By Matthew Kurian, MD

From chemotherapy and immunotherapy to targeted treatments, hematology/oncology is exploding with new and exciting developments each day. If one does not enjoy consistently learning, changing, and adapting, then this field will become a difficult one to keep up with. To become a good hematologist and oncologist, one needs to develop the foundation and principles of a thorough and skilled internist. As our field evolves, we must consider how we are training the next generation of hematologists and oncologists and whether that training is keeping pace with today’s rapidly changing and more subspecialized practice landscape. Hematology/oncology training typically requires 3 years of internal medicine residency followed by 3 years of combined hematology and oncology fellowship. If one’s goal is to go into only oncology, should there still be a requirement of 3 years of internal medicine training? Should benign/classical hematology still be part of combined hematology/oncology fellowship, or should it be a separate fellowship on its own? Should malignant hematology and bone marrow transplantation be a separate ACGME-sponsored fellowship? Are other oncology-related residencies or fellowships condensing their training? These are a few of the questions we face for the future of hematology/oncology training.

Radiation oncology is one field that has condensed their training in comparison to hematology/oncology. Much of their training is done within residency, with a minority of individuals pursuing additional 1-year fellowship training. Their residency consists of 5 years of training: 1 year of internal medicine followed by 4 years of radiation oncology training. During this time, they become very proficient and skilled at the practice of radiation oncology within their 4 years of experience, whereas a medical hematologist/oncologist has done 3 years of internal medicine training prior to doing 3 additional years of fellowship training. Most combined academic hematology/oncology fellowships typically only require 18 months of clinically based training with the remaining 18 months being primarily focused on research. In the end, many of these individuals end up pursuing an organ-specific malignancy and tend to practice only at academic centers. Could we consider adopting a similar structure to radiation oncology and pursue 1 to 2 years of internal medicine followed by 2 to 3 years of hematology- or oncology-specific training? Should trainees focus on specific organ systems if they are going into academia? Unfortunately, there is no data to show how program directors, current oncologists, and current hematology/oncology fellows at community and academic programs feel regarding this issue. This is an area where we need to collect more data regarding the attitudes toward hematology/oncology as an ever-evolving field.

The ACGME requires that fellows have a minimum of 18 months of clinical experience during their fellowship. In my own and others’ experience, many fellows feel proficient to practice general oncology after 2 years of fellowship training. The last year of my academic fellowship, I dedicated my time mostly to administrative chief fellow duties, lectures, teaching, research projects, conferences, and studying for our board examinations. The last 18 months of fellowship reserved for clinical or bench research is mainly beneficial for those pursuing a career in academia. The number of clinical hours during this time is severely reduced compared to the first 18 months of fellowship training, to the extent that many fellows feel they lose their clinical skills during this time. By omitting this portion in community programs or those pursuing community oncology in academic programs, it could encourage more individuals to go into oncology and help with an overall shortage of oncologists.

In 2007, a study co-published by ASCO and the Association of American Medical Colleges (AAMC) predicted a major shortage of oncologists by 2020 with demand rising by almost 48%. The study surveyed fellows starting their fellowship, recently graduated fellows, program directors, and 4,000 oncologists across the United States. It then calculated the demand for visits based on the SEER database in 1998-2002 compared to the National Cancer Institute’s cancer incidence and prevalence projections at the time. The study described that there were several factors responsible for the predicted workforce shortage, including a low number of residents going into hematology/oncology, increased demand due to an aging population living longer, increased retirement rates within the field, and physician dissatisfaction with practice or governmental regulations leading to increasing rates of burnout.¹

In 2018, ASCO released “Key Trends in Tracking Supply of and Demand for Oncologists” based on the data from the American Medical Association. From 2007-2017 it was noted that the composite number of hematologists involved in patient care declined by 5.5% and oncologists declined by 5%. Roughly 600 to 700 new graduates per year will not be enough to outpace a heavily aging workforce. The median age was reported to be 51 and increasing to 56 to 58 in more rural states such as Indiana, Montana, West Virginia, and others.² Another report published in 2019 found that 64% of counties had no oncologists within the primary practice location in the patient’s county and an additional 12% had no access to an oncologist in an adjacent county.³ Subsequently in 2021, the ASCO “Snapshot: State of the Oncology Workforce in America” report estimated there were 13,146 oncologists in the United States. 21% of these oncologists are 64 years old or older and nearing retirement, whereas 14.5% are early-career oncologists younger than 40, with the median age being 53. Women represent 35% of all oncologists and 45% in hematology/oncology fellowship programs. Only 11% of oncologists work in “rural” areas, with the fewest numbers working in the West North-Central and West South-Central Regions.⁴ The following 2022 ASCO Snapshot stated that only 4.7% of oncologists identified as Hispanic or Latino while only 3% were Black or African American and had limited roles in leadership, medical school faculty, and research. ASCO’s goal of increasing diversity to truly represent the American population is critical to increasing equity in cancer prevention, screening, care, and outcomes.⁵

In a letter to readers published in Oncology, Julie M. Vose, MD, MBA, explained that the simple response should be to increase the number and diversity of hematology/oncology fellows to meet this unmet demand, along with creating additional support for oncologists in the form of oncology pharmacists, advanced practice providers, oncology nurses, and additional support systems.⁶ I propose an updated and separated structure for hematology/oncology fellowship for the future to help meet this high demand for both hematologists and oncologists.

George Washington University conducted a longitudinal workforce study that examined the current hematology workforce and its future output. Of 2,500 practicing hematologists, 46% reported a shortage of classical hematology specialists and 31% reported a shortage of hematologists who specialized in blood cancers.⁷ The American Society of Hematology (ASH) keenly identified this major issue and has created several ASH-sponsored fellowship programs that will only focus on benign/classical hematology and reduce the total number of years of fellowship training from 3 years to 2 years. Programs should identify and distinguish those who are wanting to pursue classical/benign hematology versus those who want to pursue more neoplastic hematologic disease and bone marrow transplant. Those who are pursuing classical/benign hematology should pursue only 2 years of dedicated training in the field given their need within their communities, and those pursuing more neoplastic hematological disease should consider extending fellowship for an additional year for those individuals or wholly focusing on neoplastic hematologic disease.

Hematology is becoming increasingly sophisticated regarding the laboratory techniques and targeted treatments for rare bleeding disorders, sickle cell disease, thrombosis, and rare neoplastic hematologic disorders. In this sense, I believe that this requires very specific training at larger academic centers under the guidance and training of hematology experts. Oncology has also become increasingly subspecialized based on organ system with most academic oncologists only focusing on one organ system in their careers. I do feel that focused solid oncology training with upfront subspecialization in academic fellowships will lead to overall better training of fellows and improved care and patient outcomes. However, there is still a vast need for oncologists to practice general oncology in areas of need. While the subspecialization of hematology and oncology is inevitable, there are ways to potentially condense post-graduate training in a way that would benefit trainees, fellowship programs, and communities in terms of time, money, and overall improved care.

A 2022 article by Dana-Farber researchers published in JCO found that only 6% of training programs were considered regional or community-based. The 94% of the remaining training programs in urban settings may not fully address the changing landscape of hematology/oncology and may not prepare individuals to take on the challenges of community practice sufficiently. Their survey found that 38% to 56% of trainees were planning on or had already committed to non-academic practice. So why have we not adapted to offer an avenue of specific training to fellows for this career path? They describe the academic community hybrid (ACH) and value-based care to meet the growing demand for hematologists and oncologists; however, there are no formal fellowship tracks for this growing field except at Dana-Farber. Those interested in going into community practice aspire to different careers—medical directors, quality and safety, policy, community outreach, pharmaceuticals, business, clinical trial engagement in the community, and education. As stated by the article, we need to rethink how we can optimize training in a more “goal-concordant” way that matches where trainees want to take their careers.⁸

In my own opinion, I believe that oncology needs general oncologists in the same way that all people need general practitioners. A lack of oncologists in rural areas and community hospitals leads to overall delays in diagnosis and treatment of patients who don’t have access to expert care at major academic centers and want to remain close to their home for treatment. One way I propose to potentially help combat this issue is to increase the number of community hematology/oncology fellowships and overall fellowship spots in both community and academic programs. If internal medicine residents/physicians could have more options to stay within their communities to get further subspecialty training, these individuals are more likely to stay serving their own communities in a generalist fashion. Many community oncology groups and hospital systems are even partially subspecializing in two to three different organ systems to ensure more expertise in a few fields as opposed to multiple fields. This model is increasingly being used in larger physician-owned and hospital employee-based community programs to allow their programs to cover a larger range of different cancers based on their patient populations and the incidence and prevalence of different cancer types in their region.

Overall, the fields of hematology and oncology are both advancing at an astronomical pace. The increasing sophistication in the diagnosis and rapid innovation of treatment options for various liquid, solid, and classical hematologic disorders make it difficult for one to be a general hematology/oncology physician. To meet the demand for both hematologists and oncologists, I believe we need to adapt the way we train our future generations. This would entail separating the combined fellowship training program into classical hematology, malignant hematology, and solid oncology fellowships and reducing the time of combined post-graduate training from a total of 6 years to 4 to 5 years based on subspecialty. Community programs with combined hematology/oncology fellowship training should still exist, but with an emphasis on solid oncology training and reducing the number of required years of fellowship training to 2 years. I believe these changes will decrease the amount of debt trainees carry over time, improve overall care within rural and community hospitals, and lead to more specialty-specific training in hematology and oncology.

Dr. Kurian is a third-year chief hematology/oncology fellow at University Hospitals, Case Western Reserve University. An ASCO member since 2017, his interests include quality improvement and medical education; he teaches at Case Western’s medical school and is also active in the internal medicine residency programs at MetroHealth Medical Center and University Hospitals. Disclosure.

References

1. Erikson C, Salsberg E, Forte G, et al. Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Pract. 2007 Mar;3:79-86.
2. ASCO. Key Trends in Tracking Supply of and Demand for Oncologists. May 2018. Accessed 15 Jun 2023.
3. Shih YT, Kim B, Halpern MT. State of Physician and Pharmacist Oncology Workforce in the United States in 2019. JCO Oncol Pract. 2021 Jan;17:e1-e10.
4. 2021 Snapshot: State of the Oncology Workforce in America. JCO Oncol Pract. 2021 May;17:249.
5. 2022 Snapshot: State of the Oncology Workforce in America. JCO Oncol Pract. 2022 May;18:396. 
6. Vose JM. The Future of Oncology: Supply and Demand for Oncology Services. Oncology. 2021;35:303. Epub Jun 26, 2021.
7. Masselink LE, Erikson CE, Connell NT, et al. Associations between hematology/oncology fellows' training and mentorship experiences and hematology-only career plans. Blood Adv. 2019 Nov;3:3278-86.
8. Roberts DA, Faig J, Bodio-Downey K, et al. Training Hematologists/Oncologists for the Academic-Community Hybrid: Creating a Fellowship Framework for the Future. JCO Oncol Pract. 2023;19:e927-e934.