Specialization Trend Is Changing the Oncology Landscape

Frederick M. Schnell, MD

An increasing number of oncologists are choosing to specialize, affecting how patient care is delivered and the futures of small practices and large cancer clinics.

In its 2018 oncology trend report, California-based biotech company Genentech found that more than a third of participating oncologists (38%) specialized in particular tumor types.¹ In the previous 5 years, 40% of general oncologists and 64% of specialized oncologists have seen their mix of patients become more concentrated by tumor type, according to the survey. Just 6% of general oncologists and 1% of specialized oncologists reported treating a wider mix of tumor types.

The report’s conclusions were based on more than 630 completed surveys from 100 managed care organizations, 30 specialty pharmacies, 200 oncologists, 202 oncology practice managers, and 101 employer health benefit sponsors.¹ Genentech spokeswoman Courtney Aberbach said the specialization trend is a result of oncology treatment innovations and the increasing adoption of personalized medicine and digital technologies.

“Our growing understanding of the biology of cancer has made the disease more complex to manage and treat. Today there are more than 100 identified types of cancer, and some, such as breast and lung cancers, have even further subtypes, often requiring different diagnostic tests and treatments. Specialization allows oncologists to gain expertise in treating specific types of cancer, with the goal of improving patient care,” she said.

This shift is contributing to another trend: Smaller practices are consolidating or being purchased by larger hospitals and care centers. “It has the potential to improve the quality of care that patients receive because the specialist oncologist will be more knowledgeable about a specific type of cancer. From an economic and cancer-care delivery standpoint, it may be most efficient to have centralized availability of specialist oncologists who work with oncology generalists in the community and in rural areas,” Randall F. Holcombe, MD, director of the University of Hawaii Cancer Center in Honolulu, said.

“Insurance coverage for seeking second opinions from specialist oncologists, or to allow patients to transfer care to these specialists, will be important to facilitate patient choice and under stress, and a reliever is to consolidate,” said Frederick M. Schnell, MD, medical director of the Community Oncology Alliance (COA). “There’s a very active movement to consolidate, and there are burgeoning networks around the country.”

EMBRACING SPECIALIZATION

Many of these networks are based in or near major population areas, which could mean the very specialized immune and targeted thera- pies that now define modern oncology might not be available to rural populations. “The biggest risk is to patients in more remote areas, rural America,” Schnell said. “These consortiums don’t reach there.”The specialization trend seems destined to continue and gain momentum. And although there may be drawbacks, many doctors believe it’s a good thing.

“It has the potential to improve the quality of care that patients receive because the specialist oncologist will be more knowledgeable about a specific type of cancer. From an economic and cancer-care delivery standpoint, it may be most efficient to have centralized availability of specialist oncologists who work with oncology generalists in the community and in rural areas,” Randall F. Holcombe, MD, director of the University of Hawaii Cancer Center in Honolulu, said. “Insurance coverage for seeking second opinions from specialist oncologists, or to allow patients to transfer care to these specialists, will be important to facilitate patient choice and access,” he added.

FIGURE. ONCOLOGIST SPECIALIZATION IN TUMOR TYPES¹⁰

Figures are based on survey of 200 oncologists for the 2018 Genentech Oncology Trend Report Survey.

The explosion of knowledge about tumor types is a major driver of the specialization trend. With cancer care, “there’s an increasing degree of knowledge and sophistication and dramatically more therapeutic options and [ways] to use them,” said Martin J. Edelman, MD, professor and chair of the Department of Hematology/Oncology at Fox Chase Cancer Center in Philadelphia, Pennsylvania. “With lung cancer, as recently as 2000, you had small cell and non—small cell, and all our studies were based on those. Now there are more and more subsets, and you need to know the options for each."

Martha P. Mims, MD, PhD, associate director of Clinical Research at Baylor College of Medicine’s Dan L. Duncan Comprehensive Cancer Center in Houston, Texas, said her orga- nization now has clinics devoted to certain cancers—such as breast, head and neck, and gastrointestinal—and within those clinics there are multiple subspecialties.

“Older oncologists, who were trained to be generalists, have had to evolve,” said Mims, who is also chief of the Section of Hematology and Oncology at Baylor College of Medicine. “Younger oncologists, earlier and earlier in their training, are branching off into subspecialties. Although they are learning everything, they point their futures in certain directions.” When recruiting, Mims looks to fill specific needs. A recent hire specializes in melanoma and sarcoma.

“Having 1 person focused on 2 relatively rare tumors is a way to leverage your hiring,” she said. Mary Kruczynski, director of policy analysis for COA, said some seasoned doctors have told her they welcome into their practices new physicians who show a desire to specialize in blood or solid tumor types, “as they can be proclaimed the ‘practice expert’—armed with the most current knowledge of how best to treat those tumor types utilizing recent FDA-approved agents, combination therapies, genetic mutations, and next-generation sequencing.”

By necessity, oncologists working in resource-poor rural areas need to remain generalists. That could make it harder for specialization to reach communities where advanced knowledge and skills are needed.

“This may impact quality of care in rural areas where the mortality rate from cancer already exceeds that seen in urban areas,” Holcombe said. The solution, he said, “will be to train advanced practice nurses [nurse practitioners] in oncology and then for physicians to make use of their expertise to assist in patient care.” Kruczynski noted that a hospital in rural South Carolina recently closed, leaving area residents without nearby care. Perhaps, she said, such isolated facilities could use J-1 visas—nonimmigrant visas issued to visitors seeking medical or business training in the United States.² “With the status of immigration today, perhaps we can redirect those bright young men and women completing their fellowships and needing employment to positions in those underserved areas,” she said.

OPPORTUNITIES FOR NEW GRADUATES

Edelman said he worries that some oncologists are less well rounded because they’re choosing to specialize very early on in training. He has seen this in both academics and the practice world. “In some ways, we bemoan the loss of a good, outstanding generalist with a broad range of knowledge,” he said. “But that’s true in everything and goes well beyond oncology.” Still, he believes the specialization trend is a positive one, and he looks for doctors who have shown interest and ability in specialized areas.Although medical school has always been costly, modern graduates are entering the workforce hundreds of thousands of dollars in debt. That has led them to seek employment in urban areas and with major cancer centers, which tend to offer higher salaries.

Years ago, Schnell said, doctors graduated with less debt and could take jobs in the countryside and in the cities where there wasn’t enough care. “There were more economic opportunities outside the big universities, and you could be more entrepreneurial—beyond the Emorys and the Sloan Ketterings. That’s changed now.”

He wondered whether New York University School of Medicine’s recent decision to eliminate tuition³ for all its students would encourage graduates to take jobs as general oncologists in more remote parts of the country. Without overwhelming school loans, these practitioners could accept lower salaries and still enjoy a high quality of life. “If the expense burden is underwritten at large medical schools, [graduates] won’t be so deeply in debt, which will be great for America,” Schnell said. “If you’re in rural America, you don’t need superspecialized doctors. You need a broad spectrum of knowledge for patients who aren’t going to travel hundreds of miles for care.”

Richard L. Schilsky, MD, senior vice president and chief medical officer of the American Society of Clinical Oncology, agreed that the lack of crippling loans could “hopefully encourage more people to be willing to take on these important general can afford to do so.” Schilsky, a 2018 Giants of Cancer Care^® award winner, encourages oncologists to consider their career trajectory early in their training.

“The sooner you decide where you want to end up, the sooner you can organize the rest of your training program for success,” he said. “If you decide you want to practice oncology in rural Montana, you’re going to learn as much as you can about every type of cancer because that’s what you’re going to see.”

Specialization is difficult if not impossible for small practices. In larger practices, specialization can occur without significant disruption in operations as long as all the practitioners are willing to cross-refer patients to oncology specialists.

“We’re witnessing a continuing consolidation of small practices; they’re merging or being bought up by larger entities,” Schilsky said. “That’s caused increasing concern that access to care is declining.” Savvy patients with means, however, will most likely still be willing to travel to find the right doctor for their cancer. “Patients are increasingly aware that there’s really not a single disease called cancer,” Schilsky said. “Every cancer type is different, [and] every patient [with cancer] is different, and to get the optimal treatment for your cancer, you want the oncologist who spends most of their time seeing patients with your type of cancer.”

References

1. Gesme DH, McClelland S, Sherman B, et al. The 2018 Genentech oncology trend report. 10th edition. genentech-forum.com/content/dam/gene/managedcare/forum/pdfs/Oncology-Trends/2018_Genentech_Oncology_Trend_Report.pdf. Published April 2018. Accessed September 17, 2018.
2. J-1 visa exchange visitor program. US Department of State website. j1visa.state.gov/basics/. Accessed September 17, 2018.
3. Chen DW. Surprise gift: free tuition for all N.Y.U. medical students. New York Times. August 16, 2018. nytimes.com/2018/08/16/nyregion/nyu-free-tuition-medical-school.html. Accessed September 17, 2018.