Nurse practitioners (NPs) and physician assistants (PAs) are providing care to a larger population of older adults with cancer, especially in rural areas and the southern United States, according to study results published in the Journal of the American Geriatrics Society.

Researchers conducted an observational, cross-sectional study analyzing the composition of the US provider workforce treating adults with cancer age >65 years to determine whether there were differences in patients who received care from different types of providers, specifically NPs, PAs, and specialty physicians.

Data were obtained from the 2013 Surveillance, Epidemiology, and End Results cancer registries linked to the Medicare claims database, and included beneficiaries who received ambulatory care for any solid or hematologic malignancies. Patient malignancy diagnoses were grouped into the 8 most common malignancies in older adults.

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A total of 2.5 million outpatient malignancy claims were reported by 128,971 providers who cared for 201,237 adults (average visit number, 12.7); 15,227 of these providers were oncology-specific.

Of the claims provided by oncology-specific clinicians, 32% were from NPs, 28% were from hematology/oncology physicians, and 24% were from PAs. Medical oncologists, gynecologic oncologists, and hematologists provided 11%, 2.5%, and 2.4% of claims, respectively.

The largest number of malignancy claims were for hematologic care. For other types of malignancies, patients with cancer were nearly twice as likely to receive care from NPs (odds ratio [OR], 1.85) and 5 times as likely from PAs (OR, 5.33) compared with physicians.

The majority of patients were from urban or suburban settings, but for patients in rural areas, treatment by an NP was almost twice as likely as by a physician (OR, 1.84); care provided by PAs was also more likely in rural settings (OR, 1.57).

Results indicated that most patients in the study population were from moderate- or high-poverty areas and were treated more frequently by NPs compared with physicians, who provided care in higher-income areas. Rural cancer care providers included approximately 10% of the total workforce in the study but more than half the population in these settings were made up of NPs.

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The authors noted that “PAs must practice with a collaborating physician, whereas NPs’ scope of practice is more variable and may encompass independent practice,” which could explain the population distributions in the study.

“Previous research underestimated the number of PAs and NPs providing cancer care to older adults, especially to lower-income older adults, those in rural settings, and those in the South,” the researchers noted.

“Any solution to the rising demands for cancer care will need to maximize every healthcare provider’s contribution and support his/her practice at the full scope of his/her license,” added the investigators.

“Solutions that address the shortage of cancer care providers for older adults need to be based on a realistic understanding of who is providing that care. NPs and PAs can help improve care access, particularly in regions of the United States with lower-income adults.”


Coombs LA, Max WM, Kolevska T, Tonner C, Stephens C. Nurse practitioners and physician assistants: an underestimated workforce for older adults with cancer [published online May 6, 2019]. J Am Geriatr Soc. doi:10.1111/jgs.15931