An examination of the steering committee’s earnings from corporations, according to 2017 data from the federal Centers from Medicare and Medicaid, showed that while most of them easily met the criteria for financial review, 3 of the 30 members did accept more than $20,000 in general payments from a single company, and 1 of those 3 members accepted more than $50,000 from the industry. Another member who accepted payments totaling more than these listed amounts recently left the panel, although the NCCN would not reveal any reasons for this individual’s departure. Thirteen panel members accepted less than $500 total from the pharma industry, and 10 panel members received more than $10,000.
Even relatively small amounts of money may be enough to influence decision making, said Aaron Mitchell, MD, an assistant attending physician at Memorial Sloan Kettering Cancer Center, New York, New York, who researches COI. He said this is because of human nature. “There’s also the interpersonal relationship and the friendship and the sense of like, a give-and-take and mutual responsibility to give something back to someone who’s given you money,” he said.
In a recent study, Dr Mitchell showed that doctors who get money from a pharmaceutical company tend to prescribe more of that company’s drug than similar drugs.1 “It does appear to be related not to just whether you got money but the amount of money,” he noted. Doctors who received more than $100 behaved differently than people who got less, the research showed, suggesting that even relatively small amounts of money can have an impact on decision making.
There is really no way to know if payments have an effect on any individual or guidelines panel, Dr Mitchell said, because there’s no comparison group of doctors who haven’t accepted any money.
It could also be that only well-established doctors who are already major prescribers of the drug are singled out for payments, said Samir Grover, MD, an assistant professor at the University of Toronto and gastroenterologist at St. Michael’s Hospital, and Rishad Khan, a medical student at Western University, Ontario, Canada, who collaborate on COI research.
But they both said that there’s little doubt that payments to doctors have an impact — or companies wouldn’t make so many of them.
“Just as smoking is a risk factor for lots of things, having industry ties in the form of general payments — it’s a risk factor for prescribing, it’s a risk factor for physicians trying to add drugs to hospital formularies,” Dr Khan said. “We don’t actually know if it influences clinical guidelines.”
The research duo is presenting an abstract at an upcoming conference, showing that there is a “rather substantial return on investment for biologic medicines” in gastrointestinal therapies. A similar study in 2016 showed the same pattern for statin prescribing,2 and in a recent research letter in JAMA Internal Medicine, the duo found that the presence of financial conflicts of interest in clinical practice guidelines may affect the objectivity of the recommendations. 3
Khan also cited a survey that found that the majority of doctors interviewed thought pharmaceutical payments had an impact on their colleagues’ prescribing behavior — but not on their own.4
Dr Carlson said that any concerns about COI on NCCN’s guideline panels are misdirected. “It’s not an accurate concern, because we have so many checks and balances in place.”
- Mitchell AP, Winn AN, Lund JL, Dusetzina SB. Evaluating the strength of the association between industry payments and prescribing practices in oncology [published online February 6, 2019]. Oncologist. doi: 10.1634/theoncologist.2018-0423
- Fleischman W, Agrawal S, King M, et al. Association between payments from manufacturers of pharmaceuticals to physicians and regional prescribing: cross sectional ecological study. BMJ. 2016;354:i4189.
- Khan R, Scaffidi MA, Rumman A, Grindal AW, Plener IS, Grover SC. Prevalence of financial conflicts of interest among authors of clinical guidelines related to high-revenue medications. JAMA Intern Med. 2018;178(12):1712-1715.
- Korenstein D, Keyhani S, Ross JS. Physician attitudes toward industry: a view across the specialties. Arch Surg. 2010; 145(6):570–577.