Supply and Demand in the Oncology Workforce

The demand for oncology services is increasing dramatically. A National Cancer Institute (NCI) study predicts that the number of cancer patients in the United States will increase by 55 percent between 2005 and 2020, and that oncology visits will increase from 38 million in 2005 to 57 million in 2020 (Warren et al., 2008). Dr. Lawrence Shulman, Chief Medical Officer, Senior Vice President for Medical Affairs, and Chief, Division of General Oncology, Division of General Oncology, at Dana-Farber Cancer Institute, stated that the demand for cancer services is not just related to the number of cancer patients but is even more substantially impacted by the increasing complexity of cancer care. For example, in breast cancer, the current standard practice is to combine trastuzumab with cytotoxic chemotherapy to treat women with HER2-positive metastatic breast cancer. The addition of trastuzumab halves the recurrence rate in patients with this type of breast cancer (Romond et al., 2005). But this drug has to be given in weekly infusions for long periods of time. In the past, metastatic breast cancer patients would only need eight chemotherapy infusions their first year of treatment; with the advent of trastuzumab, patients now might have to have as many as 27 infusions their first year of treatment. Dr. Shulman said that the addition of trastuzumab also makes women more susceptible to serious complications that can require additional care.

Similarly, a little over a decade ago there was only one FDA-approved drug for metastatic colon cancer. Now there are several drugs for this con-



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Supply and Demand in the Oncology Workforce T he demand for oncology services is increasing dramatically. A National Cancer Institute (NCI) study predicts that the number of cancer patients in the United States will increase by 55 percent between 2005 and 2020, and that oncology visits will increase from 38 million in 2005 to 57 million in 2020 (Warren et al., 2008). Dr. Lawrence Shulman, Chief Medical Officer, Senior Vice President for Medical Affairs, and Chief, Division of General Oncology, Division of General Oncology, at Dana-Farber Cancer Institute, stated that the demand for cancer services is not just related to the number of cancer patients but is even more substan- tially impacted by the increasing complexity of cancer care. For example, in breast cancer, the current standard practice is to combine trastuzumab with cytotoxic chemotherapy to treat women with HER2-positive metastatic breast cancer. The addition of trastuzumab halves the recurrence rate in patients with this type of breast cancer (Romond et al., 2005). But this drug has to be given in weekly infusions for long periods of time. In the past, metastatic breast cancer patients would only need eight chemotherapy infu- sions their first year of treatment; with the advent of trastuzumab, patients now might have to have as many as 27 infusions their first year of treatment. Dr. Shulman said that the addition of trastuzumab also makes women more susceptible to serious complications that can require additional care. Similarly, a little over a decade ago there was only one FDA-approved drug for metastatic colon cancer. Now there are several drugs for this con- 1

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1 ENSURING QUALITY CANCER CARE dition that must be administered by infusions. “Because these drugs have doubled the survival rate for metastatic colon cancer, you’re going to be see- ing twice as many patients on any given day,” pointed out Dr. Shulman, and metastatic colon cancer patients are receiving many more infusions. “The number of approved parenteral (intravenous) oncology drugs in general continues to go up very rapidly and that affects our ability to administer care,” he added (see Figure 6). Data from Dana-Farber reveal that the num- ber of physician visits per patient, per year, during the first year of therapy at this cancer center have increased by 25 percent between 2001 and 2007, and the number of infusion visits have more than doubled (Shulman et 60 Parenteral Drugs 50 Number of Approved Drugs PO Drugs 40 30 20 10 0 1949 1954 1959 1964 1969 1974 1979 1984 1989 1994 1999 2004 Year FIGuRE 6 This graph depicts the cumulative number of FDA-approved oncology drugs by year and route of administration. Parenteral drugs are administered to the body in a manner other than through the digestive tract, such as through an intravenous or intra- muscular injection. PO drugs are administered to the body orally (from the Latin “per os,” by mouth). This data does not include re-approvals for new indications, or ancillary or support medications. It also does not reflect the volume of usage for the types of drugs. New Figure 6 SOURCE: Shulman presentation (October 20, 2008) and Shulman, L. N., L. A. Jacobs, S. Greenfield, B. Jones, M. S. McCabe, K. Syrjala, L. Diller, C. L. Shapiro, A. C. Marcus, M. Campbell, S. Santacroce, M. Kagawa-Singer, and P. A. Ganz. 2009 (In press). Cancer care and cancer survivorship care in the US: Will we be able to care for these patients in the future? Journal of Oncology Practice. Reprinted with permission. © 2009 American Society of Clinical Oncology. All rights reserved.

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1 SUPPLY AND DEMAND IN THE ONCOLOGY WORKFORCE al., in press). The intensity of “care is increasing faster than the number of patients is increasing,” stated Dr. Shulman (see Figure 7). The success of the treatments that cancer patients receive is also fueling an increase in oncology care. Two-thirds of adults diagnosed with cancer can now expect to be alive in 5 years (Jemal et al., 2005). The number of cancer survivors in the United States has steadily grown since 1971, and now exceeds 12 million survivors (Ries et al., 2008). “This results in increased care demands greater than the absolute number of cancer patients would suggest,” said Dr. Shulman. An ASCO-commissioned survey found that 68 percent of oncologist visits are for patients at more than one year post-diagnosis. The majority of these patients are no longer receiving acute cancer treatment (AAMC, 2007). However, even patients who have completed intense treatment and survivors (patients who have lived for more than 5 years) have significant cancer care needs that cannot be ignored. In addition to the prevention and detection of new or recurrent cancers, cancer survivors may require interventions for the secondary health problems, side effects and late effects of cancer treatment (some of which may not appear for many years post-treatment). Cancer survivors may also require medical attention for % Change FY01–07: 140,000 MD Visits Number of Visits or Patients 120,000 ↑ 65% 100,000 80,000 Infusion Visits ↑ 85% 60,000 Total Unique 40,000 Patients ↑ 62% 20,000 Remained for Treatment 0 ↑ 16% 2001 2002 2003 2004 2005 2006 2007 Year FIGuRE 7 MD and infusion visits are growing at a faster rate than unique patients and new patients remaining for treatment. R01474 Figure 7.eps SOURCE: Shulman presentation (October 29, 2008).

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1 ENSURING QUALITY CANCER CARE the emotional, financial, and job-related concerns raised by their cancer or cancer treatment (IOM, 2005). “The increasing number of cancer sur- vivors who need care have more treatment-related physical and emotional complications from treatment than we have appreciated, or are currently positioned to care appropriately for,” noted Dr. Shulman. Dr. Linda Jacobs, Clinical Associate Professor at the University of Pennsylvania, Director, LIVESTRONG Survivorship Center of Excellence, and Director, Living Well After Cancer Program, expanded on Dr. Shulman’s point, and added that in a recent survey of cancer survivors, 70 percent of respondents reported that their oncologists did not offer support in dealing with health problems secondary to cancer treatment, such as chronic pain, sexual dys- function, fertility problems, and depression (LAF, 2004). SHORTAGE OF ONCOLOGISTS It is highly unlikely that there will be sufficient numbers of oncologists to meet the rising demand for oncology care that many of the speakers documented. More than half of currently practicing oncologists are age 50 or older and will be retirement age by 2020, pointed out Dr. Edward Benz, President of the Dana-Farber Cancer Institute and President of the Associa- tion of American Cancer Institutes. Younger oncologists are not likely to fill their ranks (AAMC, 2007; Erikson et al., 2007). Presumably because of lifestyle preferences, productivity, as measured in visits per week, is lower for oncologists under age 45 than for those ages 45 to 64, a 2006 ASCO survey of practicing oncologists revealed (AAMC, 2007; Erikson et al., 2007). Sixty percent of respondents to a 2005 ASCO survey of graduating fellows rated balancing home and personal life as extremely important (AAMC, 2007; Erikson et al., 2007). A recent ASCO study used current data on the supply of oncologists and the demand for their services to make projections for 2020. This study predicted that the demand for oncologists will increase by 48 percent, whereas capacity will only increase by 14 percent between now and 2020. This will create a shortage of 2,550 to 4,080 oncologists (AAMC, 2007; Erikson et al., 2007) (see Figure 8). Despite this discrepancy between the supply and demand, few oncol- ogy fellowship programs have plans to increase the number of training slots between now and the 2010-2011 academic year. In a 2005 survey, oncology fellowship program directors cited many barriers to increasing training slots for oncologists, the main ones being costs of expansion and lack of financial support for fellows (AAMC, 2007; Erikson et al., 2007).

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1 SUPPLY AND DEMAND IN THE ONCOLOGY WORKFORCE Demand for oncologist 65 Total Annual Visits (in millions) visits (high) 60 Demand for oncologist visits (low) 55 Oncologist visits 50 capacity (high) 45 Oncologist visits capacity (low) 40 35 2005 2010 2015 2020 Year FIGuRE 8 Baseline projections reveal significant shortages of oncologists in 2020. SOURCE: Benz presentation (October 20, 2008) and the Association of American Figure 8.eps Medical Colleges. 2007. Forecasting the supply of and demand for oncologists: A report to the American Society of Clinical Oncology (ASCO) from the AAMC Center for Workforce Studies. http://www.asco.org/ASCO/Downloads/Cancer%20Research/Oncology%20 Workforce%20Report%20FINAL.pdf (accessed January 14, 2009). Reprinted with permission © 2008 American Society of Clinical Oncology. All rights reserved. An additional impediment to boosting the number of trained oncolo- gists is the increasing subspecialization in internal medicine and primary care (Salsberg et al., 2008). Medical oncologists and hematologists must be board certified in internal medicine before becoming board certified in medical oncology, hematology, or both. However, the number of students trained in internal medicine is only increasing marginally. This means that oncology, cardiology and other subspecialties are all competing for residents from the same small source of internal medicine trainees, Dr. Salsberg said. In addition, the lack of medical students going into internal medicine creates a second problem for cancer patients. A large percentage of cancer patients are seen by primary care physicians, rather than oncologists, and internal medicine is one of main methods of becoming a primary care physician. A survey of 4th-year medical students found that many medical students have a number of concerns about pursuing postgraduate training in internal medicine. These included inadequate administrative and techno- logical support to deal with the paperwork demands on residents. Students also found the complexities of caring for elderly and chronically ill patients

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1 ENSURING QUALITY CANCER CARE daunting, and they expressed preferences for work schedules that provided fewer demands from work and more opportunities for personal satisfac- tion and fulfillment outside of work. As a result, only 2 percent of survey respondents planned a career in internal medicine without subspecialization (Hauer et al., 2008). While applauding the increasing influx of women into oncology and the fact that women now comprise about half of all oncology residents, Dr. Michael Goldstein, from Beth Israel Deaconess Medical Center and the Chair of the ASCO Workforce Advisory Group, noted that women oncologists tend to see fewer patients than their male counterparts. As a result, the increase in women oncologists could contribute to the shortage of oncologists (AAMC, 2007; Erikson et al., 2007) (see Table 1). How- ever, Dr. Sharon Murphy, Scholar-in-Residence at IOM, commented that there are studies showing that women physicians on average spend more time with their patients (Roter et al., 2002). “Women tend to talk to their patients more, and I think that’s the reason why you see a little lower output. I think patients and families actually value this a great deal,” she said. There is also a shortage of other specialists involved in cancer care. For example, nearly two-thirds of cancer patients receive radiation therapy during their illness (ASTRO, 2006). Although the number of radiation oncologists in the United States has been growing steadily and the vacancy rate has been declining, there is currently a 5 percent vacancy rate for radia- tion therapists, Dr. Maureen Lichtveld, Professor and Chair of the Depart- ment of Environmental Health Sciences at Tulane University, School of Public Health and Tropical Medicine, and Associate Director of Population Sciences at the Louisiana Cancer Research Consortium, reported. Radia- TABLE 1 Visits per Oncologist (weekly) Private Academic Practice Other Mean Visits Mean Visits Mean Visits Age Group per Week per Week per Week Male oncologists 45-64 years 63.9 103.1 81.2 Not 45-64 44.5 83.9 72.9 Female oncologists 45-64 years 55.5 90.6 76.5 Not 45-64 39.4 70.5 57.5 SOURCE: Goldstein presentation (October 20, 2008) and AAMC, 2007; Erickson et al., 2007.

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1 SUPPLY AND DEMAND IN THE ONCOLOGY WORKFORCE tion therapy practices across the country report a need of approximately 5.2 radiation therapists per practice (ASRT, 2007). SHORTAGE OF ONCOLOGy NuRSES The shortage of nurses and nursing faculty has led to an emphasis on providing the broadest nursing education and training the fastest way possible, according to Dr. Mooney. As a result, fewer nurses are receiving education and training in specialties, such as oncology. The number of nursing schools with a specialty in oncology was cut in half in the past 5 years according to Dr. Betty Ferrell, Research Scientist, City of Hope National Medical Center (Ferrell et al., 2003; IOM, 2005). In addition, general nursing educational programs are limited in what they can cover in their curriculums. Typically, accelerated programs have no room for elec- tives, Dr. Mooney said, and overburdened faculty have less time to interest and recruit students to oncology and to prepare them for oncology-focused practice, teaching, and research. Respondents to a 2000 survey of oncology RNs, nurse executives, and oncologists reported that the shortage of experienced nurses and the decreasing length of patients’ stays in hospitals both contribute to a decrease in the quality of cancer care. They also reported that there was a lack of qual- ified applicants to fill open positions, and increasing paperwork was taking up substantial amounts of nurses’ time. In addition, respondents reported greater physician delegation of tasks to oncology RNs in free-standing ambulatory and hospital-based outpatient oncology settings, resulting in inadequate staff, difficulty retaining qualified staff, the necessity for double shifts and overtime, and a greater reliance on supplemental staff (Buerhaus et al., 2001; Lamkin et al., 2001, 2002). A 2006 survey by Dr. Buerhaus also found that nurses spent 23 percent of their time each week on patient care–related notes and documentation, with 56 percent indicating that this amount of time was too much (Buerhaus et al., 2007a). SHORTAGE OF OTHER ONCOLOGy HEALTH CARE WORKERS A shortage of other health care professionals involved in providing oncology care, such as public health workers, social workers, pharmacists, and laboratory workers and technicians, will also affect the quality of cancer care throughout the entire continuum, from prevention to late-stage disease (see Table 2).

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20 ENSURING QUALITY CANCER CARE TABLE 2 Continuum of Quality Cancer Care Stage of Disease Quality Cancer Care → None Prevention → Early stage Detect early → Mid-stage Treat and manage → Survival Monitor and support → Late stage Manage symptoms → Death Monitor and support SOURCE: Lichtveld presentation (October 20, 2008). Public health workers play an important role early in the continuum of quality cancer care, pointed out Dr. Lichtveld. They are involved in promoting health education, the screening, prevention, and early detection of cancer, as well as the surveillance of cancer incidence, prevalence, and mortality. As is true for the physician and nursing population, the public health workforce is aging, and 23 percent of the current workforce will be eligible to retire by 2012. The Association of Schools of Public Health esti- mates that 250,000 more public health workers will be needed by 2020. To replenish the workforce and avert a public health workforce crisis, schools of public health will have to train three times the current number of graduates over the next 12 years (ASPH, 2008). An impending shortage in oncology social workers is also predicted. Social workers have many roles in cancer care, pointed out Dr. Lichtveld, including patient navigation of the health care system, screening and assessment, and helping patients cope with cancer-related depression and anxiety. There are approximately 1,200 oncology social workers in the entire country (ICAN, 2004-2005), and only 13 percent of licensed social workers specialize in health (NASW, 2006). Nearly 30 percent of licensed social workers are over 55 years of age and are likely to retire in the near future (NASW, 2006). Many institutions that service cancer patients already report a shortage of social workers, including 19 percent of hospices, 14 percent of hospitals, and 8 percent of health clinics, Dr. Lichtveld reported. She added that social workers have experienced increased demands in their work, but decreased resources and supports over the past 2 years, with most social workers employed in health clinics carrying caseloads of 50 or more clients (NASW, 2004).

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21 SUPPLY AND DEMAND IN THE ONCOLOGY WORKFORCE The number of pharmacists is also likely to be hurt by the aging population and the increasing number of professionals choosing to retire. A shortage of these professionals will affect the quality of cancer care because pharmacists are important in providing chemotherapy, palliative care, treat- ment of complications, and patient education, as well as playing a key role in cancer clinical trials, Dr. Lichtveld noted. She reported that recent surveys of pharmacists reveal that about one-quarter of pharmacists are approach- ing retirement age, with more than three-quarters of pharmacy directors and middle managers anticipating resigning their positions within the next decade (White, 2005). In 2007, the pharmacist vacancy rate was 6.4 percent, comparable to the vacancy rate in 2006 and 2005 (ASHP, 2007). In addition, a workforce shortage is anticipated in cancer registrars. Cancer registrars are important in cancer care, because the data they collect and analyze are used in national and regional cancer priority research and intervention areas, Dr. Lichtveld pointed out. Currently, there are about 7,280 registrars in the United States, but future projections estimate that there will need to be 800 new registrars in 15 years to meet the needs of a larger and older population with a higher rate of cancer (NCRA, 2006). Future advances in oncology are also threatened due to shrinking sup- port for cancer research. Advances in the clinical care of cancer patients are often based on academic research, so ensuring adequate support for such research is part and parcel of providing quality cancer care. Despite recognizing the importance of academic research in cancer, many academic institutions lack sufficient funds for research. Discretionary funds are no longer available at many academic cancer centers that rely on their aca- demic researchers’ clinical activities to support their research endeavors, Dr. Goldstein pointed out. “That puts enormous pressure on physicians who are trying to become researchers, to balance family life, and do clinical work,” he said. Half of oncology graduating fellows start out in academic settings immediately after completing training, with the remaining going into private practice settings. However, about 3 to 7 years later, many academic oncologists reevaluate their careers, and due to lack of success at acquir- ing research grants, the strains of raising a family, or both, many opt out of academic institutions and pursue community practice. The reverse is not true; private practice oncologists do not move into academics, accord- ing to Dr. Goldstein (AAMC, 2007). Dr. Bajorin added that a survey of U.S. medical graduates conducted between 2000 and 2006 found that only 2 percent of respondents were from an M.D./Ph.D. program. Most

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22 ENSURING QUALITY CANCER CARE of these M.D./Ph.D.s indicated they are pursuing specialties that have more manageable lifestyles than oncology research, such as dermatology, neurology, ophthalmology, pathology, pediatrics, and radiology. All of these specialties have hours that are more controllable than general oncology care, Dr. Bajorin pointed out (Andriole et al., 2008).