By Pascal Jean-Pierre, PhD, MPH

Working with the ASCO Workforce Advisory Group (WAG) has been an enriching learning experience that highlights the challenges of a foreseeable significant oncology workforce shortage in the United States by the year 2020.^1,2,3 The aging population of the U.S. is a major factor driving the predicted shortage of oncology care providers. Other factors influencing the predicted shortage include retirement of practicing oncologists without adequate new oncologists to replace them, and growing demand for oncology services due to increases in cancer incidence and cancer survivors.¹ In addition to practicing oncologists, the predicted workforce shortage will involve other health care disciplines critical to optimal cancer-related care: for example, surgical oncology, radiology, nursing, physician assistants, social work, pharmacy, biomedical research, behavioral sciences, and other health-related specialties.³

Treating patients with cancer is a complex process at every point on the cancer care continuum, from screening to diagnosis, and from treatment decisions to treatment and completion. The multifaceted process of cancer care occurs within the context of a larger broken U.S. health care system,⁴ which may very well further exacerbate the difficulties of an insufficient oncology workforce. Challenges in health and health care access in the U.S. are likely to have a much greater and life-threatening impact on people from our most vulnerable populations, specifically, individuals from medically underserved and underrepresented racial-ethnic minorities, lower socioeconomic groups, and rural communities. A shortfall of oncology workers will have more critical adverse health outcome consequences and cancer-related morbidity and premature death for people in these groups.

Prior to my ongoing volunteer work with the ASCO WAG, I had a unique opportunity to serve on the ASCO Health Equity Committee (2014–2016). Additionally, my research program focuses on both the biobehavioral adverse effects of cancer and its treatments on the brain and its cognitive function, fatigue, and psychological distress, as well as timely access to equitably beneficial cancer care for racial-ethnic minorities and people living in poverty. My research interest and experience in cancer health inequities have informed my thinking and discussions with many colleagues about the impact of an oncology workforce shortage.

One of these interesting discussions occurred with my colleague Dr. Minggui Pan. We were at Reagan National Airport just outside of Washington, DC, awaiting our flights after having attended a WAG meeting at ASCO headquarters in nearby Alexandria. Briefly, we discussed our involvement with the WAG and volunteering experiences on other ASCO committees, clinical and research oncology interests, and our efforts to help ameliorate cancer health disparities and inequities for individuals from underserved racial-ethnic minorities, lower incomes, and those receiving treatment at Veterans Administration hospitals. Health care disparities and inequities in cancer-related care are well documented, and many efforts have been undertaken to improve the cancer care experience for multicultural and medically underserved populations. Our conversation inspired this article.

The Challenges of an Insufficient Workforce in a Broken System

Progress in early cancer screening and detection, advances in cancer therapeutics, and timely treatment initiation have resulted in decreased cancer mortality rates and increased cancer survival. Unfortunately, despite advancements in cancer detection and treatment, underserved racial-ethnic minorities—especially black and Hispanic populations—and those from underserved lower income and geographically isolated rural areas (irrespective of race and ethnicity) continue to experience difficulty accessing timely and equitably beneficial cancer-related care.

The challenges of an insufficient oncology workforce will most definitely worsen problems associated with accessing optimal cancer-related care for individuals from medically underserved racial-ethnic minorities, lower socioeconomic groups, and geographically isolated rural areas in the U.S. Systematic differences in health care and health outcomes based on race-ethnicity, socioeconomic level, and access to health care resources are socially determined and changeable. Albeit difficult, sociopolitical factors that prevent achievement of equitably beneficial health care and health outcomes across diverse communities can be improved. Strategies to address the forthcoming shortage in the oncology workforce need to particularly consider ways to ameliorate health conditions for our most vulnerable populations. Some of these strategies include facilitating opportunities to ensure access to quality cancer care and promoting multidisciplinary collaborations in underserved communities.

Strategies to build capacity to mitigate the impact of an expected oncology workforce shortage on medically underserved populations should consider and integrate community-based approaches that have been shown to reduce cancer disparities. Some of these capacity building strategies include working with communities and relevant health care stakeholders (e.g., private and public health care insurance groups, community clinics, and training institutions) to identify ways to develop and systematically align health care resources with the cancer-related needs of underserved populations. Additionally, capacity building efforts can focus on complementary approaches that involve recruitment and retention of oncology professionals, expanding the cancer care model to integrate other clinical service providers (e.g., physician assistants, nurse practitioners, and other oncology and allied health care professionals), working with family caregivers and home health care agencies, and promoting collaborations between cancer centers, community clinics, and other training institutions.³

Florida State University College of Medicine: A Successful Model

Another approach involves recruiting and promoting the training of future oncology professionals from targeted communities where it is difficult to employ and retain oncologists and other cancer care professionals. This approach has been successfully applied to address a shortage of physicians in medically underserved communities. For instance, the Florida State University College of Medicine (FSU COM) was founded to address the need for primary care physicians in Florida, especially those caring for elderly and underserved patients.^5,6 The Florida legislature passed House Bill 1121/Senate Bill 1692, which was signed into law by Governor Jeb Bush in June 2000, to create FSU COM—with a mission to serve the health care needs of Floridians through an innovative community-based model of medical education.

FSU COM’s model of program delivery and training was designed to develop physicians who will help address the unmet health care needs of Florida’s vulnerable populations, especially elderly patients, and those from geographically isolated rural communities, underrepresented racial-ethnic minorities, and lower income populations.^5,6 From its inception, an important aspect of FSU COM has been a focus on recruiting students interested in practicing in medically underserved areas, as well as qualified applicants from those underserved areas.

The FSU COM strategy has proven successful: More than half of FSU COM alumni are caring for patients in communities throughout Florida that have historically struggled to recruit new physicians, including Apalachicola, Blountstown, Bonifay, Clermont, Mariana, Quincy, and other medically underserved, lower income, and/or geographically isolated areas in the state.

Developing a mission-focused approach that includes community engagement, collaboration, and support from legislative and health care policy stakeholders could help identify, develop, and allocate needed resources to address the cancer care needs of vulnerable communities and medically underserved populations likely to be most significantly impacted by a shortage in the oncology workforce. In fact, there may be a benefit to developing and implementing capacity building strategies similar to the FSU COM model of training that are more responsive to unmet oncology care needs in the U.S., specifically for medically underserved racial-ethnic minorities and those from lower income and underrepresented rural communities. Also, 85% of patients with cancer in the U.S. receive care in community oncology settings. Thus, promoting community-based approaches to address the oncology care needs of medically underserved and vulnerable populations is a promising endeavor.

Additionally, ASCO has successful and well-developed volunteer programs (e.g., Cancer Prevention Committee, Health Equity Committee, Workforce Advisory Group, and Clinical Practice Committee, to name a few) that provide opportunities for members to contribute to advancing its mission of conquering cancer and promoting the highest quality patient care. Perhaps opportunities could be developed to help volunteers interface with relevant communities to promote understanding and community-based approaches to building capacity to address the needs of vulnerable patients with cancer.

The projected shortage in the oncology workforce is a major problem with serious implications for medically underserved and lower income populations. The health care needs of individuals in these groups should be central to discussions and strategies for improving our health and oncology care systems.

References

1. Erikson C, Salsberg E, Forte G, et al. J Oncol Pract. 2007;3:79-86.
2. Hortobagyi GN, ASCO. J Clin Oncol. 2007;25:1468-9.
3. Institute of Medicine (US) National Cancer Policy Forum. 2009. Ensuring Quality Cancer Care Through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary. Washington, DC: National Academies Press; 2009. DOI: 10.17226/12613.
4. Hoffer EP. Am J Med. 2019 Feb 26. pii: S0002-9343(19)30155-X. DOI: 10.1016/j.amjmed.2019.01.040. [Epub ahead of print].
5. Hurt MM, Harris JO. Acad Med. 2005; 80:973-9.
6. Fogarty JP, Littles AB, Romrell LJ, et al. Acad Med. 2012; 87:1699-704.