>That\u2019s right, and hence the more targeted approach to cancer treatment.<\/p>\n\n\n\n<p>The other thing that we do obviously in breast cancer surgery is remove lymph nodes or glands from the axilla or the armpit. And anybody with an invasive cancer will also have what\u2019s called a sentinel lymph node biopsy, which is removal of a few of the glands. If the node at time of presentation is normal. Is the process of analyzing lymph nodes the same as what you would do for the breast specimens?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It\u2019s a little bit different. Well, first up the breast excisions, whether they\u2019re breast-conserving, whether they\u2019re a wide local excision or mastectomy, they they tend to be big. Whereas a sentinel node biopsy is usually quite small. It\u2019s usually one or two nodes with a bit of fat around them. So it\u2019s maybe a couple of centimetres \u2026a pea size\u2026yeah or something like that..<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>or maybe smaller sometimes<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>And most of that\u2019s fat and within that be a small lymph node which is a few millimetres across. It\u2019s not very big, not very big. But what we\u2019re trying to do is we\u2019re trying to use that sample as a very high yield decision-making tool. So very important. We want to make the absolute best of that tissue. So what we do is we sample it across its long axis, like slicing up a sausage. So we don\u2019t want to slice the sausage in its long plane. Yeah, because then we only just see two faces of sausage, But if we<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>slice it across, all the way along it, then we see as much area of sausage as we can. And that\u2019s the way we stand the greatest chance of picking up tiny little metastasis, if they are there and that means that we can have great confidence that that lymph node or nodes are negative, if we don\u2019t see anything down the slide down the microscope on the slide, and that really helps you guys make a decision as to what\u2019s the likelihood of the other nodes being positive. The theory with the sentinel node biopsy is that you\u2019ve taken the node which is the closest to the tumour. So any tumor that spreading really has to go through that node.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Yeah, the most important node, the guardian of the axilla.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>It is, it is the guardian of the axilla. So if we are confident that our way of doing our histology means that when we say it\u2019s negative, it really is negative, then that gives you the confidence that you can reassure the patient that there isn\u2019t or there is unlikely to be any tumour in the rest of the axilla.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Yeah, no, that\u2019s, that\u2019s really helpful. And presumably, the slicing that you do is exactly the same in terms of the diameter and the thickness.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Yeah, yeah. it\u2019s very very thin.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Yeah.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Yeah. Well, we don\u2019t look at the whole lymph node att that interval. What we do is we\u2019ll cut it into sections which are about two millimetres to three millimetres thick. They go into one of our cassettes and then we embed them in wax and then what we do is we cut through each of those. And that\u2019s what we see as a hairs\u2019 thinness. And we\u2019ll cut several sections through each of those. So what we then see is a whole load of glass slides, maybe eight. And each one is showing us a cross-section of the lymph node. And we\u2019re looking for tiny deposit\u2026 for ductal carcinoma, the cells are usually quite big and chunky. So they\u2019re relatively easy to see, whereas, for lobular cancer, the cells are quite small. And they can look like the background cells in the lymph gland,<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Right\u2026it is trickier.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Cells in the lymph gland are also very small. So we have to then use antibodies with enzymes and stains to stain them up in different colours. And that\u2019s how we pick them up.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Okay, so it\u2019s a bit more complex, complex. So thank you very much. I mean, that\u2019s been really, really helpful. I think it just goes to show that what you do is so important. And I think you do all the work in the background because you essentially the bridge between, you know, us seeing the patient at the time of their presentation. And then, you know, at the time of giving them their diagnosis, and all of this work happens in your lab, by you and the rest of your team.<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Well, yeah, I mean, we see ourselves as absolutely part of the whole team. And, you know, the way we see things is that we\u2019re dealing with our patients, you know, we\u2019re not doing something for your patients. Actually, they are patients too. And, we, we are doing this, I think because we\u2019ve got a real passion for getting to the bottom of what\u2019s going on and fundamentally helping patients receive the best treatment and the right treatment for them.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Yes, and I think, you know, the information that you provide is absolutely pivotal in us being able to tailor the best care for our breast cancer patients. Any other things that you want to add that we haven\u2019t covered?<\/p>\n\n\n\n<p><strong>Peter<\/strong><br>Um, well, I think we really the thing that\u2019s changing in pathology is that we\u2019re moving more and more from traditional morphological work, which is, you know, looking at the shapes of things essentially, and the colour of things, to moving into molecular work. And getting to grips with the mutations that we see in different tumours is teaching us so much more about that tumour biology. And we don\u2019t all have to be research scientists to be involved in research. Because our daily work with real patients is teaching us more and more about the patterns that we see. And that\u2019s teaching us how to better tailor treatment to individual patients and we\u2019re having to become much more technical, much more advanced. That\u2019s coming in lots of different ways. And you know, we touched a little bit on AI and whilst I don\u2019t think I\u2019m going to be out of the job immediately, I\u2019m really looking forward to a technological future. There\u2019s gonna be a lot more genetics involved. a lot more computing power, but still with a human head-on, and a real human passion for getting it right.<\/p>\n\n\n\n<p><strong>Tasha<\/strong><br>Well, on that note, thank you so much for giving me and the listeners your time. It\u2019s been really, really interesting. And hopefully, it will help lots of our listeners today to better learn and better understand their cancer. Great. Thank you very much.<\/p>\n\n\n\n<p>What an interesting conversation. Thank you so much to Dr. Peter Davis for his time and his expertise. And I hope you have enjoyed this episode as much as I did. It does highlight what happens in the background and all the work that happens that help doctors diagnose the disease but also help us design the best treatment plan based on that specific tumour characteristic. Different people\u2019s cancers are very different, and it is because of the work of our pathologists that it enables doctors formulate specific and patient-centred treatment plans.<\/p>\n\n\n\n<p>If you\u2019ve enjoyed the show, and you have a few minutes to spare, then I\u2019d be grateful if you could leave a review on Apple podcast. This increases the discoverability of the show, and hopefully, more people can listen to it and so may derive benefit from it. In the next episode, I will be talking about breast examination and I get this question a lot from people who ask me how best to examine their breast. And so I thought I\u2019ll make an episode and walk you through step by step on how to do a breast examination. If you haven\u2019t done so already, subscribe to the show so you don\u2019t miss out. Thank you so much for listening today and catch up with you in the next episode.<\/p>\n\n\n\n<p>Take care. Bye.<\/p>\n\n\n\n<h3 class=\"has-text-align-center wp-block-heading\"><strong>Subscribe and review<\/strong><\/h3>\n\n\n\n<p>If you don&#8217;t want to miss out on future episodes then please make sure you subscribe to the podcast. You can do it at <a rel=\"noreferrer noopener\" href=\"https:\/\/podcasts.apple.com\/gb\/podcast\/my-breast-my-health\/id1487067681\" target=\"_blank\">Apple Podcast<\/a>, <a rel=\"noreferrer noopener\" href=\"https:\/\/open.spotify.com\/show\/2e4oOvyUKSGoWN9NIUACvZ\" target=\"_blank\">Spotify<\/a>, <a rel=\"noreferrer noopener\" href=\"https:\/\/www.stitcher.com\/podcast\/my-breast-my-health?refid=stpr\" target=\"_blank\">Stitcher<\/a>, <a rel=\"noreferrer noopener\" href=\"https:\/\/www.google.com\/podcasts?feed=aHR0cHM6Ly9mZWVkcy5idXp6c3Byb3V0LmNvbS82ODY1MTMucnNz\" target=\"_blank\">Google Podcasts<\/a>, <a rel=\"noreferrer noopener\" href=\"https:\/\/www.iheart.com\/podcast\/269-my-breast-my-health-52371985\/\" target=\"_blank\">iHeartRadio<\/a> and other podcast apps that take your fancy.<\/p>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<p>Also, if you are feeling super generous, I&#8217;d be grateful if you could help out by leaving a review on <a href=\"https:\/\/podcasts.apple.com\/gb\/podcast\/my-breast-my-health\/id1487067681\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\"Apple Podcast (opens in a new tab)\">Apple Podcast<\/a>. This will help spread the word, making the My Breast My Health podcast more discoverable to people who may not know it exists! Hopefully, by doing this, more people can benefit from it too. <\/p>\n\n\n\n<p class=\"has-text-align-center has-medium-font-size\"><strong>THANK YOU SO MUCH FOR LISTENING<\/strong><\/p>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<p class=\"has-small-font-size\"><em>DISCLAIMER: The content of this podcast and website is not a substitute for seeking medical advice from a healthcare professional.  Please do not delay in seeing a doctor for a breast problem, because of what you have read on this website or heard on this podcast.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>If you have been diagnosed with breast cancer, the treatment that has been planned for you almost certainly will be based on a breast cancer pathology report. This would have been produced by a pathologist, who analyses the breast specimen and subject it to different kinds of complex processes, before looking at it through the [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":8525,"template":"","meta":{"_acf_changed":false,"site-sidebar-layout":"default","site-content-layout":"default","ast-site-content-layout":"","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}}},"categories":[],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>S1 Ep3: Breast cancer pathology results - My Breast My Health<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/mybreastmyhealth.com\/podcasts\/s1-ep3-breast-cancer-pathology-results\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"S1 Ep3: Breast cancer pathology results - My Breast My Health\" \/>\n<meta property=\"og:description\" content=\"If you have been diagnosed with breast cancer, the treatment that has been planned for you almost certainly will be based on a breast cancer pathology report. 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