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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Page xvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Developing and Sustaining an Effective and Resilient Oncology Careforce: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25533.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Erin Balogh, Emily Zevon, Margie Patlak, and Sharyl J. Nass, Rapporteurs National Cancer Policy Forum Board on Health Care Services Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by Contract No. 200-2011-38807 (Task Order No. 75D30118F00071) and Contract No. HHSN263201800029I (Task Order No. HHSN26300008) with the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health, respectively, and by the American Association for Cancer Research, American Cancer Society, Ameri- can College of Radiology, American Society of Clinical Oncology, Association of ­ American Cancer Institutes, Association of Community Cancer Centers, Bristol-Myers Squibb, Cancer Support Community, CEO Roundtable on Cancer, Flatiron Health, Helsinn ­ erapeutics (U.S.), Inc., LIVESTRONG Foundation, Merck, National Th Compre­ ensive Cancer Network, Novartis Oncology, Oncology Nursing Society, and h Pfizer Inc. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: International Standard Book Number-10: Digital Object Identifier: https://doi.org/10.17226/25533 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Developing and sustaining an effective and resilient oncology careforce: Proceedings of a work- shop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25533. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental insti- tution to advise the nation on issues related to science and ­echnology. t Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of ­ ciences S to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of ­ ciences, S Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the partici- pants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National A ­ cademies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

WORKSHOP PLANNING COMMITTEE1 LISA KENNEDY SHELDON (Co-Chair), Chief Clinical Officer, Oncology Nursing Society LAWRENCE N. SHULMAN (Co-Chair), Professor of Medicine, Deputy Director for Clinical Services, and Director, Center for Global Cancer Medicine, Abramson Cancer Center, University of Pennsylvania AMY P. ABERNETHY, Chief Medical Officer, Chief Scientific Officer, and Senior Vice President, Oncology, Flatiron Health2 EDWARD J. BENZ, JR., President and Chief Executive Officer Emeritus, Dana-Farber Cancer Institute; Richard and Susan Smith Distinguished Professor of Medicine, Genetics and Pediatrics, Harvard Medical School ROBERT W. CARLSON, Chief Executive Officer, National Comprehensive Cancer Network CLESE ERIKSON, Deputy Director, Health Workforce Research Center, The George Washington University STANTON L. GERSON, Director, Case Comprehensive Cancer Center, Professor of Hematological Oncology; Case Western Reserve University; Director, University Hospitals Seidman Cancer Center LORI HOFFMAN HŌGG, Veterans Health Administration National Program Manager, Prevention Policy, National Center for Health Promotion and Disease Prevention; National Oncology Clinical Advisor, Office of Nursing Services, Department of Veteran Affairs RUTH E. NEMIRE, President, ASK Educational Games, LLC RANDALL A. OYER, Medical Director, Oncology, Ann B. Barshinger Cancer Institute, Lancaster General Penn Medicine DAVID SIEGEL, LCDR, U.S. Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Epidemiology and Applied Research Branch 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. ­ The responsibility for the published Proceedings of a Workshop rests with the workshop rap- porteurs and the institution. 2 As of February 2019, Dr. Abernethy’s affiliation is Principal Deputy Commissioner and Acting Chief Information Officer of Food and Drugs, Food and Drug Administration. v PREPUBLICATION COPY—Uncorrected Proofs

VIRGINIA L. VALENTIN, Assistant Professor and Associate Director, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, University of Utah School of Medicine ROBERT A. WINN, Associate Vice Chancellor, Community-Based Practice; Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Illinois at Chicago; Director, University of Illinois Cancer Center Project Staff ERIN BALOGH, Senior Program Officer RUTH COOPER, Senior Program Assistant ANNALEE GONZALES, Administrative Assistant EMILY ZEVON, Associate Program Officer SHARYL J. NASS, Forum Director and Director, Board on Health Care Services vi PREPUBLICATION COPY—Uncorrected Proofs

NATIONAL CANCER POLICY FORUM1 EDWARD J. BENZ, JR. (Chair), President and Chief Executive Officer Emeritus, Dana-Farber Cancer Institute; Richard and Susan Smith Distinguished Professor of Medicine, Genetics and Pediatrics, Harvard Medical School GARNET L. ANDERSON, Senior Vice President and Director, Public Health Sciences Division, Fred Hutchinson Cancer Research Center; Affiliate Professor, Department of Biostatistics, University of Washington KENNETH ANDERSON, Kraft Family Professor of Medicine, American Cancer Society Clinical Research Director, Jerome Lipper Multiple Myeloma Center, Harvard Medical School, Dana-Farber Cancer Institute WILLIAM L. BAILEY, Vice President, Medical & Scientific Affairs Research & Development, Helsinn Therapeutics (U.S.), Inc. KAREN BASEN-ENGQUIST, Annie Laurie Howard Research Distinguished Professor, Professor of Behavioral Science, and Director, Center for Energy Balance in Cancer Prevention and Survivorship, The University of Texas MD Anderson Cancer Center CHRISTOFFER BOSHOFF, Chief Development Officer, Oncology, Global Product Development, Pfizer Inc. CATHY J. BRADLEY, Associate Dean for Research, Colorado School of Public Health, Professor and Deputy Director, University of Colorado Cancer Center OTIS W. BRAWLEY, Bloomberg Distinguished Professor, Department of Epidemiology, Bloomberg School of Public Health, Department of Oncology, School of Medicine, Johns Hopkins University ROBERT W. CARLSON, Chief Executive Officer, National Comprehensive Cancer Network 1 The National Academies of Sciences, Engineering, and Medicine’s forums and round- tables do not issue, review, or approve individual documents. The responsibility for the pub- lished Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

NANCY E. DAVIDSON, President and Executive Director, Seattle Cancer Care Alliance; Senior Vice President, Director, and Full Member, Clinical Research Division, Fred Hutchinson Cancer Research Center; Head, Department of Medicine, Division of Medical Oncology, University of Washington GEORGE D. DEMETRI, Professor of Medicine and Director, Ludwig Center, Harvard Medical School; Senior Vice President for Experimental Therapeutics, Dana-Farber Cancer Institute; Associate Director for Clinical Sciences, Dana-Farber/Harvard Cancer Center JAMES H. DOROSHOW, Deputy Director for Clinical and Translational Research, National Cancer Institute NICOLE F. DOWLING, Associate Director for Science, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention SCOT W. EBBINGHAUS, Vice President and Therapeutic Area Head, Oncology Clinical Research, Merck Research Laboratories KOJO S. J. ELENITOBA-JOHNSON, Professor, Perelman School of Medicine; Director, Center for Personalized Diagnostics and Division of Precision and Computational Diagnostics, University of Pennsylvania AWNY FARAJALLAH, Vice President, Head, US Medical Oncology, Bristol-Myers Squibb STANTON L. GERSON, Director, Case Comprehensive Cancer Center; Professor of Hematological Oncology, Case Western Reserve University; Director, University Hospitals Seidman Cancer Center LORI HOFFMAN HŌGG, Veterans Health Administration National Program Manager, Prevention Policy, National Center for Health Promotion and Disease Prevention; National Oncology Clinical Advisor, Office of Nursing Services, Department of Veteran Affairs LINDA HOUSE, President, Cancer Support Community HEDVIG HRICAK, Chair, Department of Radiology, Memorial Sloan Kettering Cancer Center ROY A. JENSEN, President, Association of American Cancer Institutes; Director, The University of Kansas Cancer Center; William R. Jewell, M.D. Distinguished Masonic Professor, Kansas Masonic Cancer Research Institute LISA KENNEDY SHELDON, Chief Clinical Officer, Oncology Nursing Society viii PREPUBLICATION COPY—Uncorrected Proofs

SAMIR N. KHLEIF, Director, Jeannie and Tony Loop Immuno-Oncology Lab, Biomedical Scholar and Professor of Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center RONALD M. KLINE, Medical Officer, Patient Care Models Group, Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services MICHELLE M. LE BEAU, Arthur and Marian Edelstein Professor of Medicine and Director, The University of Chicago Comprehensive Cancer Center MIA LEVY, Director, Rush University Cancer Center; Associate Professor of Medicine, Division of Hematology and Oncology; System Vice President, Cancer Services, Rush System for Health J. LEONARD LICHTENFELD, Interim Chief Medical Officer, American Cancer Society NEAL J. MEROPOL, Vice President, Research Oncology, Flatiron Health MARTIN J. MURPHY, Chief Executive Officer, CEO Roundtable on Cancer RANDALL A. OYER, Medical Director, Oncology, Ann B. Barshinger Cancer Institute, Penn Medicine Lancaster General Health RICHARD PAZDUR, Director, Oncology Center of Excellence; Acting Director, Office of Hematology and Oncology Products, Food and Drug Administration RICHARD L. SCHILSKY, Senior Vice President and Chief Medical Officer, American Society of Clinical Oncology DEBORAH SCHRAG, Chief, Division of Population Sciences, Professor of Medicine, Department of Medical Oncology, Harvard Medical School, Dana-Farber Cancer Institute LAWRENCE N. SHULMAN, Professor of Medicine, Deputy Director for Clinical Services, and Director, Center for Global Cancer Medicine, Abramson Cancer Center, University of Pennsylvania DAN THEODORESCU, Director, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center VERENA VOELTER, Head, United States Oncology Clinical Development & Medical Affairs, Novartis Pharmaceuticals Corporation GEORGE J. WEINER, C.E. Block Chair of Cancer Research, Professor of Internal Medicine, and Director, Holden Comprehensive Cancer Center, The University of Iowa ix PREPUBLICATION COPY—Uncorrected Proofs

ROBERT A. WINN, Associate Vice Chancellor, Community-Based Practice; Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Illinois at Chicago; Director, University of Illinois Cancer Center National Cancer Policy Forum Staff ERIN BALOGH, Senior Program Officer RUTH COOPER, Senior Program Assistant ANNALEE GONZALES, Administrative Assistant NATALIE LUBIN, Research Assistant MICAH WINOGRAD, Financial Officer EMILY ZEVON, Associate Program Officer SHARYL J. NASS, Forum Director and Director, Board on Health Care Services x PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Proceedings of a Workshop was read in draft form by Lauren Shern and Taryn Young within the National Academies of Sciences, Engineering, and Medicine to ensure the proceedings meets institutional standards for quality and objectivity while accurately reflecting the purpose and focus of the workshop. xi PREPUBLICATION COPY—Uncorrected Proofs

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Acknowledgments Support from the many annual sponsors of the National Academies of Sciences, Engineering, and Medicine’s National Cancer Policy Forum is crucial to the work of the forum. Federal sponsors include the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health. Non-federal sponsors include the American Association for Cancer Research, American Cancer Society, American College of ­ adiology, Ameri- R can Society of Clinical Oncology, Association of American Cancer Institutes, Association of Community Cancer Centers, Bristol-Myers Squibb, Cancer Support Community, CEO Roundtable on Cancer, ­ latiron Health, ­ elsinn F H Th ­ erapeutics (U.S.), Inc., LIVESTRONG Foundation, Merck, National Comprehensive Cancer Network, Novartis Oncology, Oncology Nursing Society, and Pfizer Inc. The forum wishes to express its gratitude to the expert speakers whose presentations helped further the dialogue and advance progress to better sup- port the oncology careforce and improve the delivery of high-quality cancer care. The forum also wishes to thank the members of the planning committee for their work in developing an excellent workshop agenda. xiii PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xix PROCEEDINGS OF A WORKSHOP 1 WORKSHOP OVERVIEW 1 CANCER CARE TRENDS AND CAREFORCE NEEDS 6 Epidemiological Trends in Cancer, 7 Workforce Projections, 9 Distribution of the Workforce, 10 Clinician Burnout, 11 Complex and Time-Consuming Cancer Care, 14 Caregiving at Home, 15 OPPORTUNITIES TO ADDRESS ONCOLOGY CAREFORCE CHALLENGES 17 Organizational Opportunities, 17 Fostering High-Functioning Oncology Teams, 18 Including Caregivers on the Oncology Care Team, 19 Expanding Patient Navigation Services, 20 Integrating Palliative Care in Oncology Care, 21 Collaborating with Primary Care Clinicians for Cancer Survivorship Care, 23 Expanding Care Team Capacity with Advanced Practice Providers, 23 xv PREPUBLICATION COPY—Uncorrected Proofs

xvi CONTENTS Promoting Clinician Well-Being and Fostering a Supportive Work Environment, 24 Reducing Administrative Burdens, 25 Partnering with Community Resources, 27 Implementing Workplace Changes, 28 Technology Opportunities, 28 The Effect of New Technologies on Cancer Care, 28 Challenges of Implementing New Technologies, 36 Strategies to Improve EHRs, 38 Policies to Facilitate Adoption of New Technologies in Cancer Care, 39 Policy Opportunities, 40 New Payment Models, 41 Support for Caregivers, 43 Education, 43 Future Research, 46 WRAP-UP 47 REFERENCES 48 APPENDIX A: Statement of Task 55 APPENDIX B: Workshop Agenda 57 PREPUBLICATION COPY—Uncorrected Proofs

Boxes and Figures BOXES 1 Suggestions from Individual Workshop Participants to Enhance the Delivery of High-Quality Patient Care by Improving the Development and Support of the Oncology Careforce, 3 2 Examples of Careforce Models for Cancer Care Programs and Organizations, 29 3 Examples of Technologies to Facilitate Cancer Care, 31 4 Aetna’s Oncology Medical Home, 42 5 The Life-Sustaining Treatment Decisions Initiative of the Veterans Health Administration, 45 FIGURES 1 Cancer mortality in breast, prostate, and colorectal cancer from 1990 to 2015 by race/ethnicity, 9 2 Geographic distribution of oncology practices, 11 3 Documentation volume for outpatient visits in the United States compared with other countries, 13 4 Patient navigation as the hub of the wheel of cancer care, 21 xvii PREPUBLICATION COPY—Uncorrected Proofs

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Acronyms and Abbreviations ACA Patient Protection and Affordable Care Act ACCC Association of Community Cancer Centers AMA American Medical Association AMIA American Medical Informatics Association APP advanced practice provider ASCO American Society of Clinical Oncology CEO chief executive officer CMS Centers for Medicare & Medicaid Services CSC Cancer Support Community EHR electronic health record FDA Food and Drug Administration HPV human papillomavirus IOM Institute of Medicine NP nurse practitioner xix PREPUBLICATION COPY—Uncorrected Proofs

xx ACRONYMS AND ABBREVIATIONS OMH Oncology Medical Home ONS Oncology Nursing Society PA physician assistant PCORI Patient-Centered Outcomes Research Institute PTSD posttraumatic stress disorder SCH Symptom Care at Home VA Department of Veterans Affairs VHA Veterans Health Administration PREPUBLICATION COPY—Uncorrected Proofs

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The oncology careforce faces challenges as population growth in the U.S. contributes to increases in the number of patients diagnosed with cancer. Significant advances in cancer research, screening and diagnostic practices, and treatment have led to the age-adjusted declining mortality rate from cancer. However, as the field continues to develop and advance, cancer care has become more complex than ever before. There is a growing concern regarding the U.S. health care system’s capacity to deliver high-quality cancer care to the increasing number of patients.

The National Academies convened a workshop on February 11-12, 2019 to explore trends in cancer care and identify opportunities for improvement in the rapidly developing oncology careforce. Discussions at the workshop primarily focused on trends in demographics, the careforce, and oncology practice, as well as implications for the future of cancer care and strategies to improve the organization and delivery of cancer care. Opportunities to change policy and leverage technologies in oncology were also identified. This publication summarizes the presentations and discussions from the workshop.

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