How Institutional Conflicts of Interest Exacerbate the Anechoic Effect – the Example of ASCO Fearing “Biting the Hand that Feeds You”

Lambert Strether: Ancien regime levels of corruption wherever you look.

By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website

As we recently discussed (here, here, here and here), in May, 2015, the New England Journal of Medicine, arguably the world’s foremost medical journal, published an editorial and a three-part commentary arguing that current concerns about the effects of financial conflicts of interest (COI) on health care are overblown(1-4). On June 1, the Wall Street Journal published a report on the 2015 meeting of the American Society of Clinical Oncology (ASCO) that provided a vivid example of why these concerns should not be dismissed.

Questioning Drug Prices at the ASCO Meeting

The main issue in the article was:

In a sign of growing frustration with rising drug prices, a prominent cancer specialist on Sunday sharply criticized the costs of new cancer treatments in a high-profile speech at one of the largest annual medical meetings in the U.S.

‘These drugs cost too much,’ Leonard Saltz, chief of gastrointestinal oncology at Memorial Sloan Kettering Cancer Center, said in a speech heard by thousands of doctors here for the annual meeting of the American Society of Clinical Oncology.

The notion that health care prices are high and are rising continuously in the US should hardly be novel for regular Health Care Renewal readers. We have been writing about it for a while, starting in 2005.

We first posted about high drug prices in July, 2005, with the example of BilDil. This was a brand-name combination drug that included two compounds that were already cheaply available in generic form, advertised as a uniquely convenient therapy for congestive heart failure. We were aghast that the price of the combination drug might be $5.40 – $10.80 a day (in 2005 dollars), over three times the cost of the two drugs in generic form.

But only a few days later we noted that three cancer costs had yearly costs in the five figures, and one, Erbitux, cost as much as $100,000. Most amazingly we noted that Thalidomid was priced at $25,000 a year. Yet it was just the infamous thalidomide, the drug initially marketed as a tranquilizer that caused severe birth defects after it was initially sold in Europe. The drug was still available in generic form in South America for about seven cents a pill.

Since then, the ridiculously high prices of many tests and treatments, but most notably new drugs and devices, has been so widely covered our discussion has been limited to special cases. For example, consider just a few headlines from April to May, 2015.

How Much Would You Pay for an Old Drug? If You Have MS, a Fortune (Bloomberg)

Pharmaceutical Companies Buy Rivals’ Drugs, Then Jack Up the Prices (WSJ)

How Marketing Exclusivity Led to Higher Drug Costs and Questionable Benefits (WSJ)

Runaway Drug Prices (NY Times)

Drug Prices as a Taboo Topic

However, despite this wide attention to the problem, the speech at ASCO was notable. Back to the WSJ…

Dr. Saltz’s speech was unusual because it was made at the meeting’s plenary session, where the field’s most significant scientific research is presented and which all meeting participants are expected to attend. An estimated 25,000 doctors and scientists attended this year’s meeting.

One would think that the high price of drugs, especially cancer drugs, would be a fit subject for discussion at a plenary session of ASCO, however,

It is unprecedented for plenary speeches, which typically address scientific and medical issues, to substantially take on the topic of drug costs, said Alan Venook, a professor of medicine at the University of California San Francisco who planned the meeting’s scientific session and invited Dr. Saltz to speak.

The prominent venue for the speech was also unusual because, like many medical meetings, ASCO is sponsored by pharmaceutical companies and often focuses on highlighting advancements in drug development, said Dr. Venook. He said discussing drug prices there is ‘uncomfortable’ because it could be seen as ‘biting the hand that feeds you.’

Doctors are also reluctant to antagonize the drug industry because they need pharmaceutical firms to invest in developing new medicines for patients, he said.

‘It’s a tough balancing act for ASCO where the meeting is largely funded by pharma,’ Dr. Venook said in an interview. ‘You can’t have a [plenary] talk trashing pharma, but you can have a talk by a respected person questioning it.‘

So because pharma gives ASCO a lot of money, at best, only the most distinguished ASCO members can gently question pharma, but cannot criticize, much less “trash” the source of their mammon.

This is thus a succinct example of why financial conflicts of interest in medicine and health care can be bad. The incredibly high prices of cancer drugs should be a fit topic for discussion at a meeting run by a society of medical oncologists. But those in charge of the meeting and the society are afraid to initiate such a discussion, and even more afraid of appearing to criticize the companies that charge these prices, because the society has become dependent on money from these very same companies. So this is further an example of how conflicts of interest can create the anechoic effect – the notion that certain topics in medicine and health care are taboo, because discussing them might trouble the powers that be, and particularly the moneyed interests that now dominate medicine and health care.

In a succinct response to the NEJM series (1-4) soft pedaling concerns about conflicts of interest, the British Medical Journal ran a commentary by a former NEJM national correspondent, and two former NEJM editors.(5) It stated,

The NEJM has now sought to reinterpret and downplay the importance of conflicts of interest in medicine by publishing articles that show little understanding of the meaning of the term. The concern is not whether physicians and researchers who receive industry money have been bought by the drug companies, as Drazen writes, or whether members of guideline panels or advisory committees to the US Food and Drug Administration with ties to industry make recommendations that are motivated by a desire for financial gain, as Rosenbaum writes. The essential issue is that it is impossible for editors and readers to know one way or the other.

In this case, we seem not to be talking about the possibility that health care professionals “have been bought by the drug companies,” but how drug companies essentially “buying” a professional organization has apparently heretofore prevented medical professionals from discussing a vital issue that could have major effects on patients.

Following the Money

In case there is any question about the money involved and its sources, one only needs to go to some publicly available in formation supplied by ASCO (mostly because of reporting requirements imposed on all US non-profit organizations of a certain size).

The latest (2014) annual report from ASCO reveals that the organization only gets 16.1% of its revenue from member dues. Thus a ostensible membership organization gets only about a sixth of its funding from members’ dues.

Yet the organization has become quite wealthy. Its most recent (2013) US Internal Revenue Service 990 Form reveals that it owns over $55 million in real estate, and has over $104 million in investments (presumably as an endowment.) The organizations’ leaders are also doing very well. Its CEO, Allen Lichter MD, got $804,775 in total compensation in 2012. Eleven other managers, of which three are health care professionals (one MD, one RN, one PharmD), got at least $220,000 in total compensation. Five of them got more than $300,000.

The source of all that money seems mainly to be pharmaceutical and other health care corporations that sell goods and services for cancer care. US non-profit organizations are not forced by law to reveal the details of their financial support. However, the ASCO annual report does list 23 pharmaceutical and biotechnology companies, and one for-profit cancer hospital chain as contributing at least $1 million each in total to the non-profit over time. The report lists 37 pharmaceutical, biotechnology, and medical device companies as current corporate donors, and also 10 other for-profit health care related corporations as current corporate donors.

In addition to these apparently marked institutional conflicts of interest, ASCO leaders may have their own individual conflicts of interest. I do not have the resources to search all relationships affecting meeting organizers and ASCO officers and trustees, and the organization does not post conflicts of interest affecting its leadership and governance in a prominent place. However, Dr Alan Venook, who confessed to his discomfort about inviting a talk that might be perceived as biting the hand that feeds the finances of ASCO, is or has been on advisory boards for Thershold Pharmaceuticals, Mirna Therapeutics, and GlobeImmune. For a 2014 presentation, he gave the following disclosures: “Research support from Genentech/Roche, BMS, Lilly, Novartis; H. Lenz: Consulting, advisory boards and research support from Genentech/Roche, BMS and Merck.” Furthermore, the current chair of the ASCO Board of Directors, Julie M Vose, MD, is also on the Medical Advisory Board of EmergingMed Inc, and the Clinical Advisory Board of Bullet Biotechnology.

Summary

The New England Journal of Medicine recently launched a counter-attack against the “pharmascolds” who are allegedly slowing the pace of medical progress by their excessive and puritanical concerns about financial conflicts of interest. Yet the arguments that COIs could be bad for health care are logical, and based on at least some reasonably good evidence. (See the article by Steinbrook et al in the BMJ mentioned above[4], the accompanying BMJ editorial[5] just to start and then the 2009 Institute of Medicine report.)

Moreover, we have encountered a lot of vivid cases suggesting that conflicts of interest can have adverse influences on health care. In this most recent one, we see at least one prominent if conflicted organizational insider admitting that institutional, and perhaps individual conflicts of interest have made discussion of at least one big health care and health care policy topic taboo. This seems to corroborate our previous discussion that the anechoic effect – that certain topics in health care are taboo – may be generated by conflicts of interest of the people who ought to discuss them, or of those to whom those people may have to answer.

True health care reform requires full disclosure of conflicts of interest for honesty’s sake, and marked reduction of conflicts affecting those who make health care decisions on behalf of individual patients, and health care policy decisions that affect patients’ and the public’s health. If we allow conflicts of interest to continue, we will have difficulty even discussing the most severe problems affecting health care, because those generating the topics are benefiting from the circumstances that enable such problems.

References

1.Drazen JM. Revisiting the commercial-academic interface. N Eng J Med 2015; ; 372:1853-1854. Link here.
2. Rosenbaum L. Reconnecting the dots – reinterpreting industry-physician relations. N Eng J Med 2015; 372:1860-1864. Link here.
3. Rosenbaum L. Understanding bias – the case for careful study. N Engl J Med 2015; 372:1959-1963. Link here.
4. Rosenbaum L. Beyond moral outrage – weighing the trade-offs of COI regulation. N Engl J Med 2015; 372: 2064-2068. Link here.
5. Steinbrook R, Kassirer JP, Angell M. Justifying conflicts of interest in medical journals: a very bad idea. Brit Med J 2015; 350: h2942. Link here.
6. Loder E. Revisiting the commercial-academic interface in medical journals. Brit Med J 2015; 350: h2957. Link here.