Jun 15, 2020

Dr. Pennell and Dr. Jan Franko discuss Dr. Franko’s article, “Effect of surgical oncologist turnover on hospital volume and treatment outcomes among patients with upper gastrointestinal malignancies”

Hello, and welcome to the latest JCO Oncology Practice podcast, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all recordings, including this one, at podcast.asco.org. My name is Dr. Nate Pennell, medical oncologist at The Cleveland Clinic and consultant editor for the JCO OP.

I have no conflicts of interest related to this podcast, and a complete list of disclosures is available at the end of the podcast. Today, I'd like to talk a little bit about the impact that physician shortages can have on cancer care in the United States.

While there are some parts of the country, for example Boston or New York, where you can't turn around without tripping over a specialist in some field or another of medicine, for much of the vast geographic expanse of the United States, especially outside of larger cities, there's areas that lack adequate specialty physician coverage, perhaps having either small numbers or even a single practitioner covering large areas.

Now, this is very important for patient care because most cancer patients get their treatment in community settings closer to their home and not at large academic centers. But how does this impact care when, for example, specialized surgical services are needed and no one's available close to home?

With me today to discuss this topic is Dr. Jan Franko, chief of the division of surgical oncology at Mercy One Medical Center in Des Moines, Iowa. We'll be discussing his paper, Effect of Surgical Oncologist Turnover on Hospital Volume and Treatment Outcomes Among Patients With Upper Gastrointestinal Malignancies, which is currently in press at the JCO OP. Welcome, Dr. Franco, and thank you for joining me on this podcast.

Thank you for this opportunity, Dr. Pennell. It's my pleasure. I do not have any conflicts of interest with this work.

Thank you for that. So we hear in the media about shortages of physicians, especially in underserved areas. How common would it be that a larger community hospital would lack access to, say, a surgical oncologist?

Just to give you an example, the city where I practice currently has about 750,000 people with surrounding suburbs. And we had a shortage of surgical oncologists for about two years, where I can recall that one of the large hospital systems lost entire radiation oncology department. So for nearly two years, until they hired three new radiation oncologists, they actually could not do any radiation. We ourselves have been a flagship for many decades for gynecologic oncologists.

We lost one about three or four years ago and since then we can't hire, and then on top of that, I recall that about three years ago, we had one year where 90% of urologists left the town. After 12 urologists, about eight or nine had to leave, and they came back for different practice within the same locality. But it was about a year plus without adequate urology workforce. So these things do happen.

No, I could imagine, especially for specialties that are relatively small to begin with. And just to put this in perspective, can you explain a little bit about what exactly is a surgical oncologist, and how does that differ from, say, a general surgeon who may also do some cancer surgeries?

So thank you for this question. I mean, I myself am a surgical oncologist. And I suspect there will be a lot of different definitions. For me, it's would be a general surgeon who is focused on a cancer treatment. General surgeons do treat both cancers but also trauma and general surgical conditions, common gallbladders, hernia.

But a subset of surgeons have focused on cancer. And the majority of those have accredited fellowship. These surgeons, in my opinion, should maintain a broad spectrum of practice. For example, not only liver and pancreas but liver, pancreas, and stomach and esophagus and other organs.

And what's also very important for them is to cultivate multi-specialty understanding of how to transition the care between an operation, systemic therapies, and radiation oncology so they can maintain a momentum of cancer control and [INAUDIBLE] surgery or avoid an operation. And when it comes to the question be able to execute even the complex operations.

And given the complexity of cancer care these days and how multidisciplinary it is, I would imagine that most surgical oncologists are centered around academic university hospitals as opposed to working out in more rural areas or community hospitals. Is that the case or are they pretty much available everywhere?

So indeed, you are right. It, in fact, was published in the Annals of Surgical Oncology around 2018 and 2019. An absolute majority of surgical oncologists are centered at the university hospitals or NCI-designated cancer centers. The number varies, but for example, in Iowa, more than 80% of such a workforce is concentrated in the single university center, which is outside of our town. And that number ranges from approximately 65% up to 90% of surgical oncologists working for the university, not the community hospital.

That makes sense. If you were a patient who needed specialty surgical care for, say, pancreas cancer or esophageal cancer and you didn't have a hospital with a surgical oncologist nearby, what do they usually do? Is this something that's handled by a local surgeon or do they travel to academic centers to get that care?

So this is subject of lots of research. And I think there is a dramatic geographical variation. And also there is a variation depending on the patients and their socioeconomic status and understanding of the situation. Plus, another question which is not discussed, how long is it reasonable to travel? How far?

So I do think that complex surgical therapy should be done by people who do have experience in that. And what is experience that can be defined by number of cases, but does doing 10 pancreases improve you in operating on the stomach as well, I would believe there is some degree of cross-fertilization. Is it reasonable for people to travel for an operation 100 miles, 150, 200? Probably not reasonable, as long as they get a quality care closer to home.

Yeah. It certainly would put a burden on them, and you could think that their follow up care might be compromised by being so far away as well.

Yeah. I agree with that. One has to understand that the discharge from the hospital after operation by far doesn't mean end of the surgical care or at least it should not. Patients are these days discharged from operations very quickly. Various tricks, sometimes surgeons let them stay in the town in a hotel, which I don't know how good discharge that is.

But then they're coming back for unexpected postoperative either complications or troubles, which do not amount to major complications, that has to be readily available. So there are mechanisms how people can do that, but can you really do it on a distance of 100 miles?

With that in mind, can you take us through your study? What were you trying to show?

Thank you. This was almost classical before-and-after study. But it was not only before or after but was before the last surgical oncologist and the short period of time that we didn't have it. And the largest period of time when we actually regained surgical oncologist, which is how I came to the local practice. And I'm still practicing here for about 12 years.

So the whole study spanned over about 15 years, between 2001 and 2015, and looked at the patients who are typically taken care of by a surgical oncologist and not focusing on the technically rather simpler procedures on, let's say, skin cancer. So we focused here because of complexity and inherent risk on the esophagus cancer, gastric cancer, and pancreatic cancer.

For reason of this study we looked at carcinomas only and excluded neuroendocrine tumor, benign conditions, gastrointestinal stromal tumors, and others. And we only focused on those conditions which could be potentially resectable, because otherwise there is no practical influence of surgical oncologist for a majority of therapy.

So for esophagus and gastric cancer, we looked at stage I through III and for pancreatic cancer on stage I to II. Stage III, in general, historically was never considered for an operation. Might be changing currently, but it was not in the past.

So in 2006, our prior very excellent surgical oncologist simply retired. And the next two years, very clearly, there was no surgical oncologist in the hospital. And they observed the proportion of these diagnoses, and they observed that during the time that there was no identifiable surgical oncologist responsible for advising and executing surgical care on those patients, the number of referral cases dropped dramatically down.

Some went down from about 12.2% of these cancers diagnosed within this hospital as compared to the state, to down to only about 6.7% of all state cancers being diagnosed in that particular hospital, which at that time was missing surgical oncologist.

Once the new surgical oncologist, which was myself coming back, was able to restore those services or perhaps the confidence of referring physicians and the society at large better, and it returned back to the prior numbers, again diagnosing and treating approximately 12% of the state volume of these neoplasms.

We also wanted to see if we could not compare that to SEER database within the state of Iowa, that we obviously asked the question, did the number of these cancers for those two years somehow decrease in the state of Iowa? And it did not. So at the state level, there was maintaining of the trend of the annual diagnoses, but in the particular hospital they were not apparent there.

So we assumed that they out-migrated to other institutions. And empirically and by discussion by other physicians who were here in this time, they clearly out-migrated to different systems and out of town. They were simply not present with this hospital.

We looked at the overall survival as perhaps the most important measure of efficacy of therapy. And we were able to restore the surgical oncology quality to the point that survival after the new surgical oncologist came was not worse, perhaps even improved in some situations.

And there also was more of a higher proportion of patients undergoing multidisciplinary therapy. That means either chemotherapy or radiation or combination of those in addition to surgery. That will be expected general trend over the last 15 or 20 years, but it was very reassuring. We could actually see it to be restored back once the surgical oncologist services became available.

And how well do you think the overall state SEER numbers reflect the real results that you would see in your patient population there?

I think it reflects very tightly about the reality. Now, SEER has been demonstrated on a nationwide level to be very effective and very precise with a very low rate of the errors. Interestingly, and many don't know that Iowa was one of the original states where the SEER Database has been established and participated in the program since 1973.

And to some degree, it could be driven by the fact that there are not too many hospitals which actually have cancer registry. So in reality, you don't have to train that many registrars. But those registrars and individual cancer centers actually support both the SEER Database and other databases, including the National Cancer Database.

So there is historically, for perhaps some nearly 50 years, of consistent reporting of data. So I have a lot of trust in the data reported, especially from Iowa.

In the paper, I noted that you, over time, as we get closer to the modern time, that the outcomes seem to improve. At least compared to the time before the previous surgical oncologist was there, is that because the new surgeon was more skilled or is it that outcomes just overall are improving as we move on and have new treatments?

I think it's completely explained by the overall improvement of care of the years and multidisciplinary treatment. I had a distinct pleasure to, for about two or three operations, operate with a surgeon who continues to work in Iowa-- he's in mid 70s-- in the minor procedures, and that's an excellent surgeon. Definitely could observe it. So while many people like to think that it is because of one person or one surgeon, there's not one surgeon. It is really the whole system maintain adequacy compared to improvements, which we experienced over the last 15 years in the care overall. So I think it's the whole team, as it would be expected, gets better over time.

I think you did a very nice job of illustrating the major impact that losing a surgical oncologist has on our health system. Dramatic changes in the numbers of patients treated over time. So is there a message that health systems who maybe have only one or a couple specialists in various fields can take from this? How should they be addressing potential loss of their relatively small numbers of crucial specialists?

I think this is great point, and all that I can advise would be consideration and planning. And while I do think that some specialties with low frequency of practitioners, like surgical oncology, are at risk, there are many other specialties.

And, in fact, every single specialty could be at some degree of risk, because a medical oncologist, the level of the knowledge which is required to practice with all the molecular studies and immunotherapies is enhancing, essentially doubling every year or two. So sub-specialization within even medical radiation oncology is also ongoing.

So I think every health care system is at a risk of losing some portion of its common skill if a key individual is to leave. So surprisingly, as I mentioned at the early parts of our podcast, we actually lost, not in our hospital but in another large hospital, an entire group of radiation oncologists. Hard to believe that it occurs in a city of 750,000. But it did happen.

So I think that planning and perhaps more research and attention into who delivers care, not only how, but who delivers the care, into how do we cultivate our cadre of nurses, physicians, nurse practitioners, or extenders, it becomes extremely important, perhaps at least as important as the buildings, because it's really the professionals who create the program.

And those gaps-- you know, I definitely experienced this gap. I came and I thought I would take over a working practice. There was no practice. That is not necessarily important about me, but what about the community which actually experienced this decline?

And I would submit that every health care system in some form or another, whether large or small, is in some degree of a risk if they do not address the planning, career transition of the services which are often perceived as granted and available until those who do them are actually not present.

Dr. Franko, thanks so much for joining me on the podcast today.

Thank you very much, Dr. Pennell. It was my pleasure.

And for the listeners out there, until next time, thank you for listening to this JCO Oncology Practice podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen.

While you're there, be sure to subscribe so you never miss an episode. JCO OP Podcasts are just one of ASCO's many podcast programs. You can find all recordings at podcast.asco.org. The full text of this paper will be available online at asco.org/journal/op. This is Dr. Nate Pennell for the JCO Oncology Practice signing off.