Pharmaceutical company payments to oncologists are again in the spotlight, with a new analysis documenting how a small group of specialists have received huge payments, prompting concerns that greed may be influencing prescribing.
The analysis found that a group of high-profile oncologists each received more than $100,000 in general payments associated with specific marketed cancer drugs in 2018.
This group was composed of 139 medical oncologists, and accounted for only 1% of all US oncologists.
The median payment for each specialist was $154,613, and the total came to $24 million.
“Although some may be shocked by this analysis, it is consistent with many studies of other specialties,” writes the editorialist, Mark J. Ratain, MD, a professor of medicine at the University of Chicago, Chicago, Illinois.
“Although one would hope that drug prescribing would be evidence-based, greed and fear also factor into such decisions,” he comments.
Compared with other specialties, Ratain points out that oncology is particularly complex, given the exceedingly high cost of newer drugs and the “opportunity for physicians, hospitals, and pharmacies to reap significant financial benefits on the differential between purchase price and reimbursement.”
Additionally, the fear of recurrence and death is common among patients with cancer, and these high levels of anxiety and fear can interfere with appropriate decision making. A financially motivated oncologist interacting with a frightened patient could lead to the administration of an expensive drug, and this is particularly true when a discussion about “less toxic or less expensive treatment options (or a watch and wait approach) is time consuming, yields no revenue related to prescribing, and scores no key opinion leader prescribing points.”
Perceived and Real Conflict of Interest
The analysis did not name the oncologists who were receiving more than $100,000 each year.
However, it characterized them as mostly (95%) active in clinical work, with 56% in an academic setting, 31% at National Cancer Institute–designated cancer centers, and 23% at National Comprehensive Cancer Network (NCCN) centers.
Most of them were currently, or had been, in hospital leadership positions (60%) or faculty appointments (72%), and 21% held leadership positions in specialty associations in the past 5 years. Nearly one quarter (24%) had served on journal editorial boards, and 10% have authored clinical practice guidelines in the past 5 years.
More specifically, three physicians authored NCCN guidelines, and two authored American Society of Clinical Oncology (ASCO) guidelines during 2016-2021; one of these guidelines was published in 2018 when payments were made.
The findings highlight a risk for “perceived and real conflict of interest,” corresponding author on the analysis, Christopher Booth, MD, of Queen’s University Cancer Research Center, Kingston, Ontario, Canada, told Medscape at the time the study was published.
“Because of the leadership positions they hold, the potential impact of this small group of physicians on oncology practice and policy may be substantial,” he commented.
Further Analysis Needed
The authors’ concern over pro-industry bias is “appropriate,” writes Ratain in his editorial, but he also suggests that further analysis is needed.
One limitation of the paper was that the researchers did not analyze the payments by subcategories, such as consulting fees and speakers’ bureaus, he writes. As a quarter of those receiving high payments had zero to two publications in 2018, only 24% had served on an editorial board in the preceding 5 years, and only 56% practiced in academic institutions, it would appear that many of them were rewarded for their nonacademic activities, potentially a large number of prescriptions for specific products.
It would be important to see an analysis correlating prescribing data with pharmaceutical payments, Ratain told Medscape. “The authors should have the data for the subcategories, but correlation with prescribing data requires substantive and separate analyses.”
He also commented that thus far, the impact on care is yet unclear. “We cannot state that any of the prescribing was harmful, although further studies may be informative,” Ratain said. “For example, it would be of interest to analyze whether there is any difference in outcomes between physicians receiving high vs no or low payment.”
Ratain emphasizes that he is not suggesting that oncologists should not interact with or consult for the pharmaceutical industry, as he has his own relationships with industry. But there is a difference between true consulting regarding drug development and assistance with marketing. Specifically, participation in speakers’ bureaus should be considered a pure marketing activity lacking any academic value, he suggests.
Tightening the Noose
As one way of reining in this trend, Ratain suggests that it is time for ASCO to reconsider its position on speakers’ bureaus. The current policies prohibit certain individuals in leadership positions (chief executive officer, president, president-elect, chair of the board, and immediate past president), as well as the editors-in-chief of all ASCO journals from receiving any industry compensation. In addition, clinicians who receive compensation from a speakers’ bureau may not participate in an ASCO guideline panel if the company would be affected by the guideline.
“These policies demonstrate ASCO’s recognition that such activities represent commercial speech, rather than intellectual discourse,” he writes.
However, he also suggests that ASCO could do a lot more.
One step would be to ban individuals who received speakers’ bureau compensation within the last 2 years from speaking in Accreditation Council for Continuing Medical Education-accredited sessions at ASCO meetings. Those individuals could instead gather in the exhibition hall at a special speakers’ bureau area, he suggests.
Another step would be for ASCO to maintain and publicize a list of all members who participate in speakers’ bureaus, because, Ratain says, the Open Payments database “has not sufficiently dissuaded our colleagues who participate in this marketing activity.”
These participating oncologists may balk at being listed separately in a speakers’ bureau, but Ratain told Medscape that “it should be a stigma, like the scarlet letter.”
“The information is out there for all to see, but it has been a bit buried and thus has not been enough of a deterrent,” Ratain commented.
Ratain has disclosed the following: stock and other ownership interests for SAB Biotherapeutics; honoraria from Emerson Lake Safety; consulting or advisory role for Aptevo Therapeutics, Apotex, Genentech, Arvinas, Ayala Pharmaceuticals, Oncovalent Therapeutics, EQRx, Bluebird Bio, Bayer, Cantex Pharmaceuticals, Eagle Pharmaceuticals, and EMD Serono; research funding from AbbVie (inst), Genentech/Roche (inst), Xencor (inst), Corvus Pharmaceuticals (inst), Bristol Myers Squibb (inst), Incyte (inst); patents, royalties, and other intellectual property from royalties related to UGT1A1 genotyping for irinotecan, royalties related to UGT1A1 genotyping for irinotecan (inst), provisional patent application for method of treating viral pneumonitis with low-dose tocilizumab (inst); expert testimony for multiple generic companies (defendants in patent litigation); and other relationships with Credit Suisse, Optimal Cancer Care Alliance, and William Blair.
JCO Oncol Pract. Published Jul 14, 2022. Editorial.
Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.