Tissue navigator, an important position in the Pathology laboratory in the Precision Medicine era

We read with interest the recent publication by Gosney et al. in this journal.¹ We wish to emphasize the pivotal role of pathologists in ordering molecular reflex tests for non-small-cell lung cancer (NSCLC) and propose introducing a new professional position, the ‘tissue navigator’, in the surgical pathology laboratory. This role aims to optimize the coordination and implementation of such testing, ensuring efficient identification of NSCLC cases requiring molecular studies, obtaining patient consent for submitting paraffin blocks to external laboratories, communicating results to attending physicians, and assisting the multidisciplinary team in navigating the complex landscape of pathology results and available biomarker tests.

Comprehensive predictive studies for NSCLC are limited in Brazil, with a low testing rate and inadequate availability of in vitro diagnostic tests such as ALK D5F3 and PDL1 22c3 due to cost constraints.² The Brazilian public health care system and most private insurance providers do not cover the necessary assays.³ Consequently, there are delays in treatment decisions and initiation of therapy due to various factors such as cost coverage determination, preauthorization requirements, selection of tissue for testing, block selection, the decision on sending blocks or unstained slides, authorization from patients or family members, and communication with attending physicians for medical requests and confirmation of clinical data.⁴

In our practice, the tissue navigator serves as a liaison between pathologists, patients, attending physicians, and external laboratories. Their role involves evaluating each NSCLC case and determining its eligibility for molecular studies, ensuring optimal utilization of limited tissue resources, and minimizing delays in treatment decisions. Implementing this proactive approach has led to a significant increase, from ∼25% to over 60%, in the number of advanced NSCLC patients tested for molecular biomarkers (Tavora and de Sousa, unpublished data).

The tissue navigator also plays a crucial role in obtaining informed consent from patients for submitting paraffin blocks to external laboratories. In Brazil, next-generation sequencing testing is sponsored mainly by a pharmaceutical industry consortium, necessitating written authorization from patients for sending out the blocks. This critical step involves educating patients about the purpose and potential benefits of molecular testing, addressing their concerns, and facilitating the necessary paperwork. By assuming this responsibility, the tissue navigator alleviates the workload on pathologists, enabling them to focus on their core diagnostic duties.

Additionally, the tissue navigator acts as an efficient communication conduit between the pathology department and attending physicians. They provide timely updates to attending physicians regarding molecular testing results, highlighting actionable findings and eliciting specific medical requests for further tests or therapeutic interventions. This proactive approach ensures that treating physicians have current and relevant information to guide treatment decisions, ultimately improving patient care and outcomes.

We sincerely appreciate your consideration of this letter. We hope our proposal stimulates interest and discussion within the scientific community, leading to enhanced patient care and optimized utilization of reflex molecular testing in NSCLC.