1. Eastman, Peggy

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Against a background of rapid scientific and technological advances and demographic changes, the National Cancer Policy Forum (NCPF) of the National Academies of Sciences, Engineering, and Medicine held a meeting in Washington, D.C., to explore ways of developing and sustaining an effective and resilient oncology workforce. The meeting was held in collaboration with the Global Forum on Innovation in Health Professional Education; a summary report of the proceedings will be published.

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The planning committee co-chair and NCPF member Lawrence N. Shulman, MD, FACP, FASCO, noted the NCPF last addressed this topic in 2009, when the National Academies published a report titled "Ensuring Quality Cancer Care Through the Oncology Workforce." Now, the delivery of high-quality cancer care must become more efficient for changing times, said Shulman, Professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, where he is the Deputy Director for Clinical Services of the Abramson Cancer Center and Director of the Center for Global Cancer Medicine.


"Every patient you're seeing is going to require more work," noted Shulman. He said the increasing effort is not just related to the growing number of cancer patients, but also to new advances in science and technology that allow for more precise diagnosis and treatment and increase the complexity of care; he cited immunotherapy as just one example. Shulman also cited the increasing time demands of electronic health record (EHR) documentation and pre-authorization. "We're spending hours on pre-authorization every week," he said, adding that "many patients are surviving longer and they stay in our practices longer."


Shulman said simply training more oncology providers is not the answer. He noted that the field needs a transformative effort that includes innovative practice models. For example, a reduction in administrative burdens, a reduction in practice inefficiencies, improvements in EHR efficiency and usability (ideally decoupling payment and clinical documentation), and better use of technology. While making oncology practice and patient care more efficient in changing times is challenging, "I think we can do that," Shulman stated.


Counting Oncology Providers

Currently, there are about 12,500 U.S. oncologists, hematologists, and hematologist/oncologists, said Suanna Steeby Bruinooge, MPH, Division Director of the Research Strategy and Operations Division of the Center for Research and Analytics at ASCO. She added that there are around 1,700 U.S. practices with at least one hematologist and/or medical oncologist. "We have more people to take care of," she noted, due in part to the aging of the population and the fact that people with cancer are living longer.


Bruinooge agreed with Shulman that simply training more oncology providers is not the answer. With the rapid changes in demographics and new scientific advances, "we couldn't train enough people to keep pace even if we wanted to," she told Oncology Times. "We don't know what the ideal number of oncologists is."


Highly skilled nurses are essential to the oncology workforce, but the pool of nurses is growing older (the average age is 50), there are nursing faculty shortages, and compassion fatigue and burnout are real problems in nursing, said Brenda M. Nevidjon, RN, MSN, FAAN, who is the CEO of the Oncology Nursing Society. There are about 90,000 nurses in the U.S. who identify themselves as oncology nurses, she noted.


Like Shulman, Nevidjon cited the amount of energy and time spent on pre-authorization and said nurses who experience burnout from this and other administrative duties may end up leaving the profession. "We need technologies that support nursing, not make it harder," she stressed.


Intentionally developed high-performance teams can enhance the efficiency of top-quality cancer care delivery, said Robert W. Carlson, MD, who is the CEO of the National Comprehensive Cancer Network and an NCPF member. What is needed is a system in oncology that "allows us to accelerate the pace of change," said Carlson, who previously served as Professor of Medicine in the Division of Oncology at Stanford University Medical Center and Medical Director of Inpatient Oncology and Hematology at Stanford Cancer Institute.


Such teams, which take their cue from business models, have excellent senior leadership and a culture of mutual respect, and they unite around an exciting, aspirational vision which forces people to innovate, noted Carlson. High-performance teams are highly productive and rewarding, improve morale, and facilitate staff retention, he added.


Asked by Oncology Times how long it takes to develop a high-performance team in oncology, Carlson said, "You could initiate the process pretty quickly." Within a few months, about 60 percent of the benefits of such a team could be realized, he added, while it takes 6-12 months starting from scratch to fully implement a high-performance team. He noted that, for such a team to work, "it has to be a relatively stable" team of people who develop relationships with each other, and it cannot have high turnover.


Agreeing on the need for high-performance teams in oncology was John V. Cox, DO, MBA, FACP, FASCO, Medical Director of Oncology Services at Parkland Health System in Dallas. Cox said most oncologists have probably never practiced in such teams; rather, cancer care is most often delivered in silos by groups of professionals, each contributing their own expertise (e.g., surgeons, radiation oncologists). "We need to move from groups to teams," he noted. "High-functioning teams collectively make better decisions."


Cox, along with several other speakers, emphasized the important role of advanced practice providers (APPs) in oncology care today. He said APPs need an "expanded footprint" that allows them to practice at "the top of their license."


Indeed APP-led cancer follow-up care, primarily from physician assistants and nurse practitioners, can be a successful and efficient practice model for survivors, said Linda Jacobs, PhD, CRNP, founding Director of the Cancer Survivorship Center of Excellence at the University of Pennsylvania Abramson Cancer Center, one of the Centers of Excellence funded in seven U.S. Comprehensive Cancer Centers.


Jacobs noted that not all cancer survivors can be transitioned to primary care, and that their care must be delivered in a risk-stratified manner. She said that, if there is a care transition, the goal is to help the patient feel comfortable with that transition. She also stated that the APP-led survivorship center at Penn has decreased new patient wait times, improved patient satisfaction, and increased revenue.


In July 2017, the NCPF held a meeting on long-term survivorship care after cancer treatment. The summary report from that meeting also stated that survivorship care must be delivered in a risk-stratified manner, depending on the patient's risk of recurrence and risk of late effects of treatment.


Given the growing complexity of care, patient navigators can be an important part of the cancer care team, emphasized several speakers. "There is a business case for navigators," said Shulman.


"Everybody deserves a navigator; it's not driven by zip code," said Mary Jackson Scroggins, MA, a 22-year ovarian cancer survivor who is a writer and producer and Director of Global Outreach and Engagement for the International Gynecologic Cancer Society. "Navigators have to be recognized as the professionals they are." She said patient navigation should be a billable service. The Oncology Care Model, a demonstration project of the Centers for Medicare and Medicaid Services (CMS) does reimburse for patient navigation, but many programs operate "on a shoestring," said Scroggins.


Cancer Prevention Needs

Effective cancer prevention strategies could relieve pressures on the oncology workforce and are going to become more and more important, stressed Otis W. Brawley, MD, MACP, FASCO, FACE, Bloomberg Distinguished Professor in the School of Medicine and the Bloomberg School of Public Health at Johns Hopkins University, an NCPF member, and former longtime Chief Medical and Scientific Officer of the American Cancer Society.


"Prevention of cancer is clearly a need in the future," he noted. "We could reduce cancer deaths by 60 percent by paying attention to what we know," which includes addressing health disparities. Without targeted public health initiatives, "these disparities are going to grow," warned Brawley.


He noted that two-thirds of U.S. adults and one-third of U.S. children are overweight or obese, saying that this cancer risk factor should be addressed by health education early-in preschools and kindergarten. School-aged children need to learn about healthy eating and the importance of fruits and vegetables, and parents can be educated through their children, he said.


Among other strategies to help sustain a strong oncology workforce discussed at the meeting were the following.


* Strengthen and empower family caregivers of cancer patients. Today, family caregivers do not feel valued as part of the care team by health care providers, and they are stressed and struggling, said Courtney Harold Van Houtven, PhD, MSc, Professor in the Department of Population Health Science at Duke University School of Medicine.



She advocated more training for caregivers; use of a complex care manager as a liaison to family caregivers; "virtual huddles" via technology to coordinate care; reimbursement to health providers for their time in advising family caregivers; paid leave for family caregivers; care benefits as standard insurance for short-term disability; and insurance redesign to pay for caregivers' out-of-pocket costs.


Technology can help empower family caregivers, said Kathi Mooney, PhD, RN, FAAN, Distinguished Professor and holder of an endowed chair in the College of Nursing at the University of Utah. She described an automated, supportive coaching tool she and her colleagues developed called Symptom Care at Home, which helps guide family caregivers, alleviate their stress, and increase their resilience, which in turn helps relieve cancer patients' symptoms, said Mooney.


* Integrate palliative care into cancer care from the beginning. "If we are to cure or prolong life with compassion, we must attend to patients' concerns beyond the disease itself, from their perspective," said Diane Portman, MD, FAAHPM, Chair of the Supportive Care Medicine Department at Moffitt Cancer Center and Associate Professor in the Department of Oncologic Sciences at the University of South Florida Morsani College of Medicine. "Most of the patient experience happens between clinic appointments," she noted.


* Make use of eConsults for efficiency in practice. Scott Shipman, MD, MPH, Director of Clinical Innovations and Director of Primary Care Affairs at the Association of American Medical Colleges, described Project CORE (Coordinating Optimal Referral Experiences), which he founded and guides. CORE provides an interface between health care providers to help them manage patients. It is built into the EHR or cloud-based. Shipman said these eConsults improve access to specialty care, reduce marginal referrals, save money, and improve the patient experience. Shipman noted that CMS will pay for eConsults in 2019.



Peggy Eastman is a contributing writer.