As Late-Career Oncologists Retire, Who Will Fill the Geographic Gaps?

Melissa Accordino, MD, associate professor of medicine, director of the hematology/oncology Medical Oncology Fellowship Program, and director of Quality and Patient Safety, Division of Hematology and Oncology at the Columbia University Herbert Irving Comprehensive Cancer Center.

Kelsey Kirkwood, MPH, associate director, data scientist at the American Society of Clinical Oncology.

A recent study published in JCO Oncology Practice found that the number of oncologists qualified to treat the aging US population is declining, which is opening gaps in geographic coverage.1

Per 100,000 patients per capita, the number of oncologists has decreased over the last 10 years. In 2014, there were 15.9 per 100,000, in 2019 there were 15.1, and in 2024 there were 14.9 (P <.01). When looking at counties, 10% in rural areas lacked oncologists within or nearby compared with 0% for urban areas. Additionally, 5% of oncologists who were early-career practiced at rural site, 7% were mid-career, and 9% were late-career.

To better put this into perspective, study co-authors, Melissa Accordino, MD, and Kelsey Kirkwood, MPH, spoke with CancerNetwork® regarding the implications of these results. The pair touched upon potential incentives for further oncology coverage in rural populations, as well as the impact burnout has on the oncology community overall.

Accordino is an associate professor of medicine, director of the hematology/oncology Medical Oncology Fellowship Program, and director of Quality and Patient Safety, Division of Hematology and Oncology at the Columbia University Herbert Irving Comprehensive Cancer Center. Kirkwood is an associate director, data scientist at the American Society of Clinical Oncology (ASCO).

CancerNetwork: Given the 15.9 to 14.9 decline in oncologists per 100,000 population, what are ASCO's high-impact policies to immediately reverse this trend and meet the rising demand?

Kirkwood: These findings, coupled with recent projections from HRSA [Health Resources and Services Administration] that there will enough oncologists to meet just 29% of demand in rural areas by 2037, drew our focus to rural cancer care delivery.2 Team-based care models can help address the severe geographic maldistribution of the existing workforce. This approach focuses on optimizing system efficiency rather than solely relying on pipeline expansion. Team-based care models leverage the entire oncology team to extend the reach of specialized physician expertise into underserved areas.

This strategy has been successful in ASCO’s Montana pilot program demonstrating a collaborative model with a critical access hospital and a regional cancer center.3 The program has demonstrated a decrease in the burden of travel and associated financial toxicity for patients. Policy support for collaborative, team-based models, coupled with telehealth utilization may be vital in supporting the oncology workforce and bringing high-quality care closer to home for at-risk populations. Other levers we’re thinking about include incentives or visa waivers for young physicians to work in rural or underserved areas. Training additional oncologists is another potential solution that comes up, but adding training slots is very long process and may come at the expense of training physicians in other shortage areas.

Accordino: Adding additional training slots can be tricky because you can’t mandate what someone does after training. Every training program is different, and most training programs are within urban academic sites. It can be challenging for someone who trained entirely inan academic setting and then shift into community-based practice. There are unintended consequences of that because you could be training more fellows who then stayat urban academic sites because that’s where their interest lies. As treatments become more complex, we get more sub-specialized, and it can be hard to be a generalist these days. Our systems might not be built to support that. Another thought is to expand care from a telehealth standpoint [in terms of] having access to specialists? If there are ways to do that, it could allow access to specialist care remotely? If you’re in a remote area and are experiencing therapy complications, a patient may need access to a specialist who is not available, like an endocrinologist or a cardio-oncologist,telehealth could be a tool to bridge this gap? It really dose take a village to take care of these patients.

Kirkwood: I was in an ASCO committee meeting last week, and there was a fruitful discussion about this idea of generalization or specialization in fellowship. It’s something that I hope that we can explore further. If you’re training in these academic settings, and you’re encouraged to specialize in a certain type of cancer, then going into a community practice and seeing patients with many cancer types would be an intimidating prospect.

Accordino: It’s tough, especially as the field changes so much, to be able to stay up to date on everything.. As a sub-specialist, I don’t envy what generalists have to do. It’s challenging. With clinical trials, which we know are an integral part of care, having access—even if you were able to open them at these other sites—is a huge amount of work. Without the proper staffing, it’s hard to do that. Thinking about alternative models to support these community sites who don’t have the same resources as big academic sites is something to keep in mind

With 68% of the population living in counties having a retirement risk, what practical, system-level strategies can retain the expertise of these clinicians?

Accordino: Going back to a lot of what we just said, there are ways to maybe counteract if there shortages or if people are retiring. Are there more remote options for someone else in the state? Can we rely on telehealth? How can we get patients the access that they need if there’s just not a provider in their area? How do we make it easier for our patients to have access to clinical trials at sites without the research infrastructure that academic sites have. We need to be thoughtful about that.

Kirkwood: We published a series of papers earlier this year looking at provider well-being in oncology, as well as fellow well-being in oncology. We have a pillar of our 5-year strategic plan to focus on the profession and figure out how this can be a sustainable career. There are so many demands, an increase in patient expectation demand, as well as very burdensome administrative tasks and pressures to see a number of new patients vs if you have interest in research, how does that fit in? Eric Winer, MD, a past president of ASCO, is very interested in getting back to the joys of what oncology care provides.4 One thing that ASCO has been thinking about is setting a model of what are reasonable work expectations. Just thinking about how to keep oncologists in the workplace, we’ve interviewed oncologists who are younger but are leaving clinical care because the demands are unreasonable. That’s something, as a professional society for cancer doctors, that we’ve been focused on: trying to figure out how to make this career sustainable and focus on the things that do derive joy. What we’ve found in our surveys is providing meaningful patient care and having meaningful interactions with patients.

Accordino: While I was waiting for this meeting to start, I thought I’d get caught up [with emails and electronic medical record messages], but I didn’t. More things have just piled on. Just the number of ways that patients can access us right now is very challenging. Patients’ questions and needs need to be addressed in a timely manner to make sure that nothing urgent is falling through the cracks. It’s hard to keep up with the volume and the number of ways that messages/questions can reach you.

Are there any specific or measurable incentives that would be most effective in directing new graduates to rural or high-volume counties?

Kirkwood: It is so tricky to figure out. There are cost of living considerations, there are partners and their career paths, school districts, other family considerations. It sounds like there are so many factors that go into both personal and career [incentives]. We’ve spoken in our committee group, and we’ve worked with fellows who said, “I wanted to work in GI oncology, but I’m not finding that opportunity while I'm looking for my first position. I’m kind of having to pivot and focus on another specialty. I would like to pursue research.” Each individual’s decision-making factors are unique.

Accordino: Everyone’s motivated by different things, and everyone has different sets of priorities. For some fellows, it’s needing to be in the same city as their loved ones. Maybe during training, they haven’t been, and that’s their No. 1 factor; they will take whatever job is in that location. For some, it’s being a specific type of oncologist specializing in a specific thing…it’s not one-size-fits-all, and there are so many levers that would need to be pulled; it’s challenging. People need to have social support to go to these places that need the help that would need to be financially meaningful [for them] to go there, and the job would have to be rewarding.

Kirkwood: Do you find that some of the public service forgiveness or Health Professional Shortage Areas are some of the factors in terms of weighing medical debt? Does that come into play with your fellows?

Accordino: For some, yes. For others, where they’ve been students or lower-paid employees for some time, the debt has just been there in the background. We also don’t get formalized training on managing personal finances. Some people are more financial minded than others. In terms of decision-making, everyone comes at it differently.

I do think when people start throwing numbers at fellows, all of that is substantially higher than what fellows make during training. Non-academic jobs in more remote areas are typically much more financially rewarding. That means different things to different people. At the same time, there are those public forgiveness programs. [When] pursuing a research career (usually at an academic center), you have the opportunity to participate in the NIH’s loan repayment program based on research that you are doing. That could also be very financially rewarding for people who are taking a job. Maybe that isn’t as lucrative as others in thinking that their loans could get help paid back; I was able to participate in that myself. I have some experience, and I know a lot of our fellows do that. A lot of our faculty members have had the opportunity to do that. It is very appealing, but everyone has a different set of values.

How do the pressures of serving high-need, low-resource communities directly fuel the national oncologist burnout epidemic, and what system changes are needed for long-term retention beyond individual wellness programs?

Accordino: We are aware that burnout is high in this field. There are a lot of administrative hiccups we have to face [when] taking care of our patients. The tests that we need to diagnose them or monitor them are expensive. They often require all levels of prior authorization and approvals, and the medicines we give are also extremely expensive. There are many hoops to jump through…some of those medicines are oral, so they’re paid for differently by insurance compared with intravenous infusions. The cost gets shared with the patients. Patients have high out-of-pocket costs and then ask us for help to manage those things. There’s a lot that gets thrown at us. A lot of is uncompensated work. At more resource centers, we have bigger support staff to manage these things; more admins who can help with paperwork; more registered nurses, APPs, NPs, and PAs; and more social work support. Some of these tasks can be delegated to a greater volume of individuals where, at these lower resourced centers, all this falls back on the oncologist because they just don’t have the support staff. I would imagine the burnout rates would be much higher than someone who has a lot more support.

References

1. Kirkwood MK, Balogh EP, Accordino MK, et al. Where have we been and where are we going? the state of the hematology and medical oncologist workforce in America. JCO Oncol Pract. Published online October 7, 2025. doi:10.1200/OP-25-00144
2. Workforce Projections. HRSA Data Warehouse. November 25, 2025. Accessed November 26, 2025. https://tinyurl.com/22y7efjm
3. Torralba E. Increasing access to high-quality cancer care in rural communities. ASCO Connections. October 1, 2024. Accessed November 26, 2025. https://tinyurl.com/2jx7eumu
4. Winer EP, Levit LA, Basch E, et al. Promoting reasonable career expectations and maximizing professional fulfillment for academic oncologists: ASCO recommendations for academic medical centers. J Clin Oncol. 2025;43(17):2017-2023. doi:10.1200/JCO-24-02246