Dr Schandl on the Role of a Pathologist in Making a Diagnosis of Lung Cancer

“The pathologist is pivotal. Without the appropriate diagnostic information, the determination as to whether biomarker testing is or isn’t appropriate…cannot be made.”

Cynthia A. Schandl MD, PhD, medical director of clinical laboratories and director of the Division of Clinical Pathology in the College of Medicine at the Medical University of South Carolina, discussed the role of the pathologist in expediting biomarker-driven treatment decisions in lung cancer care.

The pathologist serves as the first critical checkpoint in determining whether biomarker testing is appropriate, Schandl explained. Without complete and accurate diagnostic information, the oncology team cannot confidently move forward with molecular profiling strategies that increasingly inform first-line therapy selection. In this way, the pathologist’s interpretation of histology and tumor characteristics lays the groundwork for precision oncology, ensuring that testing decisions are evidence based and aligned with current standards of care.

Beyond diagnosis, Schandl highlighted the pathologist’s responsibility in assessing tissue adequacy. Because pathologists directly review biopsy and resection specimens, they are uniquely positioned to determine whether sufficient tumor material is available to support the breadth of molecular testing that may be required. This early evaluation is especially important because many patients present with limited tissue samples, and inadequate specimens can result in incomplete profiling, repeat biopsies, or delays in care. By identifying potential limitations upfront, pathologists can help guide tissue stewardship and prioritize the most clinically relevant assays.

Schandl also stressed the importance of initiating molecular testing as early as possible and ideally at the time of diagnosis through reflex testing pathways. The overarching goal, she explained, is to shorten the interval between initial presentation and initiation of appropriate first-line therapy. When molecular testing is deferred until after diagnostic results are communicated to the oncology team, additional delays can occur. Time may elapse between when results are issued, reviewed, and acted upon, and further delays can arise if archived specimens must be retrieved for additional studies.

In contrast, early pathologist engagement can streamline workflow, reduce turnaround times, and minimize logistical barriers. By centralizing biomarker initiation within pathology at the point of diagnosis, multidisciplinary teams can avoid unnecessary delays and ensure that treatment decisions are informed by complete molecular data at the time of treatment selection.

As precision oncology continues to evolve, including pathologists in early testing decisions is essential to delivering timely, biomarker-informed care, Schandl concluded.