Beyond “I Know It When I See It”: The Murky Reality of Conflict of Interest in Oncology

“I know it when I see it.” These words, expressed by Justice Potter Stewart in a decision on pornography, are among the most widely recognized statements in any US Supreme Court decision and represent a reasonable starting point in a brief discussion of conflict of interest within the domain of health care.¹

One might quickly agree with this legitimate concern when discussing the composition of a recent federal advisory committee on peptides in which several of the appointed members had “active health or wellness businesses involved in the supply of” these products.²

Similarly, it might be appropriate to employ the label conflict of interest when noting the appointment of academic health system leadership to pharmaceutical company boards of directors given the potential direct or indirect influence of these individuals in the determination of institutional purchasing, research, and educational priorities.³ In a JAMA paper, the mean compensation in 2012 for a group of academic medical center leaders (n = 41) holding such board positions was reported to be $312,564, a not insignificant financial reward for their activity. One might suggest that, a decade later, the compensation for pharmaceutical board participation by health system leadership may be considerably greater.

It is also not difficult to cite examples of clearly well-intentioned strategies designed to promote a widely appreciated beneficial outcome that in retrospect potentially create the appearance of a conflict of interest. A poignant example of this situation was the decision by the Southwest Oncology Group (SWOG) to award a valuable ($1000) raffle ticket (the prize: a Porsche Boxster) for the highest accrual on an important prostate cancer study.⁴ The ultimate goals of this organizational effort to encourage participation were surely laudable. However, even a modest perception that a clinician may seek to enroll patients into the trial for the opportunity to receive a free raffle ticket was appropriately recognized to be an unfortunate and quite unintentional error.⁵

Although it is not difficult for one to consider the types of activities highlighted above as being potential or actual conflicts of interest (“I know it when I see it”), it is other far more common—one might even suggest everyday—relationships and interactions in clinical care and research that raise subtle but relevant questions of conflict of interest.

For example, in a recent report, an investigator examined the CMS Open Payments database for payments to physicians and institutions for both research and “general payments” to physicians.⁶ Of note, the largest group of programs examined involved hematology/oncology (10.4%). The study found that approximately a quarter of clinicians who received research funding also received more general payments, and the amount of such financial remuneration increased near the time of initiation of the research project.⁶ One might legitimately inquire as to the effect of these financial arrangements on the research goals and outcomes. No answer here, just questions.

It is important to acknowledge there are multiple potential organizational and individual activities that legitimately lead to inquiries of potential conflict of interest, including relationships between for-profit pharmaceutical/biotech and device companies and patient advocacy organizations,⁷ inadequate standardization of peer-review publication reporting policies,⁸ the extent of known financial relationships between clinical cancer investigators (particularly trial principal investigators) and study sponsors,⁹ and recognized rather strong opinions regarding a need to modify the status quo.¹⁰ The complexity of these and related topics cannot be understated, with substantial differences in perspectives quite evident within the clinical, research, and regulatory communities. 

Recently, the tension existing between major national professional organizations over specific recommendations in their respective cancer-related screening guidelines has raised questions of potential conflicts of interest. For example, the age at which breast cancer screening should be initiated differs between guidelines created by the American College of Physicians and the US Preventive Services Task Force and those created by the American College of Radiology and the Society of Breast Imaging.¹¹ Interpretations of the reasons for these differences include a potential financial conflict of interest as opposed to an alternative view that the radiology community has specific expertise in this clinical domain not equally represented in the other organizations. Again, there are objectively no easy resolutions to these issues.

This all-to-brief discussion related to conflict of interest would not be complete without at least a mention of unease that exists within the standard clinical practice of oncology and in the routine conduct of cancer-related interventional clinical trials. As the pressure on health systems and group practices to maximize billable output intensifies, with physician compensation tied to volume or, conversely, the withholding of specific care within a so-called “value-based payment model,” it is pertinent to inquire how decisions regarding management of individual patients may be influenced by these financial arrangements.¹² Further, what is the responsibility of a provider or health system to inform patients in general terms of any potential conflict of interest associated with the specific payment model?

Finally, it is relevant to acknowledge that concerns about conflict of interest within the oncology domain are not restricted to financial matters. What is the obligation of a clinical investigator to inform a patient who is asked to consider entry into a clinical trial of any potential conflicts that the individual or organization may have associated with the study? For example, if completion of study enrollment within a fixed time frame is a critical component of a federally funded grant for which the clinician investigator is receiving salary support or is important or essential for promotion or tenure, is that information to be disclosed?

In conclusion, it is fair to suggest that although full disclosure of potential conflicts of interest is a highly valuable exercise and clear and consistent institutional and organizational policies are critical to optimize the utility of the process, there remain many unresolved issues regarding what is, and what is not, a meaningful conflict and how different situations should be most appropriately handled. Unfortunately, conflict of interest is more complex than suggested by Stewart’s words.

References

1. Jacobellis v Ohio, 378 US 184 (1964).
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3. Anderson TS, Dave S, Good CB, Gellad WF. Academic medical center leadership on pharmaceutical company boards of directors. JAMA. 2014;311(13):1353-1355. doi:10.1001/jama.2013.284925
4. Steinberg D. A Porsche for patient accrual. Cancer Invest. 2005;23(8):741-743. doi:10.1080/07357900500360073
5. Baker LH. Response to “a Porsche for patient accrual.” Cancer Invest. 2006;24(3):337. doi:10.1080/07357900600620533
6. Bergman A. Financial relationships between research sponsors and funded investigators in the US. JAMA Netw Open. 2026;9(7):e2624164. doi:10.1001/jamanetworkopen.2026.24164
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9. Wang J, Silberman PC, Mullick Chowdhury S, Blaser BW. Trends of authors’ conflicts of interest in clinical trials published in the Journal of Clinical Oncology: a large language model–assisted longitudinal study. JCO Oncol Pract. 2026;22(5):883-890. doi:10.1200/OP-25-00293
10. Tannock IF, Niraula S. Conflict of interest: moving from disclosure to avoidance. JCO Oncol Pract. 2026;22(5):717-720. doi:10.1200/OP-25-00695
11. Rubin R. Breast cancer recommendations fuel debate over who should write screening guidelines. JAMA. 2026;336(6):447-449. doi:10.1001/jama.2026.7095
12. Powell AC, Goldstein DA, Loy BA. Why incentive transparently matters for informed consent. JAMA Oncol. Published online July 23, 2026. doi:10.1001/jamaoncol.2026.2534