CORR - 2026-07-15 - Journal Article
Are Early-career Orthopaedic Oncologists Performing Fewer Tumor Surgeries as the Number of Fellowships Increase?
O'Brien AC, Farmer SH, Koyada PK, Ata A, DiCaprio MR
Topics
Key Takeaway
Over 22 years, early-career orthopaedic oncologists' mean tumor case count during ABOS Part II collection declined by 6.1 cases per 5-year increment while fellowship positions nearly doubled and multifellowship training odds increased 1.4x per 5-year increment.
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Summary
This study queried the ABOS Part II Oral Examination Case List Database from 2002–2023 to determine whether increasing fellowship positions have diluted early-career tumor case volume. Both the proportion of tumor cases (declining 3.1 percentage points per 5-year increment, 95% CI 0.9–5.3) and absolute tumor case count (declining 6.1 cases per 5-year increment, 95% CI 3.6–8.6) decreased significantly over time. Multifellowship candidates reported substantially fewer tumor cases than oncology-only candidates (29.3 vs. 48.4 mean tumor cases; p<0.001), and the odds of pursuing multiple fellowships increased 1.4x per 5-year increment.
Key Limitation
The ABOS Part II case list captures only a 6-month window of early-career practice and cannot determine whether declining tumor case proportions translate into measurable differences in patient outcomes such as margin adequacy, local recurrence, or complication rates.
Original Abstract
BACKGROUND
Orthopaedic oncology is a low-volume subspecialty in which early-career surgeons may not receive adequate tumor case volume to develop and maintain proficiency. This risk may be greater as more orthopaedic residency graduates pursue tumor training. Surgeons may increasingly complete additional fellowship training in anticipation of low tumor volume and institutional pressure to reach specific clinical metrics. Since Duchman and Miller's report, the number of tumor fellowship positions has continued to grow, and it is unclear how these changes have influenced early-career operative experience with complex tumor cases.
QUESTIONS/PURPOSES
Over the last 22 years: (1) Has the number of candidates completing fellowship in orthopaedic oncology changed over time? (2) Have the volume and proportion of tumor versus nontumor cases reported during the American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination case collection period changed over time? (3) What are the temporal trends in multifellowship training, including the proportion of surgeons completing one or more additional fellowships?
METHODS
The ABOS Part II Oral Examination Case List Database was queried for candidates reporting completion of an orthopaedic oncology fellowship between January 1, 2002, and December 31, 2023. Cases were classified using both Current Procedural Terminology (CPT) and ICD-9 and ICD-10 codes to identify tumor-related diagnoses; remaining cases were categorized as trauma, adult reconstruction, or other. In this paper we refer to cases (for instance, an individual operation), and a case could have multiple CPT codes and thus multiple procedures. Any time a case had multiple procedures (or CPT codes), it was categorized as a tumor case if any single CPT code, or ICD code, reflected tumor procedure or diagnosis. Fifteen candidates reporting no tumor procedures during the collection period were excluded. Linear and logistic regression were used to evaluate temporal trends. Additional fellowship training was recorded, and procedure distribution was compared between oncology-only and multifellowship candidates.
RESULTS
The number of candidates increased over time, with the median (range) annual number rising from 9 (7 to 15) in 2002 to 2012 to 16 (10 to 21) in 2013 to 2023 (p = 0.002). The mean percentage and count of tumor cases per candidate decreased by 3.1 percentage points (95% confidence interval [CI] 0.9 to 5.3; p = 0.005) and 6.1 cases (95% CI 3.6 to 8.6; p < 0.001) per 5-year increment, respectively. The odds of completing multiple fellowships increased over time (OR 1.4 per 5-year increment [95% CI 1.2 to 1.8]; p = 0.001). Candidates with multiple fellowships reported a lower mean ± SD percentage of tumor cases (26% ± 2% versus 43% ± 2%; p < 0.001) and mean number of tumor cases (29.3 ± 2.7 versus 48.4 ± 2.9; p < 0.001) than oncology-only candidates.
CONCLUSION
Although the number of early-career orthopaedic oncologists increased over the study period, both the proportion and absolute number of tumor cases declined and multifellowship training became more common.
CLINICAL RELEVANCE
These findings suggest that early-career orthopaedic oncologists are entering practice with declining tumor case exposure without clearly defined thresholds for maintaining oncologic proficiency. In the absence of established volume-outcome benchmarks in orthopaedic oncology, our results highlight the need for future studies to define minimum case volumes associated with improved patient outcomes. At a systems level, the continued expansion of fellowship-trained surgeons despite the relative rarity of musculoskeletal tumors warrants evaluation of workforce alignment, including the number of fellowship positions and the potential role of regionalized referral networks to concentrate tumor care. For individual surgeons, these data support consideration of strategic employment at established referral centers or in areas with sufficient catchment populations to support a high oncologic volume. Supplementing tumor surgery with related procedures (such as level 1 trauma, adult reconstruction, or spine) may help maintain operative skillsets in lower volume environments. Further research is needed to determine whether such strategies mitigate potential volume-related differences in outcomes and to guide evidence-based recommendations for training and early-career practice.