Gunaratne, M

Background: The term classical hematology (CH), referring to a subspecialty focusing on non-cancer blood disorders, was officially adopted by the American Society of Hematology (ASH) in 2022. There is a perceived shortage of classical hematologists, although data are limited (Winter JN, Hematologist 2022). Prior studies have shown that <6% of hematology-oncology fellows pursue a practice subspecializing in CH after training (Todd RF, Blood 2004; Marshall Al, Blood Adv 2018). Moreover, mentorship is consistently cited as the most important factor guiding fellows' career decisions (Sharma D, Blood Adv 2019; Masselink LE, Blood Adv 2019). To help bridge the CH workforce gap, ASH has supported additional hematology-focused fellowship programs (HFFP) within select hematology-oncology fellowship programs. CH constitutes a large proportion of consults in US National Cancer Institute (NCI)-designated cancer centers (West CV, JCO Oncol Pract 2024). The goals of our study were: 1) to determine the proportion of adult hematologist-oncologists within NCI cancer centers who practice CH; and 2) to describe the physician characteristics of cancer centers with HFFP and compare these centers to those without HFFP. Methods: We included all NCI-designated cancer centers with a clinical program as of April 1, 2024. The only exception was St Jude Children's Hospital due to its pediatric focus. We obtained the practice profile of each internal medicine-trained adult hematologist-oncologist (henceforth, physician) as well as the availability of HFFP from the respective cancer center websites. We also searched the corresponding department of medicine and division of hematology at each affiliated academic institution to ensure inclusion of all physicians practicing CH. Each physician was classified into one of the following categories: classical hematologist (attending to only non-cancer conditions), general hematologist-oncologist (cancer and non-cancer conditions), and oncologist (cancer only). The number of hematology-oncology fellowship programs in the US was obtained from the Accreditation Council for Graduate Medical Education. Results: We included 64 NCI-designated cancer centers, 55 of which were considered as comprehensive cancer centers. There was a total of 4,616 physicians (3,891 oncologists [84.3%], 487 hematologists-oncologists [10.6%], and 238 classical hematologists [5.1%]). The median numbers of physicians, oncologists, general hematologist-oncologists, and classical hematologists per center were 55 (range, 16-275), 45 (range, 12-270), 5 (range, 0-48), and 3 (range, 0-13), respectively. The median proportions of classical hematologists and physicians practicing CH (general hematologist-oncologists plus classical hematologists) were 5.1% (range, 0-20.0) and 14.9% (range, 0-55.6%), respectively. There were 12 HFFP within NCI-designated cancer centers (18.8%). Most (11/12) centers with HFFP had >50 physicians (median 95 [range, 38-185]) and >5% classical hematologists (median 6% [range, 3.8-13.5%]); 11 centers with similar characteristics did not have HFFP. Centers with HFFP have significantly higher numbers of physicians (median 95.0 [range, 38-185] vs 49.5 [range, 16-275]; P=0.001) and classical hematologists (median 6.0 [range, 3-13] vs 2.0 [range, 0-11]; P<0.001) but similar proportions of classical hematologists (median 6.0% [range, 3.8-13.5] vs 4.5% [range, 0-20.0]; P=0.078) and physicians practicing CH (median 12.3% [range, 6.5-47.7] vs 15.7% [range, 0-55.6]; P=0.402) compared to those without HFFP. Conclusions: Among adult hematologist-oncologists at NCI-designated cancer centers, only 1 in 20 are classical hematologists, although 1 in 7 have CH as part of their practice. Within NCI-designated cancer centers, only 1 in 5 have an HFFP. These findings suggest that there is an opportunity for NCI-designated cancer centers to encourage and recruit physicians subspecializing in CH and a rationale to create additional HFFPs. These measures may help further alleviate CH workforce shortages and expand CH mentorship to meet the needs of an increasingly complex subspecialty within hematology.

Background The American Society of Clinical Oncology (ASCO) launched the Diversity in Oncology initiative in 2017 to address the need for increased minority representation in the hematology-oncology workforce. A recent series of reports, titled “State of the Oncology Workforce in America,” published in JCO Oncology Practice in 2021 and 2022, focused on this issue. Notably, these reports did not include any data regarding the representation of Asian minorities in the field. Therefore, our objective was to assess the proportion of Asian professionals within the hematology-oncology workforce, encompassing both practitioners and trainees. Methods We conducted a comprehensive search for publicly available data regarding Asian representation among US hematology-oncology practitioners and trainees in both adult and pediatric fields. Our primary data sources included the 2020 US Census, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education, and various professional societies. We defined practitioners to include hematologist-oncologists, gynecologic oncologists, radiation oncologists, surgical oncologists, hematopathologists, hematology-oncology nurse practitioners, hematology-oncology physician assistants, and nurses specializing in hematology-oncology. Trainees encompassed fellows and residents. Additionally, we gathered comparable data on the US population, medical students, adult internal medicine residents, gynecology residents, pediatric residents, pathology residents, surgery residents, nurses, nurse practitioners, and physician assistants. To provide a comprehensive overview of the hematology-oncology workforce, we utilized data from 2020 to 2022, and whenever possible, we collected longitudinal data on trainees over the years. Results As of 2020, Asians represented 6.2% of the US population. Among hematology-oncology physician practitioners, the percentage of Asian individuals ranges from 14.7% to 32.1%, including 32.1% of adult hematologist-oncologists, 20.4% of pediatric hematologist-oncologists, 25.9% of radiation oncologists, 14.7% of gynecologic oncologists, and 7.0% of hematology-oncology physician assistants. In the realm of physician trainees, Asian representation is between 17.9% and 35.3%, with 35.3% of adult hematology-oncology fellows, 20.0% of pediatric hematology-oncology fellows, 26.4% of radiation oncology residents, and 17.9% of gynecologic oncology fellows. Additionally, the proportion of Asian residents from which hematology-oncology fellows are drawn ranges from 14.9% to 35.9%. Specifically, 35.9% of internal medicine residents, 22.0% of pediatric residents, 14.9% of gynecology residents, 26.6% of pathology residents, and 19.2% of surgical residents are Asian. Furthermore, 26.7% of medical students identify as Asian. Notably, the proportions of Asian hematology-oncology trainees and medical students have remained relatively stable from 2005 to 2022. Data on hematopathologists, surgical oncologists, and non-physician practitioners are limited, although Asian representation among hematology-oncology physician assistants is 7.0% and among nurses is 7.2%. Conclusions Asians comprise a large segment of the hematology-oncology workforce in the US. While only 1 in 20 people in the US are Asians, between 1 in 3 and 1 in 5 hematology-oncology physician practitioners and trainees, are Asians. Data are limited for non-physician practitioners. Asian minority representation should be highlighted and considered as an example of success in diversity in hematology-oncology workforce. This framework should be embraced moving forward to continue advancing minority representation throughout the field of hematology-oncology.

Background Complete blood count (CBC) is the most common hematology test performed. Reference limits, aka normal values, are known to vary from one hospital to another. However, little is known about the values of the upper (UL) and lower (LL) limits of common elements reported in the CBC and how they differ among facilities. The objectives of our study were to report the UL and LL of CBC elements from various hospitals in the US, analyze the variances, and describe their clinical significance. Methods This study was approved by the Mayo Clinic institutional review board. We obtained the reference limits of CBCs from various hospitals using the Epic electronic medical records Care Everywhere health information exchange. CBCs from 2020-2023 were included. We included the following CBC elements: hemoglobin (Hgb; male and female), mean cell volume (MCV), white blood cell count (WBC), and platelet count (PLT). We performed descriptive statistics and calculated the coefficients of variation (COVs). In addition, we analyzed the data for clinical context using: A) World Health Organization (WHO) major criterion for polycythemia vera of Hgb >16.5 g/dL and >16.0 g/dL for males and females, respectively; B) WHO major criterion for essential thrombocytosis of PLT >450 x109/L; and C) common textbook reference limits for MCV (80-100 fL) and WBC (5-10 x109/L). Results We collected CBC reference limits from 143 hospitals across 43 states and 99 cities. Most (54.5%) hospitals were community-based, while the rest (45.5%) were academic. The statistics are shown in the Table. In general, there was minimal variance in the UL and LL of CBC elements, with COVs mostly under 8.0%. The one exception was WBC LL, in which the COV was 10.5%. There was no significant difference in the CBC reference limits between academic and community hospitals. The median Hgb UL and LL for males were 17.5 (range, 16.3-18.1) and 13.5 (range, 12.0-14.3), respectively. Similarly, the median Hgb UL and LL for females were 15.7 g/dL (range, 14.6-16.3) and 12.0 g/dL (range, 11.0-12.5), respectively. Majority (93.5%) of the hospitals' male Hgb UL exceeded 16.5 g/dL. In contrast, only few (3.6%) of the hospitals' female Hgb UL exceeded 16.0 g/dL (Figure A). The median MCV UL and LL were 99.0 fL (range, 92.2-103.0) and 80.0 fL (range, 77.0-88.0), respectively. A substantial minority (19.6%) of the hospitals' MCV UL exceeded 100 fL (Figure B). The median WBC UL and LL were 10.8 x109/L (range, 8.9-13.0) and 4.0 x109/L (range, 3.1-5.4), respectively. Most (80.4%) hospitals' WBC UL exceeded 10 x109/L (Figure C). The median PLT UL and LL were 400 x109/L (range, 317-500) and 150 x109/L (range, 125-172), respectively. Over a quarter (27.5%) of the hospitals' PLT UL were at or exceeded 450 x109/L (Figure D). Conclusions: There was minimal variance in CBC reference limits across hospitals in the US with WBC LL having the highest COV. Most MCV UL and WBC UL exceeded common textbook reference limits. Almost all male Hgb UL and over a quarter of PLT UL exceed the WHO major criteria of polycythemia vera and essential thrombocytosis, respectively. Since our findings suggest that there could be a risk of underdiagnosing these myeloproliferative neoplasms due to the commonly used reference limits, clinical context must be used when interpreting normal CBC results, especially when there is a suspicion of polycythemia vera or essential thrombocytosis.

Background Complete blood count (CBC) is the most common test performed in hematology-oncology. A typical CBC report contains over 10 elements. Simplifying the report by removing nonessential elements may benefit clinicians and patients. Little is known about what elements are reported by various hospitals in the US. The objective of our study was to describe how hospitals in the US report CBC. Methods After approval from the Mayo Clinic institutional review board, we obtained hospital CBC reported elements from the Epic electronic medical records Care Everywhere health information exchange. CBCs from 2020-2023 were included. For each hospital, we determined the city and state where it's located. We obtained the number and type of elements reported in the CBC and compared the findings between academic and community hospitals. Results We collected CBC data from 139 hospitals across 43 states and 102 cities (Figure 1). Fifty-four percent were community hospitals while 46% were academic hospitals. The median number of elements reported by all hospitals was 21 (range, 12-24). This was not different (P=0.98) between academic (median 22 [range, 12-24]) and community hospitals (median 21 [range, 14-24]; Figure 2). The distribution of hospitals according to the number of CBC elements reported were as follows: 12-15 (6%), 16-19 (13%), 20 (25%), 21(6%), 22 (18%), 23 (19%), and 24 (13%). A minority of the hospitals did not report % white blood cell differential count (9.4%) or mean platelet volume (20.9%). Nucleated red blood cell and immature granulocyte count were reported frequently, 46.0% and 56.8%, respectively. However, the frequency of reporting these four elements were similar between academic and community hospitals. Conclusions We found substantial variations in CBC reporting among US hospitals even within academic and community hospitals. Most hospitals reported 20 or more elements, twice as many as the hospitals reporting the least number of elements. There is an opportunity to simplify and standardize CBC reporting, which will minimize physician burnout and distraction as well as decrease patient concern and query.