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DOI: 10.1055/s-0044-1792179
Brazilian medical oncologists: current and future perspectives for 2020
Oncologistas no Brasil: perspectivas atuais e futuras para 2020ABSTRACT
Objective: In the USA there will be a shortage of medical oncologists by 2020. In Europe, a recent study showed that almost all analyzed countries will reach the estimated need. However, no data on this subject is available for Brazil, a developing country with a high cancer incidence. The aim of this study was to predict the Brazilian scenario for 2020. The number of practicing medical oncologists was obtained through Federal Council of Medicine in August 2014.
Methods: Data on cancer incidence (excluding non-melanoma skin cancer) since 2008 were obtained from Brazilian National Cancer Institute (INCA).
Results: Cancer incidence estimates for year 2020 were analyzed assuming a stable increase between 2014 and the subsequent years. Ratios of new cancer cases versus number of medical oncologists were calculated for 2014 and for 2020 per each Brazilian region. Based on the variation ratio per year, the Brazilian cancer incidence in 2020 is estimated to be 393,75/100,000 compared with 289,44/100,000 in 2014. The number of medical oncologists in Brazil will increase by 2020 in comparison to 2014, especially due to the growth of training vacancies. There will still be a heterogeneous distribution of medical oncologists through the different Brazilian regions and also a high number of patients per MO.
Conclusion: The more critic region to oncology care seems to be the Midwest. This survey shows the need of a monitoring and planning program in oncology assistance in all Brazilian regions.
RESUMO
Objetivo: Nos EUA, haverá uma escassez de médicos oncologistas em 2020. Na Europa, um estudo recente mostrou que quase todos os países analisados atingirão a necessidade estimada. No entanto, não há dados disponíveis sobre o Brasil, um país em desenvolvimento com alta incidência de câncer. O objetivo deste estudo foi prever o cenário brasileiro para 2020.
Métodos: O número de médicos oncologistas foi obtido através do Conselho Federal de Medicina em agosto de 2014. Os dados sobre incidência de câncer (excluindo o câncer de pele não-melanoma) desde 2008 foram obtidos a partir do Instituto Nacional do Câncer (INCA). Estimativas de incidência de câncer para 2020 foram analisadas assumindo um aumento estável entre 2014 e os anos subsequentes. Taxas de novos casos de câncer versus o número de médicos oncologistas foram calculadas para 2014 e 2020 em cada região brasileira.
Resultados: Com base no ráciona taxa de variação anual, a incidência de câncer no Brasil em 2020 é estimada em 393,75 / 100.000 em comparação a 289,44 / 100.000 em 2014. O número de médicos oncologistas no Brasil aumentará em 2020 em comparação a 2014, especialmente devido ao crescimento de vagas de residência. Haverá, ainda, uma distribuição heterogênea dos médicos oncologistas através das diferentes regiões do Brasil e também um elevado número de pacientes por médicos oncologistas.
Conclusão: A região mais crítica aos cuidados de oncologia parece ser o Centro-Oeste. Esta pesquisa mostra a necessidade de um programa de planejamento e acompanhamento da assistência oncológica em todas as regiões brasileiras.
INTRODUCTION
Cancer is a leading cause of death worldwide with more than 7 million people dying every year due to this disease.[1] The disease is a major public health problem in developed as well as in developing countries. In middle-income and low-income countries, non-communicable diseases including cancer are overtaking infectious disease as the leading health-care threat.(2)According to World Cancer Declaration, there will be an increase by 14% in 2020 in the cancer incidence in Brazil and by 28% in 2030.[3] The increased cancer incidence is a serious social problem since patients will require more hospitals visits, specialized treatments, and, essentially, medical oncologists (MO). The need of MO which plays a major role in providing high quality care to cancer patients has never been so urgent.
Many studies have been published showing the lack of oncologists in different countries by 2020.[4]-[9] In the USA, a survey has shown that the number of MO has more than doubled over the past two decades.[9] However, this number is projected to increase by only 20% from 2007 to 2020. In the USA, the overall demand for medical and radiation oncologists is expected to grow by 40% in 2025, whereas the supply of these specialties is expected to grow only by 25%.[9] Negative projections relating to a similar lack of professionals were also observed in Australia8, Japan (radiation therapists),[10] Latin America (radiation therapists),[11] France[6] and Belgium.[4] In contrast with these findings, an European survey has shown that based on the incidence and not on the prevalence most of 12 countries analyzed will probably meet the projected need.[7]
No data is available about prediction of MO in developing countries. Thereby, concerns related to predictions that the number of oncologists will be insufficient to meet the demands are international and this data is crucial to ensure adequate care for cancer patients. Unfortunately, no data on this subject is available for Brazil, a developing country with a high incidence of cancer. Based on this recent european study[7] concerning this subject, the aim of our study was to evaluate the current availability of medical oncologists in each Brazilian region and to predict the scenario for 2020.
METHODS
A survey was submitted by e-mail to the Federal Council of Medicine of Brazil in August 2014 enquiring about the number of medical oncologists by Brazilian region.[12] MO were considered those with registration in the council of clinical cancerology, not including hematologists and radiotherapists. Medical Oncology vacancies for training positions per Brazilian region since 2006 were obtained from the Brazilian Ministry of Education, through the “Access of Information Law” (Law nº 12,527/2011).[13] Data regarding Brazilian population was obtained from the Brazilian Institute from Geography and Statistics (IBGE) through research on the official website in February 2015.[14] Data on cancer incidence (excluding non-melanoma skin cancer) since 2008 were obtained from INCA also through research in the official website in February 2015.[15]
Statistical analysis
Based on the available data, the ratios of new cancer cases versus number of medical oncologists were calculated for 2014 and projected for 2020 for each Brazilian region. Those regions were defined as: South (RS – Rio Grande do Sul, SC – Santa Catarina and PA –Parana); Southeast (SP – São Paulo, RJ – Rio de Janeiro, ES – Espirítio Santo and MG – Minas Gerais); Midwest (MS – Mato Grosso do Sul, MT – Mato Grosso and GO – Goiás); Northeast (BA – Bahia, SE – Sergipe, AL – Alagoas, PE – Pernambuco, PB – Paraíba, RN – Rio Grande do Norte, CE – Ceará, PI – Piauí and MA – Maranhão); North (TO – Tocantins, PA – Pará, AM – Amazonas, RO – Rondônia, RR – Roraima, AC – Acre and AP – Amapá).
The projection of the Brazilian population for 2020 was calculated assuming the population variation between years 2000 and 2010. Cancer incidence estimates for 2020 were analyzed based on the variation rate from 2008 to 2014, assuming a stable increase between 2014 and the subsequent years, using the formula: number of MO in 2014 × (1 + mean annual variation × 6 years). The ratio of new cancer cases per medical oncologist was calculated by dividing the cancer incidence by the total number of MO in each year and region. The number of MO was displayed as a bubble chart created through Software Microsoft Excel® 2010, adapting the longitudes and latitudes of each Brazilian states with the map image of Brazil.
This research was approved by the Ethics Comitte of Hospital Moinhos de Vento (Porto Alegre, Brazil), on 27 August 2014.
RESULTS
The number of MO predicted for 2020 will be 2555, compared to 1037 in 2014 (an increase of 146%), without taking into account possible loss because of retirement, migration and death.[Figure 1] shows the current (1A) and future (1B) scenario of distribution of MO according to the Brazilian regions.
The prediction of Brazilian population for 2020 will be 221,596,455 individuals, compared to 193,976,530 in 2010, based on the variation ratio per year from 2000 to 2010 (0.142). Cancer incidence is predicted to increase according to the growing of the Brazilian population. The mean variation of cancer incidence ratios per year was 0.060 from 2008 to 2014. For 2020, the number of new cancer diagnosis is predicted to be 393,8/100,000 individuals, compared to 289.4/100,000 in 2014. For all Brazilian regions, the increase in population ranges from 0.105 to 0.267 and the increase in cancer incidence, ranges from 0.035 to 0.130 ([Table 1] and [Figure 2]).
The available training positions from 2006 to 2014 increased from 75 to 253 (a 237% increase). The number of new medical oncologists in 2020 is estimated to be 1518 ([Table 2]).
The ratio of new cancer cases per MO predicted for 2020 will be 342 patients/MO, compared to 541 patients per medical oncologist in 2014. Exclusively for the Midwest region, this ratio will increase (+68.7%). For the other regions, these ratios will decrease by 2020, especially the Southeast region (-54.4%) ([Table 2]).
DISCUSSION
The number of MO in 2020 will substantially grow, especially due to an increase in training positions in all Brazilian regions in the period analyzed (varying from 100 to 700% increase). However, it is important to highlight that in some regions (North, Midwest and Northeast) this huge increase will occur because the number of training positions was formerly low.
Increasing residency vacancies is one proposed solution to ensure the required number of medical oncologists worldwide. However, this requires time and resources, and based on a study of 20,058 directors of oncology programs, expansion plans would yield only 8% increase in training programs openings between 2010 and 2011.[9] Even a 50% increase in the programs between 2010 and 2018 would not be able to suppress the lack of oncologists in 2020 in the USA.[9] Another issue is that currently the residents must complete a residency in internal medicine before specializing in oncology, and internal medicine vacancies have remained constant over the last decade.(9)Therefore, a combined effort between these two specializations is encouraged in order to create solutions regarding this aspect.
The number of patients with cancer per medical oncologist will decrease in all regions analyzed, except for the Midwest. Currently there is no specific suggestion of an ideal number of patients per MO. In 2013, Brazil had the average of 1.9 physicians per 1000 people.[16] Meanwhile, for specialties like medical oncologists there is no ideal number set. Our estimative suggests a significant imbalance regarding the number of oncologists and new cancer patients per year in the Midwest region.
Regarding the Midwest, there is an important trend of population cancer incidence growth, combined with a small amount of training positions in the region. Despite the 100% growth of training positions between 2006 and 2014, the number still remains below the demands of the region. A survey conducted in 2005 showed that most doctors working on the Midwest region come from other states, mainly in the Federal District, but the medical training makes reference to the Colleges of the states of the region.[17] Thus, it is possible that the deficit in this region is overestimated if there is an important participation of doctors trained in other regions of the country, since migration processes were not analyzed in our study. In 2005, 49.6% of the Midwest’s doctors performed medical residency in the region, while 41.5% did so in the Southeast. A study conducted in 2003 about training positions in oncology in Brazil also showed a strong imbalance in the distribution, with a concentration in the Southeast.[18] Thus, it is clear that there was no breakthrough on this issue.
Currently studies have focused on evaluate not only the quantity but the productivity of each doctor. For this, the concept of full-time equivalent (FTE) has been widely used. An FTE physician is defined as one who is in the clinic 4 full days a week and spends the fifth weekday on clinic business, although not necessarily seeing patients.[19] This strategy helps in planning the needs of each local, as it takes into consideration personal questions that influence the medical care. In the near future, we expect to develop a way to better assess the medical productivity of medical oncologists in Brazil, using this kind of concept.
Our survey addressed only cancer incidence. Cancer prevalence is expected to grow because the number of cancer survivors is expected to increase, mostly due to aging of the population, early cancer detection and more effective treatments available for adjuvant and metastatic disease. Thus, the shortage of medical oncologists may be even higher than predicted.
Also, it is necessary to emphasize that the reliability of the records of Brazilian Federal Council of Medicine could be affected by the gap of non-specialists who work in this area and are not registered, besides those surgeons and radiation oncologists who are included in the record without acting in this same field as MO. Despite these limitation, council registration is still the most reliable way to obtain these records.
Another key issue found in our survey was the disparity of regional distribution of medical oncologists among the Brazilian regions. The South and the Southeast region will concentrate 75% of oncology workforce, while the population on those regions will be 55% of the total Brazilian population.[Figure 1] shows that these heterogeneities will increase in 2020. Regional disparity in oncologist’s distribution has also been reported in other countries. In the USA, oncology continues to experience an uneven geographic distribution of its workforce. The American Society of Clinical Oncology (ASCO) 2014 analysis of oncology locations identified only 600 hematologists and medical oncologists (5.5%) practicing in rural care sites.(20,21) Creating solutions that contribute to the proper distribution of professionals, while maintaining the quality of service required by the complexity of the specialty, is a challenge for Brazil.
It is well known that many factors influence the supply of and demand for oncologist services, including changes in the incidence and prevalence of cancers, population demographics, insurance status, and changes in physician retirement rates and productivity[22] We aim to future access adjustment of this Brazilian data concerning retirement, migrations and gender difference, although this data is not easily available. There is no homogeneous retirement program for MO in Brazil, and most of physicians use private secure.
Changes in medical profile in the upcoming years will also impact on the demand forecasts and supply of oncologists. Regarding feminization of oncology, surveyshave showed an increase of female population in this specialty.(4,8) A Belgium study revealed that gender plays a significant role in the number of hours worked per week, and men worked more than women both in terms of number of shifts worked and in terms of hours per turn.[4] Male hematologist-on-cologists delivered 17% more visits than their female colleagues.[22] Thus, increasing the number of women oncologists should result in reduction in supply over the coming decades, as women spend less time in professional activities compared to men. Moreover, the age of the oncologists has an important impact on the work.(4,8) Those working with private practices see more patients compared to those who work elsewhere or in education.[8] Oncologists between 45 and 65 years-old see more patients per week compared to those at the beginning of their careers or those with over 65 still active in medicine.[8] Retirement rates will also disturb the supply of professionals.(8,9) According to an US study,[9] more than half of oncologists are 50 years or older and tend to retire in 2020. Young doctors also will impact on supply due to a change in the profile of these professionals. Also, a French study concludes that the new generation will maintain a high quality of life, looking for a balance between their personal and professional lives and, consequently, working less.[6] Indeed, a research showed that hematologists-oncologists with more than 18 years of experience provided 120% more visits than the ones with 1 or 2 years of work.[22] In our survey, it was not possible to evaluate gender and age of medical oncologists due to the lack of this information in the researched records. Also, losses because of retirement, death, migration or other reasons were not estimated in our study. Yang[22] estimated the impact of a 10% decrease in the proportion of physicians. Because of these individual issues that significantly affects oncology workforce, further research should focus on more precise productivity estimates.
It is important to inform that Brazil has an unified health system (Sistema Único de Saude - SUS), which is widely used by the population In 2008, for example, SUS financed 58.6% of care and 69.6% of hospital admissions.[23] The distribution of medical oncologists on these two distinct Brazilian health systems was not the focus of this study, but should be considered in future analysis. Moreover, the elapsed time for the patient to initiate the appropriate cancer care in the public and private system should be targeted in studies in this area. In 2014, the Ministry of Health has amended a decree recognizing the maximum period of 60 days to start cancer treatment in SUS from the date of pathology signing report.[24] This survey calls the attention to better monitoring and planning the future of oncology in Brazil.
A survey conducted by IBGE showed that the Brazilian population with more than 65 years should increase from 14.9 million (7.4% of the total) in 2013 to 58.4 million (26.7 % of total) in 2060.[25] This high growth of the elderly population will also impact on cancer incidence, bringing challenges for Brazil, a country starting its walk in the aging of its population.
Oncology is going to change dramatically over the coming years. Deep understanding of Brazilian oncology burden is the first step to promote adequate solutions. Several solutions have been proposed to solve this international problem. Tackling the problem requires an approach at different levels, aiming to offer clinical oncologists through recruitment, training and participation, improving the efficiency of clinical practice and the introduction of innovative methods of care through multidisciplinary involvement of health professionals.
ASCO published in March 2015 “The State of Cancer Care in America: 2015”, highlighting the key troubling trends to spread patients access to cancer care: aging oncology workforce, poor oncology coverage in rural areas, rise of professional burnout and the growing concerns over costs of care and financial sustainability of oncology practices.[26] These 4 issues should be assessed in Brazil to better manage the consequences of these problems. Also, ASCO contracted with The Lewin Group to develop oncologist supply-and-demand model projects that predict the supply of and demand for oncologist services over time (2012-2025).[22] We support that this kind of strategy could similarly be discussed and implemented in Brazil, since there are no consolidated programs planning the future of cancer care on this country.
CONCLUSION
In summary, our study shows that the number of medical oncologists in Brazil will increase by 2020 in comparison to 2014, especially due to the growth of training vacancies. However, there will still be a heterogeneous distribution through the different Brazilian regions and also a high number of patients per medical oncologist. The more critic region to oncology care seems to be the Midwest. This is the first report on Brazil warning about this public health problem. This survey shows the need of a monitoring program for oncology assistance in all Brazilian regions.
Conflict of Interests
none
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REFERENCES
- 1 Stewart BW, Wild CP. World Cancer Report 2014. Lyon: IARC; 2014
- 2 Goss PE, Lee BL, Badovinac-Crnjevic T, Strasser-Weippl K, Chavarri-Guerra Y, St Louis J, Villarreal-Garza C, Unger-Sal-daña K, Ferreyra M, Debiasi M, Liedke PE, Touya D, Werutsky G, Higgins M, Fan L, Vasconcelos C, Cazap E, Vallejos C, Mohar A, Knaul F, Arreola H, Batura R, Luciani S, Sullivan R, Finkelstein D, Simon S, Barrios C, Kightlinger R, Gelrud A, Bychkovsky V, Lopes G, Stefani S, Blaya M, Souza FH, Santos FS, Kaemmerer A, de Azambuja E, Zorilla AF, Murillo R, Jeronimo J, Tsu V, Carvalho A, Gil CF, Sternberg C, Dueñas-Gonzalez A, Sgroi D, Cuello M, Fresco R, Reis RM, Masera G, Gabús R, Ribeiro R, Knust R, Ismael G, Rosenblatt E, Roth B, Villa L, Solares AL, Leon MX, Torres-Vigil I, Covarrubias-Gomez A, Hernández A, Bertolino M, Schwartsmann G, Santillana S, Esteva F, Fein L, Mano M, Gomez H, Hurlbert M, Durstine A, Azenha G. Planning cancer control in Latin America and the Caribbean. Lancet Oncol 2013; 14 (05) 391-436
- 3 World Cancer Declaration. A call to action from the global cancer community [Internet]. Geneva: UICC; 2008. [cited 2017 Mar 29]. Available from http://old.uicc.org/templates/uicc/pdf/declaration/wcd2008.pdf
- 4 D’Hondt V, Benahmed N, De Wever A, Dirirx L, De Vareliola D. Imbalance between supply and need of medical oncologists in Belgium. Belg J Med Oncol 2013; 7 (02) 38-45
- 5 Warren JL, Mariotto AB, Meekins A, Topor M, Brown ML. Current and future utilization of services from medical oncologists. J Clin Oncol 2008; 26 (19) 3242-37
- 6 Rivera P, Delord JP, Grosclaude P, Grand A, Bugat R. [Demography of oncologic practitioners working in France. Projection elements for the next 30 years]. Bull Cancer (Paris) 2004; 91 (03) 271-7
- 7 Azambuja E, Ameye L, Paesmans M, Zielinski CC, Piccart-Gebhart M, Preusser M. The landscape of medical oncology in Europe by 2020. Ann Oncol 2014; 25 (02) 525-8
- 8 Blinman PL, Grimison P, Barton MB, Crossing S, Walpole ET, Wong N. et al. The shortage ofmedical oncologists: the Australian Medical Oncologist Workforce Study. Med J Aust 2012; 196 (01) 58-61
- 9 Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M. Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Pract 2007; 3 (02) 79-86
- 10 Nakano T. Status of Japanese radiation oncology. Radiat Med 2004; 22 (01) 17-9
- 11 Zubizarreta EH, Poitevin A, Levin CV. Overview of radiotherapy resources in Latin America: a survey by the International Atomic Energy Agency (IAEA). Radiother Oncol J 2004; 73 (01) 97-100
- 12 Conselho Federal de Medicina [Internet]. [citado 2014 Ago 30]. Disponível http://portal.cfm.org.br/
- 13 Brazil, Leis, Decretos. Lei No.12.527/2011. Diário Oficial da União [Internet]. 2012 May 16.2012. (citado 2014 Set 29]. Disponível em http://www.acessoainformacao.gov.br/
- 14 Instituto Brasileiro de Geografia e Estatística [Internet]. [citado 2014 Out 15]. Disponível em http://www.ibge.gov.br/home/
- 15 Instituto Nacional de Cancer. Estatística [Internet]. [citado 2014 Out 15]. Disponível em http://www2.inca.gov.br/wps/wcm/connect/inca/portal/home
- 16 Physicians (per 1,000 people). World Health Organization’s Global Health Workforce Statistics, OECD, supplemented by country data [Internet]. [cited 2015 Oct 15] Available from http://data.worldbank.org/indicator/SH.MED.PHYS.ZS?order=wbapi_data_value_2013+wbapi_data_value&sort=asc)
- 17 O Médico e seu trabalho: Resultados da REGIÃO CENTRO-OESTE e seus estados. Brasília (DF): Conselho Federal de Medicina; 2005
- 18 Da Silva MG, Arregi MM. Residência médica na área de cancerologia no Brasil: distribuição dos programas e da oferta de vagas por região em 2003. Rev Bras Canceraol 2005; 51 (01) 5-13
- 19 Barr TR, Towle EL. National Oncology Practice Benchmark: An Annual Assessment of Financial and Operational Parameters–2010 Report on 2009 Data. J Oncol Pract 2011; 7 2 Suppl 2-15
- 20 American Cancer Society: Cancer treatment and survivorship: Facts and figures 2014-2015 [Internet]. (cited 2015 Apr 30]. Available from http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042801.pdf
- 21 Centers for Medicare and Medicaid Services: Official Physician Compare data [Internet]. [cited 2015 Apr 30]. Available from https://data.medicare.gov/data/physician-compare
- 22 Yang W, Williams JH, Hogan PF, Bruinooge SS, Rodriguez GI, Kosty MP. et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Oncol Pract 2014; 10 (01) 39-45
- 23 Da Silva ZP, Ribeiro MC, Barata RB, de Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003- 2008. Ciên Saúde Colet 2011; 16 (09) 3807-16
- 24 Brasil. Decreto No. 1.220 de 03/06/14 Diário Oficial da União. 2014: 91 junho 4 Section 1, No. 105 [ Changes the art. 3 of Ordinance No. 876 / GM / MS, of 05.16.2013, which provides for the application of Law No. 12,732, de 11.22.2012. Published in Federal Official Journal. 2014 junho 3]
- 25 Population Brazilian Estimates. Brazil, Law No. 8443 of July 16, 1992, in Article 102 the IBGE has published in the Official Gazette on 29 August 2013.
- 26 American Society of Clinical Oncology. The State of Cancer Care in America, 2015: A Report by the American Society of Clinical Oncology. 2015. J Oncol Pract 2015; 11 (02) 79-113
Correspondence author:
Publication History
Received: 27 January 2017
Accepted: 28 March 2017
Article published online:
25 February 2025
© 2017. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)
Thieme Revinter Publicações Ltda.
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Júlia Plentz Portich, Juliana Giacomazzi, Alessandra Menezes Morelle, Daniela Dornelles Rosa, José Roberto Freitas Rossari, Evandro de Azambuja. Brazilian medical oncologists: current and future perspectives for 2020. Brazilian Journal of Oncology 2017; 13: e-1792179.
DOI: 10.1055/s-0044-1792179
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REFERENCES
- 1 Stewart BW, Wild CP. World Cancer Report 2014. Lyon: IARC; 2014
- 2 Goss PE, Lee BL, Badovinac-Crnjevic T, Strasser-Weippl K, Chavarri-Guerra Y, St Louis J, Villarreal-Garza C, Unger-Sal-daña K, Ferreyra M, Debiasi M, Liedke PE, Touya D, Werutsky G, Higgins M, Fan L, Vasconcelos C, Cazap E, Vallejos C, Mohar A, Knaul F, Arreola H, Batura R, Luciani S, Sullivan R, Finkelstein D, Simon S, Barrios C, Kightlinger R, Gelrud A, Bychkovsky V, Lopes G, Stefani S, Blaya M, Souza FH, Santos FS, Kaemmerer A, de Azambuja E, Zorilla AF, Murillo R, Jeronimo J, Tsu V, Carvalho A, Gil CF, Sternberg C, Dueñas-Gonzalez A, Sgroi D, Cuello M, Fresco R, Reis RM, Masera G, Gabús R, Ribeiro R, Knust R, Ismael G, Rosenblatt E, Roth B, Villa L, Solares AL, Leon MX, Torres-Vigil I, Covarrubias-Gomez A, Hernández A, Bertolino M, Schwartsmann G, Santillana S, Esteva F, Fein L, Mano M, Gomez H, Hurlbert M, Durstine A, Azenha G. Planning cancer control in Latin America and the Caribbean. Lancet Oncol 2013; 14 (05) 391-436
- 3 World Cancer Declaration. A call to action from the global cancer community [Internet]. Geneva: UICC; 2008. [cited 2017 Mar 29]. Available from http://old.uicc.org/templates/uicc/pdf/declaration/wcd2008.pdf
- 4 D’Hondt V, Benahmed N, De Wever A, Dirirx L, De Vareliola D. Imbalance between supply and need of medical oncologists in Belgium. Belg J Med Oncol 2013; 7 (02) 38-45
- 5 Warren JL, Mariotto AB, Meekins A, Topor M, Brown ML. Current and future utilization of services from medical oncologists. J Clin Oncol 2008; 26 (19) 3242-37
- 6 Rivera P, Delord JP, Grosclaude P, Grand A, Bugat R. [Demography of oncologic practitioners working in France. Projection elements for the next 30 years]. Bull Cancer (Paris) 2004; 91 (03) 271-7
- 7 Azambuja E, Ameye L, Paesmans M, Zielinski CC, Piccart-Gebhart M, Preusser M. The landscape of medical oncology in Europe by 2020. Ann Oncol 2014; 25 (02) 525-8
- 8 Blinman PL, Grimison P, Barton MB, Crossing S, Walpole ET, Wong N. et al. The shortage ofmedical oncologists: the Australian Medical Oncologist Workforce Study. Med J Aust 2012; 196 (01) 58-61
- 9 Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M. Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Pract 2007; 3 (02) 79-86
- 10 Nakano T. Status of Japanese radiation oncology. Radiat Med 2004; 22 (01) 17-9
- 11 Zubizarreta EH, Poitevin A, Levin CV. Overview of radiotherapy resources in Latin America: a survey by the International Atomic Energy Agency (IAEA). Radiother Oncol J 2004; 73 (01) 97-100
- 12 Conselho Federal de Medicina [Internet]. [citado 2014 Ago 30]. Disponível http://portal.cfm.org.br/
- 13 Brazil, Leis, Decretos. Lei No.12.527/2011. Diário Oficial da União [Internet]. 2012 May 16.2012. (citado 2014 Set 29]. Disponível em http://www.acessoainformacao.gov.br/
- 14 Instituto Brasileiro de Geografia e Estatística [Internet]. [citado 2014 Out 15]. Disponível em http://www.ibge.gov.br/home/
- 15 Instituto Nacional de Cancer. Estatística [Internet]. [citado 2014 Out 15]. Disponível em http://www2.inca.gov.br/wps/wcm/connect/inca/portal/home
- 16 Physicians (per 1,000 people). World Health Organization’s Global Health Workforce Statistics, OECD, supplemented by country data [Internet]. [cited 2015 Oct 15] Available from http://data.worldbank.org/indicator/SH.MED.PHYS.ZS?order=wbapi_data_value_2013+wbapi_data_value&sort=asc)
- 17 O Médico e seu trabalho: Resultados da REGIÃO CENTRO-OESTE e seus estados. Brasília (DF): Conselho Federal de Medicina; 2005
- 18 Da Silva MG, Arregi MM. Residência médica na área de cancerologia no Brasil: distribuição dos programas e da oferta de vagas por região em 2003. Rev Bras Canceraol 2005; 51 (01) 5-13
- 19 Barr TR, Towle EL. National Oncology Practice Benchmark: An Annual Assessment of Financial and Operational Parameters–2010 Report on 2009 Data. J Oncol Pract 2011; 7 2 Suppl 2-15
- 20 American Cancer Society: Cancer treatment and survivorship: Facts and figures 2014-2015 [Internet]. (cited 2015 Apr 30]. Available from http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042801.pdf
- 21 Centers for Medicare and Medicaid Services: Official Physician Compare data [Internet]. [cited 2015 Apr 30]. Available from https://data.medicare.gov/data/physician-compare
- 22 Yang W, Williams JH, Hogan PF, Bruinooge SS, Rodriguez GI, Kosty MP. et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Oncol Pract 2014; 10 (01) 39-45
- 23 Da Silva ZP, Ribeiro MC, Barata RB, de Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003- 2008. Ciên Saúde Colet 2011; 16 (09) 3807-16
- 24 Brasil. Decreto No. 1.220 de 03/06/14 Diário Oficial da União. 2014: 91 junho 4 Section 1, No. 105 [ Changes the art. 3 of Ordinance No. 876 / GM / MS, of 05.16.2013, which provides for the application of Law No. 12,732, de 11.22.2012. Published in Federal Official Journal. 2014 junho 3]
- 25 Population Brazilian Estimates. Brazil, Law No. 8443 of July 16, 1992, in Article 102 the IBGE has published in the Official Gazette on 29 August 2013.
- 26 American Society of Clinical Oncology. The State of Cancer Care in America, 2015: A Report by the American Society of Clinical Oncology. 2015. J Oncol Pract 2015; 11 (02) 79-113