Half the top US academic medical centers have no policy on ghostwriting

Half of the top 50 academic medical centres in the United States have no policies on their staff ghostwriting research on the behalf of pharmaceutical companies – including UCLA and Mayo Medical School.

Medical ghostwriting is “the practice of pharmaceutical companies secretly authoring journal articles published under the byline of academic researchers.” By getting academics at top universities to put their names to papers, often for financial reward, pharmaceutical companies aim to improve the authority of their research or even sneak dodgy methodology or fabricated findings past journal editors and readers.

Only 10 (20%) of the top 50 US academic medical centres explicitly ban their staff from ghostwriting, according to the survey published in PLoS Medicine, although three of these institutions don’t specifically use the term “ghostwriting” in their policies.

A further three (6%) have authorship policies that prohibit medical ghostwriting in practice by insisting both that staff make a substantive contribution to the paper to qualify for authorship and that all who qualify for authorship be listed.

Although all the top 10 academic research centres in the US have authorship policies, only six ban ghostwriting and the remaining four – including Duke University and Yale – don’t have policies in place.

Ghostwritten articles can be used by pharmaceutical companies to influence the prescribing – and the sales – of their top products. The authors of the study explain this practise by describing how a pharmaceutical sales representative might use such an article to influence the prescribing of a practicing clinician. “When a pharmaceutical salesperson hands a clinician an article reprint, the name of the institution on the front page of the reprint serves as a stamp of approval,” they write. “The article is not viewed as an advertisement, but as scientific research; the reprint is an effective marketing tool because peer-reviewed journal articles generated in academia are perceived to be the result of unbiased scientific inquiry.”

For example, pharmaceutical companies have used ghostwritten articles to promote sertraline – the most prescribed antidepressant in the US in 2007 – methylphenidate – also known as ritalin, the widely used, and abused, ADHD drug – and rofecoxib – otherwise known as Vioxx, the arthritis drug withdrawn in 2004 because it caused heart attacks.

Given how ghostwritten articles can be used to influence drug approval or prescribing, the authors describe the practise as “a serious threat to public health.” To try to combat ghostwriting, they recommend that participating in medical ghostwriting is defined as academic misconduct akin to plagiarism or falsifying data.

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Lacasse J & Leo J (2010) Ghostwriting at Elite Academic Medical Centers in the United States. PLoS Medicine 7 (2) DOI: 10.1371/journal.pmed.1000230

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A diagnosis of prostate cancer ups the risk of fatal heart attack or suicide

Prostate cancerReceiving a diagnosis of prostate cancer is a very stressful and upsetting event, so much so that some men go on to have a fatal heart attack or kill themselves.

Two pieces of research by the same study group, one conducted in 340,000 men in the US and the other in 170,000 men from Sweden, have found that the risk of dying from a heart attack is raised by 2 to 11 times in men with a diagnosis of prostate cancer.

In addition, the risk of suicide in the first year after diagnosis in American men with prostate cancer was 40% higher than the national average and the risk in the first three months 90% higher. Astoundingly, Swedish guys were twice as likely to kill themselves in the first three months after diagnosis than men who were cancer free.

Interestingly, the US study found that the risk of suicide was only raised between 1979 and 1992, before the widespread use of screening to detect prostate cancer early.  There was no link between prostate cancer and suicide once screening, known as prostate-specific antigen (PSA) testing, was being used across the board.

So does this mean that screening for prostate cancer reduces the risk of suicide after a diagnosis? The authors think so, suggesting that early screening detects less aggressive tumors that are still treatable, thus less stress inducing.

On the other hand, the use of PSA testing has long been controversial. Many men will have small prostate tumours that never do them any harm and the test itself isn’t very reliable, so screening is associated with overdiagnosis and overtreatment.

By extension, some studies reckon that routine testing for prostate cancer causes undue stress and anxiety among patients who do not understand the implications of an abnormal result.  In fact, the Swedish study did not find any difference in suicide risk between the pre-screening era and after screening had been introduced.

This post was chosen as an Editor's Selection for ResearchBlogging.org

The authors aren’t sure about this difference between their two studies, admitting “The reason for this discrepancy is unclear.” However, it could potentially be caused by the large number of nonaggressive prostate cancers diagnosed during the later years in the US study or improved access to emotional support after diagnosis come the late 80s, which might have lessened despair among patients and reduced their suicide risk.

“These results add to the complex debate of pros and cons of extensive prostate-specific antigen testing and the many nonlethal prostate cancers thus detected,” say the authors.

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Fall K et al. (2009) Immediate Risk for Cardiovascular Events and Suicide Following a Prostate Cancer Diagnosis: Prospective Cohort Study PLoS Medicine 6 (12). DOI: 10.1371/journal.pmed.1000197

Fang F et al. (2010). Immediate Risk of Suicide and Cardiovascular Death After a Prostate Cancer Diagnosis: Cohort Study in the United States JNCI Journal of the National Cancer Institute DOI: 10.1093/jnci/djp537

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Drug company funded events for health professionals: the state of play in Australia

Cardiologist Jeffrey F Caren, who has a monument of over 1,200 pens gifted to him by drug companies
Cardiologist Jeffrey F Caren, who has a monument of over 1,200 pens gifted to him by drug companies

The links between the pharmaceutical industry and doctors are many and tangled. Drug companies are keen to schmooze doctors and, directly or not, persuade clinicians to prescribe their drug instead of a similar one by a competitor. One way that drug companies try to influence doctors is by sponsoring events, such as conferences or lectures.

Despite legislation, the exact extent to which the pharmaceutical industry sways doctors via this approach is not really known. To try to unravel exactly how much is being spent on sponsoring events for doctors, Robertson and colleagues investigated pharmaceutical industry funding of events in Australia, which has laws stating that details of every sponsored “do”, including the costs of any hospitality, are posted on the Medicines Australia website.

The authors found that during a six month period, the drug industry spent AUD$1 million (about £555,000 or US$900,000) a week in Australia on sponsored “educational events” for health professionals. This equates to about 600 sponsored events a week and an average annual spending of around AUD$1,000 (£555 or US$930) on each doctor.

More than a third (35%) of events were held in plush spots like restaurants, hotels or function centres, which increased the spend on the event by five-fold compared with if the event was held in a hospital (AUD$71.35 vs AUD$12.11).

Bristol-Myers Squibb was the most generous company, with an average spend per head of AUD$95.26 (£53 or US$88), although Astra Zeneca held the most events (1,310 0ver six months).

Professionals specialising in psychology or oncology were the most likely to attend sponsored events, although the biggest spend was on endocrinologists, oncologists and cardiologists.  Tellingly, specialists in these particular disciplines tend to prescribe the highest cost drugs.

Companies had some control over what was discussed at the event in 91% of cases. Where provided, topic descriptions often matched the products made by the sponsor, although there were few mentions of specific drug names.

Evidence suggests that attending a drug company sponsored event can indeed change the prescribing practices of a doctor, making the figures in this report quite disturbing.  For example, judging by the numbers in this study, as many as 13,000 Australian doctors could be under the thumb of the pharmaceutical industry.  As the authors point out, “from a company perspective, it is cheap and easy to sponsor meetings in hospitals and health centres, and the return on this ‘investment’ is likely to be high.”

In the UK, the Association of the British Pharmaceutical Industry code of conduct states that pharmaceutical companies sponsoring meetings and seminars can only provide “subsistence” for events and can only offer economy air travel to delegates sponsored to attend meetings. The code also states that lavish venues must not be used and that the costs covered “must not exceed the level which the recipients would normally adopt when paying for themselves”.

In the US, several states have mandatory disclosure laws for physician payments so that it is a bit clearer to everybody who is cosying up with drug companies and who isn’t, but these data aren’t foolproof.  For example, laws on physician reporting of industry gifts in Vermont and Minnesota exempt payments of less than US$100.

It’s worth mentioning that the system in Australia is actually more transparent than that in either the UK or the US, given that since mid-2007, there has been mandatory reporting of details of every industry-sponsored event in Oz.  On that note, the situation is probably worse in the northern hemisphere, as noted by an article last year in British newspaper The Guardian.

And although there is legislation in place these days, as the authors point out, “lavish gifts and generous travel support … have been progressively discouraged by industry and professional guidelines. It is likely that the frequent, more modest, sponsored educational events will become increasingly important and influential, and the principal form of contact between industry and health professionals.”

This research clearly outlines how endemic industry courting of doctors really is.

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Robertson J, Moynihan R, Walkom E, Bero L, & Henry D. (2009) Mandatory Disclosure of Pharmaceutical Industry-Funded Events for Health Professionals. PLoS Medicine 6 (11). DOI: 10.1371/journal.pmed.1000128

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