A 15-Year Analysis of Supply and Demand for Hematology and Oncology Training in the United States.

PURPOSE: There is a paucity of research on the supply of the hematology and oncology workforce despite projected shortages in the United States Over the past 15 years of the hematology and oncology match (HOM), we hypothesized that there would be more growth in the number of training positions relative to applicants, higher match rates for US allopathic graduates relative to non-US allopathic graduates, and fewer applicants matching at their top fellowship choices. METHODS: This was a national, retrospective cohort study of all applicants in the HOM (2009-2023). Match rates and applicant-to-training position ratios were calculated and compared over time with Pearson tests. RESULTS: Growth in the number of annual training positions (426-708; 66% increase) exceeded growth in the number of interested applicants (706-945; 34% increase; P < .001). Annual applicant-to-training position ratios decreased from 1.7 to 1.3 (r = -0.813; P < .001). Match rates increased over the study period for both US allopathic graduates (79%-88%; r = 0.761; P = .001) and non-US allopathic graduates (45%-63%; r = 0.801; P < .001). During each year, match rates for US allopathic graduates exceeded those for non-US allopathic graduates (P < .001). From 2018 to 2023, US allopathic graduates (83%) had higher match rates than US osteopathic graduates (60%) and international medical graduates (50%; P < .001). The percentage of applicants that matched at one of their top three fellowship choices increased from 53% to 60% (r = 0.480; P = .070). Fewer available annual training positions went unfilled over the study period (3%-0.3%; r = - 0.870; P < .001). CONCLUSION: Match rates have increased in the HOM but remain competitive especially for non-US allopathic graduates. Future investigation is needed to understand disparities in match outcomes by additional applicant and fellowship program characteristics. Ongoing surveillance of HOM outcomes remains critical given the projected shortages in the US hematology and oncology workforce.

Cetuximab-Based vs Carboplatin-Based Chemoradiotherapy for Patients With Head and Neck Cancer.

Importance: Cetuximab-based and carboplatin-based chemoradiotherapy (CRT) are often used for patients with locally advanced head and neck cancer who are ineligible for cisplatin. There are no prospective head-to-head data comparing cetuximab-based and carboplatin-based regimens for radiosensitization. Objective: To compare survival with cetuximab-based and carboplatin-based CRT in locally advanced head and neck squamous cell carcinoma (HNSCC). Design, Setting, and Participants: This cohort study included US veterans who received a diagnosis of HNSCC between January 2006 and December 2020 and were treated with systemic therapy and radiation. Data cutoff was March 1, 2022 and data analysis was conducted from April-May 2022. Exposures: Cisplatin, cetuximab, or carboplatin-based systemic therapy as captured in VA medication data and cancer registry. Main Outcomes and Measures: Overall survival by systemic therapy was estimated using Kaplan-Meier methods. We used propensity score and inverse probability weighting to achieve covariate balance between cetuximab-treated and carboplatin-treated patients and used Cox regression to estimate cause-specific hazard ratios of death associated with carboplatin vs cetuximab. We also performed subgroup analyses of patients with oropharynx vs nonoropharynx primary sites. Results: A total of 8290 patients (median [IQR] age, 63 [58-68] years; 8201 men [98.9%]; 1225 [15.8%] Black or African American and 6424 [82.6%] White individuals) with nonmetastatic HNSCC were treated with CRT with cisplatin (5566 [67%]), carboplatin (1231 [15%]), or cetuximab (1493 [18%]). Compared with cisplatin-treated patients, patients treated with carboplatin and cetuximab were older with worse performance status scores and higher comorbidity burden. Median (IQR) overall survival was 74.4 (22.3-162.2) months in patients treated with cisplatin radiotherapy (RT), 43.4 (15.3-123.8) months in patients treated with carboplatin RT, and 31.1 (12.4-87.8) months in patients treated with cetuximab RT. After propensity score and inverse probability weighting, carboplatin was associated with improved overall survival compared with cetuximab (cause-specific hazard ratio, 0.85; 95% CI, 0.78-0.93; P = .001). This difference was prominent in the oropharynx subgroup. Conclusions and Relevance: In this cohort study of a US veteran population with HNSCC undergoing treatment with CRT, almost a third of patients were ineligible to receive treatment with cisplatin and received cetuximab-based or carboplatin-based radiosensitization. After propensity score matching, carboplatin-based systemic therapy was associated with 15% improvement in overall survival compared with cetuximab, suggesting that carboplatin may be the preferred radiosensitizer, particularly in oropharynx cancers.

Underrepresentation in Oncology: Identifying and Addressing Structural Barriers.

Underrepresentation of minority groups in the oncology physician workforce is a pressing issue that may contribute to disparities in cancer research, clinical care, and patient outcomes. To address this, we highlight the role of medical culture and institutions in perpetuating a range of barriers that lead to the persistent underrepresentation of minority medical trainees and physicians. These barriers include an exclusionary medical culture, bias in measures of merit, financial barriers to medical subspecialty training, underrecognition of achievement, and poor representation and satisfaction among underrepresented faculty. Furthermore, we suggest a more intentional approach to diversity that values both recruitment of underrepresented undergraduates and early medical students and retention of internal medicine trainees, hematology-oncology fellows, and faculty. To counteract deeply embedded structural racism that hampers diversity efforts, this multifaceted approach will require cultural transformation of our medical institutions at all levels, including increased institutional transparency, mandatory evidence-based bias training, acknowledgment of varied achievements, changes in recruitment practices, and reinvigoration of pipeline development programs with a focus on financial support. Taken in combination, programs should recognize the scope of deterrents to representation and develop program-specific, longitudinal interventions to promote more successful diversity initiatives within the field of oncology. IMPLICATIONS FOR PRACTICE: The medical profession recognizes the value of physician workforce diversity in improving the quality of both medical education and patient care. In return, medical schools and training programs invest in recruitment programs focused on candidates who are underrepresented in medicine. In the field of oncology, where stark racial and ethnic disparities in care and health outcomes are well-defined, measures of minority physician representation remain especially stagnant. This study clearly defines the barriers that limit the effectiveness of such programs and provides recommendations to achieve the necessary workforce diversity in oncology.

Preparing Trainees to Deliver High-Value and Cost-Conscious Care in Hematology.

PURPOSE OF REVIEW: Despite national-level directives to reduce healthcare waste and promote high-value care (HVC), clinical educators struggle to equip trainees with the knowledge and skills needed to practice value-based care. In this review, we analyze ongoing efforts in graduate medical education (GME) to enhance trainee competence in delivery of high-value and cost-conscious care. RECENT FINDINGS: Surveys of residents and program directors have shown that while many training programs want to offer formal training in high-value care delivery, few succeed. Although several studies suggest that trainees model stewardship behaviors after clinical preceptors, there remains a shortage of faculty role models skilled in providing HVC. Preparing future hematologist-oncologists to provide cost-conscious care will require significant cultural change at the institutional and program levels and will depend heavily on the development of skilled clinical role models.

Views From Patients With Cancer in the Setting of Unplanned Acute Care: Informing Approaches to Reduce Health Care Utilization.

PURPOSE: New oncology care delivery models that avoid preventable acute care are needed, yet it is unclear which interventions best meet the needs of patients and caregivers. Perspectives from patients who experienced unplanned acute care events may inform the successful development and implementation of care delivery models. METHODS: We performed a qualitative interview study of patients with solid tumors on active treatment who experienced the following 3 types of unplanned acute care events: emergency department visits, first hospitalizations, and multiple hospitalizations. Patients were prospectively recruited within a large academic health system from August 2018 to January 2019. Interviews followed a semi-structured guide developed from the Consolidated Framework for Implementation Research. The constant comparative approach was used to identify themes. RESULTS: Forty-nine patients were interviewed; 51% were men, 75% were non-Hispanic White, and the mean age was 57.4 years (standard deviation, 1.9 years). Fifty-five percent of patients had metastatic disease, and 33% had an Eastern Cooperative Oncology Group performance status of 3-4. We identified the following key themes: drivers of the decision to seek acute care, patients' emotional concerns that influence interactions with the oncology team, and strategies used to avoid acute care. Patients' recommendations for interventions included anticipatory guidance, peer support, improved triage methods, and enhanced symptom management. Patients preferred options for virtual and home-based outpatient care. CONCLUSION: Patient-centered care models should focus on early delivery of supportive interventions that help patients and caregivers navigate the unexpected issues that come with cancer treatment. Patients advocate for proactive, multidisciplinary supportive interventions that enable home-based care and are led by the primary oncology team.

Patient Perspectives on the Ethical Implementation of a Rapid Learning System for Oncology Care.

INTRODUCTION: A rapid learning system (RLS) of health care harnesses data generated from routine patient care to create a virtuous cycle of data collection and analysis for quality improvement and research. The success of such systems depends on understanding patient perspectives regarding the ethical issues that arise from the ongoing implementation of this transformative concept. METHODS: An interview guide was designed to evaluate patient perspectives to inform the ethical implementation of an oncology RLS. A purposively selected, diverse sample of 32 patients with cancer was recruited from two institutions to participate in semistructured, in-depth interviews for formal qualitative analysis. RESULTS: The extent to which respondents expressed discomfort with more permissive system features (less formal notification/consent, broader uses/users, inclusion of sensitive data) reflected their trust, which in turn seemed to vary by sociodemographic features. It was also influenced by their familiarity with technology and their attitudes and beliefs regarding privacy and the use of electronic medical records more generally. Distrust of insurers and the pharmaceutical industry led subjects to desire greater oversight and restriction of these potential users of the system. Subjects were most comfortable when doctors were the primary users, engaged patients directly in the notification and consent discussion, and oversaw the system. CONCLUSION: Those actively developing RLSs should recognize the critical importance of trust and the key role that doctors will need to play in order for such systems to be successful and to ensure that their implementation is ethically palatable to the patients whose data are being included.