In 2007, ASCO reported an initial analysis that predicted a severe shortage of oncologists as both the general population and physician–scientists aged. A report summarizing workforce shortages has been updated yearly, the most recent published in the 2015 State of Cancer Care in America.1 The shortage of oncologists available to administer cancer treatment will likely put even more pressure on the dwindling number of clinical oncologists with a primary or major focus in cancer prevention, raising concerns that there will be too few available to replace the aging and retiring senior clinical oncologists who have led this activity.
Over the past 2 years, the Cancer Prevention Workforce Pipeline Workgroup of ASCO’s Cancer Prevention Committee, chaired by Dr. Fabian, has explored why a career in cancer prevention may be unattractive to oncology trainees. A formal survey of fellows and training directors designed and conducted by this workgroup has helped define the contributory factors. The results of the Oncology Fellows and Training Directors Survey have been tabulated and are, at the time of this writing, in review for publication.
There are a number of actions ASCO can take to increase current member competence in clinical prevention activities (including risk and genetic counseling) and awareness of careers in cancer prevention, as well as advocate for changes that will make part- or full-time cancer prevention practice and clinical research more attractive.
This is particularly important as the emphasis of health and medical care is likely to fundamentally change by 2025, with a paradigm shift in which prevention—not treatment—is the dominant driver of health and quality matrices, even though the number of subspecialists primarily concerned with treatment will continue to increase, and the number of primary care physicians will continue to shrink.
The following will most likely drive this process:
- The increasing interest of the general population in staying well.
- A societal mandate and approach that addresses personal habits of overeating, poor diets, and a sedentary lifestyle that leads to the early appearance of many chronic disease states, including many cancers. A wide variety of observational studies support the general notion that a vegetable-based diet, avoidance of environmental carcinogens, and moderate exercise reduces the risk for a myriad of chronic conditions, including cancer and cardiovascular diseases, and likely slows the aging process.
- A major societal acceptance of integrated systems that work and emphasize health versus disease, such as models that emulate successes in several European countries.
- The roll-out of the Affordable Care Act, with its major interest in prevention.
- The increasing participation of ASCO’s international community and their emphasis on prevention.
- The increasing importance of comparative effectiveness, amount of gain, and cost in new drug approvals and adoption of new treatment paradigms.2
- Acceptance of preventive health strategies of population health for the individual, driven by genomic and personalized medicine, will be the standard within 10-15 years. The major scientific contributors are the very technologic advances in elements that are being promulgated as the basis for personalized medicine: genetics, big data, and advanced imaging.3
Advances in Technology
Variations in basic genetic makeup clearly play a role in the risk for most diseases, the hereditary genetic cancers being at one end of the lifespan and the unique genetic makeup of people older than age 90 being at the other. Progress is occurring rapidly in understanding the basis and subtleties of the latter, which may lead to true anti-aging interventions beyond lifestyle intervention, thereby further narrowing the gap between lifespan and health span by reducing the length of chronic decline.
The shortage of oncologists available to administer cancer treatment will likely put even more pressure on the dwindling number of clinical oncologists with a primary or major focus in cancer prevention.
There are a number of actions ASCO can take to increase current member competence in clinical prevention activities (including risk and genetic counseling) and awareness of careers in cancer prevention.
We predict that although many oncology specialists in 2025 will continue
The collection and assessment of the value of massive amounts of real-time data holds great promise in the medical environment to identify factors that will improve patient care, and early returns are promising.4 Likewise, the identification of factors that may identify key causal events earlier in the disease process is also likely.
A long-standing concept promotes the notion that more sensitive screening techniques and earlier detection using various biochemical, molecular, and imaging approaches will lead to improved survival or at least reduce the amount of treatment needed. These screening techniques often demonstrate substantive benefits for populations. However, this approach has been called into question because of the high false-positive rates and receipt of potentially unnecessary treatment for small cancers that may not become clinically apparent in an individual’s lifetime. Hence, the attempts to individualize this process by the identification of inherent genetic factors and other factors will lead to improvement in the risk–benefit ratio for both screening and preventive treatment, presuming an adequate workforce skilled in prevention counseling.
PET, CT, and functional MRI have become increasingly useful to help determine the treatment of cancer, as the strengths and weaknesses of these processes have become known and experience acquired. Remarkable advances beyond these technologies driven by fluorescence-activated in vivo strategies suggest that we may soon be able to locate and measure the presence and activity of, perhaps, a small group of cells (< 100) in the intact human.5 Combined with the capture and measurement of shed cellular products in the blood, the detection of premalignant markers and cells should be achievable. The system of medical care will fundamentally operationalize into the personalized, predictive, preventive, and participatory medicine concept, championed by Leroy Hood, MD, PhD, and colleagues.3
A Paradigm Shift in the Oncology Workforce
We predict that although many oncology specialists in 2025 will continue to lead a core team of physician extenders (oncology nurses, pharmacists, radiologists, social workers, and nutritionists focused primarily on delivering cancer treatment), “onco-internists” will also be prevalent. Onco-internists, although still operating in the treatment arena, will have a prominent focus in prevention and/or survivorship. They will head or work as part of a diverse team of professionals including cardiologists, clinical health psychologists, geneticists, fertility specialists, exercise physiologists, and others to insure appropriate prevention and survivorship care, with sparing referral, as needed, to the subspecialists. As such, onco-internists, whether primarily involved in clinical practice or research, will have to be reasonably well versed in many areas not often emphasized in traditional medical oncology–hematology programs.6
The oncologist of 2025 will be nothing like the oncologist of today. In the coming year, Dr. Meyskens will be exploring this theme in his ASCO Connection blog “White Coat Conversations,” available at ASCOConnection.org.
About the Authors: Dr. Meyskens is professor of medicine, biological chemistry, public health, and epidemiology and director emeritus at the University of California, Irvine Health Chao Family Comprehensive Cancer Center and vice-dean of the School of Medicine at the University of California, Irvine. He is immediate past chair of ASCO’s Cancer Prevention Committee, a blogger for ASCOConnection.org, and has been an ASCO member since 1978. Dr. Fabian is a distinguished professor of medicine at the University of Kansas, co-leader of the Cancer Prevention and Survivorship Program at the University of Kansas Cancer Center, and co-chair of the Survivorship Committee in SWOG. She has been an ASCO member since 1977, serving in multiple leadership positions, including as chair of the Cancer Prevention Committee and currently chairs the ASCO’s Prevention Committee Workgroup examining barriers to careers encompassing cancer prevention for clinical oncologists.