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

Welcome to part four of The State of Pathology in Resource-Limited Countries. In parts one, two and three we take you to sub-Saharan Africa where pathology resources are stretched thinner than imaginable. What does this mean for patients in resource-limited countries? What does this mean for the resources that do exist? We cover this and more, so be sure to read those posts as well. Part four is an exciting post in which we will review the use of telepathology to help bridge the pathology gap in sub-Saharan Africa and around the globe.

Collaboration, support and connection -- this is what is needed from the global pathology community to help bridge the pathology gap in regions with limited pathology resources. Many institutions in the United States and Europe have collaborated with countries in Africa using telepathology to assist with cancer diagnosis. These collaborations are crucial if patients are to receive accurate diagnoses and treatment.

Dynamic imaging, a video consultation that keeps direct interaction between reviewers at the same time, and static imaging, which selects an adequate image from the original stained slide and sends these images to a reviewer via designated software, are the two most common types of telepathology. In rural Rwanda, the Butaro Cancer Center of Excellence (BCCOE) was established at the Butaro District Hospital in partnership with the Rwanda Ministry of Health, Partners in Health (PIH), and the Dana-Farber/Brigham and Women’s Cancer Center (BWH) in Boston, Massachusetts. They utilized static telepathology for rapid interpretation of common tumors (i.e., squamous cell carcinoma), which requires little ancillary testing and made up a large volume of their caseload. They were able to triage cases and shorten the turn-around time for some cases.1 This partnership continues today.

Additional examples of successful collaborations include the Kamuzu Central Hospital (KCH) Pathology Laboratory in Lilongwe, Malawi which opened as a collaborative effort between KCH, the Malawi Ministry of Health, and the University of North Carolina at Chapel Hill (UNC). This collaboration supported local pathologists, clinical care and research efforts. Malawi-based clinicians and pathologists presented patient cases at weekly telepathology conferences, which was attended by local providers and their counterparts in the United States. After discussion and guidance, a consensus diagnosis was rendered by the pathologist in Malawi.2 This helped to guide clinical care for patients with a cancer diagnosis. In settings with even less capacity, telepathology may provide the only access to pathology services. The collaboration between Desio Hospital in Desio, Italy and Mtendere Mission Hospital of Chirundu, Zambia brought pathology service to Chirundu where there previously was none. Telepathology allowed the Italian pathologists to make remote histologic and cytologic diagnoses and consult on second opinions on a variety of anatomic pathology specimens.3

Furthermore, the presence of telepathology can be a positive factor in the recruitment of pathologists - of course, especially important for regions that lack pathologists. It has been reported that pathologists have challenges when they work alone, and this may affect their retention in remote locations where they are often isolated. However, if static or dynamic forms of telepathology are available, the pathologist can communicate and share diagnosis with other local/foreign pathologists. Pairing remote locations with more experienced tertiary centers is a viable option that can be explored in both bridging the gap of pathology services and connecting the pathology community.4

A fair question arises when considering telepathology. Is it accurate when diagnosing disease? From the studies we are highlighting, the answer is yes. In the study at BCCOE, static-image telepathology diagnoses were 97% concordant with subsequent glass slide review. In the Zambia study, the original glass slides were shipped to Italy to establish a true diagnosis, and these results were compared with those made via telepathology. More than 85% of final diagnoses were either unchanged or had only minor differences on final review, and in only 3% of cases did a change in diagnosis occur that would have resulted in different treatment in Zambia. Agreement was even higher for cytology cases in this study, with no treatment-relevant differences between telepathology and final diagnoses. These results highlight the potential for remarkable accuracy when applying telepathology to appropriately selected cases.

As essential as telepathology has become for resource-limited countries, it does not come without challenges. Internet stability and adequate bandwidth are required for the telepathology framework. Like they used in Rwanda, static telepathology is an alternative to dynamic (real-time) telepathology which requires a more robust internet infrastructure. Cost is a common factor where resources are limited but a static telepathology system is also good in this area as it is a lower-cost option because it uses a lower bandwidth. The cost can also be shared by dividing the connection costs between more than one hospital, even more than one region or country.5 Relative to cost, it’s important to note that telepathology helps pathologists around the globe allocate their limited resources to the right places -- the right diagnoses, the right treatments and the right care for patients with cancer.

Collaboration and support is needed on a global scale if we are to reduce the scarcity of pathologists and pathology as a practice not only in sub-Saharan Africa but in all countries that lack pathology resources. The United States, Europe and India are among several regions that have an adequate supply of pathologists. They can help train and retain pathologists in resource-limited countries as well as assist with diagnoses leading to more accurate treatment decisions for patients.

Yes, telepathology has its own sets of challenges when it comes to implementation and long-term use; however, it’s one viable movement toward solutions desperately needed where resources are limited. Cancer doesn’t just stop because there aren’t pathologists. If it can mean the difference between life and death for a patient, shouldn’t we at least try?

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 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.

2,3 Montgomery ND, Tomoka T, Krysiak R, et al. Practical Successes in Telepathology Experiences in Africa. Clin Lab Med. 2018;38(1):141–150.

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

5 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.

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