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Community oncology practices are the backbone of cancer care in the United States, providing treatment to about 80% of all patients with cancer. However, these practices face significant challenges attracting oncology fellows.

The issue largely stems from the dearth of hematology/oncology fellowship programs at community or regional medical centers. A 2022 study found that more than 60% of nationally accredited hematology/oncology fellowship programs in the United States are at academic centers, while only 6% are in community or regional medical centers. 

While fellowship programs at academic centers may provide some training relevant to the community setting, the researchers noted that there does not appear to be any formal pathways to train oncologists for a career in the community setting.

"We only know what we know," Debra Patt, MD, PhD, executive vice president of Texas Oncology, said at the recent Community Oncology Alliance (COA) meeting. "The majority of oncologists train at large academic centers because they have big programs of fellows and so that's what you learn."

With the anticipated workforce shortage in oncology and most training programs geared toward academic medicine, some community oncologists have expressed concern about recruiting the next generation of oncologists to nonurban and rural settings and ultimately about the long-term sustainability of community practices.

The Fellowship Problem

Working in a community oncology practice comes with its share of challenges. Oncologists need to navigate complex healthcare systems and manage limited resources, all while addressing the needs of diverse patient populations.

However, this setting also offers big rewards, including the opportunity to spend more time with patients and forge deep connections.

Moshe Chasky, MD, FACP, an oncologist with Alliance Cancer Specialists, said being an oncologist at a community practice gives him a sense of pride. Community practices provide essential care to patients in local communities, and, in this setting, Chasky feels he is able to make a meaningful impact on patients' lives.

Are you largely focused on your patients, or are you more focused on how to move the field of lung cancer or pancreatic cancer to the next level? Chasky asked. "If you're about taking care of patients, there's no better place to care for them than in the independent oncology community," he said.

Another potential perk of working at a community practice is a higher salary. Although reliable salary information can be hard to come by, national self-reported data indicate that oncologists employed by a hospital or health system reported earning about 11% less overall than self-employed oncologists.

Still, most oncologist trainees enter academic settings, leaving a pressing need for more fellows to enter community oncology practices, Chasky said. The American Cancer Society predicts 2 million new cancer cases will occur this year, and much of that burden will fall to community practices.

Without more oncologists moving into community practices and a few fellowship programs with training dedicated to the community practice setting, it will be a challenge to meet the demand.

Although expanding the number of fellowship programs dedicated to community oncology would be one way to provide more young oncologists with hands-on experience and mentorship from community practitioners, that solution would likely take significant time and resources.

Another strategy would be to offer more community-based training opportunities in all fellowship programs. However, a 2024 survey indicated that is not routinely happening.

The survey, which included 125 participants, found that less than half (41.8%) reported receiving specific training during their fellowship programs for a community-based career. Many fellowships did not offer rotations in a community-based setting, direct mentorship from community practicing physicians, or experience with a high patient volume — features many survey respondents said would have been helpful before joining a community-based practice.

Fellows also said training in business and finances, health policy, patient safety, and quality improvement initiatives would be particularly useful in the community setting.

"What people told us they wish they had more during training is probably the part that's going to be more relevant to recruitment and retention for this aspect of our workforce," Deepa Rangachari, MD, an oncologist with Beth Israel Deaconess Medical Center, Boston, and author of the 2024 survey study, told Medscape Medical News.

To this end, researchers at Dana-Farber Cancer Institute, Beth Israel Deaconess Medical Center, and Harvard Medical School recently proposed a training blueprint for oncologists planning careers in the community setting. The idea is to move away from the traditional fellowship structure, which focuses heavily on laboratory-based research in the second and third years, and instead to provide a pathway that would allow trainees to substitute training in cancer equity and community access, health policy, business, and patient safety.

But without such an option available yet, Katherine Baker, MD, MMHC, currently an oncology fellow at a large academic center, carved her own path.

Baker knew she wanted to work in a community oncology practice early in her training but had few community oncology fellowship options.

Although Baker decided to attend Vanderbilt University Medical Center, Nashville, Tennessee, and is currently the chief fellow there, she has molded her training to give her the experience she would need to be successful in a community practice.

During the COA conference, Baker shared how she made her Vanderbilt fellowship work for her. A unique aspect of her fellowship is her ability to work as a primary oncologist in a Vanderbilt-affiliated clinic, under the supervision of an attending hematologist and oncologist.

"I feel very comfortable moving into a community practice role where I will be doing the same," she said.

Baker did acknowledge that her experience at Vanderbilt isn't standard for most fellows at large academic centers. But, for fellows who want experience in the community setting, she provided some guidance on how fellows can take initiative and carve out those opportunities for themselves.

"If you are at a program that doesn't have a primary clinic in which you are serving a primary oncologist, I think you can seek out those opportunities to rotate at different clinics, [such as] a satellite campus of an academic medical center," Baker said.

Rangachari agreed, noting that "if we really want to think about ways to inspire and promote community-based careers more, that's really going to require more direct engagement in community-based settings during training and with community-based mentors."