Friday, January 05, 2007

Two Cases Demonstrating the Reluctance of Medical Journals and Scientific Meetings to Air Criticisms of Vested Interests

Two follow-ups on stories recently discussed on Health Care Renewal demonstrate how hard it is to openly criticize the powers that be in health care in the venues on which most physicians depend for clinical and scientific information.

The American Society of Hypertension Panel on Conflicts of Interest

Last week we had posted about how the American Society of Hypertension had cancelled a scheduled panel discussion at its annual meeting about conflicts of interest and industry influence, after Society leadership decided the panel was too unbalanced. However, although the panel was likely to be critical of industry influence, it would have occurred at a meeting with considerable industry participation.

Now Christopher Rowland reports in the Boston Globe:

The American Society of Hypertension , accused by its critics of stifling debate, has reversed course and says it will host a panel discussion this spring on how pharmaceutical companies influence medical journals and societies.

After the cancellation was reported by the Globe last week, the society's associate executive director, Melissa Levine , said in an e-mail that the society had now decided to add the panel discussion to the agenda for the May meeting in Chicago.

The society is 'committed to conducting a session on conflicts of interest,' Levine said. 'Over the next few weeks we will be working to finalize the session and confirm the speakers.'

But the inclusion of drug industry defenders led one of the original invited panelists, Dr. Marcia Angell , former editor of the New England Journal of Medicine, to question the society's motives, even though she is considering taking part in the session.

'It seems to be standing the whole thing on its head,' said Angell.

She said the original intent of the panel had been to provide a counterweight to the drug industry's sponsorship of scientific papers and physicians at the annual meeting.

The industry advocates added to the panel are Dr. Thomas P. Stossel and William F. Keane.

Stossel, a Harvard Medical School professor and codirector of the hematology division at Brigham and Women's Hospital, said he has tentatively accepted an invitation to participate. He said he looks forward to the chance to defend drug industry involvement in medical societies.

Keane is vice president of clinical development at Merck & Co. Inc. Merck confirmed yesterday that Keane has been invited to present a lecture on 'industry/professional society relationships' but did not say whether he will accept the invitation.

Stossel said yesterday he would use the panel discussion to argue in favor of continued drug company participation and direct financial support of medical societies and doctors.

'There has been 20 years of unopposed air time of this anti-industry, anticommercial criticism,' Stossel said.

As we noted earlier, there is likely to be considerable commercial presence at the ASH meeting. At least 70 commercial exhibitors are expected in the exhibit hall. The Society is offering a variety of opportunities for corporate sponsorship of various meeting activities. Doubtless, many of the research projects to be presented were funded by industry, and many of the presenters are employed part-time by industry as consultants and on speakers' bureaus. Yet the Society seemed worried that a single panel presentation might exclusively present critics of industry, so it had to add an industry representative and an academic who has been an uncritical defender of industry to it. There may be some criticism of some practices by the pharmaceutical, biotechnology, and device industries in the media, but this case demonstrates how hard it is to criticize industry in more professional health care circles.

The "Defanged" New England Journal of Medicine Article on Epoetin

Last week, we posted about how the New England Journal of Medicine spiked a commentary by Dr Robert Steinbrook, one of its "national correspondents," that included discussion of commercial involvement in the National Kidney Foundation guidelines that promoted aggressive use of epoetin in anemic patients with renal failure. Instead, the Journal published a commentary by an author who has ties to the National Kidney Foundation, and which did not discuss or criticize the Foundation's commercial support. Steinbrook's commentary was eventually published in Lancet. [Steinbrook R. Haemoglobin concentrations in chronic kidney disease. Lancet 2006; 368: 2191-2193.]

This week the New England Journal of Medicine published another commentary by Dr Steinbrook entitled "Medicare and Erythropoietin." [Steinbrook R. Medicare and erythropoietin. N Engl J Med 2007; 356: 4-5. ] This version omitted any discussion, much less criticism, of industry involvement in these guidelines. Conspicuously absent was this passage found in Steinbrook's Lancet commentary:

Over the past decade, National Kidney Foundation guidelines have improved the clinical care of patients with chronic kidney disease in many areas, including vascular access and the adequacy of dialysis. They have, however, been questioned for their reliance on expert opinion and because of the close relations between the Foundation, the Kidney Disease Outcomes Quality Initiative (KDOQI) that formulates its recommendations, and the drug industry. In fiscal year 2005, according to its annual report, the Foundation received $19·7 million—57% of its total support—from various 'corporate and organizational partners'. In calendar year 2005, it received $4·1 million from Amgen and $3·6 million from Ortho Biotech, a subsidiary of Johnson & Johnson, the current marketers of epoetin products in the USA. Amgen supported the development of the anaemia guidelines and is acknowledged as 'the founding and principal sponsor of KDOQI.' 11 Of the 18 members of the workgroup, two-thirds disclosed financial associations with Amgen or other epoetin manufacturers or marketers. In an October, 2006, fact sheet, the Foundation responded to 'some controversy [that] has arisen due to the fact that KDOQI guidelines have been supported by industry. The NKF continually reviews its policies and procedures to safeguard the work product of KDOQI and to ensure that no sponsorship funds contributed to the NKF ever influence the content of any of the KDOQI guidelines.'

Steinbrook recommended,

Physicians and dialysis facilities need updated guidance about the management of anaemia and what is best for patients. Given the billions of dollars at stake for the drug and dialysis industries, such guidance is likely to receive the broadest acceptance if developed without industry support, and by experts without relevant financial associations. This might be accomplished under the auspices of the National Institutes of Health Consensus Development Program or the Agency for Healthcare Research and Quality.

Such a recommendation also did not appear in the New England Journal of Medicine article.

So it also seems that the New England Journal of Medicine could not bear to publish any discussion or criticism of commercial involvement in this particular instance of guideline development.

[Hat tip: GoozNews. As Merrill Goozner said, the Steinbrook article may have been "unspiked," but it surely was "defanged" in the process.]


Many physicians learn about clinical medicine, clinical science, and health policy from prominent journals and by attending prestigious scientific meetings. Yet these journals and meeting often are supported by commercial firms and other organizations with vested interests. These well-reputed fora, often regarded as objective, seem singularly reluctant to allow discussion of the role of commercial funding and influence in their proceedings. So not only are physicians who depend on these traditional sources of information likely to be exposed to information that is influenced by those with vested interests, they are unlikely to be exposed to any criticism of the biases that may thus arise.

Of course, in this age of the internet, there are other ways they may yet be exposed to such criticism. The longer the traditional journals and meetings try to pretend such criticism does not exist, the less trust they will inspire.

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