National Trends and Dynamic Responses in the Canadian Radiation Oncology Workforce From 1990 to 2018

International Journal of

Radiation Oncology biology

physics

www.redjournal.org

The Profession

National Trends and Dynamic Responses in the Canadian Radiation Oncology Workforce From 1990 to 2018 Shaun K. Loewen, PhD, MD,* Corinne M. Doll, MD,* Ross Halperin, MD,y Matthew Parliament, MD,z Robert G. Pearcey, MD,z Michael F. Milosevic, MD,x Andrea Bezjak, MD,x Eric Vigneault, MD,k and Michael Brundage, MD{ *Division of Radiation Oncology, Tom Baker Cancer Centre, Calgary; yDivision of Radiation Oncology, BC Cancer Agency, Kelowna; zDepartment of Radiation Oncology, Cross Cancer Institute, Edmonton; x Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto; kDepartment of Radiation Oncology, CHU de Que´bec, Que´bec; and {Department of Radiation Oncology, Cancer Centre of Southeastern Ontario, Kingston, Canada Received Dec 20, 2018. Accepted for publication Apr 22, 2019.

Summary The Canadian radiation oncology (RO) workforce has experienced periods of trainee supply variability, inconsistent workforce growth, and dynamic changes in age demographics. Over time, there have been proportionally fewer internationally trained radiation oncologists and more women in practice. The number of patients with cancer has increased dramatically, but crude cancer incidence rates were disproportionate across Canada. These factors add complexity to workforce

Purpose: To report radiation oncology (RO) workforce and cancer incidence trends in Canada and explore the relationship between the two. Methods and Materials: Canadian radiation oncologist, trainee, and cancer incidence data from 1990 to 2018 were collected from the following publicly accessible administrative and health information databases: Canadian Post-MD Education Registry (1990-2018), Canadian Medical Association Physician Data Centre (1994-2018), Canadian Institute for Health Information/Scott’s Medical Database (1990-2017), Canadian Cancer Registry (1990-2017), and Statistics Canada (1990-2017). Descriptive statistics were used to summarize the data. Results: The Canadian RO workforce grew from 240 radiation oncologists in 1990 to 567 in 2018, with the largest growth period from 2005 to 2015 adding 207 radiation oncologists. Regional analyses revealed steady or stepwise growth in all Canadian regions, except in Que´bec, where the number of radiation oncologists decreased from 86 in 1990 to 57 in 2003 before rising to 139 by 2018. Trainee totals were between 54 and 173 per year with 2 periods of growth (1990-1996 and 2001-2008) and regression (1996-2001 and 2008-2018), signifying trainee supply variability. Female proportions of the workforce and trainees, respectively, rose steadily from 18% to 38% and 28% to 50%, while the workforce proportion with non-Canadian medical degrees decreased from 40% to 26%. Radiation oncologists younger than 40 years increased from 70 to 171, whereas those age 60 years and older decreased from 85 in 1990 to 31 in 2002 and

Reprint requests to: Shaun K. Loewen, PhD, MD, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB, Canada T2N 4N2. Tel: (403) 5211535; E-mail: [email protected] Int J Radiation Oncol Biol Phys, Vol. 105, No. 1, pp. 31e41, 2019 0360-3016/$ - see front matter Ó 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ijrobp.2019.04.019

Disclosures: none. Supplementary material for this article can be found at https://doi.org/ 10.1016/j.ijrobp.2019.04.019.

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planning initiatives. The implications of these and other findings are discussed.

then increased to 108 in 2017. Annual cancer incidence rose steadily from 103,780 to 206,290 cases/year. The annual cancer incidence-to-provider ratio fluctuated (364475:1) and trended lower with time, and proportional cancer incidence-to-provider ratios varied between 0.7:1 and 1.6:1 in Canada’s regions before approaching 1:1. Conclusions: Our study demonstrates the challenges and successes of managing the Canadian radiation oncologist workforce. These data will inform policy makers and other stakeholders to ensure that the profession meets the current and future needs of Canadian cancer patients. Ó 2019 Elsevier Inc. All rights reserved.

Introduction Health care is a labor-intensive industry, and the health care workforce is the foundation of any health care system. The practice of radiation oncology (RO) in Canada is highly centralized, with 47 radiation therapy facilities governed by 10 provincial cancer care organizations. Conversely, equipment and funding for radiation therapy services are provided by provincial governments, with no privately operated or funded radiation therapy facilities or equipment permitted.1 Trainee supply is governed by individual universities, but trainee funding is controlled by provincial governments. As such, market forces that act to regulate job and equipment availability in a private system are largely nonexistent. Historically, this situation has led to long and unacceptable delays between rising demand for radiation therapy and an appropriate government response to increase radiation therapy capacity and health care workers in Canada.2 The Canadian Association of Radiation Oncology (CARO), together with the Canadian Association of Medical Radiation Technologists and the Canadian Organization of Medical Physicists, recommend radiation therapy practice and wait time standards to assist the provincial ministries of health with funding decisions for treatment, new equipment, and human resources.3 Several health human resources databases provide pan-Canadian health data and information to enable and accelerate improvements to health systems across the country.4,5 Furthermore, provincial and territorial cancer registries capture information on the incidence, prevalence, and mortality from cancer in Canada.6 CARO has performed independent biennial surveys of the Canadian RO workforce for internal reports capturing workforce demographics, patient workload, trainee recruitment, retirements and departures, and equipment resources since 1999 to inform stakeholders and advocate for the specialty’s future workforce needs. Workforce monitoring efforts by CARO have informed conversations within the specialty and with training program leaders to promote a stewardship culture to work together to promote workforce stability, ensure timely access to radiation therapy services, and periodically take active steps to reduce overtraining or rectify undertraining.7,8 In this article, we summarize historical supply and demand trends attained from national data repositories that

typify the challenges of, and dynamic changes by, the Canadian RO workforce to meet the needs of Canadian cancer patients. Together with complementary information, we propose a narrative that accounts for variability in the size of the trainee cohort and inconsistent workforce growth. The study’s findings are placed in context of national specialty workforce planning to inform stakeholders of potential future challenges and strategies to mitigate them.

Methods and Materials Annual RO trainee and practicing physician data were obtained from the Canadian Post-MD Education Registry (CAPER; 1990-2018)9, Canadian Medical Association Physician Data Centre (CMA-PDC; 1994-2018)4, and Canadian Institute for Health InformationeScott’s Medical Database (CIHI-SMDB; 1990-2017).5 The trainee supply consists of Canadian Citizens and Permanent Residents (CC/PR) who are eligible to enter the Canadian RO workforce. Data for visa trainees, who enter Canada on education visas and are expected to return to their home countries, were excluded from analysis. Spot-check validity of comparable CMA-PDC and CIHI-SMDB data was performed by evaluating the consistency between data sources and comparison to the recent CARO Human Resources Survey (Figure E1; available online at https://doi.org/10.1016/j. ijrobp.2019.04.019). Discordances between CMA-PDC and CIHI-SMDB databases were addressed with data averaging for reporting purposes because similar longitudinal trends were observed (Figure E2; available online at https://doi.org/10.1016/j.ijrobp.2019.04.019). Cancer incidence (1990-2017) and Canadian population (1990-2017) data were obtained from the Canadian Cancer Registry6 and Statistics Canada,10 respectively. Additional information about the databases used in this study are shown in Table 1. Data sources are indicated in the figure legends. Descriptive statistics were used to summarize the data and data trends, and c2 was performed to determine the goodness of fit between the CMA-PDC and CIHI-SMDB data. For regional analysis, Canada was divided into 6 distinct regions composed of 1 or more provinces or territories: West Coast (British Columbia), Prairies (Alberta, Saskatchewan, Manitoba), Ontario, Que´bec, Atlantic Canada (New Brunswick, Nova Scotia, Prince Edward Island,

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Data sources information Data sources

Acronym

Canadian Post-MD Education Registry

CAPER

Canadian Medical Association Physician Data Center

CMA-PDC

Canadian Institute for Health Information: Scott’s Medical Database

CIHI-SMDB

Canadian Association of Radiation Oncology: Human Resources Survey

CARO-HRS

Canadian Cancer Registry

CCR

Statistics Canada

StatCan

Brief description Central repository for statistical information on postgraduate medical education in Canada derived from the Association of Faculties of Medicine of Canada (AFMC), Resident Doctors of Canada (RDC), Canadian Medical Association (CMA), Royal College of Physicians and Surgeons of Canada (RCPSC), and Medical Council of Canada (MCC). Central repository for Canadian physician statistics derived from registries from the Colle`ge des Me´decins du Que´bec (CMQ), RCPSC, College of Family Physicians of Canada (CFPC), AFMC, and its membership data. Independent, not-for-profit organization that provides essential information on Canada’s health system. Data sources include registries from CMQ, RCPSC, CFPC, jurisdictional medical regulatory authorities, Canadian medical schools, and hospitals. Biennial survey, administered by the CARO Human Resources Committee, providing information on workforce demographics, workload, and equipment of Canadian cancer centers with radiation therapy services. Survey responses rates vary between 92% and 100%. Government-led administrative database that collects information on cancer incidence from all provincial and territorial cancer registries in Canada. The CCR was established in 1992, but evolved from the National Cancer Incidence Reporting System containing data from 1969-1991 and resides with Statistics Canada. Statistics Canada is a government agency that is regulated under the Statistics Act; it collects key information on Canada’s economy, society, and environment.

Newfoundland and Labrador), and Territories (Yukon, Northwest Territories, Nunavut). Although Central Canada is officially composed of the provinces of Ontario and Que´bec, these provinces were divided for analysis because their populations are the 2 largest in Canada, and Que´bec has the largest French-speaking population in Canada. The linguistic diversity of Quebec may serve to restrict training and practice environments for nonbilingual trainees and radiation oncologists from elsewhere in Canada where the primary spoken language is English.

Results Radiation oncology trainee supply and demographic trends Figure 1 shows the demographic trends for RO trainees in Canada between 1990 and 2018. The number of CC/PR trainees in residency programs varied between 46 and 163, with growth peaks in 1996 and 2008 (129 and 163 residents, respectively) and troughs in 1991 and 2001 (46 and

Website https://caper.ca/en/

https://www.cma.ca/ physician-data-center

https://www.cihi.ca/en/ scotts-medical-databasemetadata

http://www.caro-acro.ca/

https://www.statcan.gc.ca/

56 residents, respectively), whereas the number of CC/PR postgraduate fellowships in Canada increased from 0 to 11 per year in 1990 to 2006 to 12 to 24 per year in 2007 to 2018 (Fig. 1A). Most CC/PR trainees obtained their medical school degree in Canada Comma unnecessary with rising proportions from 1993 (63%) to 1999 (94%) followed by a downward trend reaching 78% in 2016 (Fig. 1B). Male trainees initially outnumbered female trainees by 2.5:1 in 1990, but this gap narrowed over time and reached gender parity in 2010 before slightly diverging again in favor of male trainees in 2017 to 2018 (Fig. 1C). Regional distribution of CC/PR trainees showed that the majority train in Ontario (70 of 124 in 2018) and that the recent downward trend in overall trainee numbers was primarily due to fewer Quebec trainees (Fig. 1D).

Radiation oncologists in practice: Workforce demographic trends Demographic trends of the Canadian RO workforce with respect to region, medical school training location, gender,

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A

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Fig. 1. Demographic trends of radiation oncology trainees in Canada. (A) Number of Canadian Citizen/Permanent Resident (CC/PR) trainees in residency (closed circle) or fellowship (open diamond) programs. (B) Proportion of CC/PR trainees with Canadian (closed circle) and international (open diamond) medical degrees. (C) Proportion of male (closed square) and female CC/PR trainees (open circle). (D) Number of CC/PR trainees in Ontario (closed circle), Quebec (gray triangle), Prairies (open square), West Coast (closed triangle), Atlantic Canada (open diamond), and Territories (cross). Data source: CAPER.

and age are presented in Figure 2. The workforce grew by 136% from 1990 (240 radiation oncologists) to 2018 (567 radiation oncologists) with the steepest growth rate occurring from 2005 (333 radiation oncologists) to 2015 (540 radiation oncologists; Fig. 2A). Regional analysis revealed steady workforce growth in Ontario and Atlantic Canada, stepwise growth in the Prairies and West Coast, and declining numbers in Que´bec from 1990 (86 radiation oncologists) to 2003 (57 radiation oncologists) followed by a steady rise with 139 radiation oncologists in the province in 2018 (Fig. 2B). The proportion of the workforce with nonCanadian medical degrees decreased from 40% in 1990 to 26% in 2017 (Fig. 2C), whereas the female proportion of the workforce between 1990 and 2018 rose from 18% to 38% (Fig. 2D). A downward trend in physicians older than 60 years was seen from 1990 (85 radiation oncologists) to 2002 (31 radiation oncologists) followed by a rising trend from

2002 to 2017 (108 radiation oncologists), suggesting the influence of retiring physicians in the earlier phase and a corresponding aging demographic in the later phase (Fig. 2E, 2F). Those younger than 40 years formed the largest cohort in 2017 (171 radiation oncologists; 31.4% of the workforce) and suggests increased trainee graduate entry into the workforce between 2008 and 2015 (Fig. 2E, 2F).

Cancer incidence trends Cancer incidence trends in Canada and Canadian regions are shown in Figure 3. Nationally, annual cancer incidence doubled from 1990 (103,780 cases/year) to 2017 (206,290 cases/year; Fig. 3A). The crude cancer incidence rate rose from 373 cases per 100,000 persons to 562 cases per 100,000 over the same period (Fig. 3B). Cancer incidence

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70% 60% 50% 40% 30% 20% 10%

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Fig. 2. Demographic trends in the Canadian radiation oncology workforce. (A) Number of practicing radiation oncologists in Canada. The gray area from 2004 to 2014 signifies additional temporary federal funding from the Canadian Health Accord. (B) Number of practicing radiation oncologists in Ontario (closed circle), Que´bec (gray triangle), Prairies (open square), West Coast (closed triangle), Atlantic Canada (open diamond), and Territories (cross). (C) Number of radiation oncologists with Canadian (closed circle) and international (open square) medical degrees. (D) Proportion of male (closed circle) and female (open square) ROs. (E) Number of radiation oncologists age 39 years or younger (open diamond), 40 to 49 years (close square), 50 to 59 years (gray triangle), and 60 years or older (cross). (F) Proportion of radiation oncology workforce age 39 or younger (black bar), 40 to 49 years (light gray bar), 50 to 59 years (dark gray bar), and 60 years or older (white bar). Data sources: CMA-PDC and CIHI-SMDB (Panels A, B, D) and CIHI-SMDB (Panels C, E-F). breakdown by region rose similarly in all regions (Fig. 3C). Likewise, crude cancer incidence rates by region showed similar growth trends, but absolute values varied across Canada with the highest-to-lowest incidence rates for 2017 observed in Atlantic Canada (656 cases per

100,000 persons), Que´bec (634 cases per 100,000 persons), Ontario (567 cases per 100,000 persons), West Coast (527 cases per 100,000 persons), Prairies (483 cases per 100,000 persons), and Territories (314 cases per 100,000 persons; Fig. 3D).

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A

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Fig. 3. Cancer incidence trends in Canada. (A) The number of annual cancer cases and (B) annual crude cancer incidence rate in Canada. Regional distribution of (C) the number of annual cancer cases and (D) annual crude cancer incidence rate in Ontario (closed circle), Que´bec (gray triangle), Prairies (open square), West Coast (closed triangle), Atlantic Canada (open diamond), and Territories (cross). Data sources: CCR, Statistics Canada.

Relationship of cancer incidence to the RO workforce Exploratory analysis of the relationship between cancer incidence and the RO workforce, including regional evaluation, is presented in Figure 4. For this purpose, the ratio of annual cancer incidence to the number of practicing ROs was presented over time (Fig. 4A), and the ratio of the regional proportion of total cancer incidence to regional proportion of the entire RO workforce was calculated from 1990 to 2017 to permit geographic comparison (Fig. 4B-F). In other words, the ratio reports the number of patients with a new cancer diagnosis in a given year for each RO. The national cancer incidence-to-RO workforce ratio fluctuated between 475:1 and 364:1, and it decreased from 431:1 in 1990 to 370:1 in 2017. Regional analyses also exhibited variability in proportional cancer incidence-to-provider

ratios that approached a 1:1 relationship over time. No radiation oncologists or radiation therapy capacity were in the vast and isolated geography of the Canadian Territories despite nearly 400 new cancer cases in 2017.

Discussion Our study demonstrates the value of leveraging large data repositories to evaluate supply and demand trends in the Canadian RO workforce. It also provides an effective approach to study workforce dynamics using a complete and comprehensive data set to capture and quantify changes over time. “How many” and “where” are 2 fundamental questions facing the global RO community in terms of allocating human resources to manage an expanding cancer patient population. Our Canadian data and analyses provide

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1.2 1.0 0.8 0.6

0.4 1990 1994 1998 2002 2006 2010 2014 2018

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Fig. 4. Relationship trend between cancer incidence and the radiation oncologist workforce. (A) Ratio of cancer incidence to radiation oncologist workforce from 1990 to 2017. The regional proportion of total cancer incidence to regional proportion of total number of Canadian radiation oncology workforce ratio from 1990 to 2017 is provided for (B) Ontario, (C) Que´bec, (D) Prairies, (E) West Coast, and (F) Atlantic Canada. Data Sources: CMA-PDC, CIHI-SMDB, CCR, Statistics Canada. insights into the dynamic complexity and push-pull nature of human resource planning that illustrates both successes and failures in a publicly funded health care system. RO trainee numbers have fluctuated with more than a 3-fold difference between the lowest and highest levels. The underlying reasons to explain the trainee variability are complex with multiple contributing factors. Trainee programs expanded in the early 1990s until 1996 when chronic staffing shortages, high service workloads, and inadequate funding for physician recruitment contributed to declining medical student interest in the specialty and

motivated a trainee exodus from programs that culminated in the regression of resident numbers from 129 in 1996 to 56 in 2001.11-13 By 2001, government funding commitments secured for infrastructure expansion and physician recruitment stimulated trainee growth from 2001 to 2008 to replenish the trainee supply.8 This resulted in a rise in trainee numbers that peaked in 2008 with 163 residents. The downward trend in resident numbers after 2008 was influenced by 2 factors: the start of a global economic recession and another period of recruitment slowdown as cancer centers tightened their budgets, resulting in fewer

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resident transfers into the specialty (particularly in Que´bec), and some residents transferring out of RO training programs for other medical specialties without perceived post-residency employment difficulties.14 Although RO resident intake is coordinated through the Canadian Residency Matching Service, transfers into and out of training programs are not regulated and may contribute to trainee supply variations. A call for a modest reduction in trainee numbers in 2011 resulted from collaborative efforts between the CARO Human Resources and RO Program Director committees to voluntarily decrease resident intake from 25 to 21 per year and limit resident transfers into the specialty in response to oversupply concerns.7 As a result, there were 108 residents in training in 2018. Both RO trainee and workforce demographics show improved female gender representation that reached gender parity in training programs and a 1.67:1 male-to-female ratio in the physician workforce. By comparison, the Australian RO workforce had a 1.67:1 male-to-female ratio in 2014,15 whereas the 2017 ASTRO workforce study reported a rise in female representation from 25.8% in 2012 to 28.9% in 2017 (2.88:1 and 2.46:1 male-to-female ratios, respectively) in the United States RO workforce.16 Men have traditionally outnumbered women in RO practice in Canada, but the gender gap has narrowed and is projected to reach parity sometime between 2030 and 2034. With the global rise of gender equality discussions in society, there have been concerted efforts to understand and improve female gender representation within the specialty.17-19 Que´bec experienced both trainee and workforce instability, and it seems counterintuitive that Que´bec had the highest net growth in the RO workforce over the last 10 years of all regions in Canada, with 64% growth versus 21% to 50% growth in other regions, while at the same time experiencing a 72% reduction in the province’s trainee numbers from 50 to 14 trainees. However, these relationships make sense because Que´bec faced prolonged radiation therapy wait times due to declining workforce numbers from 1990 to 2003,20 requiring a corrective increase in trainees followed by a decline in trainee numbers as workforce undersupply pressures eased. Excessive radiation therapy wait times eventually resulted in a legal challenge to the government’s monopoly over access to RO services and spurred investment in radiation therapy equipment and personnel to meet demand.21 Regional trainee data excluding visa trainees were reported only from 2000 to 2018 (Fig. 2D), but 1990 to 2018 total Que´bec trainee data indicated there were only 6 trainees in 1990 that increased to 58 trainees by 2006, suggesting that increased trainee numbers were required to mitigate staffing demand. The reason for the declining workforce trend in the 1990s is unclear, but median workforce age in Que´bec decreased from 64 years old in 1995 to 46 years old in 2003, suggesting that retirements exceeded recruitments. Between 1990 and 2003, there were 49 fewer radiation oncologists age 60 years or older in the

International Journal of Radiation Oncology  Biology  Physics

Canadian RO workforce, and 73% (36 of 49) of these providers practiced in Que´bec. English and French are the 2 official languages of Canada, but Que´bec is primarily French-speaking, and language preference undoubtedly influences the choice of location for RO training and practice for bilingual graduates from Quebec. In 2017, CIHI-SMDB indicated that 86% (113 of 132) of practicing ROs in Que´bec were Canadian medical graduates, and of these, 97% (110 of 113) obtained their medical degree from Que´bec universities. With approximately 3 graduates per year currently projected for Que´bec, these data suggest that Que´bec may be at risk for a trainee undersupply that could undermine future physician workforce needs in the province. However, migration from other provinces is possible. There is a dynamic relationship between cancer incidence, as an imperfect surrogate indicator of radiation therapy demand, and the RO workforce. This was best illustrated by proportional cancer incidenceto-provider ratios that approached 1:1 in Canada’s regions over time, and in general, workforce expansion occurred in response to the rise in patients with cancer. Although the result is not corrected for radiation therapy utilization rates, a ratio <1 could indicate a workforce oversupply relative to demand, whereas a ratio >1 could suggest an undersupply in the workforce. National cancer incidence-to-provider ratios decreased with time, suggesting that new patient consultation workload per RO across Canada may be lower today compared with the period from 1990 to 2007. Correlation from Canadian RO workforce studies are required to confirm these findings. Despite the nearly 3% steady increase in year-to-year cancer incidence, national workforce growth rate was not consistent and can be divided into 2 distinct periods: 1. From 1990 to 2004, when the average net annual expansion was 6 radiation oncologists per year (range, e3 to 13 per year) 2. From 2004 to 2018, with an average growth rate of 17 radiation oncologists per year (range, 7 to 38 per year) The former period was influenced by workforce instability in Que´bec, whereas the latter period of rapid workforce expansion can be attributed largely to the federal government’s response to prolonged national wait times for radiation therapy in the 1990s and inadequate radiotherapy capacity, during which several provinces sent cancer patients to the United States for treatment.11,22,23 In 2004, the Canadian Health Accord provided an additional $41.8 billion in federal transfer funding to the provinces with a 10-year commitment to increase the supply of health care professionals and reduce treatment wait times in 5 priority areas, including radiation therapy services.24 The optimal rate of national workforce growth is unknown to account for rising cancer incidence and radiation therapy demand, but net expansion of the workforce likely falls between 6

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and 17 radiation oncologists per year with current radiation therapy utilization rates. Workforce turnover is an important factor in determining the optimal size of the trainee cohort. Our data suggests that retirements within 5 years’ time could be as high as 19% of the workforce (108 of 557 radiation oncologists in 2017 60 years of age) with 88% (95 of 108) of these providers located in British Columbia, Alberta, Ontario, and Que´bec. These 4 provinces accounted for 86.2% and 88.3% of cancer incidence and the Canadian RO workforce in 2017, respectively. With approximately 21 trainees currently entering residency programs each year and more radiation oncologists required to meet the projected increase in annual cancer patients, there is a moderate risk that the trainee supply (105 graduates over 5 years) may have difficulties maintaining workforce growth (30-85 more radiation oncologists in the workforce in 5 years’ time) and provider turnover requirements (replacing up to 108 radiation oncologists). Needs-based RO workforce projections from 2010 to 2020 suggested a transient surplus of radiation oncologists followed by a physician shortage because of demand needs outpacing the available supply,25 signifying that periodic adjustment of trainee intake may be necessary to correct the supply and demand discordance. Recruitment of both Canadian-trained and non Canadian-trained radiation oncologists was evident from the data. The number of international medical graduate (IMG) ROs nearly doubled between 1990(95 IMG-ROs) and 2017(144 IMG-ROs) resulting in an average growth rate of 1.8 per year. Still, year-to-year growth in radiation oncologists with Canadian medical degrees outnumbered ROs with international medical degrees by 5:1 on average. The proportion of IMG ROs in 2017 was 26% and comparable to the IMG proportion of the entire specialist workforce in Canada at 22%.26 IMG ROs have CC/PR residency status and have studied in medical school abroad and subsequently performed some or all their postgraduate medical training in Canada or recruited directly into the Canadian physician workforce. International medical student applications are permitted in the Canadian Resident Matching Service. In contrast, 0.8% of trainees entering RO training programs from 2010 to 2015 in the United States are IMGs and the Association of American Medical Colleges reported that IMGs formed 12.9% (597 of 5027) of the United States RO workforce in 2017.27,28 This study has several limitations. Head-counting methodology used in administrative databases do not account for changes that may occur over a medical career. Physician work hours per week trends, part-time or semiretired employment, changes to remuneration models, and an emerging generation that places greater emphasis on work-life balance may be contributing factors that influence clinical volume per physician. Furthermore, clinical workload per physician is dependent on individual administrative, teaching, or research responsibilities, particularly in academic practice environments. Data sources and inclusion or exclusion criteria also differ between the CMA-

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PDC and CIHI-SMDB, such as a requirement for a postal code address that may exclude some locum providers, minimum billing thresholds, and “opt out” or “no publication” methodology based on individual enrollment for privacy matters. These factors result into minor differences between the databases with a high degree of correlation for similar captured events (P  .99; Figure E1, available online at https://doi.org/10.1016/j.ijrobp.2019.04.019). The Canadian Post-MD Education Registry does not report Canadian graduates who perform fellowships abroad, and there were 30% of 2011 to 2014 graduates in fellowships abroad,29 suggesting that the Canadian trainee supply is in fact higher.

Relationship of study data to national specialty workforce planning Health human resource planning in Canada remains a provincial responsibility without national planning coordination, although initial steps to establish a national oversight process with broad representation from government, medical school faculties, and specialty organizations were taken in 2013 through creation of a pan-Canadian Physician Resource Planning Task Force.30 Government regulation is both a strength and a weakness of the Canadian health care system by allowing active management of the specialty’s workforce, but regulation is dependent on available health care funding. This is in contrast to the situation in the United States where workforce regulation is not permitted because of antitrust legislation.31 This study provides a better understanding of the drivers and mitigators of Canadian RO supply and demand, but also evokes caution to policymakers to reduce funding delays and anticipate increased equipment capacity and health care workers to minimize gaps related to rising demands for radiation therapy. Uncertain influences on RO physician supply include job market dynamics, trainees’ employment location and practice preferences, staff recruitment and equipment funding, and retirement rates. While prior studies have explored RO graduate employment outcomes and trainees’ employment preferences14,29,32,33, our study forewarns that retirement numbers could climb because of rising numbers of older physicians. However, indicators also seem to point to a lengthening working life because the proportion of radiation oncologists age 65 years or older in 2018 is currently 9% (49 of 567) and trending upward. By comparison, practicing Canadian specialists aged 65 years and older in 2018 was 16% (6510 of 40,750).4 Retirement trends will need monitoring to ensure provider turnover and workforce supply needs are accounted for by the trainee supply. Although predictable influences on demand include cancer incidence rates and population growth, less predictable factors are changes in timely or geographic accessibility, the effects of alternative non-physician care delivery models, regional differences in cancer incidence

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trends, competing alternative treatments, and changes to radiation therapy indications with positive or negative consequences on radiation therapy utilization. Our study identified that there are geographic differences in crude cancer incidence rates in Canada. The implication is that some Canadian regions will have a greater demand for radiation therapy services than others per population, and national trends cannot be broadly applied. The reasons for geographic variation in crude cancer incidence rates were not investigated in our study, but this finding is likely related to regional differences in population growth, age demographics, gender proportion, genetic makeup, or prevalence of known risk factors for cancer such as diet, obesity, and tobacco and alcohol use. Another important factor influencing workforce expansion is growth in physician services budgets suggesting that workforce projections must move beyond a needs-based approach and integrate other important influences such as budget capitation, equipment resources and replacement, radiation therapy accessibility, and technology advancements. Valuable insights could be revealed from time-based equipment workflow modeling to determine supply and demand influences on radiation therapy wait times to permit the specialty to advocate for both workforce and operational resources.

Conclusion Health human resources and health information databases are important resources to understand and characterize workforce dynamics. Our study sheds some light on some of the human resources challenges and successes experienced by the RO community in Canada, and it has identified areas where improvements could be made. These data will serve as the basis for updating workforce projections and informing policymakers to help ensure that the profession meets the current and future radiation therapy needs of Canadian patients with cancer.

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