Misdirection

Getting tobacco company money for a study of early lung cancer detection via CT scanning shouldn’t count as a scandal. Publishing research purporting to support the practice while not mentioning that you’ve licensed your patent on the process to GE should count as a scandal. But guess which issue made the front page of the New York Times, and which got buried in the 15th graf?

It’s amazing sometimes what counts as a scandal and what doesn’t.

This, for example, is not actually a scandal, though it’s treated as one:

In October 2006, Dr. Claudia Henschke of Weill Cornell Medical College jolted the cancer world with a study saying that 80 percent of lung cancer deaths could be prevented through widespread use of CT scans … underwritten almost entirely by $3.6 million in grants from the parent company of the Liggett Group, maker of Liggett Select, Eve, Grand Prix, Quest and Pyramid cigarette brands.

Yes, the tobacco companies supported decades of scientific fraud in order to be able to keep killing their customers. That fraud was greater in extent, though no more successful, than the effort by DuPont and Ethyl Corp. to suppress knowledge about the health effects of lead. Of course universities shouldn’t take tobacco-industry money for smoking-related studies, and journals shouldn’t print the results.

But only in the most remote sense is studying whether CT scans can detect early lung cancers “smoking-related.” And with all due respect to the former editor of NEJM, he’s talking through his scrub cap here:

“You have to ask yourself the question, ‘Why did the tobacco company want to support her research?’ ” Dr. Kassirer said. “They want to show that lung cancer is not so bad as everybody thinks because screening can save people; and that’s outrageous.”

If the screening doesn’t work, it’s not going to change people’s ingrained belief that smoking is bad for you. Even if it does work, the promise that the lung cancer you get might not kill you isn’t really very reassuring. And even if there might be some effect on smoking rates from decreasing the mortality from lung cancer, are we really supposed to let the cancer patients die just to keep potential smokers in fear? There’s such a thing as an excess of caution.

However, there’s also such a thing as a deficit of caution. Much further down in the article is the real scandal, which never would have made it to the front page on its own:

The Cancer Letter, a newsletter, recently reported that Drs. Henschke and Yankelevitz had failed to disclose in articles and educational lectures a patent and 10 pending patents related to CT screening and follow-up. General Electric, a maker of CT scanners, licensed the issued patent beginning in 2001.

Jonathan Weil, a Weill Cornell spokesman, said Dr. Henschke did not disclose the patents in some articles and lectures because she did not deem them relevant.

[snip]

Dr. Henschke’s work, while controversial among cancer researchers, has been embraced by many lung-cancer advocacy organizations, which have pushed for legislation in California, New York and Massachusetts to create trust funds to pay for lung cancer screening — often with language tailored to benefit Dr. Henschke’s group.

In New York, a bill would create a $10 million fund “to carry out lung cancer early detection research using computer tomography (CT) scanning” at a place “that was established by the multi-institutional, multi-disciplinary research program that began at 22 sites in the state in the year 1991,” a description that could only fit Dr. Henschke’s group.

But the disclosure that Dr. Henschke’s work was in part underwritten by grants from a cigarette maker will undercut those efforts, prominent cancer researchers said.

“She’s the biggest advocate for widespread spiral CT screening,” said Dr. Paul Bunn, a lung cancer expert and executive director of the International Association for the Study of Lung Cancer. “And now her research is tainted.”

Got that? The researcher isn’t tainted by the fact that both she and the institution she works for have direct financial stakes in the outcome, but is tainted by the source of some of the funding she took several years ago.

This isn’t just a case of one more medical test that might be a waste of money. Apparently CT for early lung cancer has a high false-positive rate, and the consequences of a false positive aren’t just financial:

CT scans have radiation risks and sometimes detect cancers that would not have progressed, leading to risky procedures like biopsies and lung surgery when not needed.

Just to add the icing to the cake, the Times reports continued support for mandating payment for CT scans for lung cancer detection on the part of a “patient advocacy group.”

Laurie Fenton Ambrose, president and chief executive of the Lung Cancer Alliance, a nonprofit patient advocacy group, said she still trusted Dr. Henschke and still believed in widespread CT scanning to prevent lung cancer deaths.

But the Times misses a crucial fact picked up by the AP:

Laurie Fenton Ambrose, president of the patient advocacy group, the Lung Cancer Alliance … says attacks on Henschke are “mudslinging.”

[snip]

However, her group has taken industry money, too — from a maker of CT scanning equipment.

It looks to me as if the fuss about “tobacco money” in medical research is partly what the psychiatrists call “displacement behavior,” and a distraction from where the real conflicts of interest lie. Even in the area of smoking, it’s not only the tobacco companies who have a strong financial interest in controlling what research gets done and what results get reported.

The development of a cancer-free cigarette (fully feasible, I’m told, simply by using genetically engineered tobacco that doesn’t produce the Tobacco-Specific Nitrosamines that are the carcinogenic agents in “tar”), or the popularization of a nicotine vaporizer such as the short-lived Eclipse (which had vastly less lung impact than smoking tobacco) or the recognition that non-smoked tobacco products (snuff, chewing tobacco) have dramatically lower risks than smoking (and that the Swedish version of chewing tobacco, called “snus,” is pretty nearly innocuous) would threaten the market in tobacco-cessation remedies such as nicotine gums and patches. And yet no one thinks it scandalour for someone who gets research money from the smoking-cessation industry to review a paper or a grant application about smokeless tobacco, or testify in favor of legal restrictions on it, or for anti-smoking groups funded by that industry to lobby for legislative restrictions on nicotine vaporizers.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com