Conflict of interest in academic oncology: moving beyond the blame game and forging a path forward

Axicabtagene Ciloleucel versus Tisagenlecleucel for Relapsed or Refractory Large B Cell Lymphoma: A Systematic Review and Meta-Analysis

Axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) are CD19-directed chimeric antigen receptor T cell (CAR-T) therapies approved for relapsed/refractory aggressive large B cell lymphoma (LBCL). Significant costs and complex manufacturing underscore the importance of evidence-based counseling regarding the outcomes of these treatments. With the aim of examining the efficacy and safety of axi-cel versus tisa-cel in patients with relapsed/refractory aggressive LBCL, we performed a systematic literature search of comparative studies evaluating outcomes in relapsed/refractory aggressive LBCL after treatment with axi-cel or tisa-cel. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for response, progression-free survival (PFS), overall survival (OS), cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and hematotoxicity. Meta-analysis and meta-regression were used to generate summary statistics. A total of 2372 participants were included in the 8 studies in our analysis. The dropout rate between apheresis and infusion was 13% for axi-cel versus 18% for tisa-cel, and the median time from apheresis to infusion was 32 days versus 45 days. Axi-cel showed higher odds for a complete response (OR, 1.65; P < .001) and was associated with higher odds for PFS at 1 year after infusion (OR, .60; P < .001). OS appeared to be improved with axi-cel (OR, .84; 95% CI, .68 to 1.02; P = .08), whereas the cumulative incidence of nonrelapse mortality (NRM) was 11.5% for axi-cel versus 3.7% for tisa-cel (P = .002). The main predictors for survival were lactate dehydrogenase level, Eastern Cooperative Oncology Group Performance Status, and response to bridging, and axi-cel maintained superior efficacy even in elderly patients. In terms of safety, axi-cel was associated with significantly higher odds of any-grade CRS (OR, 3.23; P < .001), but not of grade ≥3 CRS (P = .92). Axi-cel was associated with significantly higher odds of severe ICANS grade ≥3 (OR, 4.03; P < .001). In terms of hematotoxicity, axi-cel was significantly associated with higher odds of severe neutropenia at 1 month after infusion (OR, 2.06; P = .003). As a result, axi-cel was associated with significantly greater resource utilization, including prolonged hospital stay, more frequent intensive care admission, and use of agents such as tocilizumab for toxicity management. We provide strong evidence of the greater efficacy of axi-cel versus tisa-cel in relapsed/refractory aggressive LBCL. The higher toxicity and NRM seen with axi-cel might not counterbalance the overall results, highlighting the need for timely intervention and careful selection of patients, balancing resource utilization and clinical benefit.

Financial conflicts of interest of physicians followed by oncology journals on Twitter

BACKGROUND

Physicians have increasingly adopted Twitter as a discussion and distribution platform for oncology research. While the influence of financial conflicts of interests (FCOI) on medical research is well documented, their role in the dissemination of research on social media platforms is not well known. In this study, we sought to evaluate the FCOIs of physicians followed by the top three oncology journals on Twitter.

MATERIALS AND METHODS

We used the Open Payments Search Tool ( https://openpaymentsdata.cms.gov ) to assess FCOIs between 2016 and 2021 of United States (US) physicians followed by three oncology journals (Journal of Clinical Oncology, The Lancet Oncology, and Annals of Oncology) on Twitter.

RESULTS

Of 1914 Twitter accounts followed by the top three oncology journals on Twitter, 547 (28.6%) belonged to US physicians. Of these, 463 (84.6%) received general payments between 2016 and 2021. After excluding 30 US physicians currently in residency or fellowship, this percentage increased to 88.2% (n = 456/517). Combined, the median (interquartile range) general payment amount was $8100 ($200-90,000). Additionally, over $42 million in general payments were made between 2016 and 2021.

CONCLUSION

Our findings offer insight on FCOIs between oncology journals and US physicians on Twitter. These findings may serve as the foundation for future research regarding optimal medical journal conduct on social media platforms.

Financial conflicts of interest of physicians followed by neurosurgical journals on Twitter

BACKGROUND

Social media, particularly Twitter, has played an increasing role in networking and the dissemination of neurosurgical research. Despite extensive study on financial conflicts of interest (FCOI) influencing medical research, little is known about the function of conflicts of interest on social media and the influence they may have. In this study, we sought to evaluate the FCOI of physicians followed on Twitter by the top three neurosurgical journals.

MATERIALS AND METHODS

We analysed the FCOI of United States (US) physicians followed by the top three neurosurgical journals (Journal of Neurosurgery, World Neurosurgery, Neurosurgery) on Twitter. We determined the FCOIs of each physician using the Open Payments Search Tool located at https://openpaymentsdata.cms.gov and summed the data between 2014 and 2021.

RESULTS

We examined 2651 Twitter accounts followed by the top three neurosurgical journals on Twitter and determined 705 (26.6%) belonged to US physicians. Of the 705 US physicians, 577 (81.8%) received general payments between 2014 and 2021. After excluding US physicians currently in residency or fellowship (n = 157), this percentage increased to 93.2% (n = 511/548). In total, nearly $70 million in general payments were made between 2014 and 2021.

CONCLUSION

These findings raise questions regarding the interaction between neurosurgical journals and the medical community on Twitter. This study may serve as the basis for future work on best practices for medical journals navigating their affiliations on Twitter.

Do Editorialists With Industry-Related Conflicts of Interest Write Unduly Favorable Editorials for Cancer Drugs in Top Journals?

BACKGROUND

Editorials accompanying the publication of trials in major oncology journals can have a substantial influence on clinical practice. We describe the prevalence of financial conflicts of interest (FCOIs) of authors writing such editorials and the extent to which FCOIs may shape the interpretation of clinical trials.

METHODS

We examined editorials published in 2018 alongside trial reports in the top 5 journals that publish cancer drug trials (New England Journal of Medicine, Lancet, Lancet Oncology, JAMA Oncology, and Journal of Clinical Oncology). An editorial was considered to have an FCOI if at least one of the editorialists had any disclosed FCOI. An FCOI with the same company whose drug was being discussed in the editorial was classified as a direct FCOI. Editorials were reviewed for their content and classified as being unduly favorable (defined as the presence of a positive spin without discussion of limitations) or not. Association of an FCOI and a direct FCOI with writing an unduly favorable editorial was assessed.

RESULTS

Of the 90 editorials assessed, 74% (n=67) were classified as having an FCOI with the pharmaceutical industry, and 39% (n=35) had an FCOI with the same company whose product was being discussed in the editorial (direct FCOI). Editorials were classified as being unduly favorable toward the study drug in 12% (8 of 67) and 13% (3 of 23) (P=1.0) of those with and without FCOIs, respectively; corresponding rates with and without direct FCOI were 23% (8 of 35) and 5% (3 of 55), respectively (P=.009).

CONCLUSIONS

Editorials in top oncology journals were frequently authored by experts with FCOIs, including direct FCOIs. Authoring an unduly favorable editorial for a new cancer drug was significantly associated with the author having a direct FCOI with the same company. These findings support the call for journals to ensure that authors of editorials have no direct FCOIs.

Food and Drug Administration approvals in phase 3 Cancer clinical trials

BACKGROUND

Phase 3 oncologic randomized clinical trials (RCTs) can lead to Food and Drug Administration (FDA) approvals. In this study, we aim to identify trial-related factors associated with trials leading to subsequent FDA drug approvals.

METHODS

We performed a database query through the ClinicalTrials.gov registry to search for oncologic phase 3 RCTs on February 2020. We screened all trials for therapeutic, cancer-specific, phase 3, randomized, multi-arm trials. We then identified whether a trial was used for subsequent FDA drug approval through screening of FDA approval announcements.

RESULTS

In total, 790 trials were included in our study, with 225 trials (28.4%) generating data that were subsequently used for FDA approvals. Of the 225 FDA approvals identified, 65 (28.9%) were based on trials assessing overall survival (OS) as a primary endpoint (PEP), two (0.9%) were based on trials with a quality of life (QoL) PEP, and 158 approvals (70.2%) were based on trials with other PEP (P = 0.01). FDA approvals were more common among industry funded-trials (219, 97.3%; P < 0.001), and less common among trials sponsored by national cooperative groups (21, 9.3%; P < 0.001). Finally, increased pre-hoc power and meeting patients' accrual target were associated with FDA approvals (P < 0.001).

CONCLUSIONS

The majority of FDA approvals are based on data generated from trials analyzing surrogate primary endpoints and trials receiving industry funding. Additional studies are required to understand the complexity of FDA approvals.

Professional Medical Writer Assistance in Oncology Clinical Trials

Background

The use of professional medical writers (PMWs) has been historically low, but contemporary data regarding PMW usage are scarce. In this study, we sought to quantify PMW use in oncologic phase III randomized controlled trials (RCTs).

Methods

We performed a database query through ClinicalTrials.gov to identify cancer‐specific phase III RCTs; we then identified whether a PMW was involved in writing the associated trial manuscript reporting primary endpoint results.

Results

Two‐hundred sixty trials of 600 (43.3%) used a PMW. Industry‐funded trials used PMWs more often than nonindustry trials (54.9% vs. 3.0%, p < .001). Increased PMW usage was further noted among trials meeting their primary endpoint (53.4% vs. 32.9%, p < .001) and trials that led to subsequent Food and Drug Administration approval (63.1% vs. 36.3%, p < .001). By treatment interventions, PMW use was highest among systemic therapy trials (50.2%). Lastly, the use of PMWs increased significantly over time (odds ratio: 1.11/year, p = .001).

Conclusion

PMW use rates are high among industry‐funded trials. We urge continued and increased transparency in reporting the funding and use of PMWs.

Considering the increase in industry‐sponsored cancer clinical trials, the use of professional medical writers for publication of trial results has become an increasingly important topic. This brief communication reports the current rate of involvement of medical writers in publications of cancer clinical trials.

Strategizing health technology assessment for containment of cancer drug costs in a universal health care system: Case of the pan-Canadian Oncology Drug Review

A universal health care system has been a source of both identity and pride for Canadians for the last 6 decades. Currently, Canada actively negotiates the prices of cancer drugs but is not immune to their overwhelming financial toxicities. Prices of cancer drugs are set to ensure maximal profit based on what the market will bear rather than by the value they offer or solely because of the cost of research and development, as often is claimed by the manufacturers. The pan-Canadian Oncology Drug Review (pCODR) is mandated to provide funding recommendations to Canada's provinces and territories. For the most part, the pCODR has been crucial in assessing the cost-effectiveness and feasibility of new drugs in the Canadian context but it could assist more in safeguarding payers against extreme drug costs. Herein, the author suggests a few strategies by which national efforts such as the pCODR and its partners can help Canada to become a leader in facilitating value-based sustainable cancer care.

The Sunshine Act and oncology: Lessons learned from urology

INTRODUCTION

The Physician Payment Sunshine Act was enacted to increase the transparency of financial relationships between physicians and the pharmaceutical industry. These financial relationships are prevalent in the field of oncology, as they are in other fields of medicine. We explored the relationship between industry and urologists for compensations associated with the treatment of urologic malignancies.

METHODS

The publicly available Open Payments database was obtained from the Centers for Medicare & Medicaid Services. We performed a descriptive analysis of payments made to urologists for drugs associated with urologic malignancies.

RESULTS

In total, 44,334 payments, summing to $ 4,638,856, were made to 5,666 urologists for drugs used to treat urologic cancers. The median payment per transaction was $14, and most (74.3%) were £ $20. Of the transactions, 39,368 (88.8%) were associated with drugs for prostate cancer, 3,475 (7.8%) for bladder cancer, and 1,491 (3.4%) for kidney cancer. Most payments were made the form of food or beverage (89%), equating to $826,667.

CONCLUSIONS

For urologists, industry payments associated with cancer treatment are prevalent. Treatments for prostate cancer are associated with the most financial relationships, followed by bladder cancer and kidney cancer. Payments are small in amount, and are commonly in the form of food or beverage.

The relation between publication rate and financial conflict of interest among physician authors of high-impact oncology publications: an observational study

BACKGROUND

Despite the abundant research on financial conflict of interest regarding provider behaviour and the interpretation and results of research, little is known about the relation between these conflicts in academia and the trajectory of one's academic career. We performed a study to examine whether the presence of financial ties to drug makers among academics is associated with research productivity.

METHODS

We hand-searched 3 high-impact general medical journals (New England Journal of Medicine, JAMA and The Lancet) and 3 high-impact oncology journals that publish original science (The Lancet Oncology, Journal of Clinical Oncology and Journal of the National Cancer Institute) to identify physicians based in the United States who were first or last authors on original papers on hematologic or oncologic topics that appeared in 2015. We ascertained their publication history from Scopus and their personal and research payments from the Centers for Medicare & Medicaid Services' Open Payments Web site (2013-2015). The strength of association between general (personal) financial payments from 2013 to 2015 and publications from 2013 to 2016 was determined by multivariate regression.

RESULTS

Our sample consisted of 435 physicians who had authored a median of 140 publications, earning a median h-index of 36 and a median of 5639 citations. The median total of general payments from 2013 to 2015 was US$3282 (range $0-$3.4 million), and the median amount of research payments was US$3500 (range $0-$23 million). General payments were associated with contemporary publications, with an increase of 1.99 papers (95% confidence interval [CI] 1.1 to 2.9) per $10 000 in payments. This association persisted in multivariate analysis after adjustment for prior publications, seniority and research payments (0.84 papers [95% CI 0.15 to 1.5] per $10 000 in payments).

INTERPRETATION

The findings suggest that there is a positive association between personal payments from drug makers and publications, and that this association persists after adjustment for prior publications, time since medical school graduation and research payments.