Workload and Staffing Study of Hospital Cancer Registries

Abstract

The purpose of the workload and staffing study of hospital cancer registries conducted in 2024 was to update previous studies of workload and staffing guidelines. The population studied was composed of hospital cancer registries. Potential respondents for this study were hospital registry leads identified in the National Cancer Registrars Association (NCRA) membership database and their cancer registry staff. An online survey was sent to lead registrars along with directions for forwarding a separate cancer registrar survey to their staff. Postsurvey interviews were conducted with 11 experts in the field to review findings and discuss the future of the cancer registry workforce. There were 237 responses to the registry lead survey (RLS) and 290 responses to the cancer registrar survey (CRS). Results indicated a 22% increase in the mean budgeted full-time equivalents (FTEs) from 2019 in 2022; yet filled FTEs decreased slightly from 2019 to 2022. Registry leads reported that nearly half of their staff need additional training in data analysis and were very concerned about recruiting qualified staff, providing adequate compensation, and funding additional positions. Caseload continued to be the main predictor of staffing needs, as in the previous study. In staffing models, we found that for single-institution registries, for every 1,000 cases, staffing should increase by 1.8 to 2.1 FTEs. For multi-institution registries, staffing should increase by 1.6 to 1.9 FTEs for every 1,000 cases. Postsurvey interviewees were concerned about industry-wide vacancies and worker burnout. They mentioned contributing factors such as low wages, lack of recognition, isolated work, the lack of credentialed registrars, and pending retirements. They stressed that technological innovations and automation will not eliminate the registrar's role but will change it. These changes in registrar work may create more specialization in the role such as in data analytics and acting on real-time data and reporting. These changes may also create new career paths that would attract future students and workers to the cancer registry profession. Findings from this study may be useful for hospital registries to benchmark their own workload and staffing and to cancer registry organization leaders in planning for the future.

Introduction

Cancer registrars play a critical role in cancer surveillance and monitoring. Currently nearly 6,000 registrars have received the oncology data specialist (ODS) certification by the National Cancer Registrars Association (NCRA) (N. Walker, email communication, December 2024). Until January 2024, the credential was certified tumor registrar. The US Bureau of Labor Statistics (BLS) uses standard occupational codes (SOCs) to produce descriptions of occupations and track labor statistics, including the number of jobs in an occupation and projections for growth. While cancer registrars are grouped with medical technologists and other medical registrars in an SOC code, there is a substantial growth in jobs predicted for the future. BLS predicts 16% growth in the next decade, an average growth of 3,200 jobs per year nationally.¹ As cancer registrars retire or leave the field, there will be an ongoing need to train and retain new workers.

Need for Updated Workload and Staffing Guidelines

In a 2006 NCRA-funded study, cancer registrars and managers reported a need for workload and staffing standards to better understand staffing needs and to advocate for needed staff.² Based on that request, studies of hospital and central cancer registries staffing and workload were launched and completed in 2011 and 2013, respectively.^3,4 These reports and publications included staffing guidelines. Since the report was published, many changes have impacted registry functions, such as automation and the number of data items collected.

The purpose of this study was to update workload and staffing data for use by hospital registry managers, directors, and industry leaders. Another goal of this study was to conduct an in-depth qualitative assessment of the study findings and the future implications for the workforce in skill development, training, roles, and career development.

Methods

This mixed methods study began with the formation of an advisory committee composed of experienced cancer registry leaders. The committee provided guidance regarding design of the study and survey measures. Components of the study included the following:

• Conducted presurvey video interviews with 9 cancer registry leaders and leaders of national cancer data organizations

• Fielded 2 surveys: registry managers/leads and cancer registrars

• Conducted 11 postsurvey video interviews with national cancer experts

The study was approved by the university's institutional review board.

Surveys

The surveys were developed with input from the advisory committee and were reviewed for input over several meetings and online forums. Draft surveys were tested by 9 volunteer cancer registry leads and cancer registrars. The registry lead survey was (RLS) conducted from March to May 2023 and the cancer registry survey (CRS) was conducted from March to July 2023. The target population for the RLS was NCRA members working at a hospital registry who self-identified as registry managers/leads. The target population for the CRS were cancer registrars in NCRA's membership database who were working at a hospital registry.

We used the NCRA membership database to identify self-designated lead registrars for the RLS. After cleaning the database for duplication of institutions, those registry leads were sent a link to the online survey using the Qualtrics survey platform. Lead registrars were instructed to forward a link of the online Qualtrics CRS survey to their staff cancer registrars. RLS and CRS surveys completed by leads and registrars who worked at the same registry were matched and linked to each other with a study generated identification (ID) code. The RLS was sent to approximately 1,000 lead registrars representing about 800 registries. Participation in both surveys was voluntary.

Survey Content

The RLS included 6 sections with 44 items in the following areas:

• Registry characteristics

• Staffing and administration

• Caseload size and composition

• Registry procedures

• Data management and automation

• Respondent opinions and concerns

The CRS included 5 sections with 28 items in the following areas:

• Job information and activity log (daily activity tracker for 1 week)

• Job experience

• Time estimates: daily, weekly, monthly, annually

• COVID-19 supplement

• Stress and burnout supplement

Postsurvey Interviews

Semi-structured interviews were conducted online from October 2023 to January 2024 with 11 national experts in cancer registry operations and national partner organizations. The purpose of those interviews was to explore perspectives on what the survey findings meant for the future of cancer registry work.

Results

There were 237 responses to the RLS. The respondents represented 141 single-institution registries (60.0%) and 94 multi-institution registries (40.0%). All 10 Health and Human Services regions in the United States were represented in the responses. While respondents could choose more than 1 answer to this item, most registries (212 respondents) served in a private, community, or hospital system, while 40 registries supported university hospitals and 28 served government or public hospitals.

Registry Staffing

We asked about productivity standards because this might be an indicator of how registries planned staffing needs. Fifty-one percent of registries had productivity standards for all positions, but 24% had no productivity standards in place for any positions.

We asked about registry staffing over the past 4 years and complied the results in Table 1. While the number of budgeted full-time equivalents (FTEs) increased by 22% from 2019 to 2022 (5.8% to 6.8%), there was some volatility in the percentage of filled positions during the same time, between 93.1% (2021) and 96.4% (2019) landing at 94.1% in 2022. Employment of contract staff was reported by 32.5% of registries.

Table 1.

Registry Staffing, Fiscal Years 2019–2022

	2019 N = 199	2020 N = 199	2021 N = 202	2022 N = 210
Budgeted FTE positions, mean	5.6	5.8	6.1	6.8
Filled FTE positions, mean	5.4	5.5	5.7	6.4
Filled FTE positions, %	96.4	94.8	93.4	94.1

FTE, full-time equivalent.

Staff Training Needs

Registry leads reported that nearly half (49.1%) of their staff need additional training in data analysis, and about one-quarter of their staff need additional training in case finding and abstracting software (Table 2).

Table 2.

Staff Training Needs Reported by Lead Registrars

Training activity	Mean, %	Median, %	Standard	n
Data analysis	49.1	50	31.9	114
Casefinding software	26.5	20	25.8	101
Abstracting software	24.4	14	27.3	123
Follow-up, if applicable	23.3	12	27.4	97

Staffing Concerns

When asked about concerns regarding staffing, the registry leads reported being very concerned about recruiting qualified staff (62%), compensating enough to retain staff (54%), and funding additional positions (48%) (Table 3). The respondents were least concerned with providing workspace, providing equipment, and resources.

Table 3.

Staffing Concerns Reported by Lead Registrars

Staffing concerns	% Very concerned	% Somewhat concerned	% Not concerned	n
Recruiting well-trained staff	61.7	25.9	12.4	193
Compensating staff well enough to retain them	54.2	28.1	17.7	203
Funding additional positions	47.6	29.4	23.0	187
Allocating time for training	35.8	33.7	30.6	193
Training newly certified staff	33.7	37.4	29.0	190
Funding ongoing training	27.3	31.8	40.9	198
Tracking productivity of staff accurately and fairly	15.2	36.6	48.2	197
Procuring equipment and other resources	7.2	25.8	67.0	194
Providing adequate workspace	6.0	13.1	80.9	183

Findings from Cancer Registrar Survey

There were 290 responses to the CRS. About 15% work for more than 1 registry and most (97.5%) of the registrars were facility employees, not contract employees. Because of the small number of contract employee responses (n = 7), contract employee responses are not tabulated.

Ninety percent of cancer registrars reported working full-time, defined as 35 hours per week or more. About 11.9% worked over 40 hours per week, and 7.0% worked 30 hours or fewer per week.

Caseload, Concurrent Abstracting, and Follow-Up

Registrars were asked about the time they spend on various activities. The main activities that were reported were casefinding, abstracting, and follow-up. When asked about the time they spent on these activities, for those who perform them, the mean estimated time was 3.5 hours per day on casefinding (78 respondents), 6.8 hours per day abstracting (157 respondents), and 2.4 hours per day on follow-up (54 respondents). Not all respondents provided time estimates on their activities.

Wages

Mean wages varied by years of experience ranging from $25 per hour with 1 to 5 years of experience to $34 per hour for registrars with over 20 years of experience. More detailed information on salaries can be found in NCRA's Salary Considerations for Cancer Registrars: 2022 Survey Data.⁵

Job Satisfaction

Respondents reported high rates of job satisfaction. Most (64.1%) reported being extremely satisfied with the profession and another 29.9% reported being somewhat satisfied with the profession. Only 3.5% of respondents reported dissatisfaction with the profession. Respondents were at various stages in their careers, with 28% having 1 to 5 years in the profession and 23% having more than 20 years in the profession at the time of the survey.

Retirement and Plans to Leave the Profession

When asked about plans to leave the profession in the next 5 years, 14.5% reported planning to leave due to retirement, while 3.3% planned to leave due to other reasons. Almost 70% (68.5%) planned to remain in the profession for the next 5 years and 13.8% were not sure of their plans for the next 5 years.

Factors to Consider in Staffing Guidelines: Time to Complete Cases

A consideration for staffing levels is the amount of time it takes to complete cases. As seen in Table 4, RLS respondents estimated the mean time to complete a simpler case was 61 minutes and 1 hour and 30 minutes for complicated cases. Perhaps not surprisingly, CRS respondents reported longer mean times for case completions: 75 minutes for simpler cases and 2 hours 30 minutes for more complex cases.

Table 4.

Mean Time in Minutes to Complete Simpler and Complex Cases as Reported by Registry Leads and Cancer Registrars

Respondents	Minutes for simpler case	Minutes for complex case
Registry leads	61	90
Cancer registrars	75	150

Staffing Guidelines

We conducted regression analyses to determine which factors were predominant in predicting staffing needs. Registry caseload and registry type (single-vs multi-institution) were the key factors in determining staffing guidelines. While the primary functions of registrars are to perform casefinding, abstracting, and follow-up, registry managers making staffing decisions may also want to consider current abstracting year, time to complete cases, and whether they are meeting the requirements for completion times.

Staffing guidelines suggested from our regression analyses suggest an additional 1.8 to 2.1 additional FTEs for every 1,000 cases at a single institution registry. The estimate decreases to 1.6 to 1.9 FTEs for every 1,000 cases at multiinstitution registries.

In comparing staffing guidelines to the previous 2011 study (Table 5), it is important to consider key differences in data collection. These may be due to differences in the study design, population, and methodology as well as changes in automation and workload between the study periods. Key differences between the 2024 study (data collected in 2022) and the 2011 study (data collected in 2007) include an increase in reported accessioned cases from 1,313 to 3,132 and an increase in the median number of cases in followup from 5,394 to 8,917. The mean number of new cases decreased from 475 per FTE in the 2011 study to 441 in the 2024 study (Table 5).

Table 5.

Key Comparisons Between the 2011 and 2024 Workload and Staffing Studies

2011 Study	2024 Study
The mean number of new accessioned cases in 2007 was 1,313.	The mean number of accessioned cases in 2022 was 3,132.
The mean number of follow-up cases in 2007 was 8,003. The median was 5,394 cases, and the range was from 223 to 70,000 cases.	The mean number of follow-up cases in 2022 was 18,270. The median was 8,917 cases, and the range was from fewer than 100 to more than 100,000 cases.
The mean number of new cases was 475 per FTE; of those, the number of cases meeting timely completion rates was 386 per FTE.	The mean number of cases per FTE was 441, ranging from 295 for single-institution registries with low caseloads to 620 for multi-institution registries with high caseloads.
Nearly two-thirds (67%) of cancer registries operated with 2 or fewer FTEs.	In 2022, the mean number of FTEs was 6.9 per registry, ranging from 1.6 for single-institution registries with low caseloads to 26.2 for multi-institution registries with high caseloads.

FTE, full-time equivalent.

Interview Findings

The 11 postsurvey interviews included experts in national cancer data standards, experienced cancer registrars, cancer registry software developers and providers, and cancer registry contracting representatives. Using qualitative analysis methods, several themes emerged related to staffing, technology, promoting the profession, and recommendations for the future workforce.

Staffing Practices and Vacancies

Interviewees were asked for their opinions about contributing factors to industry-wide vacancies and worker burnout. Interviewees mentioned low wages, lack of recognition, isolated work, the lack of credentialed registrars, pending retirements, and burnout.

Burnout was reported to be related to some of the same factors as staffing, workforce shortages, isolated work, undervalued role, and fast-paced work requirements. In attempting to address burnout, interviewees suggested increased wages, increased staffing, and shifting registrar activities away from manual data entry.

Technology's Impact on the Workforce

Interviewees felt strongly that technological innovations and automation will not eliminate the registrar's role. The implementation of new software programs will automate some tasks (eg, casefinding, data collection) and facilitate their completion. Registrars could apply any recovered time to activities such as quality control/quality assurance, data analytics/informatics, concurrent abstracting, specialization (eg, pharmacology, pathology), and leadership functions. Interviewees noted potential barriers to the implementation of new technologies including hesitation or resistance to adoption, time for full development, financial constraints, and health system readiness.

Promoting the Profession

Despite the challenges in cancer registrar work, interviewees reported positive aspects of the profession that may help draw workers to the profession. Those included flexible hours, remote work allowing national recruitment, interesting work, and the high satisfaction level of workers once they are in the role. Interviewees stressed the importance of promoting the profession through marketing efforts, especially on social media platforms, to increase awareness of the profession.

Interviewee Recommendations for Future Workforce

Interviewees had several reflections and predictions about the future cancer registry workforce, changes that will likely occur in the role and the work, and the need for future training and career development. Interviewees reflected changes in registrar work may spur the development of more specialization in the role such as data analytics, quality management, acting on real time data, and reporting. They predicted that these changes brought about by technology and the changing nature of the work could create new career paths that would attract prospective students.

Discussion

Staffing shortages have been a theme for cancer registries since the first NCRA workforce report in 2006. Registry leads noted the need for staffing guidelines in order to advocate with hospital leadership for needed staffing. While our survey found that, from 2019 to 2022, the mean budgeted FTEs grew from 5.6 to 6.8, in 2022, the percent of filled positions dropped from 96% to 94%. The use of contract staffing in registries has grown. In this survey, about one-third of registries reported employing contract staff. This is an increase from 21% in the 2011 survey.

There was little change in respondents' concerns about recruiting well-trained and qualified staff from 2011 (58%) to the current survey (62%). While recruitment may have changed due to contract staffing agencies, nationwide recruitment, and trends toward remote work, the industry will likely continue to face staffing challenges. Pending retirements and intent to leave the profession add to the staffing challenge. About 18% of cancer registrar respondents indicated that they intend to leave the profession in the next 5 years (about 15% due to retirement).

Remote work has also increased and changed the nature of cancer registry work. Our survey found that, before the COVID-19 pandemic, about 35% of cancer registrar respondents mostly worked remotely. That increased to 82% during the pandemic and was at 75% postpandemic.

Productivity standards may be used as a tool to assess staffing needs. Standards may be used to assess registrar performance but also to assess staffing needs to reach case completion requirements. Our findings indicated that 51% of registries had productivity standards for all positions, 25% had for some positions, and 24% did not have any productivity standards. In the 2011 hospital survey, 47% of respondents reported having workload standards.³ These findings indicate that developing productivity standards may still be a goal for more registries.

Long-time experts in the field emphasized how cancer registry work has changed and will continue to change with changing technology developments such as informatics initiatives, artificial intelligence, natural language processing, and electronic data collection from electronic health record systems that continues to improve. Researchers from several cancer centers described 12 of these active initiatives in 2022.⁶

As cancer registry work continues to develop with more automated processes and procedures, training in these technologies is critical. A paper by Merriman and colleagues described how cancer registrars used informatics to enhance their work.⁷ Cancer registrars will need to embrace these changes, play a vital role in the process of technology development, and be drivers in how they impact workload and cancer registration processes. In our survey, nearly 50% of registry leads reported that cancer registry staff need additional training in data analytics.

Career development was another issue that was discussed with key informants. Interviewees stressed that further training in analytics, data and quality management, and increased real-time reporting and analysis may lead to new roles and advanced credentials for cancer registrars. This effort will require a partnership between educators, standards setting organizations, federal partners, and national cancer registry leadership.

Limitations

Several challenges were encountered with sampling and data collection. Key concerns were a low response rate and reliance on a membership database to identify sample participants. Despite these issues, over 230 responses to the RLS were received for an estimated registry population of 1,800. Another limitation is that we did not collect data from contract staff who are a growing part of the cancer registry workforce. They may not have received the survey from the registry lead or did not respond.

Recommendations

There are several recommendations that could be considered as further work to address the issues raised by survey respondents and interviewees for this workforce study. A few of the key recommendations are the following:

• Continue to address recruitment and attracting new entrants to the field. National recruitment strategies, increasing awareness of the field to college students, and stressing the health information technology aspects of the job were suggested.

• Consider developing advanced credentials to address the innovations in cancer diagnosis and treatment and in technological advancements that will continue to impact the work and responsibilities of cancer registrars.

• Develop education and training models to address future changes in cancer registrars' roles and responsibilities, such as informatics, data management, quality control, real-time reporting, and data analysis and presentation.

• Conduct ongoing research to provide cancer registry managers with real-time workload data and trends to inform staffing needs and guidelines.

Conclusion

This workload and staffing study for hospital registries was an update to a similar study conducted more than 10 years ago. The cancer registry field has changed, as has the role of cancer registries and the way they work. It will be important to continue to monitor workload and staffing at the local cancer registry level and assure an adequate and satisfied workforce for the future.

Funding Statement

This study was funded by the National Cancer Registrars Association (NCRA). Information on the study population was provided by the NCRA membership database.