Making Sense of Non-Financial Competing Interests

  • The PLoS Medicine Editors
  • Published: September 30, 2008
  • DOI: 10.1371/journal.pmed.0050199

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Non-financial competing interests: A very serious issue for patients’ care.

Posted by plosmedicine on 31 Mar 2009 at 00:31 GMT

Author: Alain Braillon
Position: MD
Institution: Department of Public Health, University hospitals of Amiens, France
Additional Authors: Gérard Dubois
Submitted Date: October 20, 2008
Published Date: October 20, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

The editors’ pledge lacked true examples about the severity of the consequences for patients.

Physicians’ organizations provide examples of serious conflicts.

The American Association for the Study of Liver Diseases recommends that “Patients at high risk for developing hepatocellular carcinoma should be entered into surveillance programs (Level I) ».1 In fact, this is a level III (expert opinion), the weakest level of evidence, because no randomized controlled trials demonstrated benefit. Accordingly, the National Cancer Institute states that “Based on fair evidence, screening would not result in a decrease in mortality from HCC.” and “Based on fair evidence, screening would result in rare but serious side effects”.2 Moreover, screening necessitates a national program which must ensure a minimal participation, quality controls, and evaluation of the results. The AASLD failed to implement such basic requirements.

The French and the American Associations of Urologists recommend prostate cancer screening despite universal agreement that evidence is insufficient to assess the balance of benefits and harms.3 This was pointed out recently.4 Then after, the US Preventive Services Task Force repeated its statement.5 In contrast, in France, the Parliament Public Health Assessment Committee mandated the French Association of Urologists to evaluate the state of the art and the Health Care Watchdog (Haute Autorité de Santé) reminded silent.6 In France, the burden of prostate cancer screening is estimated at 8,400 cases of septicaemia and haemorrhages due to unnecessary biopsies and 33,000 complications (impotence, incontinence…) due to unproven treatment.14 This is not sufficient to prevent conflicts of interest and passivity!

Editors also may have conflicts. A recent study investigating HCC screening concluded that screening improved survival (5 months).8 However, looking at the raw data, one can find that screened patients died 18 months younger than nonscreened patients (length time and lead time biases)! However, the editor of this specialized journal repeatedly refused to publish our correspondence. Fortunately, the “error” was disclosed in another journal which was not related to the speciality.9

1. Bruix J, Sherman M; Practice Guidelines Committee, American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma. Hepatology. 2005;42:1208-1236.

2. National Cancer Institute, US National Institutes of Health. Liver cancer screening (PDQ®). Available at Accessed October 13, 2008.

3. Gignon M, Braillon A, Chaine, Dubois. Le dépistage du cancer de la prostate: hétérogénéités des recommandations. Une exception française? Can J Public Health. 2007; 98 :212–6.

4. Braillon A. Re: Is a screening interval of every 4 Years for prostate cancer acceptable? J Natl Cancer Inst. 2008;100:222-3.

5. U.S. Preventive Services Task Force. Screening for Prostate Cancer: U.S. Preventive Services Task Force: Recommendation statement. Ann Intern Med 2008,149 :185-91

6. Braillon A, Dubois G, Zielinski O. Screening for prostate cancer: a public campaign, EBM and conflicting interests. Eur J Public Health. 2008 (in press)

7. Aupérin A, Laplanche A, Hill C. Dépistage du cancer de la prostate dans la population

générale : des inconvénients certains, un bénéfice hypothétique. Presse Med. 2007;36:1045-


8. Trevisani F, Santi V, Gramenzi A, et al. Surveillance for early diagnosis of hepatocellular carcinoma: is it effective in intermediate/advanced cirrhosis? Am J Gastroenterol. 2007;102:2448-2457.

9. Braillon A, Nguyen-Kac. Hepatocellular carcinoma : a pledge for Evidence Based Medicine. Am J Med. 2008:121:e9.

No competing interests declared.