Geographic Variation in the Utilization of Cancer Care From Subspecialized Medical Oncologists in the United States, 2008 to 2020

Abstract

Background: The growing complexity of cancer care may be driving an increase in subspecialized medical oncologists who focus on treating specific cancer types. However, little is known about trends in subspecialization among oncologists and differences in utilization of subspecialists.

Objective: To quantify trends in oncologist subspecialization and assess differences in utilization of subspecialized cancer care in the United States.

Design: Retrospective cohort study using Medicare claims data from 2007 to 2021.

Setting: National, fee-for-service Medicare.

Participants: Medicare beneficiaries initiating chemotherapy between 2008 and 2020.

Measurements: Chemotherapy episodes were defined using methods from the Oncology Care Model. Subspecialization was identified based on whether oncologists managed more than 80% of chemotherapy episodes within a single cancer category. Outcomes included the annual share of oncologists classified as subspecialists, and the share of chemotherapy episodes managed by these oncologists, stratified by cancer type, geography, and socioeconomic characteristics.

Results: Among 18 633 oncologists and 9.25 million chemotherapy episodes, the proportion of episodes managed by subspecialists increased from 9% in 2008 to 18% in 2020. Utilization varied widely across cancer types and regions, with the highest levels observed in large metropolitan areas. Differences by income widened over time: in 2020, 27.6% of episodes in the highest-income counties were managed by subspecialists, compared with only 8.8% in the lowest-income counties, despite higher cancer mortality in the latter.

Limitations: Analyses were limited to fee-for-service Medicare beneficiaries and excluded patients treated with surgery or radiation alone. Subspecialization was defined using practice patterns rather than formal training, and the study does not assess patient outcomes or causal effects.

Conclusion: Subspecialization in oncology is increasing but is unevenly distributed, with growing differences in utilization across income groups and regions.

Primary Funding Source: National Institute on Aging.