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 related to the issue of pornography are among the most widely recognized statements in any U.S. 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 where 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 when one considers 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 creates 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: Porsche Boxster automobile) 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

While it 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 conflicts of interest.

 For example, in a recent report an investigator examined the Center for Medicare and Medicaid Services 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 one-quarter of clinicians who received research funding also received more general payments and the amount of such financial renumeration 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 with patient advocacy organizations⁷, inadequate standardization of peer-review publication reporting policies⁸, the extent of known financial relationships between clinical cancer investigators (particularly trial principal investigators) with study sponsors⁹, 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 (ACP) and the US Preventive Services Task Force vs the American College of Radiology and Society of Breast Imaging.¹¹ Interpretations of the reasons for these differences include a potential financial conflict of interest vs 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 of these issues.

Finally, this all-to-brief discussion related to conflict of interest would not be complete without at least mention of unease that exists within the standard clinical practice of oncology as well as 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 with 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 timeframe is a critical component of a federally funded grant for which the clinician investigator is receiving salary support or is important/essential for promotion/tenure, is that information to be disclosed?

In conclusion, it is fair to suggest that while full disclosure of potential conflicts of interest is a highly valuable exercise and that 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 the words of Justice Stewart.

References

1. Jacobellis v. Ohio, 378 U.S. 184 (1964)
2. Liang L. Peptides: FDA appointed advisory committee criticized for conflicts of interest.BMJ. 2026;394e100181. doi:10.1136/bmj-2026-100181
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;24:337. 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
7. Bhat S, Ross JS, Ramachandran R. Medical product industry ties to patient advocacy organizations’ executive leadership. JAMA Intern Med. 2023;183(10):1164-1166. doi:10.1001/jamainternmed.2023.2842
8. Kesselheim AS, Lee JL, Avorn J, et al. Conflict of interest in oncology publications. Cancer. 2012;118:188-195. doi:10.1002/cncr.26237
9. Wang J, Silberman PC, Chowdhury SM, 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. Published online July 17, 2026. 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