Where There's Smoke? ... A University President Who Simultaneously Lead a Failed Financial Company and a Tobacco Company Which Apologized for International Bribery

A long time ago, in 2006, we first blogged about a "new species of conflict of interest" which we thought might prove to be even more important than those afflicting health care that were then starting to be discussed.  This involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive.  It ostensibly requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]   Thus, for example, the conflict posed by the president of a university, to whom a medical school and academic medical center report, who also is the director of a pharmaceutical company, would be extreme.

Since then, we noted yet another variant on this theme, university presidents who were supposedly the top leaders of failed financial firms, and then who did various dances to try to avoid accountability for these firms' fates.  That theme recently made it to the big time, a front page article on the Sunday Business section of the New York Times.

The most extreme version was the case of that of Eugene Trani, the former President of Virginia Commonwealth University ( full disclosure: I spent 7 years on the faculty of its medical school, and am still an adjunct faculty member).  Trani turned out to be on the board of a tobacco company, and soon after this was revealed, retired from the presidency (see most recent blog post here).

Now a Washington Post blogger has yet another twist on this case:

Eugene P. Trani left the presidency of Virginia Commonwealth University in 2009 after improving the school and expanding its presence in downtown Richmond. But Trani was also a director of LandAmerica Financial Group, a Richmond-area title insurer that went belly-up in 2008, taking with it millions in investors' money.

Today, Trani is on the board of Richmond-based Universal Corporation, a global tobacco marketer. Universal's subsidiaries have just agreed to pay $8.98 million in a tobacco bribery scandal that stretches from Brazil to Thailand to Africa. The firm has issued a public apology. Trani received $159,032 in total compensation for his board service.

So Trani was not only on the board of directors of a tobacco company, he was on the board of directors of a tobacco company that was forced to settle charges of international bribery and issue apologies for same, and just to ice the cake, was on the board of a failed financial company whose failure affected residents of the locality which his university served.

As the saying goes, "the fish rots from the head down."  How can academic leaders expect integrity from their faculty when they willingly take on such grotesque conflicts?  Leaders who thus try to serve two, or many masters are likely to run health care organizations that do not serve their primary constituents, patients who expect good care, learners who expect honest, competent teaching, and the public who expects important, unbiased research, well.  If we really want to reform health care, we need leaders who put the mission, not their own pocketbooks, prestige, and cronies, first.

"Smoke Detector" - Medical Center Leader (and Former Biotech CEO) Outed as Tobacco Investor

Last year we posted about the seemingly incongruous choice of a wealthy biotechnology executive with little academic or practice experience to run the prestigious University of California - San Francisco, a health oriented university housing a respected medical school.  We wondered whether her corporate background would make it difficult to uphold the university's academic and patient care missions.

In line with our concerns, Duff Wilson, writing in the New York Times, reported:

When Dr. Susan Desmond-Hellmann was named chancellor of the University of California, San Francisco, last summer, she took over a medical institution focused on world health generally and tobacco control in particular.

But she forgot one thing in adjusting to her new role: personal stock holdings listed last year in the range of $100,000 to $1 million in Altria, owner of Philip Morris USA, the maker of Marlboro cigarettes. Altria has been blamed for thousands of deaths and repeatedly criticized by the Center for Tobacco Control Research and Education at the university.

Last week, a day after The New York Times inquired about the Altria stock, Dr. Desmond-Hellmann and her husband, also a doctor, ordered it to be immediately sold and imposed 'values screening' on their personal investments.

Experts on tobacco control were aghast:

Dr. Stanton A. Glantz, director of the university’s tobacco control center, said he was unaware of Dr. Desmond-Hellmann’s Altria stock, which was contained in a university filing but not made public until now, after a public records request by a former student who passed it on to The Times.

“I do find that kind of shocking, but at least she got rid of it,” Dr. Glantz said on Monday, adding that Dr. Desmond-Hellmann had been very supportive of the center.

Dr. Kenneth E. Warner, dean of the school of public health at the University of Michigan and a national antitobacco leader, said, “I find it frankly a bit appalling that the chancellor of a major medical center would have held such stock. It strikes me as unthinking, frankly.”

We should give Dr Desmond-Hellmann credit for selling her Altria stock as soon as its connotations were made plain to her. (And at least she was not on the board of a tobacco company, to our knowledge, as was one former president of a university and large health sciences center.)

However, this little incident underlines the clash between the culture that dominates large health care corporations and the mission of medical schools and academic medical centers. In the last 30 years, academic medicine has rushed to embrace the reigning corporate culture, not to mention corporate money. I submit that this embrace has been at the peril of the fundamental academic and patient care missions.

Academic medical leaders need to promote better patient care, and honest, responsible teaching and research. To do so, they may have to give up some of the glitz, glamor, and cash proffered by industry. If they do not make this sacrifice, they risk losing the trust of an increasingly skeptical, if not cynical public.

After Controversy Over Tobacco Money Funding Medical School, University President Steps Down

We have posted about the controversies arising from recently revealed research agreements between Richmond, Virginia based Virginia Commonwealth University (VCU) and tobacco company Philip Morris. These were first publicly discussed in May in a New York Times article. As we posted here, the main issues were that the research agreements themselves were secret; the agreements apparently gave Philip Morris control over all publications arising from the research, since they defined all products of the work as proprietary information belonging to Philip Morris; and that research for hire on behalf of a tobacco company, given that tobacco products have known severe health risks and no health benefits, seems to go against the mission of a medical school and academic medical center. We also noted that the university administration's apparent lack of qualms about its relationship with Philip Morris might have been related to its president's role as a leader of a tobacco company. (He sits on the board of Universal Corp, a tobacco buyer, processor, and distributor.) We later observed how little attention this subject has gotten in Richmond's major news outlet. Then, we noted that some university leaders were willing to open a public dialogue about the issue, thus exhibiting more transparency under criticism than has been shown by many other organizations. Most recently, we discussed how the Dean of the university's Medical School had allegedly actively sought grant support from Philip Morris for a center for research on women's health.

Today, the Richmond Times-Dispatch reported that VCU President Eugene Trani will step down next year. The article hailed Trani for his efforts to enlarge and expand the University. It also noted, however,

Trani was so intent on unifying the university in a shared mission that he forbid the mention of the Medical College of Virginia, renaming it the VCU Health System.

Furthermore, although the Times Dispatch has not published much about the controversy over the relationship between VCU and Philip Morris (see post here), it did acknowledge

But collaboration between VCU and Philip Morris also has stirred controversy because of the tobacco company's apparent level of control over research it sponsors through the university.

'The events of the summer are unfortunate,' [Professor of Political Science and Public Administration Blue] Wooldridge said, 'and would be a stain on [Trani's] legacy that didn't need to be there.'

A former president of the faculty senate, Wooldridge said he admires much of what Trani has done -- from building the engineering school to forging 15 alliances with universities in other countries -- especially while maintaining his own scholarship as a historian.

However, too often Trani hasn't considered the full costs to the university of his ambitions or listened to the informed opinions of others, Wooldridge said.

'I don't think the faculty has had their voices heard as much as they should.'

I hope that the impending retirement of President Trani will lead the VCU administration to rethink its apparent infatuation with cultivating tobacco as a source of funding for the medical school. The medical school's mission of promoting the health of individual patients, and the health of the public through teaching and research is ill served by financial arrangements with companies whose products only promote ill health.

Courting Tobacco Money

We have posted about the controversies arising from recently revealed research agreements between Richmond, Virginia based Virginia Commonwealth University (VCU) and tobacco company Philip Morris. These were first publicly discussed in May in a New York Times article. As we posted here, the main issues were that the research agreements themselves were secret; the agreements apparently gave Philip Morris control over all publications arising from the research, since they defined all products of the work as proprietary information belonging to Philip Morris; and that research for hire on behalf of a tobacco company, given that tobacco products have known severe health risks and no health benefits, seems to go against the mission of a medical school and academic medical center. We also noted that the university administration's apparent lack of qualms about its relationship with Philip Morris might have been related to its president's role as a leader of a tobacco company. (He sits on the board of Universal Corp, a tobacco buyer, processor, and distributor.) We later observed how little attention this subject has gotten in Richmond's major news outlet. Most recently, we noted that some university leaders were willing to open a public dialogue about the issue, thus exhibiting more transparency under criticism than has been shown by many other organizations.

This week's Richmond (VA) Style Weekly reported that there were plans for even greater ties between VCU and Philip Morris,

Virginia Commonwealth University officials have repeatedly denied the existence of a proposal to create a women’s health center funded by Philip Morris USA, but a draft copy of the proposal shows the idea did — and in some iteration still does — exist.

A copy of a working paper titled 'Proposal to Create the VCU Center for Health Pregnancy and Neonatal Outcomes,' obtained by Style Weekly, shows plans for a center focused on treatment and research into preventing defects, early birth and mortality.

Furthermore, it appeared that VCU leadership, not Philip Morris, initiated these plans,

In part, the memo obtained by Style reveals a plan for how VCU could solicit money from Philip Morris.

The seven-page proposal includes various attachments and is detailed down to budget projections for such specifics as bus and cab fare for participants. It concludes with a subheading titled 'Why Philip Morris USA should support this initiative.' The rationale for the pitch? 'Philip Morris USA will be investing in the future of the Richmond community,' and 'giving new meaning to ‘being well-born’.'

Pam Lepley, a university spokeswoman, says she was unaware of the proposal until contacted about it last week. During a July 16 community forum held on the medical campus, Dr. Francis L. Macrina, the school’s vice president for research, repeatedly denied knowledge of the proposal, saying that no proposal has ever existed.

Lepley now says the proposal is a working paper developed by the dean of the medical school, Jerry Strauss, but adds that it was not specifically aimed at attracting the financial support of Philip Morris.

'This is a draft proposal that Jerry Strauss was working on for any number of potential philanthropic providers,' Lepley says, calling it a working proposal that remains internal to the school. 'This is an initiative of Jerry Strauss’.'

The Richmond-based tobacco company is the only private corporation mentioned in the proposal and the only entity mentioned that is not the university or one of various governmental service providers foreseen as partners.

The assertion that the proposal has yet to see the light may not be worth a pack of smokes, either.

'This was a proposal that the dean of medicine shopped with Philip Morris,' says a medical school faculty member, speaking on condition of anonymity. 'Since all this has broken, [Strauss] has said [in meetings] that Philip Morris did not accept it or they did not fund it.'

We have previously discussed how medical school and academic medical center leaders often seem to care more about financial goals than the fulfillment of their clinical and academic missions. This can lead to pressure on faculty to raise research money from commercial sponsors, such as drug, biotechnology and device companies who have vested interests in having the research results favor their products. Medical schools and academic medical centers often seem so eager to get such money that they let the research sponsors control many aspects of the research, making it easier for them to manipulate the research to favor their products (see post here). Faculty pushed to work with commercial sponsors may be prone to become "key opinion leaders" who help the sponsors market their products.

All that is bad enough, but at least drug, biotechnology and device companies make products designed to treat, prevent, and sometimes even cure disease. In my humble opinion, medical school leaders fundamentally violate their institution's mission when they solicit money from a company whose products cause disease without providing any clinical benefits.

A Town Meeting About Tobacco-Funded Research in Academic Medicine

We have posted about the controversies arising from recently revealed research agreements between Richmond, Virginia based Virginia Commonwealth University (VCU) and tobacco company Philip Morris. These were first publicly discussed in May in a New York Times article. As we posted here, the main issues were that the research agreements themselves were secret; the agreements apparently gave Philip Morris control over all publications arising from the research, since they defined all products of the work as proprietary information belonging to Philip Morris; and that research for hire on behalf of a tobacco company, given that tobacco products have known severe health risks and no health benefits, seems to go against the mission of a medical school and academic medical center. We also noted that the university administration's apparent lack of qualms about its relationship with Philip Morris might have been related to its president's role as a leader of a tobacco company. (He sits on the board of Universal Corp, a tobacco buyer, processor, and distributor.) Finally, we just observed how little attention this subject has gotten in Richmond's major news outlet.

VCU just held a "town meeting" that allowed faculty and students to comment on or question this recent unpleasantness. The meeting was covered by Richmond.com, the Associated Press, and, to its credit, the Richmond Times-Dispatch. According to the latter,

Francis Macrina, vice president of research at Virginia Commonwealth University and chairman of a task force on corporate-sponsored research, told a gathering tonight that the university made a mistake in its deal with cigarette giant Philip Morris.

Macrina said a confidentiality clause in the deal appeared to offer secrecy to the company.

'It won't happen again,' he said during the town-hall meeting at the Kontos Building on the university's MCV campus. 'We will not enter into any agreements that support secrecy.'

An estimated 75 attended the meeting, and about 20 spoke, many declining to give their names.

'Transparency at VCU is pathetic,' said one speaker who did not identify herself.

Another speaker, a faculty member in the pharmaceutical sciences, defended corporate research in general.

'I've never had a situation in which I felt my integrity was endangered,' he said.

Some wondered how a confidentiality agreement could be reached with a corporation without halting the publication of research information.

'That's a good question,' [Associate Dean of the School of Social Work Kia] Bentley said. The task force will address that, she said.

First, for what my opinions may be worth, I commend VCU for setting up this meeting, and setting up a task force to consider issues raised by the Philip Morris contracts. Second, I commend the Richmond Times-Dispatch and other media for covering it.

But I do wonder about how, at least according to the media reports, this meeting seemed to skirt some some of the issues involved. First, Vice President Macrina seemed not to be acknowledging just how comprehensive the secrecy provisions of the contract were. According to the original NY Times article,

The contract bars professors from publishing the results of their studies, or even talking about them, without Philip Morris’s permission. If 'a third party,' including news organizations, asks about the agreement, university officials have to decline to comment and tell the company.

Second, at least the Richmond Times-Dispatch coverage seemed to soft-pedal Philip Morris' control over publication of research results. Again, according to the NY Times,

Philip Morris alone decides whether the researchers can publish because the contract defines 'without limitation all work product or other material created by V.C.U.' as proprietary information belonging to the company.

Finally, it is not clear whether the issue of the VCU President's simultaneous responsibilities to the share-holders of a tobacco company was even mentioned.

Perhaps these are quibbles, given that this university was at least willing to have a public discussion of this problem. Many of the issues involving mismanagement by and conflicts of interest affecting leadership of academic medicine that we have mentioned on Health Care Renewal have never been discussed in anything like a town meeting at the relevant institutions.

So I hope that VCU is making some progress towards making its clinical and health related research transparent in all respects, its design, implementation, analysis, reporting, and who funds it and under what agreements. It would be nice if some other academic medical institutions also could show some progress.

VCU, Philip Morris, and the "Recent Unpleasantness"

While I lived in Richmond, Virginia from 1987 to 1994, one could still find some people who referred to the US Civil War as the "recent unpleasantness." Similarly, we have noted the "anechoic effect," how cases involving deficient ethics, poor leadership, and flawed governance in health care occurs produce few echoes. Many important cases and issues that have been discussed on Health Care Renewal have never appeared in medical or health care journals. Many specific cases have never been publicly discussed at the institutions in which they originated. Some specific cases have never appeared in the national news media. Some specific cases have not been covered even in the relevant local news media.

Here is a case in point, from Richmond, Virginia. The Richmond Times-Dispatch, the only major newspaper in that city, just reported that the President of Virginia Commonwealth University (VCU), Eugene P Trani, is recovering from coronary artery bypass grafting (CABG) surgery. We wish President Trani a speedy recovery. But buried in that article is the only mention that has ever appeared in the Richmond Times-Dispatch of the recent unpleasantness about research contracts between VCU and tobacco company Philip Morris. Here it is:

Trani was scheduled to be on a two-month sabbatical at Harvard University's Taubman Center for State and Local Government through mid-August. In his note to the university community, he said he returned to Richmond after his first month because the university was 'experiencing a number of recent challenges.'

Recent controversies have brought VCU some unwelcome attention.

There have been questions about whether a research agreement with Philip Morris USA was in accordance with traditional accepted research guidelines and policy.

A university Task Force on Corporate Sponsored Research will hold a town-hall meeting tomorrow to hear from faculty and students on the research issue.

We have discussed this "recent challenge" on Health Care Renewal. Briefly, the New York Times reported last month that VCU has been doing research under contract with Philip Morris USA. Contract provisions forbade the university from even revealing the existence of the contract itself. By classifying all products of the research as "proprietary," the contract seemed to bar university faculty from publishing or publicly discussing the research without permission from Philip Morris. Such provisions apparently violated not only the university's stated policies, but its fundamental mission. Furthermore, it appeared that the university's coziness with Philip Morris might relate to its President's leadership role for a company in the tobacco industry. President Trani, it turns out, is on the board of directors of Universal Corp, which buys, processes, and ships tobacco. For a university President who also leads a medical school and academic medical center simultaneously to be responsible to the stock-holders of a tobacco company seems quite a major conflict of interest, given that tobacco products clearly cause much disease, disability, and death in the absence of any health benefits.

But to the Richmond Times-Dispatch, all this seems just to be some recent unpleasantness.

The cone of silence that seems to confine much unethical behavior, poor leadership, and poor governance in health care has disabled medicine's and society's ability to address these problems.

Key Opinion Leaders, Drugs for Smoking Cessation, and Transparency as a Cause of "Confusion"

A perspectives article from the April 1 issue of the Annals of Internal Medicine has provoked a slowly growing controversy. (1) Let me summarize the main points of the article before getting to the controversy.

As the title, "the case for treating tobacco dependence as a chronic disease," suggests, the authors argue "for some smokers, long-term pharmacotherapy [which] is the difference between tobacco abstinence and lifelong smoking," based on the argument that smoking is like a chronic disease.

They called for long-term use of pharmacologic treatments for tobacco addiction, including nicotine replacement therapy (NRT), buproprion, and verenicline, asserting that these drugs are safe and effective, and have "proven benefits." Such proven treatments, therefore, ought to be used long term.

Although long-term use is considered off-label, patients should be encouraged to remain smoke-free, and if extended courses of pharmacotherapy will assist them, treatment should be continued, encouraged, and reimbursed.

Rather than considering cessation medications as a short-term aid in smoking cessation, these medications should be covered in the same manner as the treatment of other long-term illnesses and conditions, such as asthma, depression, and diabetes....

However, their enthusiasm for pharmacologic treatment for smoking cessation, even in the short-term, seems to go beyond the evidence. That evidence shows that the "proven benefits" of these treatments do not accrue to the majority of patients receiving them. For example, in one widely disseminated study comparing verenicline, buproprion and placebo, the proportions of patients who were abstinent for one year (the duration of follow-up) were 21.9% for verenicline, 16.1% for bupropion, and 8.4% for placebo. Although the most effective drug, verenicline, more than doubled the continuous abstinence rate compared to placebo, the large majority of patients treated with that drug, 78.1%, did not achieve continuous abstinence, even for one year.(2) In another recent study, patients given verenicline were somewhat more likely to be abstinent at the end of a year (26.1%) than those treated with nicotine patches (20.3%), although the difference did not reach statistical significance.(3) However, again the great majority of patients treated with either medicine were not continuously abstinent, even for one year.

Thus, most smokers treated with drugs will not remain abstinent from smoking, even for one year. Furthermore, I am aware of, and Steinberg et al did not cite any data from controlled trials about the safety or effectiveness of any pharmacologic treatments of tobacco addiction for patients followed for more than one year. There is no reason to suspect that these drugs' effectiveness over the long-term would be any better than their rather marginal effectiveness when when used short-term.

In my humble opinion, Steinberg et al might have been able to make a case for controlled trials of these drugs' use that would follow patients for more than one year. But they presented no evidence to support the clinical use of these drugs, much less insurance company reimbursement for them, for time periods longer than those found in the published trials.

So why did these authors make arguments that went beyond the evidence?

Soon after the article came out, Adriane Fugh-Berman and Douglas Melnick, writing in the Bioethics Forum, noted:

The most important section of this article is the conflict of interest statement. The two authors who have advanced degrees are on the speaker’s bureau of Pfizer and are consultants to Pfizer, Novartis, GlaxoSmithKline, and Celtic Pharma. Pfizer makes varenecline (marketed under the brand name Chantix) and Nicotrol, a nicotine nasal spray. GSK makes Nicorette gum, Commit nicotine lozenges, Nicoderm nicotine patches, and Zyban (buproprion, which GSK also sells as an antidepressant under the name Wellbutrin). Novartis makes Thrive, a nicotine chewing gum ('thrive,' which means to prosper or flourish, seems a rather peculiar association for a delivery system for an addictive drug.) And Celtic Pharma is developing TA-NIC, a nicotine vaccine.

Furthermore, last week, an article in BusinessWeek provided more information about the financial ties of two authors of the Steinberg et al paper.

In 2006, Pfizer recruited Foulds to serve on its paid national advisory board for Chantix. The company also selected Foulds and Steinberg to be 'key opinion leaders,' sending them to talk to doctors about Chantix over fancy dinners and paying them each $900 per presentation. Foulds and Steinberg say that between them they have made a total of about a dozen appearances.

Steinberg received a $30,000 grant from Pfizer in April 2007 to study the effect of Chantix on patients forced to forgo cigarettes while hospitalized for other illnesses. He says this was his first research grant from a drug company. (The Robert Wood Johnson Foundation separately provided $300,000 for the hospital study.)

Steinberg, according to BusinessWeek, denied that he is influenced by his ties to Pfizer:

Adamant that his work for Pfizer and other drug companies poses no problem, he adds: 'We look at the data, and we look at our own clinical experience.'

While the authors disclosed the nature but not the effect size of their financial relationships in the Annals of Internal Medicine article, they were not so forthcoming to their patients. Per BusinessWeek,

Both doctors stress that it's not standard practice to tell patients about potential conflicts.

On the Web site for UMDNJ's smoking clinic, it's not easy for a layman to find disclosures. There is no clearly labeled list of companies that pay Foulds and Steinberg that is directly accessible from the home page. There are links to journal articles, some of which reveal industry ties. But getting the information takes effort. The online version of the Annals article requires a viewer to have a paid subscription for full access. Their twice-a-year newsletter, The Nicotine Challenger, doesn't disclose their work for Pfizer, even in articles that speak highly of Chantix.

Foulds includes a broadly worded disclosure on his blog, but doesn't name companies for which he consults.

Finally, neither author saw the need to provide more disclosures to patients.

Telling patients more about industry ties 'would just puzzle them,' Foulds says.

Steinberg sees no need to be more forthcoming. His passion for helping people quit is fueled by treating numerous cases of high blood pressure and other problems precipitated by smoking.

To add a final touch, Cathryn M Clary, vice president for external medical affairs for Pfizer, "fears too much transparency will cause confusion,"

The more information that's out there, the more difficult it will be for patients to process

There has been a good deal of discussion about drug, biotechnology and device companies paying "key opinion leaders" to help market these products (for example, see these posts here and here). And there has been a good deal of indignation that it is an affront to physicians to judge the content of medical education they provide based on who paid for it (see this link.)

Although the case of the Annals article is essentially only an anecdote, it does suggest an association between payments to key opinion leaders, and opinions that are more enthusiastic about the payers' products than the evidence seems to warrant.

Furthermore, it suggests that key key opinion leaders and the companies who sponsor them may dismiss transparency about their financial relationships as a cause of "confusion." If patients really are too naive to understand the implications of payments by drug and other commercial firms to key opinion leaders, would the KOLs and their patrons prefer that government step in to protect these poor, naive patients from such relationships they cannot understand? That is what their attitude seems to invite.

References

1. Steinberg MG, Schmelzer AC, Richardson DL, and Foulds J. The case for treating tobacco dependence as a chronic disease. Ann Intern Med 2008; 148: 554-556. Link here.
2. Gonzales D, Rennard SI, Nides M, Oncken C, Azoulay S, Billing CB et al. Verenicline, and alpha-4-beta-2 nicotinic acetylcholine receptor partial agonist, vs sustained release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA 2006; 296: 47-55. Link here.
3. Aubin HJ, Bobak A, Britton JR, Oncken C et al. Verenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open-label trial. Thorax 2008. Link here.

Linking the Anechoic Effect and Suppression of Research to Conflicts of Interest and Mission-Hostile Management: the VCU Case

We recently discussed ties between Virginia Commonwealth University (VCU) and the tobacco industry. Here we discussed how the university got a grant which gave proprietary control of any research results to the sponsor, Philip Morris, a tobacco company, not the academic researcher, and required the grant itself to be secret. Here we discussed issues raised by the university president's position on the board of directors of another tobacco company, Universal Corporation.

A recent article in (Richmond, VA) Style Weekly alleged that VCU faculty fear publicly criticizing the university's relationships with tobacco companies:

Virginia Commonwealth University researchers and faculty who fear reprisal for speaking out against a secret smoke-filled-room research agreement between the school and Philip Morris USA are taking extraordinary steps to protect themselves.

A form letter, which many say they plan to sign and send to the university’s Human Resources Department, is being circulated via e-mail that states 'on the record that I am concerned about a May 22nd New York Times report' about the Philip Morris research agreement’s covenants that restrict publication and use of research findings in violation of university policy.

The letter cites a fear of retaliation 'if I openly express my concerns,' and its purpose is 'to document and date this apprehension in case action is later taken against me that could be linked to a decision to voice my disapproval .…'

According to numerous VCU faculty and staff members, the letter is the only protection they feel they have against the possibility of unfair treatment for speaking out about what they consider a clear violation of research ethics. While it’s unclear how many faculty members are contemplating signing the form letter, Style Weekly has interviewed half a dozen faculty members and researchers who say they plan to sign it.

They all spoke on the condition of anonymity.

'Part of the paranoia comes from seeing what already has come to pass,' one high-level researcher on federal grant projects says of 'senior people at VCU' who have left because of the Philip Morris deal. 'We’ve all come to the conclusion that the potential risks from [signing the letter] are minimal compared to the risks of not doing it.'

The article also alleged that some of the fear may be due to the possibility that the university will soon have much larger ties to the tobacco industry than have been heretofore revealed.

A pending proposal, highlighted at various meetings by Jerome Strauss, dean of the VCU School of Medicine, could link federal grant funds with 'several million dollars' — initially about $30 million, but since scaled back — directly from Philip Morris for the creation of a women’s health center. Numerous college sources cited the deal, with one providing details that included in an early draft proposal for the center.

The tentatively named Philip Morris Women’s Health Center would examine disparities between women’s health care and other areas of health care, but according to one source, Strauss has said the exact focus could be affected depending on Philip Morris’ participation.

This case now illustrates the inter-relationships of several topics we commonly discuss on Health Care Renewal: conflicts of interest affecting health care decisionmakers, suppression of research, and the anechoic effect. To look at it another way, it shows academic medical institutions lead by the conflicted are prone to take actions hostile to their clinical and academic missions.

So as I wrote in my last post, this case too makes a striking argument for the need to drastically reform the leadership and governance of health care organizations, and academic medical centers in particular.

A Worse Variant of a New Species of Conflict of Interest

We recently commented on a New York Times article that revealed that Virginia Commonwealth University got a research grant from the tobacco company Philip Morris, a grant which gave proprietary control of any research results to the company, not the academic researcher, and required the grant itself to be secret.

It turns out that VCU has more extensive ties to the tobacco industry. In particular, first the Medical Writing, Editing and Grantsmanship blog, then the Richmond, VA publication Style Weekly reported that the president of VCU, Eugene Trani, is on the board of directors of a tobacco company (not Philip Morris). From Style Weekly,

As a member of the board of directors of Universal Corp., Trani receives an annual retainer of $40,000, including stock options. He also receives a fee of $2,000 for each board of directors’ meeting he attends and another $1,500 for attending committee meetings.

Based in Richmond, Universal Corp. is a leaf tobacco merchant and processor. The company’s Web site describes its operations as 'selecting, buying, shipping, processing, packing, storing, and financing of leaf tobacco in tobacco growing countries for sale … throughout the world.'

Though it does not manufacture cigarettes, the Web site says 'the Company’s revenues are derived from sales of processed tobacco and from fees and commissions for specific services.'

Actually, Style Weekly understated Trani's financial ties to Universal Tobacco. In fact, according to the company's 2007 proxy statement, in May, 2007, Mr Trani held 12,642 shares of company stock (including shares which he had the right to acquire via options within 60 days of May 25, 2007). His total director's compensation in 2007, including fees and stock options, was valued at $117,575. He held 6000 stock options valued at $41.88 per share (thus worth $251,280). Finally, his aggregate balance of his director's retirement plan was $321,740.

Style Weekly quoted a VCU spokesperson who thought that Trani's board service was irrelevant:

'I don’t see any connection between these two,' university spokeswoman Pam Lepley says. 'And his being on the board doesn’t really pertain to the university.'

Similarly, an editorialist for the Richmond Times Dispatch shrugged off this new development. However, in my humble opinion, it really is important.

We have previously discussed conflicts of interest incurred when the leaders of health care organizations also serve on the board of pharmaceutical, biotechnology, medical device companies and the like. The issue goes beyond just the often generous payments board service entails. The important consideration is that directors of public for-profit corporations have a duty to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] It would seem that the conflict created when the president of a university to whom a medical school and academic medical center report also is the director of, for example, a pharmaceutical company is obvious.

I have not previously heard of case in which the leader to whom a medical school or academic medical center report who also leads a tobacco company. That of Mr Trani appears to be the first case reported of this worse variant of what we once called "a new species of conflicts of interest."

It seems to me that the conflict created by this situation is much worse than that of, for example, a university president who also is on the board of a pharmaceutical corporation. At least pharmaceutical, biotechnology, and medical device companies make products that are intended to provide more benefit than harm to patients. Tobacco companies make products that increase the risk of severe medical problems, but provide no medical benefits. It does not seem ethical for a medical school or academic medical center to report to someone with a fiduciary duty to increase the profits of a company that facilitates the making of such products.

Thus, Dr Trani's "being on the board" of Universal Corporation pertains most seriously to Virginia Commonwealth University, particularly to the VCU School of Medicine and VCU Medical Center. They ought not to be lead by someone with "unyielding loyalty" to the shareholders of a tobacco company.

(Note, for the purposes of full disclosure, that I am an unpaid, adjunct faculty member in the Department of Internal Medicine of the VCU School of Medicine of Virginia Commonwealth University.)

For a Few Dollars More: Academic Ideals Go Up in Smoke

In the New York Times was a report on an unusual research program at Virginia Commonwealth University:

a contract with extremely restrictive terms that the university signed in 2006 to do research for Philip Morris USA, the nation’s largest tobacco company and a unit of Altria Group.

The contract bars professors from publishing the results of their studies, or even talking about them, without Philip Morris’s permission. If 'a third party,' including news organizations, asks about the agreement, university officials have to decline to comment and tell the company. Nearly all patent and other intellectual property rights go to the company, not the university or its professors.

The contract appeared to contradict the university's research policies:

Virginia Commonwealth’s guidelines for industry-sponsored research state, 'University faculty and students must be free to publish their results.' The guidelines also say the university must retain all patent and other intellectual property rights from sponsored research.

Under the agreement, though, Philip Morris alone decides whether the researchers can publish because the contract defines 'without limitation all work product or other material created by V.C.U.' as proprietary information belonging to the company.

Ms Saul asked Francis L Macrina, vice president for research at VCU, to explain the apparent discrepancies between the contract and the university's policies:

'There is restrictive language in here,' said Francis L. Macrina, Virginia Commonwealth’s vice president for research, who acknowledged that many of the provisions violated the university’s guidelines for industry-sponsored research. 'In the end, it was language we thought we could agree to. It’s a balancing act.'

Also,

'These restrictive clauses seek to protect the rights and interests of multiple parties in the agreement,' Dr. Macrina said, pointing out that Virginia Commonwealth scientists would be working with other researchers.

And,

Dr. Macrina also defended the requirement that the university decline comment and tell the company if asked about the agreement by news organizations and other third parties.

'Language like that occurs in agreements like this because the sponsor wants to be sure there are no slip-ups, that things will not be released inadvertently,' he said.

A Philip Morris executive, Rick Solana, "senior vice president for research and technology," rationalized the secrecy provisions thus,

Dr. Solana also said the contract represented a new focus on developing tobacco products with reduced risks, a shift in strategy in underwriting university research that requires more confidentiality to protect the corporation’s intellectual property rights. And he said Philip Morris had similar arrangements with other universities — although he declined to say how many or which ones.

And he noted that maybe under certain circumstances the company would allow university researchers to publish:

saying that once the company determined that its competitive interests were protected, it could permit researchers to publish.

'We have to start out with is anyone’s intellectual property going to be compromised?' Dr. Solana said. 'Once the intellectual property is protected, then it’s usually O.K. to publish.'

'Something being proprietary does not mean something cannot be published. We try to be very supportive in the health area of work being published.'

What's wrong with all this? Where do I start?

First of all, the fundamental mission of the university is to seek and disseminate the truth. Letting a research sponsor control whether research can be published, and making secret research agreements with research sponsors violate this fundamental mission. Perhaps under some special circumstances, such as when national security is involved, exceptions could be made. But obviously doing research for a tobacco company does not involve national security.

It is painful to see a university vice president for research verbally squirming to try to justify signing a contract that so fundamentally violates the university's mission.

Second of all, the research was being done on behalf of the interests of a tobacco company. There is no doubt that smoking cigarettes leads to severe health risks, and has never been shown to provide any important health benefits. It has been shown by others that tobacco companies seek to have academic institutions do research on their behalf to give their selling of hazardous products a cloak of respectability. For a university that includes a proud and venerable medical school (formerly the Medical College of Virginia, and, for the purposes of full disclosure, a medical school on whose faculty I served for seven years), to help a tobacco company gain such a cloak violates the fundamental health care mission of the school, in my humble opinion.

Thus, it is obvious why this story provoked some outrage among academics:

'When universities sign contracts with these covenants, they are basically giving up their ethos, compromising their values as a university,' said Sheldon Krimsky, a professor at Tufts University who is an expert on corporate influence on medical research. 'There should be no debate about having a sponsor with control over the publishing of results.'

Stanton A. Glantz, a professor at the University of California, San Francisco, School of Medicine who has lobbied for banning tobacco money on campuses, said, 'University administrators who are desperate for money will basically do anything they have to for money.'

At Virginia Commonwealth, few professors appeared to know about the contract; when told about it, a number of them said they were concerned about its secretiveness.

'It’s a controversial area, and I personally prefer transparency,' said Richard P. Wenzel, chairman of the department of internal medicine at the university’s medical school, who had not heard of the contract before a reporter’s call.

A tenured scientist at Virginia Commonwealth, who would not be interviewed for attribution because he said he feared retribution against his junior colleagues, called the contract’s restrictions, especially the limitations on publication, 'completely unacceptable in the research world.'

As we have noted before, often the leaders of academic medical institutions seem to make the pursuit of money, prettied up as "external funding," their highest priority. Thus do the high ideals of academia go up in smoke.

ADDENDUM (26 May, 2008) - See also comments on the Clinical Psychology and Psychiatry blog.

Smoke Alarm: Tobacco Funding of Medical Research at Reputable Medical Schools May be Prevalent

We recently posted about a controversial study of using CT scans to screen for lung cancer that turned out to have been partially sponsored by a tobacco company. Even though we have written quite a bit about conflicts of interest, this surprised even me, since the conflicts of interest presented by financial relationships with tobacco companies seem so blatantly risky that I would have thought few physicians or medical researchers would dare contemplate them. It looks like even having blogged on Health Care Renewal for several years, I am still too naive.

For example, the Boston Globe just reported on funding of medical research in the Boston area just by tobacco company Philip Morris USA, just spun off from Altria Group Inc.

The nation's largest cigarette maker has paid for scientific research at four Massachusetts universities since 2000....

Philip Morris USA, which makes Marlboro and other top-selling cigarette lines, gave grants to scientists at Boston University, Harvard University, the Massachusetts Institute of Technology, and the University of Massachusetts, company spokesman David M. Sylvia said Friday.

The research supported by the company touched on conditions such as heart disease and cancer that are linked to smoking.

Funding went to Boston University.

BU's acceptance of research grants from Philip Morris was first disclosed Thursday in The Daily Free Press, a student newspaper at the university.

At BU, one recipient, Dr. Douglas Faller, is a longtime professor and director of the BU Cancer Center. According to a document detailing work at the university's Women's Health Interdisciplinary Research Center, Faller received $268,759 from Philip Morris to investigate a cancer drug.

Reached at his home late Friday, Faller deferred to university officials for comment.

Funding went to Harvard, although it has decreased since Harvard banned new tobacco funding of research in 2004.

At Harvard Medical School, researchers were ordered to stop pursuing tobacco-industry grants in July 2004. 'The policy did, however, allow those few researchers who had ongoing projects funded by those entities to complete them,' Margaret Dale, dean for faculty and research integrity at Harvard Medical School, said in a statement released Friday by a university spokesman.

Funding previously went to University of Massachusetts Medical Center, but the institution does not currently get tobacco funding.

A UMass Medical School spokeswoman said that the school does not currently have any research supported by tobacco companies and that it had accepted 'no more than' $2 million from the industry over the past decade.

No Philip Morris funding went to Tufts University School of Medicine, but the school did admit to receiving money from another tobacco company.

The Tufts University School of Medicine received no Philip Morris grants, but a school spokeswoman said that one laboratory there had received a grant in 2006 from a tobacco company.

The argument against funding of clinical research by pharmaceutical, biotechnology and medical device companies has been that such companies often try to exert influence, subtle or overt, that might bias the research to favor their products, or even suppress research that shows their products in a bad light. Such influence could adversely affect the advancement of science, and decision making by physicians and patients who accept the published research as unbiased. Such influence also breaks the trust of research subjects who were told that they were volunteering to advance science and health care.

But at least pharmaceutical, biotechnology, and device companies make products intended to help patients more than they harm them.

Tobacco products obviously pose serious health risks, and have no health benefits to counterbalance them. So the bias that could result from tobacco companies' sponsorship of research could be much worse for science, for medical decision making, and for research subjects than bias resulting from pharma, biotech, or device companies' research sponsorship.

Yet some medical schools seem to push their faculty so hard to get "external research support" that they do not mind if such support comes from tobacco companies.

Kudos to Harvard, though, for trying to cut back.

No medical school administrator nor researcher willing to be quoted by the Boston Globe reporter dealt directly with why tobacco company research support might not be a good idea. For example,

In a statement issued Friday evening, the provost of BU's medical campus, Dr. Karen Antman, said the school had received $3.99 million from Philip Morris during the past decade and devoted it to the study of tobacco-related diseases.

'We adhere to the highest ethical conduct in research and pursue funding from a variety of sources for unrestricted medical research,' Antman said in the statement. 'Our research is conducted and the results are assessed against the standard benchmarks that apply to any research.'

Again, the issue is that a researcher getting "unrestricted" research funding, funding that might be keeping his or her academic career alive, might naturally feel some gratitude for the funding, and consequently might unconsciously be less likely to criticize his or her funding source or its products than otherwise. Of course, the more the researcher might need future funding from this sponsor, the more likely would be a conscious sense of obligation to be nice to that sponsor. Furthermore, even "unrestricted" funding may open up some lines of communication between the sponsor and the researcher which the sponsor could use to further increase its influence.

Also, the tobacco companies surely are not spending money to support research out of pure altruism,

'Their interest now is to try to convince the public that they are truly concerned companies and that they care enough to fund important research at reputable institutions,' said Dr. Michael Siegel, a Boston University School of Public Health researcher who has extensively studied the tobacco industry. 'And, they're using the good name of these institutions to try to bolster their own scientific and public credibility.'

That seemed to be working, as demonstrated by this seemingly self-contradictory quote from a Massachusetts Institute of Technology researcher:

'As there were no strings attached in the application process I had no qualms in applying for this funding,' Rami Tzafriri, of MIT, said in an e-mail. 'In retrospect I can say that the whole process was very professional and friendly and that under similar circumstances I would apply for such funding again. Funding for research is essential, but unfortunately scarce. So any source that does not compromise my independence is welcome.'

On the other hand,

'Taking money from the tobacco industry to conduct scientific research is like the DA taking money from the Mafia to conduct investigations of crime,' said Gregory Connolly, a Harvard School of Public Health professor and former director of the Massachusetts Tobacco Control Program.

Indeed. It would strongly be in society's interest to find a way to wean academic medical institutions from their addiction to research dollars proffered by those with something to sell other than science and improving health care.

ADDENDUM (2 April, 2008) - See also comments on the Effect Measure blog.

Smoked Out: Funding Lung Cancer Screening Research with Tobacco Money

A few weeks ago, we posted about conflicts of interest affecting a widely publicized study of using CT scans to screen for lung cancer. The study, basically a large case-series, was susceptible to multiple kinds of study bias that challenged its validity. Yet its authors used this limited and flawed data to strongly advocate such screening. Two lead study investigators, Dr Claudia Henschke and Dr David Yankelevitz of Weill Medical College of Cornell University, held multiple patents on technology used for the screening, and had licensed one patent to General Electric, a manufacturer of CT scans, and exchanged another for rights in a start-up manufacturer of lung biopsy devices. They did not disclose these conflicts in the articles they published describing study results, including one in the New England Journal of Medicine. We noted that perhaps these conflicts were related to the investigators' great enthusiasm for CT scan based lung cancer screening that went well beyond the data from their study.

Since then, the plot has thickened. A follow up article in the Cancer Letter(1) noted that the New England Journal of Medicine article which failed to disclose the authors' patents and licensing agreement also was a vehicle for continuing medical education (CME). Ethics rules for US CME require full disclosure of all authors' conflicts of interest. Futhermore, the authors had given multiple CME talks. Their disclosure of these conflicts was inconsistent across these talks. Thus, on the GoozNews blog, Merrill Goozner announced that "The Center for Science in the Public Interest later this week will ask the ACCME [Accreditation Council for Continuing Medical Education] to order all the CME providers where Henschke failed to disclose to send proper disclosures to anyone who participated in those activities."

Henschke and Yankelewitz wrote a letter to JAMA in which they acknowledged they had failed to disclose "potential conflicts of interest" in a previous JAMA article and letter.(2) The letter was rather defensive, in my humble opinion, declaring that "The license agreement was between General Electric and Cornell, the institution listed on the title page. A portion of the royalties are distributed to both of us and to the other co-inventors pursuant to Cornell policy, which in turn is consistent with the Bayh-Dole Act." The letter also asserted the authors' very narrow interpretation of conflicts of interest, "we believe that none of the patent applications or the license agreement played any role in the design of the study, interpretation of the data, or drafting of the publications in JAMA and therefore did not disclose them."

A recent AP article noted that even getting to Henschke and Yankelevitz to write this much was not easy.

Dr. Catherine DeAngelis, editor in chief of JAMA, the Journal of the American Medical Association, said she contacted Henschke months ago after others pointed out patents not disclosed in a July 2006 study. DeAngelis said Henschke didn't believe the patents were relevant to the research and resisted disclosing them.

'We'd been working with Dr. Henschke trying to get her to write a letter of apology — which is our policy — and to take responsibility,' DeAngelis said. 'It was not easy to get her to do anything.'

But you ain't seen nothing yet.

This week, Gardiner Harris writing in the New York Times revealed that the same study which was reported in the New England Journal of Medicine article(3), was substantially funded by money from a tobacco company.

Small print at the end of the study, published in The New England Journal of Medicine, noted that it had been financed in part by a little-known charity called the Foundation for Lung Cancer: Early Detection, Prevention & Treatment. A review of tax records by The New York Times shows that the foundation was 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 [Vector Group Ltd].

Moreover, Henschke and Yankelevitz could hardly deny knowing about this source of their funding. They were the ones running the foundation.

Dr. Henschke was the foundation president, and her longtime collaborator, Dr. David Yankelevitz, was its secretary-treasurer.

It turns out that the leadership of Weill Medical College of Cornell University were in on this.

Dr. Antonio Gotto, dean of Weill Cornell, and Arthur J. Mahon, vice chairman of the college board of overseers, were directors.

The Cornell leadership denied that the intent was hiding tobacco money. On the other hand, the purpose of the foundation, other than to serve as a conduit for this money to the research project, was not exactly clear.

In an e-mail message, Drs. Henschke and Yankelevitz wrote, 'It seems clear that you are trying to suggest that Cornell was trying to conceal this gift, which is entirely false.'

'The gift was announced publicly, the advocacy and public health community knew about it, it is quite easy to look it up on the Internet, its board has independent Cornell faculty on it, and it was fully disclosed to grant funding organizations,' they wrote, adding that the Vector grant represented a small part of the study’s overall cost. The foundation no longer accepts grants from tobacco companies, they wrote.

In the Vector press release, Dr. Henschke was quoted as saying that, thanks to the Vector grants, 'we have raised the initial funding needed to support this important research and data collection on the effectiveness of spiral CT screening.'

Dr. Gotto said in an interview that Dr. Henschke, Dr. Yankelevitz and another colleague set up the foundation initially without the university’s approval, which he said faculty members are allowed to do. He and Mr. Mahon joined the board some weeks or months after its creation to ensure that the Vector grants were handled correctly, he said.

'If we had been approached, we would not have set up the foundation,' Dr. Gotto said. 'We would have accepted the gift directly. We think we behaved honorably. There was no attempt to set up a foundation to hide tobacco money.'

Days earlier, Andrew Ben Ami, assistant secretary of the foundation, said in an interview he would not disclose the source of the charity’s financing at the request of the university.

In another interview before Dr. Gotto agreed to speak, Mr. Mahon, another foundation director, said he did not know the source of the funds.

Note that the Foundation for Lung Cancer: Early Detection, Prevention, & Treatment seems quite obscure. It has no web-site. Its address and email address, as reported by SourceWatch, are for Dr Henschke's office. What it has done other than transfer tobacco money to the research project is unknown.

You just can't make this stuff up.

So we have yet another case which illustrates how pervasive is the web of conflicts of interest that entangles physicians, researchers, academic medical institutions, and industry. Moreover, the web increasingly appears to involve not only industries that make products meant to do patients more good than harm, that is drugs and medical devices, but also industries whose products have no medical use, and even now tobacco, certainly one of the major man-made health scourges.

So this case has actually produced some outrage. Per the New York Times article,

Prominent cancer researchers and journal editors, told of the foundation by The Times, said they were stunned to learn of Dr. Henschke’s association with Liggett. Cigarette makers are so reviled among cancer advocates and researchers that any association with the industry can taint researchers and bar their work from being published.

'If you’re using blood money, you need to tell people you’re using blood money,' said Dr. Otis Brawley, chief medical officer of the American Cancer Society. The society gave Dr. Henschke more than $100,000 in grants from 2004 to 2007, money it would not have provided had it known of Liggett’s grants, Dr. Brawley said.

Also,

Dr. Jerome Kassirer, a former editor of The New England Journal of Medicine and the author of a book about conflicts of interest, said he believed that Weill Cornell had created the foundation to hide its receipt of money from a cigarette company. '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.'

The case also illustrates the messiness of relationships among researchers, academic medical leaders, and industry. As Gardiner Harris wrote in the NY Times,

Universities are responsible for policing conflicts of interest and, in many cases, the required disclosures of their faculty. But Weill Cornell shared in the proceeds of Dr. Henschke’s patent and pending patents, and university officials were on the foundation board.

'We have a very strict oversight policy' for conflicts of interest, Dr. Gotto of Weill Cornell said. He dismissed any suggestion that the university could not police and benefit from faculty members’ financial deals.

But Dr. Kassirer said, 'The problem is that universities, because they’re so conflicted themselves, ignore the conflicts of interest of their faculty.'

To illustrate Dr Kassirer's last point, a quick Google search revealed that Dr Gotto, in addition to being dean of the medical school, is a top leader of two pharmaceutical companies. He is on the board of directors of Aegerion Pharmaceuticals and of Arisaph Pharmaceuticals. So where do his interests lie? - promoting the integrity of the medical school, promoting more funding to the medical school, promoting the profits of these two companies, or promoting the interests of the power elite who simultaneously can run medical schools and run health care corporations? Who can tell?

And that is, as we have said before, the curse of conflicts of interest in health care. Conflicts lead to confused thought, speech, and action. One cannot tell what interests lie behind the speech and actions of the conflicted. So clinical research designed, implemented, analyzed, and discussed by the conflicted rather than leading to further clarity about how to care for patients, just leaves us in a fog of doubt.

But financial ties to various industries, regardless of the conflicts they produce, fuel academic medical institutions and universities who want their faculty to become "taxpayers" rather than teachers and researchers (see post here). Such funding may be one reason why administrators now outnumber faculty in higher educational institutions. Such funding fuels the imperial pretensions of their leadership (see post here). So the universities will not give up their conflicts without quite a fight. But it's time for that fight to start.

ADDENDUM (28 March, 2008) - See also comments by Merrill Goozner on Gooznews, and by Gary Schwitzer on the Schwitzer Health News Blog.

References

1. Goldberg P. NEJM says Henschke conflicts irrelevant; propriety of granting CME questioned. Cancer Letter 2008; 34: 1.
2. Henschke CI, Yankelevitz DF. Unreported financial disclosures. JAMA 2008. (Link here.)
3. The International Early Lung Cancer Action Program Investigators. Survival of patients with stage I lung cancer detected on CT screening. N Engl J Med 2006; 355: 1763-1771. (Link here.)