José Baselga, Memorial Sloan Kettering Cancer Center’s chief medical officer, resigned a few weeks ago following his failure to disclose his financial connections with pharmaceutical and device companies. An exposé a week later revealed the hospital may have a conflict of interest in its relations with a new start-up company.
But disclosures alone cannot cure the most fundamental disorder created by these relationships. Medical-industrial bonds distort medical care itself. Such bonds have created many useful products, including diagnostic X-ray. But they have defined the choice of interventions used by entire specialties, devaluing more scientifically informed measures of clinical effectiveness and patient harm.
Radiation therapy exemplifies a century-long history of medical-industrial alliance, which built new technologies and the radiation therapy specialty itself (renamed radiation oncology by midcentury). Noting severe skin burns generated by newly discovered radioactive elements and X-rays in the 1890s, physicians and physicists immediately sought to use them in treating cancer. Marie Curie — whose death, ironically, was linked to her years of exposure to radiation — worked closely with industry to commercialize radium for medical use.
The oft-told (if disputed) American story is that a tube manufacturer — and homeopathic medical student — used X-rays to treat a breast-cancer patient just 23 days after Wilhelm Roentgen announced their existence. After purchasing its major competitor, General Electric Co. played a central role in developing X-ray tubes, as well as their diagnostic and therapeutic use. GE initiated contact with medical leaders, many at Cornell’s medical school, to test and market its tubes during the 1910s and 1920s. Over the next century, doctors used the joint radiation therapy product line to bombard patients with X-rays, radioactive radium and cobalt-60, and beams of neutrons and protons.
Widespread publicity portrayed each new radiation device as a major advance in the fight against cancer, and reports in the medical literature sometimes depicted spectacular reductions in tumor size. Studies soon noted, however, that radiation treatments inflicted major damage on patients, including severe skin burns, and destroyed tissues surrounding tumors, without curing most of their cancers. The disappointing findings did not, however, lead to a reconsideration of radiation.
Rather, they drove aspirations that the very next technology would shoot the silver bullet — or lay the golden egg. Medical-industrial collaborations drove the sense that increasingly powerful X-ray devices needed to be developed, if not to improve patients' outcomes, then to help hospitals appear cutting-edge and boost their bottom lines.
Illustrating this tension between pushing technological progress for business reasons and focusing on improved outcomes for patients, in the 1930s Columbia University professor Francis Carter Wood criticized the adoption of new machines in the absence of studies investigating outcomes. He proposed a moratorium on new installations pending “definitive” evidence of effectiveness. But Wood succumbed to temptation and subsequently installed (without evidence) a giant X-ray treatment machine.
Wood’s move spurred General Electric to announce that James Ewing, medical director of Memorial Sloan Kettering, not far from Columbia, was installing GE’s new million-volt X-ray instrument. Memorial had close ties with GE, according to a history of its radiology department, and the company used Memorial’s brand loyalty in its advertising.
The radiation race heated up after World War II. Massachusetts Institute of Technology engineer John Trump (uncle to the president) established the High Voltage Engineering Corp. to manufacture MIT’s Van de Graaff machine and recruited radiologists from the Lahey Clinic in Boston to staff his X-ray clinic at MIT. Competitors criticized Trump for bombastic publicity and having a conflict of interest after he instigated a newspaper article proclaiming that a “mighty new X-ray cannon” was “mowing down tumors with an efficiency beyond scientists’ dreams.” GE accused Trump of unethically using his professorship to promote the device while serving as company board chairman — and profiting from its sales as a major stockholder.
Even as the arms race for ever-bigger radiation devices heated up, the strong undercurrent of professional doubt continued. Radiologists at a 1958 National Academy of Sciences conference questioned the many uncontrolled, single-center reports claiming success with higher-powered devices. Nonetheless, they all had one (or more) and used them extensively. In a moment of brutal honesty, New York University radiologist Milton Friedman — not the University of Chicago economist — advised a colleague in private correspondence that, although the higher-powered devices provided “no additional benefits to the cancer patient … the public relations impact of these gadgets is enormous.”
Around the same time, Edward Ginzton — the Stanford University engineer and Varian Associates (now Varian Medical Systems) partner who would become company CEO and board chairman — bet that the Stanford/Varian linear accelerator (linac) would outcompete cobalt-60 devices because it could process patients faster and generate greater hospital revenue. Ginzton teamed up with Stanford radiologist Henry Kaplan, whose laboratory — like Trump’s at MIT — conducted company R&D. In what has been called the best use of radiotherapy (in conjunction with chemotherapy), Kaplan made his name treating Hodgkin lymphoma patients on the linac, and Varian came to supply the world with them.
Although effectiveness research methods had gained in sophistication, they still were not adequately applied to clinical care. Many radiation oncologists conceded in Certificate of Need applications to purchase new devices in the 1970s that there was little evidence that upgraded linacs brought better outcomes than the lower-voltage ones or the cobalt-60 “bombs” they were replacing. But, as the oncologists explained, their hospital departments needed to provide the latest devices to attract more patients and compete in the marketplace, and the doctors needed to use the devices to avoid professional obsolescence.
Twenty-first-century developments in “radio surgery” and proton beam therapy bring the history of industry’s role in using and diffusing high-cost technologies of uncertain efficacy up to date. Proton oncologists have been famously resistant to comparative randomized controlled trials to assess outcomes of their work, and proton center websites make unsupported claims of effectiveness. Accuray, launched by a Stanford neurosurgeon to manufacture his CyberKnife innovation, has been accused of deceptive advertising.
This preference for market-based, rather than science-based, solutions continues to escalate the cost of medical care in the United States while making it less effective. The public should not only demand greater transparency, but greater reliance on science and less reliance on industry hype when it comes to medical treatment.