This article summarizes key observations from the peer-reviewed study “Digital Pathology in Cameroon” examining telepathology feasibility in a district hospital without on-site pathology expertise.
Authors: Ulrike Gruber-Mösenbacher, Lauren Katzell, Mark McNeely, Elisabeth Neier, Bobo Jean, Avelino Kuran, and Srikar Chamala
Published: JCO Global Oncology, Volume 7, pages 1380-1389, 2021
DOI: https://ascopubs.org/doi/10.1200/GO.21.00166
Digital pathology adoption has expanded globally, yet access to clinical pathology services and diagnostic services remains limited in many regions. This study evaluates whether telepathology can support diagnostic workflows in a district hospital in Cameroon where no pathologist is available onsite.
Glass slides prepared locally were digitized into high-resolution digital slides and shared for remote viewing by a pathologist in Europe, enabling diagnosis without physical slide transport. Pathology resources remain limited, with an estimated 0.28 pathologists per million inhabitants, making timely and accurate diagnosis difficult, particularly outside major urban centers.
The shortage of pathologists in Cameroon significantly affects access to diagnostic services. In the district hospital described in the study, serving approximately 100,000 people, no histopathologist was available. Surgical specimens were previously transported to Austria for processing and diagnosis, resulting in long delays.
Local clinical teams were capable of performing cancer surgery and treatment, but lacked access to histopathology needed to guide decisions. Establishing a telepathology workflow aimed to address this gap by enabling remote diagnosis based on locally prepared slides.
A histology laboratory was established in 2018 with donated equipment. One histotechnologist processed surgical biopsies into hematoxylin and eosin slides, supported by initial training from a visiting pathologist.
The study implemented two imaging approaches:
Phase I: Mobile phone imaging (2018–2019)
Slides were photographed through a microscope eyepiece using an iPhone. Multiple images were captured per specimen and sent electronically to a pathologist in Austria for review.
Phase II: Whole slide imaging (2019–2020)
A portable slide imaging system, the Grundium Ocus, was introduced, enabling high-resolution whole slide images and more consistent image acquisition. A standardized workflow was developed, including training and written protocols. The system functioned as a telepathology solution, enabling remote viewing of digital images through standard viewing software rather than a centralized reference laboratory.
The diagnostic process followed these steps:
Tissue excision and slide preparation at the hospital
Slide digitization using either mobile imaging or WSI
Upload of images to cloud storage
Remote review by a pathologist
Return of diagnostic reports via digital communication
This workflow allowed continuous case documentation and analysis of turnaround times. Digital slides and associated metadata were stored and shared to support interpretation and quality control. Whole slide images also support more consistent review compared with static mobile device images.
The study compared mobile phone imaging with whole slide imaging across patient cohorts.
Mobile imaging: 101 patients (2018–2019)
Whole slide imaging: 282 patients (2019–2020)
Whole slide imaging improved diagnostic performance compared with mobile imaging. The rate of non-diagnostic cases decreased from 16.8% to 5.5%, indicating a higher likelihood of obtaining clinically useful results:
Metric | Mobile Phone Imaging | Whole Slide Imaging |
|---|---|---|
Non-diagnostic rate | 16.8% (17/101 cases) | 5.5% (15/273 cases) |
Diagnostic certainty | Lower proportion achieving exact diagnosis | Higher proportion achieving exact diagnosis |
WSI provided several practical advantages:
Full tissue coverage, preserving spatial context
Ability to navigate across the entire slide at different magnifications
Reduced dependence on selecting representative fields during image capture
In contrast, mobile imaging required manual selection of areas of interest. This introduced variability and, in some cases, led to missed diagnostic regions. The study reports that in certain cases, incorrect areas were selected, preventing diagnosis.
Overall, WSI increased diagnostic confidence and improved the ability to provide specific diagnoses that could guide treatment.
Despite successful implementation, several challenges affected the workflow.
Power supply instability
Unreliable electricity affected slide preparation and processing. Tissue processing required uninterrupted power for extended periods, and interruptions led to repeated preparation steps and delays.
Connectivity limitations
Whole slide images required significant data transfer capacity. Uploading and transmitting images could take several hours depending on network conditions and power availability.
Limited laboratory capabilities
Only hematoxylin and eosin staining was available. The absence of additional staining methods and immunohistochemistry limited diagnostic detail in some cases.
Workflow delays
The time between specimen collection and digitization contributed most to delays in diagnosis. Although WSI improved image review efficiency, upstream workflow constraints remained significant.
The telepathology system relied on accessible technologies, including cloud storage, viewing software, and secure data transfer for digital pathology workflows. Images were shared securely using encrypted data transfer and anonymized storage.
Training played a key role in maintaining the workflow. Written protocols and initial instruction enabled local staff to perform slide preparation and digitization independently.
Although equipment was initially donated, long-term sustainability depends on maintaining infrastructure, consumables, and connectivity.
The study demonstrates that telepathology can support diagnostic services in settings without local pathologists. By enabling remote interpretation of digitized slides, the workflow provided access to expertise that would otherwise be unavailable. Whole slide imaging, in particular, improved diagnostic yield and confidence compared with mobile phone imaging. The reduction in non-diagnostic cases suggests that more patients are more likely to receive diagnostic results that can support treatment decisions, which may support more appropriate treatment decisions. This supports more timely results and improved patient care in settings where access to expert pathologists is limited.
At the same time, the study highlights that digital pathology alone does not resolve all constraints. Laboratory processes, power supply, and infrastructure remain critical components of effective pathology services. Future developments may include integration of image analysis tools, artificial intelligence, and machine learning to support digital pathology workflows.
This study shows that telepathology using whole slide imaging can be implemented in a district hospital without onsite pathology expertise. Compared with mobile phone imaging, whole slide imaging improved diagnostic yield and confidence while enabling remote diagnosis through digital workflows.
However, the effectiveness of telepathology depends on the broader system in which it operates. Reliable slide preparation, infrastructure, and training remain essential to ensure consistent diagnostic outcomes. Within these constraints, the findings indicate that digital pathology can extend access to diagnostic services and support cancer care in resource-limited settings where pathology expertise is scarce.
A curated collection of digital pathology studies and references is available on Grundium’s website.
