Prof. Janina Kulka | European Society of Pathology
Breast cancer diagnosis and treatment are witnessing unprecedented, rapid development.
In radiology, digital tomosynthesis, contrast mammography, and the use of AI tools have increased the specificity and sensitivity of imaging. Various biopsy techniques are available for different breast lesions.
In pathology, molecular assessment of breast cancer samples has become an everyday need. Computational and digital pathology systems are already established, or are being introduced in several European centres, and the use of AI-assisted tools to increase diagnostic accuracy is not exceptional anymore. The spectacular development of pathology reflects rapid advances in precision, personalized, molecular-based treatment opportunities in oncology.
However, the situation remains far from ideal across Europe, despite initiatives aiming to achieve equally high standards of care for every European cancer patient.
Regarding pathology, a major problem in almost all European countries is the shortage of pathologists, particularly considering the increasing complexity of handling individual breast cancer cases from macroscopy through microscopic evaluation to molecular analysis and to multidisciplinary discussions.
At the same time, the shortage of trained technicians has also become an increasing problem. The European Society of Pathology and national pathology societies are working to attract young people to the profession as medical doctors or technicians.
Furthermore, new complex molecular techniques require specially trained biologists, computational scientists and geneticists.
Increasing the visibility of our profession through social media, courses, workshops and summer schools may help attract young people. Cutting-edge computational and molecular techniques, the key role of pathologists in cancer patient management and broad research opportunities may be particularly attractive to the younger generation.
There is a well-recognised disparity in pathology workforce density across the globe. Considerable variation persists within Europe, and comparisons between countries are further complicated by differences in how the profession is defined – for instance, whether clinical pathologists are included alongside anatomical/surgical pathologists in national counts.
Technology may help alleviate some of these pressures, but it cannot fully compensate for workforce shortages.
Digital slides allow remote diagnostic work. However, working remotely is not fully optimal since close co-operation with radiologists, surgeons and oncologists becomes more difficult. Consultation of difficult cases, on the other hand, is easy and quick using digital slides.
Furthermore, implementation requires appropriate infrastructure, investment, interoperability and training. Unequal capacity to implement these technologies may itself contribute to disparities between European centres and countries.
“Technology may help alleviate some of these pressures, but it cannot fully compensate for workforce shortages.”
Workforce and technological capacity are only part of the picture. Access to modern therapies based on molecular alterations also differs between countries, often due to inadequate or missing reimbursement of molecular pathology diagnostics and targeted drugs.
Differences in healthcare expenditure provide important context, although expenditure alone cannot explain differences in breast cancer outcomes. Screening participation, stage at diagnosis, organisation of care and access to treatment also play major roles.
A short survey circulated through the European Working Group for Breast Screening Pathology (EWGBSP) gathered 18 responses from 15 countries, providing a snapshot of these challenges. Workforce shortages emerged clearly from the responses, with 17 of 18 respondents reporting some degree of shortage of both pathologists and pathology technicians.
The survey also highlighted differences in access to comprehensive breast centres, screening participation and reimbursement. Close to half of respondents indicated that not all guideline-approved targeted therapies are reimbursed for every eligible patient in their country, while a comparable proportion reported that pathology investigations, including molecular testing, are only partially funded.
When asked what changes would most improve breast cancer management nationally, respondents highlighted faster turnaround times, particularly for biopsy, surgical pathology and molecular results, as well as increased staffing, more consistent reimbursement of molecular diagnostics and wider adoption of structured, standardised reporting. Digital pathology and artificial intelligence, together with stronger multidisciplinary team coordination, were also identified as potential areas for improvement.
Ultimately, these capacity and access gaps affect the delivery of timely and accurate diagnosis.
Accurate diagnosis also depends on effective integration of pathology within the multidisciplinary diagnostic pathway. Close cooperation between pathologists, radiologists, surgeons and oncologists is particularly important for radiological–pathological correlation, resolving discordant findings and ensuring appropriate next steps for the patient.
Taken together, these challenges suggest that improving timely and accurate breast cancer diagnosis in Europe requires adequate workforce capacity, equitable access to diagnostic innovation, appropriate reimbursement, strong multidisciplinary collaboration and measurable quality standards.
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