Interview: Dr Vinay Prasad - European Medical Journal

9 Mins
Oncology

Dr Vinay Prasad |Haemato-oncologist and Associate Professor of Medicine at the University of California, San Francisco, California, USA

#### You have an impressive background in science communication within the medical field, not only working with patients as a haematologist and oncologist, and with medical students and residency trainees as an associate professor and mentor, but educating the wider community of doctors and researchers through your podcast, YouTube channel, twitter discussions, books, and academic publications. How would you describe your work and what do you consider your primary focus?

That’s a generous summary. I will draw a distinction. There is the work I do, and the way I disseminate that work. The work I do is studying cancer health policy and low-value medical care. I’m interested in the cost, usage, approval, and evidence supporting cancer drugs. The primary output of that work is peer-reviewed academic articles that readers can find at my website.1 Having done this work, I am interested in using all the modern methods of dissemination. That’s why I write books, tweet, make a podcast, and am a novice YouTuber. It’s a sad truth of our business that many academics write articles that end up having very low readership or metrics. That’s why I try to take advantage of all the tools of 2020 to get the findings and ideas to other people to run with. That’s what science boils down to: sharing and discussing your ideas and findings with others.

#### You characterise your field of work as ‘meta-research’: interrogating the methods, analyses, intentions, and evidence that underpin cancer drug development and the ways that research is translated into practice. What drew you to this broader curiosity and scepticism, beyond bedside practice?

I went to medical school to be a doctor, and later decided to be a cancer doctor. In a perfect world, that is all I would do. I would go to my clinic and see patients, go home and ride my bicycle, read books, and watch Netflix. I would be able to trust the clinical trials to give me useful information, and trust the experts who write the guidelines.

As I went through my training, I realised slowly and with growing horror that we did not live in that world. We live in a world where the evidence for new products can be poor. The cost is often excessive. On several occasions, experts have recommended the use of products for which they are paid by the makers; this could be problematic as it may result in a large scientific and moral discrepancy in the system.

Having realised my predicament, I started trying to brainstorm ways to do research that would re-orient the compass of care back to doctors and patients. After a while, I had done enough projects that I became known for this work. I picked up the tool of meta-research from academics before me because it is the perfect way to illustrate the problems in the cancer drug ecosystem. Eventually, these projects kept me busy, and that’s where I am today. Now half my time is service and clinic, but half my time is research. I still dream of living in a world where all my time can be clinical.

#### Do you think that clinicians should generally have more active engagement with drug development and research, and how can we build towards this?

I think clinicians should understand drug development, as it can be misused to deceive them. My book Malignant tries to explain it as simply as I can. I think clinicians should encourage patients to participate in good clinical trials (a fraction of all trials) and accrue patients on these studies. Beyond that, I don’t think the average clinician has any further obligation for research and development. Those are separate pursuits for those inclined.

#### You have highlighted issues in research and development, but still advocate for the positives of evidence-based practice. What is the value of research and evidence-based medicine in patient care and how can clinicians and researchers amplify useful strategies and benefits?

Randomised controlled trials are an aeroplane. They’re a really useful tool, a technological marvel. Simultaneously, the current research system is a failing airline: it is a miserable experience. But blaming randomised trials for the current system is like blaming the aeroplane for the failing airline. It’s not the aeroplane’s fault.

We have a choice: to make a research system that empowers patients or one that enriches shareholders. We have chosen, over and over, the latter, but I think we can focus on the former. This means rethinking our studies: better controls, better post-protocol therapy, better endpoints. I have a lot of specifics in the book, but I want to be careful. Just because an airline has packed too many seats on an aeroplane does not mean there is something wrong with flying. We can spread the seats out and make it a more pleasurable experience, which ironically, it once was.