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Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today our subject is radiation oncologist and an impending shortage of radiation oncologist to treat the increasing number of patients who are undergoing radiation therapy treatment. Our guest today is Dr. Benjamin Smith. He is the Assistant Professor of Radiation Oncology here at MD Anderson. Dr. Smith, you did a study about the shortage of radiation oncologists. Tell me about your study and it was published last October.
Benjamin Smith, M.D.: That is correct. Thank you very much for inviting me to participate in this podcast today. So we, our group had previously documented that the number of individuals diagnosed with cancer in the United States will increase dramatically over the next 20 years primarily due to the aging of the United States population. Between the years 2000 and the years 2030, the number of older adults in the US aged 65 and older is projected to approximately double from about 35 million older adults in the year 2000 to about 72 million older adults in the year 2030. And when we know that cancer is primarily a disease of older adults, and as a result, this dramatic increase in the number of older adults in our population translates into an expected marked increase in the number of cancer diagnosis in the US over the next 20 years. So in a paper we previously published approximately 2 years ago, we projected that the number of cancers diagnosed in the United States would increase by 45 percent between the years 2010 and 2030, an absolute increase from about 1.6 million diagnosis per year to 2.3 million diagnosis per year. And as a radiation oncologist, our next question was how is this trend going to impact the services that we provide as radiation oncologists? So we used a similar analytic framework that we used to project the total number of cancers diagnosed to then look at the number of patients receiving radiation therapy within the first course of their cancer treatment to see how that number would increase over time. And we just looked between the years 2010 and 2020 because we weren't sure that we could really prognostically keep this out through 20 years. And so what we found is between 2010 and 2020, we projected that the demand for radiation therapy, in other words the number of patients receiving treatment per year as part of their initial cancer treatment would increase by about 22 percent. And this again is largely driven by the fact that the US population is aging. And the other interesting that we were able to do with our study is that we were able to give very detailed data about the current radiation oncology workforce from the American Board of Radiology. So we received data on currently board certified radiation oncologist including their age and their gender, and also current residents in radiation oncology including their age and their gender. And so, it's a relatively simple matter than to project over the next 10 years how many radiation oncologists will be actively practicing radiation oncology. And so what we found is currently in the United States, there is about 4000 full-time equivalent radiation oncologists practicing radiation oncology. And over the next 10 years, given the current projected number of trainees per year, this number will only increase by about 2 percent. So we find--we found a real disconnect between growth and demand and growth and supply, a 22 percent growth in demand compared to a 2 percent growth in supply or a 10 fold discrepancy in the growth of these two parameters.
Lisa Garvin:What does this mean in the short term for patients who require radiation therapy?
Benjamin Smith, M.D.: I think for the--in the very short term, the general perception amongst radiation oncologists is that there is sufficient supply to treat patients. But my concern is not in the next 1 or 2 years but more 10 years from now that we may find ourselves in an environment where the consults just keep coming in and is very difficult to schedule everyone and get everyone's treatment started within a timely fashion.
Lisa Garvin: And you said that it's really not a question of fewer people wanting to be radiation oncologist. It's just that demand is outstripping supply.
Benjamin Smith, M.D.: That's correct, actually radiation oncology is one of the most highly sought after medical specialties currently, and there is various metrics that you can look at the number of MD/PhDs entering radiation oncol--or the percentage of MD/PhDs entering radiation oncology residency is higher than any other specialty in the country. If you look at metrics like board scores or number of applications per number of slots, radiation oncology ranks in the top 3 or 4 specialties. So there certainly is an interest amongst medicals students in going into radiation oncology. Currently, there is a bout 160 training slots per year in radiation oncology. And even if we were to maintain that level of trainee positions, the workforce would only grow by no more than about 4 percent over the next 10 years, indicating still a big discrepancy between demand and supply.
Lisa Garvin: That's quite a chasm, I mean is there--it sounds like you would have to graduate a lot more people through residency programs per year. It sounds and almost untenable number.
Benjamin Smith, M.D.: Right. So in our model it indicated that we would have to have 280 residents graduate per year, basically about double the current number of trainees in order for the growth in supply to be equal to the growth in demand.
Lisa Garvin:You mentioned in your study that you had three big recommendations to kind of fill the gap in the short term since we can't graduate, you know, new oncologists any faster. What were those three? Well, the first one was talking about using like a patient management team model. Explain.
Benjamin Smith, M.D.: Right. So at MD Anderson for example, I work in a team typically with a midlevel practitioner which would mean either a physician assistant or a nurse practitioner and also a nurse. And I have to say that working in that team rather than just working by myself certainly maximizes my efficiency and my ability to care for more patients without compromising the quality of a patient's care. So I think moving towards more of a team model can really help to optimize the efficiency of the radiation oncologist to treat the most number of patients safely without compromising care.
Lisa Garvin: And your second point was providing shorter radiation treatment courses. Typically, excluding proton, most radiation patients go once a day for 5 days a week, is that correct?
Benjamin Smith, M.D.:That's correct.
Lisa Garvin:How would you go about shortening the treatment regimen?
Benjamin Smith, M.D.: Right. So a standard treatment for breast cancer is daily treatments Monday through Friday for 6 weeks or 30 treatments. For prostate cancer, patients can go up to 8 weeks of daily radiation treatments, so very long courses of treatment. In countries where there has historically been more pressure to economize delivery of care, for example Canada and the United Kingdom, there have been randomized clinical trials which have been done which have compared shorter courses of radiation therapy to longer courses of radiation therapy. And a classic example is breast cancer. Last year there was a randomized clinical trial published in the New England Journal of Medicine which showed that a 3-week course of radiation therapy to the breast was equivalent to a 5-week course of radiation therapy to the breast both with respect to tumor control and long term side effects. Now, there is always some difficulty in applying data like that to our own patient population that we treat here. And actually to help bridge that gap, I've helped to launch a clinical trial in our own breast cancer radiation group where we're comparing a 4-week course of radiation to a 6-week course of radiation, so essentially decreasing the length of radiation by a third. And so, I feel very strongly that research along those lines is very important to try to figure out how we can offer the most efficient and cost effective treatment to our patients and also help to increase our capacity to provide care without increasing the number of physicians or the number of treatment machines.
Lisa Garvin: What role do you see advanced technology playing such as brachytherapy like Accelerated Partial Breast Irradiation or even proton therapy?
Benjamin Smith, M.D.: Sure. So some technology actually is much more labor intensive. So for example, Accelerated Partial Breast Irradiation requires much more--even though it's completed in a week, requires much more physician time and involvement than of 5 or 6 week course of whole breast irradiation. So similarly, there are some complex new technologies like intensity-modulated radiation therapy which can actually require much more resources than simpler radiation techniques. So in some ways, new technology is actually to our detriment because it might actually increase the amount of physician time involved in planning and executing radiotherapy. In other cases, new technologies might be beneficial for increasing capacity. And so, one example I would think of is the treatment of early stage medically inoperable lung cancer. When I was a trainee, those patients were typically treated on a daily basis Monday through Friday for 6, 7 weeks of treatment. And there is now very good data to suggest that shorter courses of treatment, either a 5-day treatment course or a 10-day treatment course actually confers better tumor control rates and that type of treatment also is, although is slightly more labor intensive for physicians doesn't consume a giant amount of physician resources. So I could certainly see that that type of new technology is very beneficial and will help to increase capacity. So I think you have to take all of the technologies on a case by case basis.
Lisa Garvin: And the third recommendation from your paper was simple, just increase the size of the residency programs. How--you said we would probably need to double that. How do you go about increasing residency opportunities?
Benjamin Smith, M.D.: Yeah. So there has been a gradual increase in the number of residency positions over the last decade. When I applied for a residency position in the fall of the year 2000, there were about 100 positions available in the country. And the most recent match here to my recollection, there are about 160 positions available in the country. So certainly there has been an increase in the number of training slots in response to both the demand for radiation therapy and the interest amongst medical students and radiation oncology. And typically these numbers of positions can only increase gradually because they are predicated upon an individual institution having sufficient numbers of patients to support training and additional radiation oncologist. So we train about 25 radiation oncology residents at MD Anderson. We couldn't just turn around and increase that number to 50. That would be a major logistical hurdle but maybe we could increase to 26 or 27 and slowly grow the program. But it's not--these are not the kinds of changes that where you can double a residency program overnight.
Lisa Garvin: And you're not having problems. Obviously, you know, new residents are joining the ranks every year but are you having a problem with the aging of the current crop of radiation oncologists. Is that an issue or are--they're getting out of--they're retiring.
Benjamin Smith, M.D.: Yeah, it's a good question. And I don't know that that's been studied very well in the past several years. There are multiple factors that impact a physician's decision to retire. One factor may be a sense of burnout or feeling overwhelmed. Then it's possible if our patient number has increased, people may choose to retire more quickly. Another factor might be one's feeling of preparedness for the financial realities of retirement and given the recent financial crisis I think some physicians may be less inclined to retire. So I think the decision to retire is multifactorial and probably could vary a great deal from year to year depending on multiple extrinsic factors.
Lisa Garvin: Now, any delay in administering radiation treatment, it is a problem, is it not?
Benjamin Smith, M.D.: That's correct.
Lisa Garvin:I mean the earlier you get the treatment, the better off you're going to be.
Benjamin Smith, M.D.: Especially for rapidly growing cancer, so this has been studied very well in head and neck cancer. And say a patient is diagnosed with a head and neck cancer, in my mind the clock starts ticking the second you get the biopsy back that says that they have a cancer. And these cancers can double up to every 3 to 5 days, at least potentially double that quickly. And so, it's very incumbent upon the entire team of physicians treating the patient to complete care quickly in order to optimize control of the disease and the patient's survival. So for example a patient has surgery to remove a cancerous tumor in the throat, they really need to get their radiation started within 4, 5, or 6 weeks. And a lot of things happen, have to happen in order for the patient to start their treatment on time. And if we have a waiting list of just getting patients in the door, that really has the potential to compromise patient's outcome in a significant and meaningful way. So it's very important that we have sufficient resources to accommodate patients and get their treatment started in a timely manner.
Lisa Garvin: Sounds like you have a steep hill to climb.
Benjamin Smith, M.D.: The next 10 years will be interesting.
Lisa Garvin: So where do you--based on your study in your research, what's your next step?
Benjamin Smith, M.D.: Yeah, so the next step is actually already happening. So I'm part of a workforce, task force that's been created by the American Society for Radiation Oncology, ASTRO. And we are working on putting together a survey of the current work force. And this survey will target not only radiation oncologists but radiation therapists, dosimetrists, physicists and nurses and try to get a picture from the entire care team that delivers radiation therapy. The survey is targeted at multiple questions but one of the key questions is to assess the current level of excess capacity in the system. So for example if everyone feels like we could accommodate a 10 percent increase in patient load with no adverse effects, then half of our problem is solved right there. So that's really the first step is to define and measure the amount of capacity in the current system, and then from there try to devise strategies to meet whatever excess demand for a capacity is there that cannot be accommodated by the current system.
Lisa Garvin: How does--and of course MD Anderson has four regional care centers which basically started out as radiation treatment centers, does making it more convenient for the patient help? Probably not but I don't know, I'm just throwing that out there.
Benjamin Smith, M.D.: Yeah, well MD Anderson has certainly been at the forefront of trying to bring radiation therapy to where people live. And there is a lot to be said for that. I'm not sure that the regional care model necessarily increases capacity in and of itself for a given number of physicians. But I certainly think from a patient perspective to optimize their care. In many instances it's great and helpful for their overall care and quality of life during radiation if we can bring the treatment to them rather than always make the patient come to us.
Lisa Garvin: Sounds like a work in progress. Thank you very much. If you have questions about anything you've heard today on Cancer Newsline, contact askMDAnderson at 1-877-MDA-6789, or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. [Background music] Tune in next week for the next podcast in our series.
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