Clinical and Translational Oncology https://doi.org/10.1007/s12094-022-02989-3 RESEARCH ARTICLE Current professional standing of young medical oncologists in Spain: a nationwide survey by the Spanish Society of Medical Oncology + MIR section Domingo Antonio Sanchez Martinez1 · Aliica Quilez‑Cutillas2 · Pablo Jimenez‑Labaig3 · Andrea Sesma4 · Noelia Tarazona5,6 · Vilma Pacheco‑Barcia7 · Berta Obispo8 · David Paez9 · Teresa Quintanar10 · Manuel Sanchez‑Canovas11 · Ana Fernandez Montes12 · Enriqueta Felip13 · Alvaro Rodriguez‑Lescure10 · Elena Elez13 Received: 9 August 2022 / Accepted: 18 October 2022 © The Author(s) 2022 Abstract Background There is a lack of knowledge about the career paths and employment situation of young medical oncologists. The aim of our study was to evaluate the current professional standing of these professionals in Spain. Methods The Spanish Society of Medical Oncology + MIR section conducted a national online survey in May 2021 of young medical oncology consultants (< 6 years of expertise) and final year medical oncology residents. Results A total of 162 responses were eligible for analysis and included participants from 16 autonomous communities; 64% were women, 80% were consultants, and 20% were residents. More than half of the participants performed routine healthcare activity and only 7% research activity. Almost three quarters (73%) were subspecialized in a main area of interest and almost half of these chose this area because it was the only option available after residency. Half of the respondents (51%) consid- ered working abroad and 81% believed the professional standing in Spain was worse than in other countries. After finishing their residency, only 22 were offered a job at their training hospital. Just 16% of participants had a permanent employment contract and 87% were concerned (score of ≥ 5 on a scale of 1–10) about their job stability. In addition, one quarter of the participants in our study showed an interest in increasing their research activity. Conclusions The choice of subspecialty in medical oncology may depend on job opportunities after residency rather than personal interest. The abundance of temporary contracts may have influenced the job stability concerns observed. Future mentoring strategies should engage in building a long-term career path for young medical oncologists. Keywords Career path · Young oncologist · Professional standing · Job performance · Oncology professionals Introduction countries in Europe to do so. Medical oncologists (MO) are professionals dedicated to the care and treatment of cancer As it is known, cancer is a major public health problem due patients from diagnosis to the final stages of the disease, to its high incidence and prevalence, and it continues to be actively collaborating in the emotional, social, and psy- one of the leading causes of mortality worldwide. The Inter- chological support of patients and their families. Medical national Agency for Research on Cancer estimated that, in oncology is a demanding, dynamic and evolving medical 2018, some 18.1 million cancers were diagnosed globally specialty, which calls for continuous learning and dedica- [1]. According to world population estimates, by 2040, there tion [3]. Acquiring the title of MO requires a training period will be 30.2 million cases per year [2]. consisting of 2 years of core training and 3 years of spe- In Spain, the official recognition of medical oncology cialized training in medical oncology. Throughout the two as a specialty occurred in 1978, becoming one of the first periods, the students must develop different competencies, either generic or cross-disciplinary, which are common to all health science specialties [4]. However, knowledge about * Elena Elez how to develop a career path and the employment status of meelez@vhio.net young MO is scarce in Spain [5]. The career pathway is Extended author information available on the last page of the article a workforce development strategy that integrates programs 13 Vol.:(0123456789) Clinical and Translational Oncology and services intended to support and develop workers’ aca- medical oncology consultants (<6 years of expertise) and demic, technical and employability skills. This strategy is final year medical oncology residents. Using the electronic lacking in many countries in Europe, including Spain, but mailing available in the SEOM database, professionals from is well adopted in particular countries like the United States Spain (N = 343) were invited to participate in this survey. [6]. The survey consisted of 12 multiple-choice and open-ended Some problems have been detected in the oncology prac- questions. Participants were not required to answer all ques- tice. These problems are often associated with the intrin- tions. Demographic characteristics, employment contracts, sic practice of the specialty and at other times are due to professional development, long-term career goals, and con- external factors (e.g., the work environment, the infrastruc- cerns about job stability were examined. Questions were also ture of the department where you are working, the learning asked regarding mentorship. A copy of the complete survey process, etc.). Cancer care professionals, especially young is shown in Annex 1. oncologists (which includes oncology residents [registrars] A descriptive analysis of study variables was performed. and oncology specialists [consultants] in their first 5 years Categorical variables were expressed as percentages and of practice), are at special risk of developing burnout syn- counts. Data analyses were carried out using IBM SPSS drome. This is due mainly to direct contact with seriously ill Statistics v27 software (Armonk, NY, USA). patients and their families, a continuously changing medi- cal landscape, and significant healthcare pressure [7]. Con- sequently, young MOs often experience a prolonged state Results of physical and mental exhaustion that can reduce profes- sional efficacy and result in negative effects on the quality of Participant demographics patient care [8]. The European Society for Medical Oncol- ogy (ESMO) recently studied burnout syndrome in young A summary of participant demographics and professional oncologists, showing that measures promoting a good work- characteristics is shown in Table 1. Of the total number life balance, access to support services, and adequate vaca- of surveys sent to the target population, we obtained 162 tion time may reduce burnout levels [9]. The aforementioned responses in total after three rounds of mails (Fig. 1), 64% situation should be taken into account in the development of which were from women. The Community of Madrid was of the training programs and professional careers of these the Autonomous Region with most participants (21%), fol- future oncologists. lowed by Catalonia and Valencia. In relation to the profes- In 2021, the Spanish Society of Medical Oncology sional status shown in Table 1, nearly 80% were employed (SEOM) published the results of a survey on workloads, when the questionnaire was conducted. Among these, census, and needs for MOs in Spain [10], and found that only 20% had a permanent contract and 23% had signed a almost 40% of participants had a temporary contract and COVID19 temporary contract. 77% worked in healthcare activities. Furthermore, a strong demand for MOs was observed; however, in order to satisfy Professional environment and satisfaction this need, long-term career paths would need to be estab- lished for young MOs. More than two-thirds of participants worked in routine clini- In this context, the aim of our study was to evaluate the cal care while only 11 (7%) were involved in research activ- current professional standing of young MOs in Spain and to ity. Three-quarters (73%) were subspecialized in a main area seek improvement strategies that could enhance the careers of interest, and in more than half of them (59%), this was of these professionals. chosen because it was the only option available after resi- dency. Options such as working in management or in the pharmaceutical industry were not selected by respondents. Methods Among the total number of doctors surveyed, 54% had considered different employment opportunities other than A descriptive observational study was carried out by the routine clinical care and almost a quarter showed interest SEOM + MIR Section (represented by 12 oncologists, in increasing their research activity. In addition, 32 partici- including specialists, residency mentors, and resident pants in the sample considered working in the pharmaceuti- medical interns [MIR, Médico Interno Residente]), a sec- cal industry as an alternative. tion devoted to analyzing and addressing the specific con- In relation to the question about working in countries cerns of young MOs in Spain. Due to the subject matter other than Spain, 51% (80 participants) had considered of the study and data processing, the study did not require working abroad (56% in countries within the European ethics committee approval. We conducted an anonymous Union [EU] and 44% outside the EU). Among the dif- online survey between 19 April and 20 May 2021 of young ferent reasons given, 41 thought it might increase their 13 Clinical and Translational Oncology Table 1  Participant demographics and professional characteristics Total n (%) N = 162 (100.0) Sex Female 103 (63.6) Male 59 (36.4) Autonomous Community Andalusia 19 (11.7) Aragon 5 (3.1) Asturias 2 (1.2) Balearic Islands 5 (3.1) Canary Islands 5 (3.1) Cantabria 3 (1.9) Castile and Leon 5 (3.1) Castilla La Mancha 3 (1.9) Catalonia 32 (19.8) Valencia 14 (8.6) Estremadura 3 (1.9) Galicia 13 (8.0) Madrid 34 (20.1) Murcia 7 (4.3) Navarre 4 (2.5) Fig. 1  Flowchart of participants’ recruitment Basque Country 8 (4.9) La Rioja 0 (0.0) Ceuta 0 (0.0) In order to determine the degree of the precariousness of Melilla 0 (0.0) our respondents, a set of questions was focused on determin- Work distribution between participants ing their level of professional satisfaction. Forty percent of Final year resident (registrar) 33 (20.4) the population was concerned about their work situation. First Year consultant 31 (19.1) Figure 2 presents a summary of the findings: 87% were wor- Second Year consultant 28 (17.3) Third Year consultant 27 (16.7) ried about their job stability (scoring ≥ 5 on a scale of 1–10, Fourth Year consultant 20 (12.4) where 1 = not worried at all and 10 = extremely worried), Fifth Year consultant 23 (12.4) and almost four in ten were extremely worried. As can be Position seen in Fig. 3, 41% of the surveyed participants had signed Inpatient unit 5 (3.1) five or more employment contracts in the last 2 years. Palliative care 0 (0.0) Combination of inpatient ward and general oncol- 14 (8.6) ogy clinic 22 (13.6) Strategies to improve professional development Activity set by oncology residency training 3 (1.9) program 118 (72.8) When asked about the possibility of participating in a Other mentoring program focused on helping their professional Unanswered Professional situation Finishing medical residency 34 (20.1) Employed 126 (77.8) Permanent contract 26 (16.1) Temporary contract 100 (61.7) Unemployed 2 (1.2) professional development and 33 stated better salary con- ditions. Furthermore, 132 participants believed the profes- sional standing in Spain was worse than in other countries. Regarding the person that helped the surveyed oncolo- gists to achieve their professional goals, most said the chief resident, followed by their mentor and tutor. More than a quarter of the respondents stated that they did not obtain any help from the aforementioned figures. Fig. 2  Perceived concerns about job stability among young oncolo- gists 13 Clinical and Translational Oncology Fig. 3  Percentage of respond- ents according to the number of employment contracts signed in the last 2 years development, most of the participants (80%) found it a posi- teaching medical students, and any number of combinations tive strategy, and almost 70% said they would participate. and variations thereof [13]. Related to the distribution of the type of work in our popu- lation, up to a quarter of the participants were considering Discussion increasing their research activity, and half of those looking for new career opportunities would like to include research Our study analyzed the employment situation of young MOs activity in their working day. However, only 7% were engaged in Spain, finding that the first years after residency present in research in their job, which according to the aforemen- great uncertainty and only a small possibility of subspecial- tioned study by the SEOM takes place outside working hours izing in the desired area. Up to 59% of newly trained oncolo- 50% of the time [9]. This trend seems to be contrary to the gists report having chosen their subspecialty based on job American trend, where around 60% of research activity has availability, rather than on previous experience, curriculum been described among those MOs in the process of subspe- vitae, or personal interest. The authors consider this a huge cializing and is far from the current needs and interest in this obstacle to career development. Another point to note in area. Furthermore, the absence of participants who reported this respect is that Spain does not have clearly defined sub- working in the pharmaceutical industry is striking, an aspect specialty programs, unlike other countries [11]. As far as that is addressed in more depth among the limitations of this the authors are aware, this is the first study published on the study, but which, nevertheless, coincides with what has been aspirations, career prospects, and recruitment data of MOs reported in American studies [14]. after completing their training period. A nationwide cross-sectional study carried out in France Within clinical care, the complexity of new molecular investigated the main factors affecting the career path choice diagnostic tests and targeted treatments together with com- of oncology residents [6]. These factors were the cross-sec- plex multidisciplinary management require physicians to tional nature, interest in oncology, variety of human relations have ever more expertise in specific fields of oncology [10]. and the multi-disciplinary field of work. The preferred career Subspecialization, with its pros and cons, is the current trend choice was working in a public hospital followed by a career in modern oncology with the creation of different working as a doctor/professor involving teaching or research. However, units [12]. As our population showed, the majority of MOs most residents stated that, during their training period, they had entered the subspecialty through different routes. However, not received enough information about future work options in this path to modernization, our study demonstrates the and the different potential career paths. The development of a importance of chance in becoming subspecialized, taking mentoring program, promoting interest in research, and career any vacant contracts offered, as we mentioned. development during the residency period appears to have a Subspecialization and the long-term career path are positive influence on career decisions [10]. In addition, this accompanied by extensive and multiple professional profiles group of medical residents was particularly concerned about that include scientific and clinical knowledge, etc., or vari- their future employment, mainly due to a shortage of openings, ations of these categories, and that have a specific learning heavy workload, and lack of work-life balance [7]. curve. While many consider oncology to be a highly special- As we can see, working and living conditions are key to ized and narrow field, it does in fact encompass a wide range setting forth a career path. The present study highlights a of careers that includes (but is not limited to) clinical oncol- clear precariousness in the job stability and financial remu- ogy, research in specific cancers in universities or hospitals, neration of young oncologists compared to the situation of 13 Clinical and Translational Oncology the same professionals in other countries [15]. Almost nine to selection bias, as many of these professionals do not out of ten young oncologists had temporary contracts, 40% belong to the medical society through which the survey was of them signing five or more contracts in their first 5 years disseminated. as specialists. Half of the participants in this study expressed The main strength of this study is that, to the authors’ an interest in working abroad (majority in the UE), either to knowledge, it is the most comprehensive overview to date improve their financial situation or to develop profession- of the employment landscape of newly specialized MOs. A ally. In our view, this poses a serious risk of brain drain, as high participation rate was obtained as well as good repre- previously described in other studies [16], as well as higher sentativeness of the different geographical regions of the rates of burnout and job dissatisfaction [17, 18]. country among the study participants. Furthermore, the In terms of the demographic profile obtained, this showed a period of data collection coincided with the SARS-COV-2 significant predominance of female professionals (64%). This pandemic emergency situation, which had a significant represents a slight increase with respect to the total medical impact on training and employment in this population [5]. oncology specialty in Spain, which stands at 62% in the most This may undoubtedly influence the study findings, espe- recent literature [19]. This figure contrasts with the European cially regarding aspects such as job stability and the mental average (47.2%) [20] and the US average (35.2%) [21]. health of the professionals. However, there is no doubt that Talent flight and work dissatisfaction is compounded by this situation will condition the employment outlook for pro- the limited remuneration of healthcare professionals, which fessionals in the coming years, which is why it is interesting is much lower in Spain than in other countries. The average and important to have been able to reflect this situation in gross earnings in Spain for a physician are $57,000 between the study. Some studies have begun to point the way towards the public and private sector, compared to other European the competency profiles of these future professionals [20]. countries such as Italy, with salaries of $70,000, France $98,000, England $138,000, and Germany $183,000; far- thest from this situation is the USA, with gross earnings of $316,000 [19]. In the case of the youngest oncologist, the Conclusion income range is $23.000–26.000 [22]. The emigration of doctors and the process of subspecialization are considered to This study is the first to analyze the aspirations and career be worse in Europe than further east, according to one study prospects of oncologists after completing their residency, that noted the lack of professionals and high workload [20]. showing that special involvement and interest from stake- Along the career path, the support and influence of third- holders is needed to improve oncology now and in the future. party professional partners are invaluable and can be a An absence of engagement in the long-term career paths of determining factor [23, 24]. According to those surveyed, young MOs in Spain was observed. Furthermore, there is a 27% indicated that the figure of the chief resident had con- lack of contractual quality and planning for entry into the tributed most to this objective. The mentor, named by 20% labor market of newly trained oncologists. Further studies of respondents, and the tutor, with 18%, also stand out as are needed to substantiate concrete measures at the national figures that have aided the professional development of the level to improve the working conditions of the future provid- oncologists surveyed. Also notable is that up to 27% of the ers of medical oncology services. sample reported not having obtained any help from the fig- Supplementary Information The online version contains supplemen- ures mentioned. tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 12094-0​ 22-0​ 2989-3. This study also has some limitations. First, it is a retro- spective study conducted through a voluntary online survey. Acknowledgements We thank SEOM for their technical and personnel This design carries an implicit risk of selection and recall support. This report has been possible thanks to the collaboration of the MIR community who participated in the survey and the Spanish bias in the participants owing to the pull effect to the most Society of Medical Oncology (SEOM), particularly the SEOM MIR affected population by the hiring issues. This study has not section. The project received technical support from MS-C Medical evaluated the psychological effect that the lack of work may Science Consulting (Valencia). have on young physicians, in terms of depression and/or Funding This project received funding from the Spanish Society of anxiety. Medical Oncology (SEOM). However, the results obtained at both the demographic and occupational levels coincide consistently with those Declarations described in previous literature, so we do not consider these biases to have a relevant impact. On the other hand, the Conflict of interest The authors have declared no conflicts of interest. absence of participants in the present study who reported Ethical approval and Informed consent This online survey is compliant activities related to the pharmaceutical industry is strik- with General Data Protection Regulation rules and the confidentiality ing; the authors postulate that this is probably again due and anonymity of the participants were guaranteed. Participants were 13 Clinical and Translational Oncology advised about Data Protection before doing the survey and it did not 10. Observatorio SEOM: Carga de trabajo, censo y necesidades de require further regulations. oncólogos médicos en España. 2021. SEOM 2021. Available from: https://​seom.​org/​images/​Infor​me_​cargas_​traba​jo_y_​neces​ Open Access This article is licensed under a Creative Commons Attri- idades_​om_​seom.​pdf. bution 4.0 International License, which permits use, sharing, adapta- 11. Medical Oncology Status in Europe Survey (MOSES Study). tion, distribution and reproduction in any medium or format, as long ESMO MOSES Task Force 2008;(September):1–37. Available as you give appropriate credit to the original author(s) and the source, from: https://​www.​esmo.​org/​conte​nt/​downl​oad/​8358/​170037/​1/​ provide a link to the Creative Commons licence, and indicate if changes 2008-​ESMO-​MOSES-​Phase​III.​pdf. were made. The images or other third party material in this article are 12. Gesme DH, Wiseman M. Subspecialization in community oncol- included in the article's Creative Commons licence, unless indicated ogy: option or necessity? J Oncol Pract. 2011;7(3):199–201. otherwise in a credit line to the material. If material is not included in 13. Shanafelt T, Chung H, White H, Lyckholm LJ. Shaping your the article's Creative Commons licence and your intended use is not career to maximize personal satisfaction in the practice of oncol- permitted by statutory regulation or exceeds the permitted use, you will ogy. J Clin Oncol. 2006;24(24):4020–6. need to obtain permission directly from the copyright holder. To view a 14. Horn L, Koehler E, Gilbert J, Johnson DH. Factors associated with copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. the career choices of hematology and medical oncology fellows trained at academic institutions in the United States. J Clin Oncol. 2011;29(29):3932–8. 15. Boyle S, Petch J, Batt K, Durand-Zaleski I, Thomson S. How References much do cancer specialists earn? A comparison of physician fees and remuneration in oncology and radiology in high-income coun- 1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal tries. Health Policy. 2018;122(2):94–101. A. Global cancer statistics 2018: GLOBOCAN estimates of inci- 16. Dodani S, LaPorte RE. Brain drain from developing countries: dence and mortality worldwide for 36 cancers in 185 countries. how can brain drain be converted into wisdom gain? J R Soc Med. CA Cancer J Clin. 2018;68(6):394–424. 2005;98(11):487–91. 2. Observatorio SEOM; Informe anual: Las cifras del cáncer en 17. Hlubocky FJ, Back AL, Shanafelt TD. Addressing burnout in España 2022. Available from: https://​seom.​org/​images/​Cifras_​ oncology: why cancer care clinicians are at risk, what individuals del_​cancer_​en_​Espna​ha_​2021.​pdf. can do, and how organizations can respond. Am Soc Clin Oncol 3. Observatorio SEOM. Historia de la oncología médica en España. Educ Book Am Soc Clin Oncol Annu Meet. 2016;35:271–9. SEOM 2009. Available from: https://​www.​seom.​org/​seomc​ms/​ 18. Aymerich C, Pedruzo B, Pérez JL, Laborda M, Herrero J, Blanco images/​stori​es/​recur​sos/​infop​ublico/​publi​cacio​nes/​Libro_​Oncol​ J, et al. COVID-19 Pandemic effects on health worker´s men- ogia_​SEOM.​pdf. tal health: systematic review and meta-analysis. Eur Psychiatry. 4. Ministerio de Sanidad SS e I. Orden SSI/577/2013, de 5 de abril, 2022;65(1): e10. por la que se aprueba y publica el programa formativo de la espe- 19. Medscape Observatory. Medscape Physician compensation report cialidad de Oncología Médica y los criterios de evaluación de los 2021. Medscape.com. 2021. Available from: https://​www.​medsc​ especialistas en formación. 2013. ape.​com/​slide​show/​2021-​compe​nsati​on-​oncol​ogist-​60138​55. 5. Pacheco-Barcia V, Sanchez DA, Obispo B, Quilez A, Sesma A, 20. W40 Observatory. Women for Oncology. ESMO. 2022. Avail- Jiménez Labaig P, et al. 1847P Professional standing of young able from: https://w ​ ww.e​ smo.o​ rg/c​ areer-d​ evelo​ pment/w ​ omen-f​ or-​ medical oncologists in Spain during COVID-19 pandemic: a oncol​ogy. nationwide survey by the Spanish Society of Medical Oncology 21. Élez E. Rotaciones Externas del Residente de Oncología - SEOM. (SEOM) +MIR Section. Ann Oncol. 2021;32:S1245–6. https://​ Sociedad Española de Oncología Médica, SEOM. 2018. doi.​org/​10.​1016/j.​annonc.​2021.​08.​735. 22. Vicente Matas. Estudio comparativo de las retribuciones de los 6. Faivre JC, Bibault JE, Bellesoeur A, Salleron J, Wack M, Biau facultativos residentes en España en el año 2021 y recortes desde J, et al. Choosing a career in oncology: results of a nationwide el año 2009. Centro de estudios Sindicato Médico de Granada. cross-sectional study. BMC Med Educ. 2018;18(1):1–9. 2021. http://​www.​medic​osypa​cient​es.​com/​sites/​defau​lt/​files/​Retri​ 7. Hlubocky FJ, Back AL, Shanafelt TD. Addressing burnout in bucio​nes-​MIR-​2021.​pdf. oncology: why cancer care clinicians are at risk, what individuals 23. Seruga B, Sullivan R, Fundytus A, Hopman WM, Ocana A, Joffe can do, and how organizations can respond. Am Soc Clin Oncol J, et al. Medical Oncology Workload in Europe: One Continent, Educ Book. 2016;36:271–9. Several Worlds. Clin Oncol. 2020;32(1):e19–26. 8. Jiménez-Labaig P, Pacheco-Barcia V, Cebrià A, Gálvez F, Obispo 24. American Society of Clinical Oncology (ASCO). Key Trends in B, Páez D, et al. Identifying and preventing burnout in young Tracking Supply of and Demand for Oncologists. 2018; (May):1– oncologists, an overwhelming challenge in the COVID-19 era: 42. Available from: https://​www.​asco.​org/​sites/​new-​www.​asco.​ a study of the Spanish Society of Medical Oncology (SEOM). org/​files/​conte​nt-​files/​resea​rch-​and-​progr​ess/​docum​ents/​2015-​ ESMO Open. 2021;6(4): 100215. https://​d oi.​o rg/​1 0.​1 016/j.​ cancer-​care-​in-​ameri​ca-​report.​pdf. esmoop.​2021.​100215. 9. Banerjee S, Califano R, Corral J, de Azambuja E, De Mattos- Publisher's Note Springer Nature remains neutral with regard to Arruda L, Guarneri V, et al. Professional burnout in European jurisdictional claims in published maps and institutional affiliations. young oncologists: results of the European Society for Medical Oncology (ESMO) Young Oncologists Committee Burnout Sur- vey. Ann Oncol. 2017;28(7):1590–6. 13 Clinical and Translational Oncology Authors and Affiliations Domingo Antonio Sanchez Martinez1 · Aliica Quilez‑Cutillas2 · Pablo Jimenez‑Labaig3 · Andrea Sesma4 · Noelia Tarazona5,6 · Vilma Pacheco‑Barcia7 · Berta Obispo8 · David Paez9 · Teresa Quintanar10 · Manuel Sanchez‑Canovas11 · Ana Fernandez Montes12 · Enriqueta Felip13 · Alvaro Rodriguez‑Lescure10 · Elena Elez13 1 8 Department of Medical Oncology, IMIB, Virgen de La Department of Medical Oncology, Infanta Leonor University Arrixaca University Hospital, Murcia, Región de Murcia, Hospital, Madrid, Spain Spain 9 Department of Medical Oncology, Santa Creu i Sant Pau 2 Department of Medical Oncology, Can Misses Hospital, University Hospital, Barcelona, Catalunya, Spain Área de Salud de Ibiza y Formentera (ASEF), Ibiza, 10 Department of Medical Oncology, Elche University General Illes Balears, Spain Hospital, Elche, Comunitat Valenciana, Spain 3 Department of Medical Oncology, Cruces University 11 Department of Hematology and Medical Oncology, Hospital, Barakaldo, Bizkaia, Spain Morales Meseguer University General Hospital, Murcia, 4 Department of Medical Oncology, Lozano Blesa University Región de Murcia, Spain Clinical Hospital, Zaragossa, Aragón, Spain 12 Department of Medical Oncology, University Hospital 5 Department of Medical Oncology, INCLIVA Biomedical Complex of Ourense (CHUO), Ourense, Galicia, Spain Research Institute, Comunitat Valenciana, Spain 13 Vall d’Hebron Institute of Oncology (VHIO), Medical 6 Instituto de Salud Carlos III, CIBERONC, Madrid, Spain Oncology Department, Vall d’Hebron University 7 Hospital, Univesitat Autònoma de Barcelona (UAB), Department of Medical Oncology, Torrejón University 119‑129, 08035 Barcelona, Catalunya, Spain Hospital, Madrid, Spain 13