Ensuring Quality Cancer Care Through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary (2009)

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National Cancer Policy Forum Margie Patlak and Laura Levit, Rapporteurs 

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, N.W.  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by Contract Nos. HHSN261200611002C, 200-2005- 13434 TO #1, and 223-01-2460 to #27, between the National Academy of Sciences and the National Cancer Institute, the Centers for Disease Control and Prevention, and the Food and Drug Administration, respectively. This study was also supported by the American Cancer Society, the American Society of Clinical Oncology, the Association of American Cancer Institutes, and C-Change. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13:  978-0-309-13671-6 International Standard Book Number-10:  0-309-13671-7 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover art created by Tim Cook and used with permission from the National Institutes of Health, 2004. Suggested citation: IOM (Institute of Medicine). 2009. Ensuring Quality Cancer Care Through the Oncology Workforce: Sustaining Research and Care in the 21st Century: Work- shop Summary. Washington, DC: The National Academies Press. 



The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a man- date that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the N ­ ational Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org 

WORKSHOP PLANNING COMMITTEE Betty Ferrell (Chair), Research Scientist, Department of Nursing, Research, and Education, City of Hope National Medical Center, Los Angeles Edward Benz, President, Dana-Farber Cancer Institute and Director, Harvard Cancer Center, Harvard School of Medicine Suanna Bruinooge, Director of the Research Policy Division, American Society of Clinical Oncology Clese Erikson, Director, Workforce Research, Association of American Medical Colleges Amy Hanley, Workforce and Health Policy Specialist, American Society of Clinical Oncology Tom Kean, Executive Director, C-Change Brenda Nevidjon, President, Oncology Nursing Society Edward Salsberg, Director, Center for Workforce Studies, Association of American Medical Colleges Lawrence Shulman, Chief Medical Officer, Dana-Farber Cancer Institute Alison Smith, Director, Cancer Research, Cancer Workforce, Annual Meetings, C-Change Study Staff Laura Levit, Study Director Erin Balogh, Research Associate Michael Park, Senior Program Assistant Patrick Burke, Financial Associate Roger Herdman, Director, National Cancer Policy Forum and Board on Health Care Services MARGIE PATLAK, Science Writer Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.  

NATIONAL CANCER POLICY FORUM HAROLD MOSES (Chair), Director Emeritus, Vanderbilt-Ingram Cancer Center, Nashville, TN FRED APPELBAUM, Director, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA PETER B. BACH, Associate Attending Physician, Memorial Sloan- Kettering Cancer Center, New York EDWARD BENZ, Jr., President, Dana-Farber Cancer Institute and Director, Harvard Cancer Center, Harvard School of Medicine, Boston, MA THOMAS G. BURISH, Past Chair, American Cancer Society Board of Directors and Provost, Notre Dame University, South Bend, IN Michaele Chamblee Christian, Retired, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Washington, DC Robert Erwin, President, Marti Nelson Cancer Foundation, Davis, CA BETTY R. FERRELL, Research Scientist, City of Hope National Medical Center, Duarte, CA JOSEPH F. FRAUMENI, Jr., Director, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD PATRICIA A. GANZ, Professor, UCLA Schools of Medicine & Public Health, Division of Cancer Prevention & Control Research, Jonsson Comprehensive Cancer Center, Los Angeles ROBERT R. GERMAN, Associate Director for Science (Acting), Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Bethesda, MD ROY S. HERBST, Chief, Thoracic/Head & Neck, Medical Oncology, M. D. Anderson Cancer Center, Houston, TX THOMAS J. KEAN, Executive Director, C-Change, Washington, DC JOHN MENDELSOHN, President, M. D. Anderson Cancer Center, Houston, TX JOHN E. NIEDERHUBER, Director, National Cancer Institute DAVID R. PARKINSON, President and CEO, Nodality, Inc., San Francisco, CA IOM forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. vi 

SCOTT RAMSEY, Full Member, Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, WA John Wagner, Executive Director, Clinical Pharmacology, Merck and Company, Inc., Whitehouse Station, NJ JANET WOODCOCK, Deputy Commissioner & Chief Medical Officer, Food and Drug Administration, Rockville, MD National Cancer Policy Forum Staff Roger Herdman, Director, National Cancer Policy Forum and Board on Health Care Services Sharyl Nass, Senior Program Officer Christine Micheel, Program Officer Laura Levit, Associate Program Officer Erin Balogh, Research Associate Michael Park, Senior Program Assistant Ashley McWilliams, Senior Program Assistant Patrick Burke, Financial Associate Adam Schickedanz, Christine Mirzayan Science and Technology Policy Graduate Fellow ANIA WOLOSZNSKA-READ, Christine Mirzayan Science and Technology Policy Graduate Fellow Sharon Murphy, Scholar in Residence vii 



Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Lisa Diller, Dana-Farber Cancer Institute Edward Salsberg, Center for Workforce Studies, Association of American Medical Colleges Alison P. Smith, C-Change Virginia Sun, Nursing Research and Education, Department of Population Sciences, City of Hope National Medical Center Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Melvin Worth. Appointed by the Institute of Medicine, he was responsible ix 

 REVIEWERS for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the rapporteurs and the institution. 

Contents Introduction 1 Supply and Demand in the Health Care Workforce 3 Shortage of Physicians, 4 Shortage of Nurses, 7 Shortage of Allied Health Care Professionals, 9 Supply and Demand in the Oncology Workforce 13 Shortage of Oncologists, 16 Shortage of Oncology Nurses, 19 Shortage of Other Oncology Health Care Workers, 19 Solutions to the Oncology Workforce Shortage 23 New Models of Care Solutions, 24 Improving Efficiency, 25 Teamwork, 27 Survivorship Care, 30 Palliative and Hospice Care, 34 Family Caregiving and Home Health Care Agencies, 38 Medical Home, 40 Recruitment and Retention Solutions, 41 Marketing Health Care and Oncology Careers, 41 Retention Strategies, 43 xi 

xii CONTENTS Education and Training Solutions, 46 Nurses, 47 Physicians, 50 Allied Health Care Professionals, 51 Culture Change, 53 Research Support Solutions, 55 Policy Solutions, 58 Summary 65 References 67 Acronyms 73 Appendixes A Workshop Agenda 75 B Workshop Speakers and Moderators 81