Head and Neck Cancer Manpower Study ,’ M. Stuart Strong, MD, Boston, Massachusetts Herbert L. Kayne, PhD, Boston, Massachusetts
During the past twenty-five years, the management of patients with cancer of the head and neck has steadily evolved; the disease has become understood more completely, surgical technics for ablation of cancer and reconstruction have been refined, and technics of radiotherapy and chemotherapy have become more standardized. Little information, however, is available concerning the magnitude of the problem, the number of surgeons involved in head and neck cancer surgery, and the number of potential head and neck cancer surgeons who are being prepared in the training programs to manage patients with cancer of the head and neck. At the annual meeting of the Committee for Head and Neck Surgery of the American Academy of Ophthalmology and Otolaryngology in 1972, Doctor George Sisson, Chairman of the Committee for Head and Neck Surgery, appointed a task force to study head and neck cancer manpower. The members of the Committee were Doctors J. Ryan Chandler, Emanuel Skolnik, M. Stuart Strong, and Paul Ward. Doctor Strong was appointed chairman of the study group. The task force met, planned the study, and accumulated the data. Doctor Herbert Kayne reviewed and assisted in the analysis of the data. Additional sponsorship for the study was sought and received from the American Society of Head
From the Departments of Ototaryngology and Physiology, Boston University School of Medicine, Boston, Massachusetts. Reprint requests should be addressed to M. Stuart Strong, MD. University Hospital, 750 Harrison Avenue, Boston, Massachusetts 02118.
Volume 129, March 1975
and Neck Surgery and the Society of Head and Neck Surgeons. The American Academy of Ophthalmology and Otolaryngology provided funds for the surveys. The goals of the study were as follows: (1) to determine the incidence of new cases of head and neck cancer occurring annually in the United States; (2) to determine the number of surgeons who assume the responsibility for surgery in patients with cancer of the head and neck; (3) to assess the number of cases managed each year by the “average” head and neck cancer surgeon; (4) to assess the number of potential head and neck cancer surgeons who graduate from training programs each year. It was recognized immediately by the members of the task force that the answers to these questions would be estimates at best and that it would be impossible to secure absolute figures. It was hoped, however, that the findings would indicate significant trends or relationships that might be useful to those responsible for the future planning of manpower needs in this area. Methods
1. The number of new cases of head and neck cancer occurring annually can be estimated from the National Cancer Institutes Third National Cancer Study [1] of twenty million people during 1969, when the total population of the United States was 203 million. Statistics are available for cancer of the lip, oral cavity and salivary glands, pharynx, larynx, nose
273
Strong and Kayne
507
40 1
0-
25
26 - 50
51 - 100
No. of
101 - 300
and sinuses, and thyroid. Statistics are not available on the number of cases of skin cancer occurring in the head and neck region. 2. It was assumed by the task force that most cases of head and neck cancer that require surgery are managed by surgeons who are members of either the American Society of Head and Neck Surgery or the Society of Head and NeckbSurgeons. The number of patients managed by surgeons who are not members of either of these organizations was thought to be small. A questionnaire was sent to each active member of the two societies requesting an estimate of the number of cases of cancer of the head and neck for whose surgery they assume responsibility each year; lesions of the nose and sinuses, lip and oral cavity, laryngopharynx, thyroid, and skin were to be included. This estimate included private patients as well as patients treated under their supervision on their services by the resident staff. Some estimates would include a large number of skin lesions, such as those treated by plastic surgeons, and others very few. It was expected that these data could be used to identify the annual case load of the “average” head and neck cancer surgeon, anticipating that some surgeons would be responsible for only a few cases and that a few surgeons would be responsible for a large number of cases. 3. To estimate the number of potential head and neck cancer surgeons who would graduate from training programs each year, a questionnaire was
274
301 - 500
Cases/Surgeon /Annum
501- 1500
Figure 1. The number of cases managed by each surgeon varies widely; only 70 per cent can manage more than 300 cases per year.
sent to the Directors of each training program in otolaryngology, plastic surgery, and general surgery. Each program director was asked to supply a figure for the total number of surgeons graduating from his program annually and to estimate the number of graduates he would expect to remain active in head and neck cancer surgery. Results
1. The number of new cases of head and neck cancer (excluding that of the skin) was found to be 3,760 in a sample of twenty million people in 1969. In 1970, when this same population was sampled, the figure was 3,991, which represents a variation of only 5 per cent [2]. The total population of the United States at that time was 203 million, so that the total number of cases of head and neck cancer was 38,000 to 40,000 per annum. It is probable that the number of new cases of head and neck cancer (excluding that of the skin) is not more than 40,000 per annum in the United States. The proportion of these cases that are treated by surgery is not known, but from the experience of the members of the task force, it is probably about half, radiation and chemotherapy being used in the remaining cases. 2. Replies were received from 366 of 436 (84 per cent) members of the two societies. These 366 surgeons accounted for the management of 50,106 cases; the mean number of cases
The American
Journal of Surgery
Cancer Manpower Study
/
100% 90
% Cases
70
504
Figure 2. When the percentage of cases is plaited against the percentage of surgeons, It appears that a sign/f&ant percentage of surgeons (37 per cent) are being underutilized.
per surgeon per year was therefore 137. Figure 1 shows that only a few surgeons manage 500 cases or more per year and 58 per cent of surgeons are responsible for 50 to 300 cases per year. Figure 2 shows that most cases are managed by a modest proportion of surg ons; 90 per cent of the cases were cared for by 63 per cent of the surgeons! Many of the larger estimates probably include numerous cases of skin cancer; one plastic surgeon reported 300 cases of skin cancer and indicated that he was not involved in other types of head and neck cancer. 3. Replies were received from 96 of 103 directors (90 per cent) of otolaryngologic programs. The directors estimated that 70 per cent of their graduates could be expected to continue actively in head and neck cancer surgery. By including 103 programs it is estimated that 206 potential head and neck surgeons are trained in departments of otolaryngology each year. Eighty-one of ninety-nine directors (81 per cent) of plastic surgery programs replied and estimated that 73 per cent of their graduates could be expected to continue in head and neck cancer surgery. Ninety-nine plastic surgery programs, therefore, contribute approximately 135 potential head and neck cancer surgeons each year. In general surgery, 310 of 420 program directors (74 per cent) replied and estimated that 34 per cent of their graduates would maintain an active interest in head and neck cancer surgery; therefore, 420 programs contribute approximately 390
Volume 129, March 1975
TO Surgeons
potential head and neck cancer surgeons each year. If the graduates from the three disciplines are included, a total of 730 potential head and neck cancer surgeons are being recruited each year. It should be borne in mind that some of these will devote much of their energy to cancer of the thyroid, others to cancer of the skin, and the remainder to cancer of the aerodigestive tract as well as a proportion of cases of thyroid and skin cancer. Comments
It was surprising to find that only 40,000 new cases of head and neck cancer (excluding that of the skin) appear in the United States each year. Since this figure is based on a large sample of twenty million people, it is likely to be reliable. Although the sample was surveyed in 1969 and 1970, there appears to be no reason to expect that the incidence of head and neck cancer will change in the foreseeable future. In retrospect, it would probably have been wiser to omit cases of skin cancer from the questionnaire because there is no known source for determining the incidence of skin cancer, except melanoma. The reason for this is that many cases of skin cancer are treated in a physician’s office, sometimes without histologic verification. Although there was a wide variation in the number of cases treated by each surgeon (0 to 1,500), it was apparent that many of the “busy” head and
275
Strong and Kayne
neck cancer surgeons practice in large medical centers or institutions that have a reputation for cancer treatment and for the training of cancer surgeons. There were a few notable exceptions to this pattern. It would be difficult for a surgeon to care for more than fifty cases of cancer involving major resection each year without adequate assistance from a house staff both on the wards and in the operating room. In practical terms, the number of cases a surgeon can manage successfully will be determined by the type of case load (skin lesions versus lesions of the aerodigestive tract) and associated morbidity and the amount of back-up assistance he can count on from surgical colleagues and house staff. The finding that 90 per cent of cases are cared for by 63 per cent of the surgeons, however, does suggest that a sizable proportion of head and neck surgical talent is underutilized. The production and attrition of surgeons in all specialties in the United States have been studied in detail by Moore et al [3]. They found that the proportion of certain specialties to the general population was rising faster than that of others, but “head and neck cancer surgeons” could not be identified as such. The investigators did find, however, that the total work force of board-certified surgeons in all specialties was about 46,000 and that each year 2,759 new surgeons are certified by their respective boards to at least maintain this manpower pool. Our study reveals what appears to be a severe imbalance between the annual input of potential head and neck cancer surgeons (approximately 730) and the work force of approximately 450 known head and neck cancer surgeons. If all of these recruits, who had been at least partially prepared to practice head and neck cancer surgery, actually continued to be active in the field, the dilution of practical experience would be so great that the level of expertise would drop precipitously-
It is apparent that this conclusion is drawn from figures that represent “best estimates”; however, if the estimates of the program directors were off by as much as 50 per cent or 100 per cent, there still
276
would appear to be a gross imbalance in the number of new potential head and neck cancer surgeons in relation to the present manpower pool. If the population growth rate continues to level off, there will be a serious overproduction of surgeons trained to care for patients with head and neck cancer. The situation clearly presents a difficult problem, but it is one with which program directors in otolaryngology, plastic surgery, and general surgery must come to grips. Extensive study and discussion will be necessary by all concerned if a workable plan is to evolve. Summary
1. Approximately 40,000 cases of cancer of the head and neck (excluding skin) are diagnosed each year. 2. Approximately 20,000 of these cases and 30,000 cases of skin cancer are treated by 366 head and neck cancer surgeons. 3. Ninety per cent of the cases are treated by 63 per cent of the surgeons. 4. Fifty-eight per cent of the surgeons care for between 50 and 300 cases per year. 5. While 2,759 new board-certified surgeons of all specialties are recruited annually to maintain a work force of 46,000 board-certified surgeons [3], apparently 730 potential head and neck cancer surgeons are being prepared to maintain a work force of approximately 450 head and neck cancer surgeons. 6. These findings indicate the need for in-depth study of the manpower needs in head and neck cancer surgery by all who are responsible for the training of surgeons in this field. References 1. Third National Cancer Survey, National Cancer Institute, September 9, 1971, Table no. .OOOl. 2. Geller H: Special Cancer Survey Section, National Cancer Institute. Personal communication, 1973. 3. Moore FD, Boyden CM, Sabiston D, et al: The production, attrition, and biologic life time of surgeons in relation to the population of the United States. Ann Surg 176: 457, 1972.
The American Journalof Surgery
During the past twenty-five years, the management of patients with cancer of the head and neck has steadily evolved; the disease has become understood more completely, surgical technics for ablation of cancer and reconstruction have been refined, and technics of radiotherapy and chemotherapy have become more standardized. Little information, however, is available concerning the magnitude of the problem, the number of surgeons involved in head and neck cancer surgery, and the number of potential head and neck cancer surgeons who are being prepared in the training programs to manage patients with cancer of the head and neck. At the annual meeting of the Committee for Head and Neck Surgery of the American Academy of Ophthalmology and Otolaryngology in 1972, Doctor George Sisson, Chairman of the Committee for Head and Neck Surgery, appointed a task force to study head and neck cancer manpower. The members of the Committee were Doctors J. Ryan Chandler, Emanuel Skolnik, M. Stuart Strong, and Paul Ward. Doctor Strong was appointed chairman of the study group. The task force met, planned the study, and accumulated the data. Doctor Herbert Kayne reviewed and assisted in the analysis of the data. Additional sponsorship for the study was sought and received from the American Society of Head
From the Departments of Ototaryngology and Physiology, Boston University School of Medicine, Boston, Massachusetts. Reprint requests should be addressed to M. Stuart Strong, MD. University Hospital, 750 Harrison Avenue, Boston, Massachusetts 02118.
Volume 129, March 1975
and Neck Surgery and the Society of Head and Neck Surgeons. The American Academy of Ophthalmology and Otolaryngology provided funds for the surveys. The goals of the study were as follows: (1) to determine the incidence of new cases of head and neck cancer occurring annually in the United States; (2) to determine the number of surgeons who assume the responsibility for surgery in patients with cancer of the head and neck; (3) to assess the number of cases managed each year by the “average” head and neck cancer surgeon; (4) to assess the number of potential head and neck cancer surgeons who graduate from training programs each year. It was recognized immediately by the members of the task force that the answers to these questions would be estimates at best and that it would be impossible to secure absolute figures. It was hoped, however, that the findings would indicate significant trends or relationships that might be useful to those responsible for the future planning of manpower needs in this area. Methods
1. The number of new cases of head and neck cancer occurring annually can be estimated from the National Cancer Institutes Third National Cancer Study [1] of twenty million people during 1969, when the total population of the United States was 203 million. Statistics are available for cancer of the lip, oral cavity and salivary glands, pharynx, larynx, nose
273
Strong and Kayne
507
40 1
0-
25
26 - 50
51 - 100
No. of
101 - 300
and sinuses, and thyroid. Statistics are not available on the number of cases of skin cancer occurring in the head and neck region. 2. It was assumed by the task force that most cases of head and neck cancer that require surgery are managed by surgeons who are members of either the American Society of Head and Neck Surgery or the Society of Head and NeckbSurgeons. The number of patients managed by surgeons who are not members of either of these organizations was thought to be small. A questionnaire was sent to each active member of the two societies requesting an estimate of the number of cases of cancer of the head and neck for whose surgery they assume responsibility each year; lesions of the nose and sinuses, lip and oral cavity, laryngopharynx, thyroid, and skin were to be included. This estimate included private patients as well as patients treated under their supervision on their services by the resident staff. Some estimates would include a large number of skin lesions, such as those treated by plastic surgeons, and others very few. It was expected that these data could be used to identify the annual case load of the “average” head and neck cancer surgeon, anticipating that some surgeons would be responsible for only a few cases and that a few surgeons would be responsible for a large number of cases. 3. To estimate the number of potential head and neck cancer surgeons who would graduate from training programs each year, a questionnaire was
274
301 - 500
Cases/Surgeon /Annum
501- 1500
Figure 1. The number of cases managed by each surgeon varies widely; only 70 per cent can manage more than 300 cases per year.
sent to the Directors of each training program in otolaryngology, plastic surgery, and general surgery. Each program director was asked to supply a figure for the total number of surgeons graduating from his program annually and to estimate the number of graduates he would expect to remain active in head and neck cancer surgery. Results
1. The number of new cases of head and neck cancer (excluding that of the skin) was found to be 3,760 in a sample of twenty million people in 1969. In 1970, when this same population was sampled, the figure was 3,991, which represents a variation of only 5 per cent [2]. The total population of the United States at that time was 203 million, so that the total number of cases of head and neck cancer was 38,000 to 40,000 per annum. It is probable that the number of new cases of head and neck cancer (excluding that of the skin) is not more than 40,000 per annum in the United States. The proportion of these cases that are treated by surgery is not known, but from the experience of the members of the task force, it is probably about half, radiation and chemotherapy being used in the remaining cases. 2. Replies were received from 366 of 436 (84 per cent) members of the two societies. These 366 surgeons accounted for the management of 50,106 cases; the mean number of cases
The American
Journal of Surgery
Cancer Manpower Study
/
100% 90
% Cases
70
504
Figure 2. When the percentage of cases is plaited against the percentage of surgeons, It appears that a sign/f&ant percentage of surgeons (37 per cent) are being underutilized.
per surgeon per year was therefore 137. Figure 1 shows that only a few surgeons manage 500 cases or more per year and 58 per cent of surgeons are responsible for 50 to 300 cases per year. Figure 2 shows that most cases are managed by a modest proportion of surg ons; 90 per cent of the cases were cared for by 63 per cent of the surgeons! Many of the larger estimates probably include numerous cases of skin cancer; one plastic surgeon reported 300 cases of skin cancer and indicated that he was not involved in other types of head and neck cancer. 3. Replies were received from 96 of 103 directors (90 per cent) of otolaryngologic programs. The directors estimated that 70 per cent of their graduates could be expected to continue actively in head and neck cancer surgery. By including 103 programs it is estimated that 206 potential head and neck surgeons are trained in departments of otolaryngology each year. Eighty-one of ninety-nine directors (81 per cent) of plastic surgery programs replied and estimated that 73 per cent of their graduates could be expected to continue in head and neck cancer surgery. Ninety-nine plastic surgery programs, therefore, contribute approximately 135 potential head and neck cancer surgeons each year. In general surgery, 310 of 420 program directors (74 per cent) replied and estimated that 34 per cent of their graduates would maintain an active interest in head and neck cancer surgery; therefore, 420 programs contribute approximately 390
Volume 129, March 1975
TO Surgeons
potential head and neck cancer surgeons each year. If the graduates from the three disciplines are included, a total of 730 potential head and neck cancer surgeons are being recruited each year. It should be borne in mind that some of these will devote much of their energy to cancer of the thyroid, others to cancer of the skin, and the remainder to cancer of the aerodigestive tract as well as a proportion of cases of thyroid and skin cancer. Comments
It was surprising to find that only 40,000 new cases of head and neck cancer (excluding that of the skin) appear in the United States each year. Since this figure is based on a large sample of twenty million people, it is likely to be reliable. Although the sample was surveyed in 1969 and 1970, there appears to be no reason to expect that the incidence of head and neck cancer will change in the foreseeable future. In retrospect, it would probably have been wiser to omit cases of skin cancer from the questionnaire because there is no known source for determining the incidence of skin cancer, except melanoma. The reason for this is that many cases of skin cancer are treated in a physician’s office, sometimes without histologic verification. Although there was a wide variation in the number of cases treated by each surgeon (0 to 1,500), it was apparent that many of the “busy” head and
275
Strong and Kayne
neck cancer surgeons practice in large medical centers or institutions that have a reputation for cancer treatment and for the training of cancer surgeons. There were a few notable exceptions to this pattern. It would be difficult for a surgeon to care for more than fifty cases of cancer involving major resection each year without adequate assistance from a house staff both on the wards and in the operating room. In practical terms, the number of cases a surgeon can manage successfully will be determined by the type of case load (skin lesions versus lesions of the aerodigestive tract) and associated morbidity and the amount of back-up assistance he can count on from surgical colleagues and house staff. The finding that 90 per cent of cases are cared for by 63 per cent of the surgeons, however, does suggest that a sizable proportion of head and neck surgical talent is underutilized. The production and attrition of surgeons in all specialties in the United States have been studied in detail by Moore et al [3]. They found that the proportion of certain specialties to the general population was rising faster than that of others, but “head and neck cancer surgeons” could not be identified as such. The investigators did find, however, that the total work force of board-certified surgeons in all specialties was about 46,000 and that each year 2,759 new surgeons are certified by their respective boards to at least maintain this manpower pool. Our study reveals what appears to be a severe imbalance between the annual input of potential head and neck cancer surgeons (approximately 730) and the work force of approximately 450 known head and neck cancer surgeons. If all of these recruits, who had been at least partially prepared to practice head and neck cancer surgery, actually continued to be active in the field, the dilution of practical experience would be so great that the level of expertise would drop precipitously-
It is apparent that this conclusion is drawn from figures that represent “best estimates”; however, if the estimates of the program directors were off by as much as 50 per cent or 100 per cent, there still
276
would appear to be a gross imbalance in the number of new potential head and neck cancer surgeons in relation to the present manpower pool. If the population growth rate continues to level off, there will be a serious overproduction of surgeons trained to care for patients with head and neck cancer. The situation clearly presents a difficult problem, but it is one with which program directors in otolaryngology, plastic surgery, and general surgery must come to grips. Extensive study and discussion will be necessary by all concerned if a workable plan is to evolve. Summary
1. Approximately 40,000 cases of cancer of the head and neck (excluding skin) are diagnosed each year. 2. Approximately 20,000 of these cases and 30,000 cases of skin cancer are treated by 366 head and neck cancer surgeons. 3. Ninety per cent of the cases are treated by 63 per cent of the surgeons. 4. Fifty-eight per cent of the surgeons care for between 50 and 300 cases per year. 5. While 2,759 new board-certified surgeons of all specialties are recruited annually to maintain a work force of 46,000 board-certified surgeons [3], apparently 730 potential head and neck cancer surgeons are being prepared to maintain a work force of approximately 450 head and neck cancer surgeons. 6. These findings indicate the need for in-depth study of the manpower needs in head and neck cancer surgery by all who are responsible for the training of surgeons in this field. References 1. Third National Cancer Survey, National Cancer Institute, September 9, 1971, Table no. .OOOl. 2. Geller H: Special Cancer Survey Section, National Cancer Institute. Personal communication, 1973. 3. Moore FD, Boyden CM, Sabiston D, et al: The production, attrition, and biologic life time of surgeons in relation to the population of the United States. Ann Surg 176: 457, 1972.
The American Journalof Surgery
