Vipal Durkal, MD

William Osler, MD noted that “The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.” This adage was as an apt description of modern medicine at the turn of the last century. During this time, the fi eld of oncology has advanced rapidly, from the discovery of nitrogen mustard as chemotherapy by Goodman and Gilman

 to the revolution of molecular testing today. The burden of new and evolving information in diagnostics, therapeutics, and biomarker surveillance has led many community oncologists to subspecialize in a particular field of interest. Demands by patients, market pressures, and changing delivery models have brought to the fore the urgency to address whether subspecialization is necessary and entirely feasible.

It has become evident that subspecialization in many disease types and treatments in oncology leads to improved outcomes for patients. Data from numerous studies in surgical oncology fellowship training have demonstrated improved outcomes in terms of pathologic and clinical outcomes.

This has led surgeons to subspecialize in oncologic areas of expertise, and patients to inquire about surgical subspecialization. One study’s findings showed that surgical oncology fellowship training resulted in a 36% reduction in the risk of death at 5 years when controlling for other variables such as surgeon volume, age, and cancer stage.

 Data from similar studies among hematologic malignancies demonstrate improved outcomes in multiple disease types such as non-Hodgkin lymphoma, multiple myeloma, and acute leukemias.

Although these data may reflect temporary differences among subspecialists and general oncologists, perhaps an early trend that normalizes as general oncologists adopt new therapies and diagnostics, they also question the model of treatment delivery among oncologists. Can tumor boards, continuing medical education conferences, and panel discussions fill the gap for generalists in the community? This is an area of active research that will need ongoing evaluation.

Community Oncology Practices Explore Specialization

In many ways, community oncology practices are responding to the changes in specialization noted by their counterparts at academic centers. Evidence from one study of treatment patterns in multiple myeloma showed an association with firstline treatment using proteasome inhibitorimmunomodulatory imide combinations in the percentage of patients with hematologic malignancies seen by the oncologist.

 Less specialization in hematologic malignancy showed a significant correlation with the types of therapies that were prescribed. these findings are reflected across multiple disease types, including other hematologic malignancies and sarcomas. The same study looking at Surveillance, Epidemiology, and End Results Program–Medicare data demonstrated in its findings that academic centers have a bimodal distribution of hematologic malignancy specialization, with some centers with providers who almost exclusively treat hematologic malignancies, whereas others have almost no specialization. What accounts for this wide difference? The authors concluded that wide variation in hematologic malignancy subspecialization reflects the acquisition of community practices by academic centers. Could acquisition of community oncology groups by academic centers lead to changes in how oncology is practiced? Market forces such as patient demand for subspecialists and quality metrics by insurers may lead to changes in how oncology care is delivered and perhaps how it is taught.

More than half of all patients in the United States pursue their care in the community setting.

 With these high volumes of patients, community oncologists play a central role in clinical trial enrollment. The need to improve therapeutic outcomes with clinical trials has also led to interest in subspecialization among community oncologists. But does this lead to increased enrollment? A recent meta-analysis of 30 trials found a statistically significant difference in clinical trial enrollment between community oncology practice  and academic centers.

 These trends held across socio-economic and ethnic groups among patients in the same study. Although multiple factors such as practice setting and demographics can account for this difference, subspecialization by disease of interest is a major factor that differentiates between community practices and academic centers. Subspecialization may offer more confidence on the part of the oncologist and the patient and close the gap between clinical trial accrual patterns in these practice settings.

There is an abundance of interest in bringing down the cost of cancer care with improved rates of hospitalization, better value, and cost of care. Study findings of oncology nurses and oncology pharmacists, who specialize in their particular area of expertise, show improvement in terms of value and a decrease in adverse events.

The rate of oncologists who experience burnout, partly due to the demands of keeping pace with scientific advances, is estimated to be around 35%.8 Burnout rates have an effect on the quality of care. Subspecialization offers a possible solution to rising concerns regarding burnout.

However, there are challenges and barriers that prevent a smooth transition to subspecialization. There are also potential drawbacks.

Results of one survey of community oncologists indicated that, as expected, breast oncologists have an easier time adopting a subspecialization than those of other specialties.

 The advantages ofsubspecialization included ease of staying up-to-date, increased referrals, expertise, and increased ability to attend tumor board meetings, among others.

However, the potential barriers in that survey included difficulty staying up-to-date on other disease types, differences in workload and reimbursement in a group, and difficulty adopting subspecialization within small groups or in rural practice settings. Concerns were also expressed regarding potential workforce shortages if oncologists specialized in only 1 or 2 disease types.

Although the survey authors concluded that such practice changes are inevitable given the complexity of modern oncology, they also concluded that general oncology would have a role based on the location and needs of a particular community.

Community oncologists face growing challenges and potential opportunities if adaptation is pursued in a timely and practical manner. Individual oncologists and their groups will see increasing demand by patients, communities, insurers, and policymakers for accessible quality and value-based care. Both competition and cooperation with academic centers instruct the necessity of subspecialization in oncology practice. The opportunities include increased satisfaction, possibly lower rates of burnout, and higher patient satisfaction. The central role that community oncologists play in clinical trial enrollment and the differences in enrollment patterns between academic and community practices might also find a solution in subspecialization. 

1. From the field of battle, an early strike at cancer. Yale Medicine Magazine. 2005 Summer. Accessed December 13, 2022. https://bit.ly/3iXasuk

2. Nayak JG, Drachenberg DE, Mau E, et al. The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis. 

. 2014;14:82. doi:10.1186/1471-2490-14-82

3. Skinner KA, Helsper JT, Deapen D, Ye W, Sposto R. Breast cancer: do specialists make a difference?

. 2003;10(6):606-615. doi:10.1245/aso.2003.06.017

4. Vardell VA, Ermann DA, Tantravahi SK, et al. Multiple myeloma patients treated at academic centers have improved survival outcomes. 

. 2021;138(suppl 1):1971. doi:10.1182/blood-2021-151899

5. Davidoff AJ, Long JB, Neparidze N, et al. Oncologist sub-specialization, care setting, and multiple myeloma treatment and outcomes. 

. 2020;136(suppl 1):2-3. doi:10.1182/blood-2020-140728

6. Fact sheet: what is community oncology? Community Oncology Alliance. Accessed December 13, 2022. https://bit.ly/3WvYDdh

7. Unger JM, Hershman DL, Till C, et al. “When offered to participate”: a systematic review and meta-analysis of patient agreement to participate in cancer clinical trials. 

. 2021;113(3):244-257. doi:10.1093/jnci/djaa155

8. Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. 

 2012;30(11):1235-1241. doi:10.1200/JCO.2011.39.7380

9. Gesme DH, Wiseman M. Subspecialization in community oncology: option or necessity? 

. 2011;7(3):199-201. doi:10.1200/JOP.2011.000292

Articles

Demands by patients, market pressures, and changing delivery models have brought to the fore the urgency to address whether subspecialization is necessary and entirely feasible.

Vipal Durkal, MD | Authors

Articles

Adaptation in Oncology Practice Opens the Door to Specialization