Page 177 - Journal of Special Operations Medicine - Spring 2017

also drives a lot of marginal products, or products that of the healthiest patient, the people who are the fittest
don’t work. And the people who designed those trials of the patients. On average, the age is almost 10 years
are I think very clever. You can sort of tilt the playing younger in pivotal trials for the FDA drug approval than
field a little bit to favor your drug and the incentive to in the real world. And then when you start to extrapo-
do so is often tremendous—billions of dollars hinge on late drugs that have real side effects in very carefully
one of these pivotal trials. And to some degree that’s be- selected populations, and small benefits, in carefully
cause it’s a human pursuit. But to some degree we could selected populations, to the average patient that walks
have policy changes that could more align the medical into my clinic, who is older, who has other problems,
research agenda with what really matters to patients who is taking heart medicine. There was a paper that
and doctors. came out about one of those costly expensive drugs for
liver cancer, and in the pivotal trial it had the benefit of
DUBNER: Let me ask you: in your own field, in oncol- about two, three months, something like that. But in the
ogy and in the particular cancers that you treat, how real world, in the Medicare data set, it had no improve-
much more effective generally would you say the new ment in survival over just giving somebody good nurs-
cancer drugs are, than the ones that they are replacing ing care and good supportive care. And I think that’s
or augmenting? the reality for many of these marginal drugs, when you
actually use them in the real world, they start to not
PRASAD: Let me say that there are a few cancer drugs work so well, and maybe not work at all.
that have come out in the last two decades that are re-
ally wonderful drugs, great drugs. One drug came out DUBNER: You’ve written and spoken about cronyism
of work here, in the Oregon Health and Science Uni- and conflicts of interest between drug makers and the
versity, by Dr Druker, Gleevec, and that’s a drug that doctors who prescribe drugs. I’m curious what happens
transformed a condition where maybe 50 or 60 percent when you go to an oncology conference. Are you an
of people are alive at three years to one where people unpopular person there?
more or less have a normal life expectancy. So that’s a
really wonderful drug. But I think if we’re honest with PRASAD: Stephen, I always wear a bulletproof vest
ourselves, we’ll have to admit that the majority of new when I go. No, but this has really been sort of the way
cancer drugs are marginal, that they offer sort of very medicine has operated for many years. To some degree,
small gains at tremendous prices, and to give you an practicing doctors in the community having ties to the
example of that, among 71 drugs approved for the solid drug makers—that’s one thing—but increasingly, we see
cancers, the median improvement in overall survival or that the leaders in the field, the ones who design the
how long people lived was just 2.1 months. And those clinical trials, who write up the manuscripts, who write
drugs routinely cost over $100,000 per year of treat- the review articles, who sort of guide everyone in how
ment or course of treatment. to practice in those fields, they have heavy financial ties
to drug makers. And there’s a large body of evidence
DUBNER: But that points to one of the tricks that suggesting that biases the literature of towards finding
works so well—which is if it’s 2.1 months extra, and benefits, where benefits may not exist, towards more fa-
if the expected lifespan was, just let’s pretend for a vorable cost-effective analyses when drugs are really not
moment, it was 6 months, then on a percentage basis cost-effective. It’s a bias.
that’s a massive improvement. So as the patient or as
the pharma representative, I’m not talking about that LISA BERO [professor of medicine and co-chair of the
length of time—which might be lived under physical du- Cochrane Collaboration]: Yes, well, we have a great
ress and financial duress—but rather I’m thinking about deal of empirical data showing that funding sources and
goodness gracious, 33 percent life expectancy extension! author financial conflicts of interest are associated with
overoptimistic data.
PRASAD: Right, a new drug improves lifespan 33 per-
cent longer. To find out more, check out the podcasts from which
this text was drawn: “Bad Medicine, Part 1: The Story
DUBNER: And who doesn’t want that, especially when of 98.6” and “Bad Medicine, Part 2: (Drug) Trials
you’re sitting there with your loved one in a horrible and Tribulations” (http://freakonomics.com/podcast/bad
situation, facing the end? -medicine-part-1-drug-trials-tribulations/).

PRASAD: The other thing that I’d point out is, those 2.1
months, these clinical trials that are often conducted by
the biopharmaceutical industry, they really choose sort

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