Americans are rightly furious about the high and unsustainable price of cancer drugs, which now routinely cost more than $100,000 per year of therapy. Those prices are made worse by the fact that most cancer drugs offer only modest benefits — one study put the median benefit at 2.1 extra months of life — along with the fact that expert physicians frequently recommend these drugs for off-label uses, meaning using a drug for a purpose it was not initially approved for.
The House of Representatives, the Senate, presidential candidates, and even the president have floated proposals to tackle drug prices. While all contain good ideas, none address one of the elephants in the room: the experts who tell doctors how to use these medications.
Expert physicians play an oversized role in cancer medicine. They write the editorials in major medical journals that can influence physicians’ prescribing practices, they give educational sessions at national meetings, and they decide what evidence is good enough for off-label use. Spoiler alert: That evidence is often weak. All of this might be fine if experts offered neutral or unbiased information, but evidence suggests they do not.
One study found that 85% of the experts who wrote widely used cancer guidelines had received payments averaging more than $10,000 from pharmaceutical companies. These guidelines mandate that Medicare pay for off-label use of cancer drugs. Research also shows that physicians who consistently put pharmaceutical money in their bank accounts are more likely to prescribe that company’s drugs.
Financial conflict of interest in cancer medicine matters. The pharmaceutical industry is run by intelligent people who choose to pay physicians millions of dollars. It is hard to believe they have not calculated that this aids their bottom lines. Within the profession, there is little interest in reform. Our rules are suggestions. Our punishments lack teeth.
Last year, Dr. José Baselga, the physician-in-chief at Memorial Sloan Kettering Cancer Center, was found to have violated the disclosure policies of several medical journals across dozens of publications. Baselga resigned from his position, but his “punishment” lasted only 116 days before he was named executive vice president of AstraZeneca, a prominent and coveted industry position.
Want more proof that cancer doctors don’t take conflicts of interest seriously? At the American Society of Clinical Oncology meeting, a major national cancer meeting, speakers are asked to disclose their conflicts of interest at the beginning of their talks. My team found that 38% of slides were flashed faster than a human being can read. That isn’t disclosure. It’s a token gesture.
Oncologists are now on Twitter in ever-growing numbers. My team found that when oncologists tweet about a cancer drug and have a financial tie to the maker, their tweets are more likely to be positive than when they tweet about a drug for which no tie exists. We published this finding in the journal Lancet Haematology, though you might think it was a better fit for the Journal of Obvious Things.
The fundamental problem is that, as a profession, cancer physicians are not interested in addressing conflict of interest. Too many people in prominent positions benefit from the current lax policies. Disclosure is not the solution —ending these payments is.
I want to be clear: I’m all for doctors interacting with and working with the pharmaceutical and device industries. I have lectured at major pharmaceutical companies, but without accepting money, travel expenses, or meals. Researchers should be free to work with pharmaceutical companies on trials, but there is no legitimate reason why a well-paid physician needs to take personal payments, gifts, meals, or travel expenses from the pharmaceutical industry. That practice must end.
Conflict of interest is the cancer growing in cancer medicine. It poisons the field. It leads us to celebrate marginal drugs as if they were game-changers. It leads experts to ignore or downplay flaws and deficits in cancer clinical trials. It keeps doctors silent about the crushing price of cancer medicines. It is rampant in guidelines that lead to off-label prescribing and that mandate payment. It is surely a calculated maneuver by the industry to increase their profits.
The sunshine clause of the Affordable Care Act, which requires listing industry payments to physicians on the Open Payments website, was a reform passed by Congress. It did not emerge through self-regulation by doctors. Ending payments from the industry to physicians is also unlikely to come from self-regulation. We need the people of America, through political processes, to cure us of this cancer.
Vinay Prasad, M.D. is associate professor of medicine in the Division of Hematology and Medical Oncology at Oregon Health and Science University, creator of the podcast “Plenary Session,” and author of “Ending Medical Reversal” (Johns Hopkins University Press, 2015) and the forthcoming “Malignant: How Bad Policy and Bad Evidence Harm People with Cancer” (Johns Hopkins University Press, April 2020). Prasad reports receiving royalties from his books; that his work is funded by Arnold Ventures; that he has received honoraria for grand rounds/lectures from several universities, medical centers, and professional societies; and that he has received payments for contributions to Medscape.
Dr Prasad,
Your list of professional and medical industry ties belies your writing.
This is a problem for all medicine. How many times do I have to say Dr Albert Salk ? He did not profit from his vaccine. With the national reboot of the oral vaccine and again Dr Sabin did not receive any monetary profits: there was a massive public health campaign where medical professionals worked for FREE to inoculated the children of the United States. Doctors and nurses and even the main medical professionals were available to TALK to ANY concerned parent. I saw this was my own eyes.
Until American Medicine separates itself from monetary bondage we as a country are less.
And as a person who lived with and or lived folks involved in clinical oncological trials and as a LISW saw folks rolled off to treatment from the medical floor never knowing if they would return alive or dead please cut to the bottom line human lives, human hopes and fears, the gift to be a hero to help human by human suffering. Maybe it is time to return to the little black bag. A few tools but the healing was from a human heart. Science and research are fascinating and without Dr Jenner where would we be? But KOL’s and grants used as profit making gambits have corporates the ENTIRE profession in ALL fields.
There are no listed industry ties….He’s a practicing doctor, of course he has professional ties
Iam shocked, absolutely shocked to hear this terrible news, which I’ve known seemingly forever.
The issue of conflict of interest in creation of guidelines and opinion pieces is as prevalent in the field of diabetes treatment as with cancer treatment. Don’t assume that a payment of $10,000 is too small an amount to influence a doctors sentiments toward boosting a particular drug as getting “in” with a particular company(s) can eventually generate many speaking gigs begetting yearly income totaling in the 6 figures. Despite recommendations by NAM most members of guideline creating bodies in the field of diabetes treatment including the chair people are heavily indebted to their pharmaceutical sponsors. The result is putting the brand drugs with prices 100 times that of generics and with just a few years of general use at the top of the algorithm.
Let’s just move the money around. Clearly the pharmaceutical companies can afford to spend it, so let’s direct it to a fund for graduate student fellowships, cancer patients in need of financial relief, and–scary though it may be to the company–actual R&D.
The disingenuousness that emanates from the Memorial Sloan – Kettering Cancer Center is intermittently palpable. Egregious conflicts of interest and bioethics concerns are not new and sadly, the recent exposes will likely not be the last to fester forth. When such bioethics (and environmental health and safety) concerns are rightfully reported, Sloan merely conjures and synchronizes their cover stories. The confluence of safety concerns/infractions/systemic and otherwise at MSKCC fostered by MSKCC’s Facilities Team and their Confederates (Contractors, Organizations) does affect/effect employee / community safety and stands to affect and has likely effected (and could impeach the efficacy of) reaction conditions relative to clinical trial candidates created and tested at Sloan and elsewhere. The Chief Financial Officer of MSKCC has stated (paraphrased): Sloan is … pursuing a systemic approach to reducing expenses and increasing revenues. … this effort involves … policy decisions that seek to strike a … balance between providing service and squandering resources. One example of this is discouraging terminally ill patients from seeking initial treatment or second opinions from the cancer center … the admission of such patients is counterproductive for a facility like Sloan-Kettering. Unfortunately, you or a loved one may have a cancer scare, and after hurdling administrative / insurance obstacles (being fortunate enough to obtain an appointment for treatment) the forces of commerce (profit and/or potential profit [e.g. large milestone dependent royalty payments, contingent on completion of a clinical trial phase, with an unsuspecting patient as a pawn]) may influence enrollment in a clinical trial (in variance with candidate efficacy). People who are guilty of such craven self-servitude clearly know better. Sloan’s slogan is: MSKCC, The Best Cancer Care Anywhere … apparently, as long as it’s consistent with Sloan’s revenue stream and/or the potential stock portfolio of powerful employees.
Great article, might be eye-opening for some. But I am missing an essentially applicable term : CORRUPTION. Indeed, it is up to voters to select politicians who will address this serious issue (oh, and terminate lobbyists too). Note in the margin: what if those politicians too are “bought” ? There is a lot of work ahead in what appears to be an out-of-control system.
CANCER PATIENTS ARE ALREADY UNDER LOTS OF FINANCIAL PRESSURE & HENCE GLOBAL AUTHORITIES SHOULDN’T HESITATE TO PUT PROPER RESTRICTIONS ON UNNECESSARY REASONS FOR UNDULY INFLATED PRICES OF ONCOLOGY DRUGS.
Vinay: I do not find it difficult to believe physicians may exhibit a bias towards prescribing a drug they have studied in a clinical trial – but the suggestion that bias is driven by money strikes me as naive. At least in the US, I have yet to meet a cancer doc who could be swayed by sums as low as $10,000. Far more likely I imagine is the comfort level a physician develops with certain treatments over time – participating in a clinical trial bestows any treatment a head start in getting up that learning curve.
The issue of bias is truly important, and merits serious study with good science – which does not include painting association as cause.
Vinay: you raise some good points but in your academic position I doubt you’re struggling to make a living. Physicians, as you are aware, are burning out and struggling with additional expenses. If a physician would sell his soul to recommend a certain drug I think there is a bigger problem. Pharma relies on physicians as thought leaders and they have every right to be compensated for their time and travel. The other aspect is that there are so many “me too” drugs does it really make a difference if someone recommends Keytruda over Opdivo?