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Objectives: To understand how and why Australian cancer physicians interact with the pharmaceutical industry., Design: Qualitative study using semistructured interviews, performed by a medical oncologist. Thematic analysis using a combination of deductive and inductive codes., Setting: Given the evidence on industry influences on clinical practice and the importance to the market of oncology drugs, we sought to better understand cancer physicians' experiences. Practising consultant medical oncologists and clinical haematologists from four Australian states were interviewed over Zoom., Participants: 16 cancer physicians were interviewed between November 2021 and March 2022, from 37 invited (response rate 43%). Most were medical oncologists (n=12 of 16, 75%) and male (n=9 of 16, 56%)., Outcome Measures: The analysis of all interviews was based on grounded theory. Transcripts were coded and then codes formed into themes with supporting quotes. The themes were then placed into categories, used to describe the broad areas into which the themes could be grouped., Results: Six themes were identified that fell within two broad categories: cancer physicians' views and experiences of interactions and management of these interactions . Views and experiences included: the transactional nature of relationships, risks of research dependence, ethical challenges and varied attitudes based on interaction type. Management themes included: lack of useful guidance and reduced interactions during the COVID-19 pandemic. These led to an overarching seventh theme, on the desire for a 'middle road'. Cancer physicians identified the transactional nature of industry relationships and felt uncomfortable with several types of interactions, including those with sales representatives. Most wanted less contact with industry, and the forced separation that occurred with the COVID-19 pandemic was generally welcome., Conclusions: Cancer physicians may have difficulty balancing the perceived need to interact with industry in modern cancer care while maintaining distance to minimise conflicts of interest. Further research is needed to assess management strategies in this area., Competing Interests: Competing interests: DJK has received speaker fees from Merck Sharp & Dohme in the past 2 years. In 2020, BM acted as an expert witness for Health Canada in a legal case related to marketing of an unregistered product in Canada. There are no other conflicts to declare., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: No previous review has assessed the extent and effect of industry interactions on medical oncologists and haematologists specifically., Methods: A systematic review investigated interactions with the pharmaceutical industry and how these might affect the clinical practice, knowledge and beliefs of cancer physicians. MEDLINE, Embase, PsycINFO and Web of Science Core Collection databases were searched from inception to February 2021., Results: Twenty-nine cross-sectional and two cohort studies met the inclusion criteria. These were classified into three categories of investigation: (1) extent of exposure to industry for cancer physicians as whole (n = 11); (2) financial ties among influential cancer physicians specifically (n = 11) and (3) associations between industry exposure and prescribing (n = 9). Cancer physicians frequently receive payments from or maintain financial ties with industry, at a prevalence of up to 63% in the United States (US) and 70.6% in Japan. Among influential clinicians, 86% of US and 78% of Japanese oncology guidelines authors receive payments. Payments were associated with either a neutral or negative influence on the quality of prescribing practice. Limited evidence suggests oncologists believe education by industry could lead to unconscious bias., Conclusions: There is substantial evidence of frequent relationships between cancer physicians and the pharmaceutical industry in a range of high-income countries. More research is needed on clinical implications for patients and better management of these relationships., Registration: PROSPERO identification number CRD42020143353., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Pharmaceutical industry funding has transformed much grassroots community activism on health into corporate-sponsored advocacy. This critical commentary outlines recent evidence about industry funding of patient advocacy groups, offers a commentary on the history of grassroots activism appearing in this issue of the journal, and calls for greater scrutiny of the impacts and ethics of such sponsorship.

Objectives: To investigate the proportion of potentially relevant undisclosed financial ties between clinical practice guideline writers and pharmaceutical companies., Design: Cross-sectional study of a stratified random sample of Australian guidelines and writers., Setting: Guidelines available from Australia's National Health and Medical Research Council guideline database, 2012-2014, stratified across 10 health priority areas., Population: 402 authors of 33 guidelines, including up to four from each area, dependent on availability: arthritis/musculoskeletal (3); asthma (4); cancer (4); cardiovascular (4); diabetes (4); injury (3); kidney/urogenital (4); mental health (4); neurological (1); obesity (1). For guideline writers with no disclosures, or who disclosed no ties, a search of disclosures in the medical literature in the 5 years prior to guideline publication identified potentially relevant ties, undisclosed in guidelines. Guidelines were included if they contained recommendations of medicines, and writers included if developing or writing guidelines., Main Outcome Measures: Proportions of guideline writers with potentially relevant undisclosed financial ties to pharmaceutical companies active in the therapeutic area; proportion of guidelines including at least one writer with a potentially relevant undisclosed tie., Results: 344 of 402 writers (86%; 95% CI 82% to 89%) either had no published disclosures (228) or disclosed they had no ties (116). Of the 344 with no disclosed ties, 83 (24%; 95% CI 20% to 29%) had potentially relevant undisclosed ties. Of 33 guidelines, 23 (70%; 95% CI 51% to 84%) included at least one writer with a potentially relevant undisclosed tie. Writers of guidelines developed and funded by governments were less likely to have undisclosed financial ties (8.1%vs30.6%; risk ratio 0.26; 95% CI 0.13 to 0.53; p<0.001)., Conclusions: Almost one in four guideline writers with no disclosed ties may have potentially relevant undisclosed ties to pharmaceutical companies. These data confirm the need for strategies to ensure greater transparency and more independence in relationships between guidelines and industry., Competing Interests: Competing interests: HJ was an employee of NHMRC. SG and GD are employees of NHMRC. LB is an employee of The University of Sydney and had no funding specifically for this work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To investigate patterns of industry-sponsored educational events that focus on specific health conditions for which there are concerns about overdiagnosis and overtreatment., Design and Setting: This retrospective cohort study examines publicly reported industry-sponsored events in Australia from October 2011 to September 2015 for three conditions potentially subject to overdiagnosis and overtreatment: depression, osteoporosis and overactive bladder. We used a database of transparency reports to identify events with a focus on depression, osteoporosis and overactive bladder and compared these with other sponsored events. We hypothesised that companies marketing treatments for each condition would sponsor related events and that target audiences would mainly work in primary care, reflecting a broad patient population., Main Outcome Measures: Event and attendee characteristics, sponsoring companies, related marketed treatments, cost-effectiveness ratings and dispensing rates., Results: Over the study period, we identified 1567 events focusing on depression, 1375 on osteoporosis and 190 on overactive bladder (total n=3132, with 96 660 attendees). These events were attended by primary care doctors more often than sponsored events without a focus on these three conditions: relative risk (RR)=3.06 (95% CI 2.81 to 3.32) for depression, RR=1.48 (95% CI 1.41 to 1.55) for osteoporosis and RR=2.59 (95% CI 2.09 to 3.21) for overactive bladder. Servier, which markets agomelatine and AstraZeneca (quetiapine) sponsored 51.2% and 23.0% of depression events, respectively. Amgen and GlaxoSmithKline, which co-market denosumab, sponsored 49.5% of osteoporosis events and Astellas and Commonwealth Serum Laboratories (CSL) (mirabegron and solifenacin) sponsored 80.5% of overactive bladder events., Conclusions: This 4-year overview of industry-sponsored events on three overdiagnosed and overtreated conditions found that primary care clinicians were often targeted, dinner was often provided and that a few companies sponsored most events. In most cases, sponsors' products are not cost-effective choices for the specified condition. This pattern highlights the need for professional education to be free of commercial sponsorship., Competing Interests: Competing interests: BM reported that she was an expert witness on behalf of plaintiffs in a Canadian class action suit concerning cardiovascular risks of a testosterone gel., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: The aim of the study was to assess the extent of pharmacist participation in pharmaceutical industry-sponsored educational events in Australia., Methods: A descriptive analysis was performed of 14 649 educational events provided by 43 companies between July and December 2007, using publicly available reports posted on the Medicines Australia website. Pharmacist participation was assessed according to duration and type of event, whether continuing professional education credits were awarded, type of venue, hospitality provided and cost of hospitality., Key Findings: Most of the 14 649 industry-sponsored events reported in this mandatory reporting programme were targeted at doctors (specialists and general practitioners). Pharmacists were present at 621 events (4.2%); 209 events were pharmacist-only events. Of pharmacist-only events, 68% were held in hospitals and professional rooms and 13% in restaurants. In contrast, 32% of events involving doctors were held in restaurants (difference in proportions 18.9%; 95% confidence interval 13.5-22.9%) Sixty-six per cent of pharmacist-only events were 1 h or less in duration; 81% were 2 h or less. Almost 40% were reported as training or in-service activities, generally conducted in hospitals. Only three events had continuing professional education credits assigned. The most common topics discussed were oncology, diabetes, haematology, cardiology and gastroenterology; a specific medicine was mentioned in the descriptor for 23 of the 209 (11%) events. Hospitality provided was generally modest, averaging AU$36.24 per pharmacist across all pharmacist-only events, and lower in hospital (AU$9.21 per head) than those held in restaurants (AU$51.42)., Conclusions: The data from this first report suggest pharmacists were not a major target for industry-funded educational events. Exposure to such events will likely increase as pharmacists take on enhanced prescribing roles and it is important that this is captured under the mandatory disclosure requirements that have been introduced in a number of jurisdictions. It is also desirable that such schemes include generic medicines manufacturers and that pharmacy professional bodies use these data to monitor and manage the level and impact of interactions between pharmacists and industry.

The financial ties between doctors and drug companies have come under intense scrutiny in recent years. Some commentators--such as Marcia Angell, former editor-in-chief of the New England Journal of Medicine--argue that the mission of doctors is fundamentally different to the mission of drug companies and that the ties between them should be completely cut. "Drug companies are investor owned businesses with a responsibility to maximise profits for their shareholders," says Angell. "That is quite different from the mission of the medical profession, which is to provide the best care possible for patients." Other commentators have argued that clinicians and drug companies do have some shared goals in aiming to maximize human health. In this debate, Emma D'Arcy, co-founder of a social networking site that facilitates interactions between doctors and drug companies, argues that it would be valuable to the public if we could establish "authentic alliances" between these professionals. But journalist Ray Moynihan argues that such alliances are prone to the corrupting influence of pharmaceutical industry money, and that disentanglement is a healthier alternative.

The Introduction and Overview will contain a bold statement of the essay themes. Next the section on Entanglement will look at the many forms of doctor-drug company relationships, and the evidence for how these can distort practice. Selling Sickness will briefly explore the way doctor-drug company relationships are important to the widening of boundaries of treatable illness. And finally, Disclosure to Disentanglement will look at self-regulatory and statutory attempts around the world to get more independence in the relationship between doctors and drug companies.