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.


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.


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.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Paul Tioxon

    Dr Zeke Emmanuel, you know who’s brother, speaking at BIO, a large medical conference earlier this month, criticized high costs of technology driven medicine, especially Big Pharma. How bad is drug pricing from his point of view? Pretty bad. Enough to propose that the only solution would be a single national body negotiating for all health care providers with the Big Pharma drug producers.

    “….pharmaceutical companies have the highest profit margin of any sector in the health care economy.

    “We don’t have a system,” Emanuel said in the Inquirer interview, referring to controlling the cost of drugs in America. “It is basically pharma setting its own prices but you can’t replace that with nothing, so we need to do something about having the right pricing model. It’s clear it (the current process) is not based on cost-effectiveness because they (pharma companies) are not trying to justify it with cost effectiveness. It certainly doesn’t hold in my field, cancer.”

    Medicaid, which provides health insurance for low-income Americans, is financed by federal and state governments. Medicare is handled only by the federal government.

    Laws allow Medicaid officials to bargain for lower drug prices. But with lobbying money from drug companies, Congress has passed laws that prevent Medicare from bargaining directly on price. Would applying the Medicaid laws to Medicare help?

    “That might solve the government problem, but it won’t solve The Problem because then drug companies will raise the prices on private payers,” Emanuel said, referring to insurance companies and the patients they cover through drug plans. “We need a broader solution.”

    Emanuel imagines one imperfect “perverse back door,” solution occurring, if enough states and health systems – 4,000 by his count – all begin negotiating more forcefully with drug companies.

    “They,” Emanuel said, referring to drugmakers, “might think a national system where we all know the rules might be a better system.”


    Now if this is guy is complaining about the high cost of drugs and he is well established at a major Ivy League teaching hospital and medical research center where money is being spent like water on new buildings and huge cancer center medical devices such as the Proton Beam Cancer center where reports indicate a $10,000.00/day electric bill just to operate the machine, you know there is a problem. Additionally, Bill Clinton spoke at the convention and his main service was how to smooth out the push back and general political turbulence on sky high pricing. His answer to high prices? Explain yourself, use transparency. What we have here is a failure to communicate!!! The high prices are so bad, that expert politicians are paid to come in and speak to the drug makers and medical device providers. Clinton offers PR to blunt the story about unaffordable drugs, except for the precious few who can afford and Emmanuel offers forming a national united front for hard ball price negotiations with Big Pharma. Gee, which will happen in the next administration?

  2. TheCatSaid

    It’s bad enough that the pricing of drugs is so captured.

    What’s possibly even worse is the anechoic effect on the many treatment options that must not be considered, researched, discussed or even mentioned–plus the brainwashing to which medical students are subjected from their earliest days.

    Big pharma pays for the professional journals and medical school training, in addition to funding most of the research.

    1. Jeremy Grimm

      I don’t know — just askin’ — are you sure big pharma pays for the research? I can believe believe big pharma pays for the development of drugs but I thought the Federal Government paid for the basic research.

      1. Alejandro

        I’ve always been under the impression that government does most of the research that takes it into the “ red-zone” and big pharma does the “marketing” ‘research” that takes it into the end-zone…with similar “game plans” in most industries…

      2. Paper Mac

        Institutions often own the patents on the basic research, pharma buys the patents (often for substantially less than fair value). The taxpayer foots the bill, the institution books some profit.

  3. nat scientist

    It’s no wonder that University professors feel the ‘millenials’ are an alien force of rejection of STEM subjects; when the see that in “The Wizard of Oz”, the curtain drops on the Grand Poobah’s scheme and something important happens, but not in the world they’re going to inhabit.
    It’s transparent completely to them that Obama’s “Secretary of Explainin’ Stuff” is the same Global Clinton Insertion that he helped out with in the Financial Modernization scheme opening the door to the infinite insurance loop of derivative leverage to ensure the “more perfect union” goals of universal health coverage at infinite loop taxpayer expense when things do awry as awry they must… on their backs. There’s too the feeling that this “More Perfect Union” stuff and the bad grammar (more unique, more one-of-a-kind, etc) comes from reading the Kama Sutra!

  4. Faye Carr

    Beyond the whole get as much as the market will pay pricing.

    Isn’t it obvious that the cost of life saving/extending medications and therapies is yet another way to “thin the herd”?

  5. Mbuna

    I think if you consider the lack of enforcement in the financial fields, the shredding of sovereignty and monopoly pricing extensions in the TPP, the results of the Citizens United decision, Obamacare and other situations that have a corporate or institutional parallel to the one in this article, you can start to see a kind of emergence of corporate political and even philosophical hegemony. Humanity is becoming the ultimate crop to be raised on the corporate farm to be ultimately sacrificed on its altar of profit. When you look at the actions taken by these corporate institutions it is clear that every conceivable action to enhance profitability can be taken and can be defended purely by this motive.
    –I hope you enjoyed this hyperbolic moment–

    1. redleg

      That’s not hyperbolic. That’s braiding together the loose threads from seemingly different topics to form a common cord.

    2. Jeremy Grimm

      I feel compelled to echo and resonate on your hyperbolic moment. The oncologists must have felt not only should one not bite the hand that feeds but “People who live in glass houses should not throw stones.” Physicians set their own fees.

      As you pointed out, we have laws in this country against monopolies and monopoly pricing. They are not enforced and have not been enforced for decades. Patents, like the Post Office, were special to Ben Franklin … and both have been ravished by the very government of and by the people — no more — which established both these remarkable and wonderful institutions.

      I am very concerned for the future. I am not a revolutionary. I recall the old song about calves growing wings like swallows to fly away — but where is there to fly? Perhaps the true revolutionaries are little more than cornered rats.

  6. shinola

    The escalating cost issue is nothing new, it’s just getting worse.

    In the mid 70’s I had an econ prof. (an avowed plutocrat) who advised students to go into “medicine” if they wanted a near guaranteed high income. Not necessarily becoming an MD but anything that had to do with the medical field. After all, “People will pay just about anything for their life or health.”

  7. Vatch

    Oh, come on, what’s the big deal? Just avoid illness and injury, and you’ll never have to worry about drug prices! See how simple that is?

    Disclaimer: there is a wee possibility that I’m being sarcastic. I just thought I should mention that, since you can’t hear my tone of voice.

  8. nothing but the truth

    behind the pampered and extortionate sectors of the economy (FIRE + healthcare + weapons manufacturers + govt employees) is the might of the govt.

    doctors are as much to blame as pharma. Insurance is just trying to spread the extortionate healthcare charges to the entire society; the fundamental problem is extortion by healthcare. insurance cannot do magic in such situation.

    rent seeking by definition cannot happen without a powerful govt.

    what you need is a less powerful govt. more competition in healthcare. small term limit for patents. more and more difficult patent regimes.

      1. Ulysses

        The U.S. government today is not like an honest cop on the beat, enforcing laws impartially, and protecting people from predators. It is like a cop on the take, protecting the biggest gangsters in town, and helping them shake down decent people at every opportunity.

        The cop is the enforcer for the crooks who set up the shell game to fleece the people!!

    1. different clue

      How much money does the insurance industry its own self add to this whole process by its particular existence?

    2. Legendary bbigfoot

      Nothing but bujjshjt, you mean. Magic beans make unicorns fart rainbows, and anti government libertarian nonsense are the best magic beans of all.

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