COMMENTARY

Oncology Is Not Immune From Online 'Confirmation Bias'

'The Line Between Creativity and Malpractice Can Be Thin'

H. Jack West, MD

Disclosures

October 15, 2020

It's an increasingly common story: An oncologist looking for guidance shares a complex case on social media with hundreds, if not thousands, of colleagues from around the world. Rather than walking down the hall or picking up the phone for a curbside consult, he or she now taps the collective wisdom of a global oncology community.

Generally, I'm a big proponent of online education and social media. But I'm also witnessing something more disheartening. Even though our questions may be more complex and our data far more technical, the medical community is prone to the same baser impulses that have led to low-quality online discourse in many other arenas, like politics, where arguments eventually devolve into a chronic misunderstanding of many questions.

Take, for example, this recent question about an 86-year-old man with advanced non–small cell lung cancer showing high tumor PD-L1 as well as a MET exon 14 skip mutation, KRAS G12D mutation, potentially a RET fusion, and a few other genomic abnormalities without clear clinical relevance. The oncologist tagged a few thoracic oncologists (including me) for input and waited for the oncology community on Twitter to weigh in, given that there is no clear standard of care in this scenario.

In theory, it's fantastic: Oncologists can now solicit views from around the world. Each institution has its own unique culture of managing cases and now they, along with the preferences of individual oncologists, can be battle-tested by comparing them online and openly discussing their merits.

But like online discussions elsewhere, these interactions about cancer management can also feed our confirmation biases. They have the potential to broaden our views, yet it seems more and more often that they instead crystallize our predispositions or simply lead us down rabbit holes.

For the case above, much of the debate focused on a poorly defined question: What are the relative merits of starting with a newly approved targeted therapy that has yet to be well studied as first-line treatment vs immunotherapy or chemoimmunotherapy in an elderly man who is wary of adverse effects? Another suggestion came in to combine the targeted agent capmatinib with pembrolizumab, with both at attenuated doses.

Here's the problem: There is no clear evidence-based best answer to this or many other complex cases. And not all contributions are created equal; some of the ideas put forth were associated with very significant risk or highly questionable benefit. While we have no idea whether the combination of capmatinib with pembrolizumab is a synergistic one, we have seen a concerning number of toxicities when immune checkpoint inhibitors are administered concurrently with targeted therapies, and sometimes even when they are delivered sequentially.

For my part, I weighed in with my particular concern about cobbling together an untested combination of immunotherapy and a tyrosine kinase inhibitor in an 86-year-old patient: "The line between creativity and malpractice can be thin."

Fortunately, several respected experts corroborated this view with similar strongly worded admonitions.

We Are at a Crossroads

The openness of our online discussions is both a blessing and a curse. At its best, it can challenge us to reexamine and even dispense with our biases as we become aware of new data and their interpretation. But the unfiltered discussions taking place on Twitter and other online platforms open us up to a range of recommendations that are dubious and even dangerous.

We are in the midst of a global struggle to combat misinformation and disinformation in our social and political lives. As a cancer community, we should hold ourselves to a higher standard and be guided by a far more consistent level of rigor. We cannot allow ourselves to seek input online that only validates our biases. The choices made now will determine whether we lead by example and demonstrate how to elevate the level of online conversation or devolve into a free-for-all of dubious recommendations.

H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, California, regularly comments on lung cancer for Medscape. Dr West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing education programs and other educational programs, including hosting the audio podcast West Wind.

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