Australian cancer physicians and the pharmaceutical industry: understanding current interactions to guide future policy

Medical oncologists and clinical haematologists, defined together as cancer physicians, prescribe medications that treat cancer. Cancer physicians are a source of focus for influence by the pharmaceutical industry, and may accordingly be at risk of bias to the detriment of cancer patients. The aim of this thesis was to understand the nature and extent of interactions between Australian cancer physicians and industry, to better inform policy discussions in this area. A mixed-methods approach was used, consisting of four studies. A systematic review of the literature assessed relationships between cancer physicians and industry globally, and how these affect the practice, knowledge and beliefs of clinicians. This identified thirty-one papers, finding that up to 63% of US and 70.6% of Japanese cancer physicians have financial conflicts of interest with industry. Payments were associated with either neutral or negative influence on the quality of prescribing, and there was some evidence that oncologists felt industry-sponsored education may lead to unconscious bias. A cross-sectional analysis of publicly-available disclosures found that 31.7% of medical oncologists and 30.9% of clinical haematologists in Australia received non-research payments from industry over a six-month period, higher proportional frequencies than any other internal medicine specialty group. Most payments were for travel costs and fees for service. In a survey, most Australian cancer physicians (n=79 of 104, 76%) reported interacting with industry at least once a month, and 67.7% (n=63 of 93) acknowledged having received non-research payments from industry at some point. Physicians with more favourable attitudes towards industry were more likely to have frequent interactions, specifically perceived acceptability of interactions with sales representatives (odds ratio [OR] 9.37 [95% CI, 1.05-83.41], p=0.045) or clinician sponsorship (OR 3.22 [95% CI, 1.01-10.30], p=0.049). In a qualitative study of sixteen Australian cancer physicians, three categories with seven key themes were identified: Views and experiences of interactions (1. Transactional nature of relationships, 2. Research dependence and associated risk, 3. Complexity of payments, 4. Attitudes reflect forms of interaction), Management of interactions (5. Lack of useful guidance, 6. Reduced interactions due to the COVID-19 pandemic), and a Summary theme (7. Desire for a ‘middle road’). Most participants wanted less contact with industry, though acknowledged difficulty with this due to the reliance on industry in modern cancer care. The research showed a complex relationship between cancer physicians and industry in Australia, to which improvements could be made. Three potential policies are proposed: 1. Removal of sales representatives from the industry-cancer physician interface, 2. Creation of an independent centralised database of drug access programs, and 3. Redesign of industry funding of conference registration, travel and education. More research is required to assess the acceptability and feasibility of these propositions, to assess the objective effects of industry interactions on prescribing in Australia, and to understand alternative perspectives on these interactions, such as those of patients and industry itself