Why 'Don't Make Enemies' Is Cowardly Advice

Our lives begin to end the day we become silent about things that matter.

—Martin Luther King, Jr.

Recently on Twitter, I saw a thread of advice for budding oncologists. There were many great suggestions, including "Strive always to do good work" and "It is OK to push yourself outside your comfort zone," but one suggestion stayed with me. It went like this: "Oncology is a small world; don't make enemies."

At first glance, it seems like good advice, but upon further reflection it isn't. It is problematic and perpetuates many of the entrenched problems of our profession.

The Problems in Oncology

Oncology is one of the richest and most fulfilling fields of medicine, where scientific advances intertwine with deep and meaningful human connections. But our profession also has serious problems.

First, most of our new drugs offer merely marginal benefits. Fojo and colleagues^[1] found that the average solid tumor drug added just 2.1 months of survival. Many drugs merely improve progression-free survival. This is not good enough for our patients. We have to aspire for better.

Second, we confuse the number of drug approvals per annum with progress. Progress is the approval of transformational drugs, not merely approving marginal, me-too drugs. Yet, the FDA frequently congratulates itself for the sheer number of approvals per year.^[2]

Third, the price of our medications is unjustified. It is disconnected from R&D outlays, benefits, and the regulatory pathway to approval.^[3] It bankrupts our patients. It is the product of insatiable greed. It represents our failure as a society to act upon it.

It sanctions cowardice.

Fourth, our experts are often silent or worse. They often have heavy financial ties to companies and frequently extol the virtues of marginal drugs.^[4,5] A few courageous leaders speak out harshly about drug prices, but many are happy to remain silent. Perhaps they are anxious about their next consulting opportunity or ghostwritten industry publication.

Fifth, our patient advocacy groups are also often silent about drug prices.^[6] They are often eager to advocate for marginally effective and financially toxic drug approvals at the FDA Drug Advisory meetings.^[7] Coincidentally, many are funded by the pharmaceutical industry.

Sixth, many oncologists engage in unrepentant hype. They call negative trials positive, and marginal drugs "game-changers." They embellish, spin, distort, and make false promises. Again, coincidentally, there is often a financial conflict.

Seventh, we treat conflict of interest with laughable policies. Experts flash disclosure slides at national meetings faster than humans can read.^[8] No one takes the real solution seriously: divesture of personal payments (personal payments, not research payments)

Together, these seven problems are fundamental to modern cancer medicine. To some degree, they probably discourage trainees away from oncology toward other specialties. They inspire other fields to criticize oncology. They must be remedied.

The Problem With 'Don't Make Enemies'

The problem with the advice of "Don't make enemies" is that it sanctions cowardice. The easiest way to avoid making enemies is to stay silent; to ignore ineffective drugs; to celebrate bad approvals, like adjuvant sunitinib in kidney cancer; and to promote hype—for example, retweeting an inaccurate message. Instead of criticizing conflicts of interest with pharmaceutical companies, the easiest way to not make enemies is to partake in conflicted relationships with industry or ignore them.

Don't make it personal, but don't accept the status quo.

"Don't make enemies" is bad advice for a field in need of morality and a reorientation of the compass towards patients and not profit. If you are honest and tell the truth, some people will not like you. You will make enemies. That's OK; your job isn't to make everyone happy. It is to fix the deep and pernicious failings of our profession. If someone doesn't like you for doing that, that's their problem.

Consider 'Don't Make It Personal'

The right advice is "Don't make it personal." Don't attack people; attack the systemic problem. Don't just fault one drug approval; show that it is emblematic of broader failures. Don't just call out one conflicted key opinion leader (KOL) on Twitter; study all oncologists on Twitter. Oncologists on Twitter are often conflicted and tweet more positively about drugs where conflict exists.^[9] As journalist and Washington Post editor Marty Baron's character in the movie Spotlight says, focus on the institution, not the individual.

Don't make drug costs personal; ie, don't dislike people who work for the industry—they are often good, decent people. But don't go easy on the manuscript they had written by a medical writer. Don't go easy on the lobby groups who oppose Medicare Part B drug reform. Don't make it personal, but don't accept the status quo.

Saving Cancer Medicine

If our field is going to survive the impending crisis of public opinion, it will only be because young people were not afraid to make enemies of the apathetic, the powerful, the connected, and the conflicted. We need young oncologists to be unafraid of making enemies—because our drugs cost too much, too often deliver too little, and are sold with too much hype and misinformation.

Many don't care enough to do anything about it, or they benefit from the status quo. "Don't make enemies" is cowardly advice. Another Martin Luther King Jr. quote: "In the end, we will remember not the words of our enemies, but the silence of our friends."

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