Coping With a Shortage of Cancer Doctors

Over the next decade it will get harder and harder for cancer patients to find a doctor, according to a new report released Tuesday in the Journal of Oncology Practice. The cause: an oncoming crush of cancer patients which will create a demand for care that dwarfs the supply of doctors able to provide it.

Advances in cancer-fighting medicine and technology have resulted in increasing numbers of cancer survivors. At the same time, an aging and significantly large population of baby boomers will mean an increase in cancer diagnoses as this pivotal group passes 65, the age at which cancer rates spike. Add to the mix a slowing growth in the supply of oncologists, and according to the authors of the study, the result is a drastic shortage of oncologists by 2020, just as cancer rates in the country are expected to soar.

Even current figures are worrisome. There are about 10,400 oncologists in the United States today with roughly 500 new ones entering the workforce each year. Yet, an estimated 1.4 million people will be diagnosed with cancer in 2007. Looking ahead, the study predicts a 48 percent jump in cancer incidence and an 81 percent increase in Americans living with or surviving cancer in the years leading up to 2020. But the crunch might be felt even earlier as oncologist caseloads rise. "It will likely get tougher to get an appointment with an oncologist over the next few years," predicts one of the study's authors, Edward Salsberg, director of the Center for Workforce Studies at the Association of American Medical Colleges, which conducted the study.

If a boomer does manage to get penciled in, they still may not have much cause for celebration. "The medical oncologist of the future might be more of a team leader," says Michael Goldstein, chair of the ASCO (American Society of Clinical Oncology) Workforce in Oncology Task Force and an oncologist at Beth Israel Deaconess Medical Center in Boston. "There will be less face-to-face time with a single patient." Once a patient is treated, she will be more likely to be seen by a primary-care physician and less likely to receive follow-up care from an oncologist, who would need to focus on urgent or new cases, not continued care. It's a potential trend that has only 15 percent of surveyed oncologists convinced it might alleviate the shortage. Study author Salsberg suggests this might be due to the fact that "many oncologists have already heard that there will be a shortage in primary-care doctors as well, or it's because cancer care has gotten so complicated that you really do need to be seen by a specialist."

The anticipated strain on the health care system by the demands of the boomer generation is daunting—particularly in the cancer fields. At present, there are 27 oncologists for every 100,000 Americans over the age of 65, and total patient caseloads per doctor are up. Meanwhile, the Census Bureau predicts the number of Americans over the age of 65 will double by 2030. Compounding the problem, the existing supply of oncologist providers is due to fall short by as many as 4,080 by the year 2020. (The study focuses on medical oncologists—usually the main caretakers of cancer patients as well as hematologist oncologists, who focus on cancers of the blood, and gynecological oncologists. There was little data available on pediatric, surgical and radiation oncologists, a smaller group that accounts for less than one quarter of all oncologists nationwide.)

The reasons for the dwindling number of oncologists are two-fold: more than half of today's oncologists are close to retirement; at the same time there is a nationwide limit on the number of oncology fellowship training slots because of what critics argue were faulty projections in the past. "In the mid-90s, policy planners predicted there would be a surplus of 165,000 doctors in 2020," says Dr. Richard Cooper, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, whose work is mentioned in the study, and who has been a leader in warning of an impending physician shortage across all fields for the past decade. "It was clear to me back then the basis for their projections were not valid. No one understood at the time that technological advances would increase demand for services, not the other way around." For example, he says that in oncology, there is new technology for treating lung cancer. "Before that technology, it's true, you wouldn't need more doctors—that's because, before the technology, people simply died." He says there are about 10 million cancer survivors currently living in the United States.

The numbers suggest that a staggering number of patients may end up going without the specialized cancer care they need. According to the study, the demand for visits to oncologists will rise 48 percent by 2020 just as the population over 65 doubles, but that the actual number of visits will only increase by 14 percent, leaving a shortfall of 9.4 to 15.1 million visits. Even now, only 47 percent of cancer patients are seen by medical or gynecological oncologists. And by 2020, the study suggests that oncologists will be in "a state of acute shortage."

Part of that shortage is due to a generational difference between oncologists themselves, with older doctors trumping their younger colleagues when it comes to productivity. While exact numbers were not given, the study reports that oncologists between 45 to 64 years of age see more patients per week than oncologists at the beginning of their careers. It takes several years to build up a practice, but lifestyle also plays a role. "Younger oncologists want more personal time and they have to balance family concerns. We don't know yet if this is a historical pattern or a generational change," Salsberg tells NEWSWEEK. He adds that preliminary data, so far unpublished, suggests that among female oncologists under 50, nearly a quarter are working only part time, especially those in private practice. Many younger professionals are also drawn to medical professions like dermatology or allergy and immunology, says fellow study author Goldstein, "where there is more control over schedule." If the younger generation continues to have a lower productivity rate than older physicians, the shortage of visits could increase by yet another 4.8 million, the study warns.

Goldstein says that oncologists themselves are already feeling the shortage. "We started to feel the strains of this impending shortage in 2003. Some private practices have had to wait two to three years to recruit oncologists. If the practice is in San Francisco or somewhere desirable, there's no problem. But if you're in parts of the Midwest, the South, or an inner city, you get problems."

A second phase of the study, which will focus on recommendations, will be presented by the end of the year. But it is already clear that it will be impossible to make up for the shortfall by just training more oncologists, due to both the present limits on fellowships, and the years it takes to train an oncologist. Instead, study authors are calling for a system-wide reform to what they call the looming crisis. Sixty-one percent of oncologists surveyed said a reduction of paperwork and regulations would increase efficiency. Other scenarios that could alleviate the shortage include a 50 percent increase in training slots, delayed retirement of older oncologists, and joint initiatives with non-oncologists, like primary-care physicians and hospice workers, to help pick up some of the workload. Cancer vaccines, like Merck's cervical cancer vaccine Gardasil and recent advances in treatment for kidney cancer might make a small dip in the cancer rate, says Dean Bajorin, co-chair of the American Society of Clinical Oncology's Workforce Implementation Working Group at Memorial Sloan-Kettering Cancer Center in New York. At the same time, lifestyle factors that can increase the likelihood of malignancies, like increased obesity rates, might further burden the system.

But wealthy baby boomers probably don't have to worry, says Goldstein. "The rich will always get what they want."