If you want to understand why some of us are concerned about conflicts of interest, you need go no further than an article that appeared in last Friday’s edition of the Cancer Letter.
The article, written by Paul Goldberg, goes into great detail to explain why a scientific review on vitamin D, sun exposure and tanning booths which appeared in the New England Journal of Medicine last July may have been influenced by tanning industry funding.
The fallout from this conflict, in my opinion, may have substantial negative impact on how we are able to regulate tanning bed use, especially among young women who are putting their health at risk from the adverse effects of articial tanning.
The story is not new to regular readers of this blog. I covered it in July 2007 when the review article first appeared in the New England Journal.
Essentially, the article was a review article on vitamin D and its potential role in health and disease. As I noted at that time and on many occasions subsequently, I admired the depth of the science in the report regarding vitamin D and how it relates to human health.
Where I had a problem was that the author, who is widely known to be supported by and supportive of the indoor tanning industry, failed to make any comment in the article about the potential harms and risks of his recommendation that we should get regular sun exposure to get adequate amounts of vitamin D. He also recommended tanning salons as an effective and safe means of getting vitamin D.
What he didn’t do was comment on the fact that there are many well-qualified experts in this field who disagree with his recommendations. These experts don’t dispute the need to better understand vitamin D as it applies to our population, or that there is a role for vitamin D as part of being healthy. The evidence is strong that vitamin D plays a role in muscle and bone health. There is evidence that suggests vitamin D may play a role in cancer prevention.
These experts feel that the recommendations for sun exposure and using tanning salons to increase vitamin D levels in our bodies do not take into account the risks of skin cancer that would result. Nor do these recommendations take into consideration the realities that we are all different in where we live, the color of our skin, and our individual sensitivity to sun. All of these factors and others influence our sensitivity to sun and how much vitamin D we produce in our bodies from sun exposure.
These experts feel that there is a safe alternative to get vitamin D into our bodies, either through our diets (which admittedly is difficult to accomplish) or through inexpensive, safe dietary supplements which are available at virtually every supermarket, drug stores and many other retail outlets throughout the country.
The Cancer Letter article makes the same points I did in my blog last July, and expands in greater detail to show how a conflict that is not recognized or declared can influence a host of subsequent events.
Basically, what happened in the New England Journal article was that the author acknowledged his research was supported by the Ultraviolet Foundation.
Google the Ultraviolet Foundation and its tax filings and you find out that it is funded by the Indoor Tanning Association.
And that is not a conflict that should be considered in editing or publishing an article on vitamin D and health?
The Cancer Letter notes that the amount of support in question is small when viewed as a totality of the research support for the author. But it was significant enough in this circumstance to be noted as a source of funding for the research that led to the publication of the article.
One needs to take a look at what I call “second level effects” of such events.
Maybe the author and the New England Journal consider the conflict of interest to be immaterial. The potential fallout and damage is not.
Here is a possible scenario of how these things play out, and what in fact is happening right now:
The New England Journal of Medicine is one of—if not the—finest and most highly regarded medical journals in the world. It is viewed as an authoritative source of medical information, and its influence in scientific, medical and legislative arenas is without peer.
As a result, having research published in the New England Journal provides a widely accepted “stamp of approval” on the research reported, or the information provided in a review article.
Since the editors and reviewers of the article did not see any reason for the author to address the concerns of many experts regarding the risks of tanning and sun exposure—even a sentence or two would have been sufficient—the article stands alone as a firm recommendation on the value of sun exposure and tanning beds as a means of getting vitamin D into our bodies. (I should note that supplements were also offered as an option. I am concentrating here on the absence of comment by the author on the risks of tanning beds and sun exposure.)
There are a number of states that are considering or have implemented legislation and regulation of tanning bed use, particularly by young women who represent a population at risk that use these services.
If you have watched legislation and public policy being formulated and debated, you know it is not always a pretty process. It is usually not very deliberative—legislators always have many items on their agendas, and too little time to do much independent research or investigation.
That’s where this article comes in.
An article in a prestigious medical journal which makes positive comments about tanning booths is invaluable when lobbying legislators. What could be more authoritative in making the case that effective regulation of this potentially life-threatening device is unnecessary?
Now maybe you can appreciate why I am so concerned about this particular conflict of interest.
This scenario is not so far fetched.
The Indoor Tanning Association has embarked on a nationwide advertising campaign to influence people--including state legislators--that tanning is safe, and actually healthy for you.
Unfortunately, I can’t link to a copy of an ad which recently appeared in the New York Times. What you see, in large print, is the statement, “Tanning Causes Melanoma.” Superimposed over that is a “stamp” that says, in bold letters, “HYPE.” At the bottom of the ad is a link to a website called “SunlightScam.com.”
Although I can’t find much in the way of true scientifically valid supportive evidence on the website, I can’t help but think somewhere someone is using the New England Journal article to support the claims of “hype” and “scam.”
Maybe I am moving with the wrong crowd on this one.
My problem is that the experts I rely on don’t think that the claims of increased risk of skin cancer and melanoma are a hype or scam. They do acknowledge that not all melanoma is caused by sun exposure, but they do note that sunburns in youth are a major risk factor for melanoma later in life. And ultraviolet light—definitely UVB and quite possibly UVA—are the major risk factor for skin cancer. Skin cancer is not always “benign”. It can be fatal (melanoma) or very disfiguring when treated (squamous cell and basal cell carcinomas).
Perhaps you can now appreciate why understanding conflicts of interest are important, and that they are not trivial. Many of us involved in medical science and medical leadership have conflicts. They are almost unavoidable.
It’s not the conflicts that are always the problem (although in an increasing number of circumstances, they are in fact problematic). It’s the recognition of the conflict, the declaration of the conflict, and the mitigation of the conflict that offer us the best hope to enable us to continue to maintain our trust in our most valued institutions, researchers, and leaders in medicine.
As I have said recently in another blog, it is up to the professions to deal with conflicts of interest issues and give them the visibility they deserve.
Only through awareness, discussion and full disclosure will we be able to move forward and maintain the trust that the public has vested in us as physicians and medical scientists.
