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The State of Pathology in Resource-Limited Countries: Part Five

We have taken you on a whirlwind trip around the state of pathology in resource-limited countries, specifically in sub-Saharan Africa. It’s important to note that pathology scarcity expands the globe; every continent has an area or region lacking pathology services. We ended part four with a bold question. If it means the difference between life and death for many patients, shouldn’t we at least try to bring pathology resources to where they are scarce? We propose ideas on how this can be achieved.

Let’s go fully digital. A digital pathology system with fresh tissue scanning and telepathology capabilities will bring significant changes to resource-limited countries. Fresh tissue scanners eliminate the rate limiting step of fixation or inconsistencies related to cutting/tissue processing observed in histology. So, within minutes, tissues could be scanned and ready for evaluation between local staff and the consulting pathologist (who could be located literally anywhere in the world). And digital pathology doesn’t have to stop at pathologists. Connecting oncologists and interventional radiologists can help guide treatment decisions resulting in better patient outcomes. This brings even more resources to where they are scarce and often nonexistent.

Studies surrounding the use of digital pathology with telepathology to reach resource-limited countries around the globe are growing. Additional studies demonstrating real-world experience with digital pathology are still needed to bring the technology to the forefront of pathology as a viable solution to connecting pathologists to remote areas. A common and fair concern is if a consistently accurate diagnosis can be made looking at digital images on a computer screen instead of glass slides under a microscope. In two studies we highlighted in part four, the accuracy is remarkable. In rural Rwanda at the Butaro Cancer Center of Excellence (BCCOE) diagnoses were 97% concordant with subsequent glass slide review.1 In Chirundu, Zambia at the Mtendere Mission Hospital, more than 85% of final diagnoses were either unchanged or had only minor differences on final review. Agreement was even higher for cytology cases in this study, with no treatment-relevant differences between digital images and final diagnoses.2 Benefits experienced at BCCOE included rapid interpretation of common tumors, ability to triage cases and shortened turn-around times.3 Previous studies have found that a digital workflow released up to 13% of an individual pathologist's time in addition to laboratory technician time.4 Additional real-world experiences would solidify digital pathology as a necessary solution to pathology scarcity.

A digital pathology system with fresh tissue scanning and telepathology capabilities is an investment, there is no question about that. Implementation costs include acquisition and maintenance, requirement for large bandwidth internet service and data storage for high resolution image file sizes.5 A few cost solutions exist. First, many digital pathology companies will lease their systems to users - minimizing large up-front costs. Second, in tandem with a collaboration and/or study with an established pathology service, the cost could be shared between institutions and laboratories. Third, multiple hospitals in resource-limited countries using the technology could divide the costs related to leasing/purchasing the system, internet connection and data storage.6

Potential benefits of successful implementation include enhanced collaboration, improved teaching, cost savings, research facilitation, growth of specialty and enhanced patient-centered care. Cost savings may be achieved by reducing production of glass slide teaching sets, purchase and maintenance of microscopes, improved turn-around times, and reduction in error logs that require investigation. However, key barriers need to be addressed in order to fully implement digital pathology and to realize these potential benefits. Barriers to transitioning to digital pathology include standardization, validation, storage and back-up of data, training, logistical implementation, cost-effectiveness, privacy and legality.7 Digital pathology companies in turn need to build affordable systems that require minimal maintenance.

If we do not work towards global digital pathology, regions will continue to experience shortages in pathology services. Lack of pathology can result in low cancer survival rates, generate delays and costs, and constrain surgery options and planning.8 Where pathology resources are limited, so are the resources of patients. A patient may not have the transportation resources to go to another institution. And in many countries, even larger institutions are limited in specialists. Digital pathology systems with fresh tissue scanners would potentially allow the biopsy and diagnosis to be made during the patient’s same visit at the same institution. Telepathology allows the specialist to come to the patient, making the most of the patient’s resources.

It’s clear that immediate changes are needed to improve the availability of pathologists and pathology services in resource-limited countries. A viable solution is digital pathology, bringing with it opportunities for more timely and accurate tissue diagnosis, appropriate cancer care and improved patient outcomes. Digital pathology with telepathology capabilities introduces global collaboration, exchange of knowledge and expertise and a new standard of care every patient deserves. Add in fresh tissues scanners - and we can ensure every region is equipped with a way to consistently prepare tissue samples for global pathology service collaboration.

Built on the vision of better patient outcomes, Instapath was founded in 2017 by engineers and scientists to enable patients to immediately know their cancer diagnosis. Our team made it our mission to develop fast and easy digital pathology technology so diagnosis can be made in minutes instead of days. To learn more about Instapath and our technology, visit or contact us at


1, 3 Mpunga T, Hedt-Gauthier BL, Tapela N, et al. Implementation and Validation of Telepathology Triage at Cancer Referral Center in Rural Rwanda. J Glob Oncol. 2016;2(2):76–82. Published 2016 Jan 20.

2 Montgomery ND, Tomoka T, Krysiak R, et al. Practical Successes in Telepathology Experiences in Africa. Clin Lab Med. 2018;38(1):141–150.

4 Stratman C, Drogowski L, Ho J. Digital pathology in the clinical workflow: A time and motion study. Pathol Vis San Diego Calif Digit Pathol Assoc. 2011

5 Orah N, Rotimi O. Telepathology in Low Resource African Settings. Front Public Health. 2019;7:264. Published 2019 Sep 13.

6 Pagni F, Bono F, Di Bella C, et al. Virtual surgical pathology in underdeveloped countries: the Zambia project. Arch Pathol Lab Med. 2011;135:215–219.

7 Turnquist C, Roberts-Gant S, Hemsworth H, et al. On the Edge of a Digital Pathology Transformation: Views from a Cellular Pathology Laboratory Focus Group. J Pathol Inform. 2019;10:37. Published 2019 Dec 3.

8 Trudel M-C, Paré G, Têtu B, Sicotte C. The effects of a regional telepathology project: a study protocol. BMC Health Serv Res. 2012;12(64):1–11.

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