Integrated diagnostics (ID), currently defined as the convergence of imaging, pathology and laboratory tests with advanced information technology, has great potential for revolutionising diagnosis and therapeutic management of various diseases, including cancer, cardiovascular and infectious diseases. It can provide numerous potential benefits to patients and give radiologists the opportunity to become more involved in clinical decision support beyond providing imaging data. In a joint session held by the ESR and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM), experts will provide insights into how much ID has to offer and which hurdles still need to be overcome.

When addressing a subject like ID, there is probably no better cooperation partner than the EFLM, a federation that connects 40 national societies of clinical chemistry and laboratory medicine, which aims to enhance patient care and improve outcomes by promoting and improving the scientific, professional and clinical aspects of clinical chemistry and laboratory medicine. ECR Today spoke to EFLM past president Prof. Michael Neumaier, Director of the Institute for Clinical Chemistry at University Clinic Mannheim, Germany, and Prof. Stefan O. Schönberg, Director of the Institute of Clinical Radiology and Nuclear Medicine at University Clinic Mannheim, who will discuss ID from different perspectives during a two-part presentation, as well as ESR president Prof. Boris Brkljačić, from the University of Zagreb School of Medicine, Croatia, who will co-chair the session.

ECR Today: Why are partnerships such as the one between the EFLM and ESR important for the further development of modern medicine?

Boris Brkljačić: Today, laboratory medicine, radiology and pathology still work largely in silos, disconnected, each creating their own reports, although advances in information technology allow integrated decision support and delivery systems, in which medical specialists share information and findings and embark on teamwork to assess which diagnostic tests and procedures are necessary. This allows more personalised patient care and a more efficient use of scarce healthcare resources. Thus, it is time for Europe’s professional and scientific societies in these disciplines to enter into dialogue, explore avenues of collaboration and encourage the implementation of ID in daily clinical practice to benefit our patients. Also, an important role of our organisations is to raise awareness of the concept of ID and the synergies between radiology and laboratory medicine, as, until now, the concept has largely been associated with radiology and pathology.

ECRT: Can you tell us a few details about the possible framework of the EFLM-ESR partnership and benefits which might result from it?

Boris Brkljačić: A collaboration like this can take the form of joint statements, guidelines and recommendations. Also, we could envisage collaborating on European affairs and advocacy in topics of joint interest, such as good clinical practice and quality of care for Europe’s patients, engaging in eHealth and AI topics, and addressing current challenges in this field. And, of course, encouraging joint research in this domain is important to foster the development, piloting and adoption of clinical decision support systems and AI algorithms to aid integration and analysis of diagnostic data and the introduction of integrated reports.

ECRT: Can you describe how you understand the term ‘integrated diagnostics’ in the context of your work and what you see as the main characteristics of ID?

Michael Neumaier: The term ‘integrated diagnostics’ is used with different meanings in various settings. For example, integrating the results of different tests within laboratory medicine allows us to compile useful information on different biological levels and assess their mutual influences, and thus can be helpful for diagnosis. The same holds true for the integration of technologies in radiology. Here, the use of different imaging techniques will provide separate imaging results, each with specific features. The integration of the imaging data may provide additional functional or morphological insights that are not available when they are separate.

Prof. Michael Neumaier is Director of the Institute for Clinical Chemistry at University Clinic Mannheim, Germany, and a former president of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM).

In our initiative, we understand the term ‘integrative diagnostics’ in the context of combining diagnostic data and findings in an interdisciplinary fashion, i.e. between diagnostic disciplines.

Stefan O. Schönberg: In today’s standard medical procedures, each diagnostic discipline will provide its specific perspective of the diagnostic question, based on dedicated technology, methods, expertise and other aspects. Thus, it will produce isolated findings. The diagnostic perspective of one discipline may be different from another. In contrast, the diagnostic approach pursued in this initiative addresses a given diagnostic task directly, from the outset, in an integrated fashion. Specifically, the early combination of task-oriented and appropriate methods and modalities is expected to create synergies and result in superior assessments toward the diagnostic question.

ECRT: Can you explain how ID may improve patient outcome?

Boris Brkljačić: Laboratory medicine, radiology and pathology share and overlap in their missions and all heavily rely on IT infrastructure and solutions. Thus, a synergistic and integrated use of different diagnostic pathways is essential in modern healthcare. ID implies collaboration between the diagnostic specialists, including pathologists, laboratory physicians, chemists, and radiologists. The aim is to reduce the time and cost of diagnostic processes and to enable clinicians to be provided with practical and fully actionable diagnostic results and findings with the support of IT solutions. This will allow more efficient patient management by providing faster, more cost-efficient and higher-quality diagnoses to our patients through integrated reports.

Michael Neumaier: Each diagnostic discipline has its specific strengths and weaknesses, while it stays within its respective methodological area. A systematic integrative approach, on the other hand, will make the diagnostic outcome more effective. In cancer patients, for example, earlier diagnosis of tumour recurrence or earlier detection of therapy resistance offers the chance to improve the treating physician’s clinical decision making.

For example, the analysis of circulating tumour DNA in the blood stream of a patient can avoid risky biopsies and is the method of choice for the earliest detection of tumour recurrence. However, while laboratory testing provides tumour detection with high sensitivity, so far, it can give little to no information regarding the site of such a recurrence. In contrast, imaging provides information on tumour localisation, provided the tumour has sufficient mass. Obviously, an integrated diagnostic approach can be envisaged, in which regular monitoring tests are done at intervals, planned on the basis of the molecular profile and malignancy of the tumour. In a workflow shared with the radiologist, differentiated strategies for imaging will then localise the lesions and assess their accessibility for further intervention or surgical removal.

Prof. Stefan O. Schönberg is Director of the Institute of Clinical Radiology and Nuclear Medicine at University Clinic Mannheim.

Stefan O. Schönberg: The integrated approach has two major advantages, as best exemplified by, but not limited to, the area of oncology: the earlier detection of tumour relapse allows diagnosis at a time of smaller tumour mass in contrast to fixed schematic diagnostic plans that do not take the individual situation of the patient into account. Furthermore, unnecessary and ineffective imaging can be replaced by more advanced imaging strategies tailored to the individual patient. In sum, ID appears to be the next logical step to improve modern medicine.

ECRT: In your opinion, why does the current diagnostic approach need improvement?

Michael Neumaier: In an era in which both our knowledge of individual disease profiles is constantly increasing and digitalisation allows data to be assessed in an interdisciplinary way, it appears nonsensical not to benefit from these improvements by sharing or coordinating diagnostic activities.

However, today’s medical guidelines call for diagnostic and therapeutic workflows based on statistical evidence, while taking much less account of individual disease conditions. Also, diagnostic data are often perceived as technical commodities. With the expanding spectrum of diagnostic possibilities, the therapist is facing an increasingly complex situation, i.e. being obliged to compile and interpret diagnostic data separately raised and independently reported from various diagnostic disciplines and to assemble them for clinical decision making.

ECRT: Can you reveal some highlights of your talks?

Stefan O. Schönberg: We will introduce the potential of ID, exemplified by the combination of in vitro and in vivo diagnostic disciplines; radiology/nuclear medicine and laboratory medicine in oncology. With respect to future developments, we will discuss the concept of the ‘crystal ball’ comprising the various disciplines of diagnostic medicine. There, the diagnostic tasks are taken up through coordinated testing in a qualified fashion. The answer reflected back to the physician is shaped by the various contributions and deliberations between an integrative diagnostic strategy.

Boris Brkljačić: Besides outlining the potential benefits of a partnership between the EFLM and ESR during my introductory talk, I will also address some of the current key challenges in radiology as a diagnostic discipline, such as the commoditisation of our profession, the challenges of keeping radiology an attractive profession for the young generation, and the importance of equipping them with the skill mix needed in the era of advanced IT and AI through an adequate modernisation and adaptation of training curricula. It is important that radiologists follow a participatory approach in the clinical team in order to remain in the driving seat on the diagnostic pathway.

Concept of the ‘crystal ball’, which comprises the various disciplines of diagnostic medicine (provided by Prof. Michael Neumaier)

Also in this session, Dr. Verena Haselmann, from the Institute for Clinical Chemistry at University Clinic Mannheim, will address the question of how to improve cancer detection through integrated diagnostics, while Prof. Paul Collinson, chemical pathologist at St George’s University Hospitals NHS Foundation Trust, London, UK, will discuss the diagnosis of heart failure, specifically outlining the current limitations of biomarkers used to diagnose the condition and impact of heart failure biomarker measurement for clinical decision making and therapy stratification.

Please note that for pre-recorded sessions published during the ECR Highlight Weeks, there will be no chairpersons. However, we still wanted to keep Professor Brkljačić’s answers for the article as he initially gave them.

Joint Session of the ESR and the EFLM
Integrated diagnostics: are we ready for it?

  • Can we improve patient outcome by integrating radiology and laboratory medicine? (Part 1)
    Michael Neumaier; Mannheim/DE
  • Can we improve patient outcome by integrating radiology and laboratory medicine? (Part 2)
    Stefan O. Schönberg; Mannheim/DE
  • How to improve cancer detection through integrated diagnostics?
    Verena Haselmann; Mannheim/DE
  • Diagnosing heart failure: is there a better way?
    Paul Collinson; London/UK

FURTHER READING

Ní Leidhin C, Mulholland D, McEniff N, Guiney M, Brennan IM, Ryan M (2019) All you need to know about catheter-based reperfusion treatment of acute pulmonary embolism. ECR 2019 / C-1910: myESR.org/191910

Vinci V, Bernardo S, Saldari M, Manganaro L (2015) MRI and ovarian biomarkers to determinate the undeterminate. ECR 2015 / C-2556: myESR.org/152556

Yoo RE, Yun TJ, Hwang I et al (2019) Arterial spin labeling perfusion-weighted imaging aids in prediction of molecular biomarkers and survival in glioblastomas. Eur Radiol. doi: 10.1007/s00330-019-06379-2: european-radiology.org/6379

Giganti F, Tang L, Baba H (2019) Gastric cancer and imaging biomarkers: Part 1 – a critical review of DW-MRI and CE-MDCT findings. Eur Radiol. 29(4):1743-1753: european-radiology.org/5732

Kiessling F (2018) The changing face of cancer diagnosis: From computational image analysis to systems biology. Eur Radiol. 28(8):3160-3164: european-radiology.org/5347