The floor, not the ceiling: industry ties across the cancer ecosystem.

Industry financial ties to the US cancer ecosystem are everywhere. Kim et al.'s systematic review and meta-analysis finds that financial conflicts of interest exceed 50% prevalence across most oncology domains. These relationships are not always benign. A robust body of health services research, including a 2021 systematic review of 36 studies, demonstrates that 83% of analyses identify a positive association between industry payments and prescribing behavior. Even a single industry-sponsored meal costing <$20 has been linked to significantly higher odds of prescribing the promoted drug. As federal National Institute of Health (NIH) funding faces cuts, industry's role in shaping the research agenda will only expand. Current US policy responses such as the disclosure through the Sunshine Act and dollar thresholds for guideline panelists have had minimal effectiveness in curtailing the money flowing to oncologists. This editorial argues for stronger structural reforms, specifically mandatory cooling-off periods for guideline committee members modeled on existing federal ethics statutes. Disclosure alone is insufficient, and some evidence suggests it may paradoxically license conflicted behavior. Meaningful progress requires moving beyond transparency toward policies that prevent conflicts from influencing clinical decision making.