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.