Unveiling Regional Disparities in Cancer Care - Analysis of the Geographical Journey and Relocation Patterns of Hematology/Oncology Fellowship Graduates

Background: In the United States, disparities in the distribution of hematologists/oncologists are influenced by several factors. These disparities extend beyond geographic factors to include racial, ethnic, and socioeconomic differences, which further impact the quality and availability of care. The geographical distribution of Hematology/Oncology fellowship graduates (HOFs) is crucial for shaping healthcare delivery and highlighting regional health disparities in cancer care. Our comprehensive study examines the transition and relocation patterns of HOFs during their training, from medical school to residency (T1), residency to fellowship (T2), and fellowship to the first attending position (T3). The goal of this project is to gain insights into the geographical aspects of cancer care disparities, providing a robust foundation for future research and policy decisions.

Methods: We analyzed the transitions of 703 graduates from 65 ACGME-accredited HOF programs (2019-2022) that included alumni data on their websites. Geographical relocation was measured by straight-line distance, and retention was assessed across four regions as defined by the US Census. Socioeconomic and racial factors were evaluated based on public US Census data for respective zip codes. We used Welch's two-sample t-test to compare average travel distances between transitions and compared socioeconomic and demographic factors between each transition's start and endpoints. We conducted a regression analysis to determine which determinants most correlated with mobility from that area at each transition phase.

Results: In T1, trainees traveled significantly further (674 miles), which decreased to 491 miles in T2 and further reduced to 450 miles in T3 (p<0.001). Regional retention was noted to be highest in the Western region from T1 (71.4%) to T2 (83%) to T3 (75.8%). It was observed that trainees moved to less rural areas during T1 and T2 but then shifted towards more rural areas in T3. HOFs traveled less distance in T1 if they hailed from a rural region (p<0.02). For factors such as the uninsured population, trainees initially relocated to areas with higher uninsured rates during T1, but in T2 and T3, they moved away from these areas. HOFs traveled more distance in T2 (p<0.001) if the uninsured population was the factor. Unemployment rates were directly correlated with greater miles traveled in all transitions. In T1, trainees move towards areas with higher median household income, and the trend continues in T2 and T3. Looking into racial determinants, there is a clear trend among trainees to move away from the non-Hispanic black population as they progress from T1 to T2 to T3.

Conclusions: The substantial distance trainees cover during T1 reflects their initial efforts to broaden their clinical training and seek diverse educational experiences, which are critical for their development as hematologists/oncologists. The reduction in travel distance during T2 and T3 indicates a trend towards stabilization and preference for establishing roots, potentially influenced by professional and personal network considerations. The initial movement away from rural areas, followed by a shift back towards these areas in T3, highlights a complex dynamic where early training is sought in urban centers with more resources, but eventual practice might be to areas with lower cost of living, higher physician demand and higher salaries which are classified as more rural areas. The consistent trend of moving towards regions with higher median household incomes and away from areas with higher uninsured populations underscores the socioeconomic considerations influencing these transitions. The persistent relocation away from non-Hispanic black populations suggests underlying racial disparities in the distribution of the oncology workforce. These findings underscore the need for targeted policies to mitigate geographic, socioeconomic, and racial inequality, ensuring equitable access to quality cancer care across all regions.