A true scientist reserves the right to possibly err, even about his own discipline! ~Robert Bendavid.
Unlike Richard Horton (Editor-in-Chief of the Lancet), in his remarkable comment, “Offline: What is medicine’s 5 sigma?”, I cannot entirely observe Chatham House rules through which one cannot say who made what statement, nor can one take photographs of slides. I do not fear to live in “purdah” (his word) for my views as long as they are couched in honesty and integrity.
Still, several conclusions were confirmed in Horton’s comment: namely that “A lot of what is published in incorrect … much of the scientific literature, perhaps half, may simply be untrue … science has taken a turn for darkness … As one participant put it ‘poor methods get results’, … the apparent endemicity of bad research behaviour is alarming; … scientists too often sculpt data to fit their preferred theory of the world; … or they retrofit their hypotheses to fit their data; … our love of ‘significance’ pollutes the literature with many a statistical fairy tale; … and individual scientists, including their most senior leaders, do little to alter a research culture that occasionally veers close to misconduct”! (1).
Such dire warnings are not new. They have been proffered more and more often in the last dozen years. I for one, have lost a certain trust in hernia societies, some registries, myriad authors, many peer reviewers, biased editors, the FDA and last but certainly not least … the device industry and mesh manufacturers.
Professor Peter C. Gøtzsche, who was a co-founder of the Cochrane Collaboration in 1993 along with Sir Iain Chalmers and 80 other investigators, and leader of the Nordic Cochrane Center in Copenhagen which he created in 2010, has pointed out that the code of ethics observed by big Pharma and by extension, their collaborative physicians and surgeons, is reminiscent of “mafia” practices (2). Pr. Gøtzsche has condemned ghost writing, a common practice by the industry and collaborators, as “scientific misconduct” (3). He had the fortitude to express his concerns about “growing top-down authoritarian culture and an increasingly commercial business model that threatens the scientific, moral and social objectives of the organization”. He further asserted that “Cochrane no longer lives up to its core values of collaboration, openness, transparency, accountability, democracy and keeping the drug industry at arm’s length’! (4). For such criticism by a founding father of the Cochrane Collaborative, Pr. Peter Gøtzsche was dismissed from his functions by a vote of 6 to 5 at Cochrane’s headquarters in Edinburgh, Scotland on September 26-2018. The need for such a stand by upright if incensed individuals is no longer an ideal but a moral obligation which sadly, is not frequently shared in the board rooms of venal societies, insatiate research departments and greedy plunderbunds driven by profit margins which have often been described as obscene but are still the envy of the business world.
Several publications in respected journals have reflected the suspicions and confirmations of Peter Gøtzsche. Probst et al. have reported in Annals of Surgery (2016) that “industry-funded trials more often reported positive outcome without statistical justification” and “exaggerated positive reporting of outcomes” (5). Criss and Gadepalli concluded in the American Journal of Surgery that “this initial pilot study highlights a potential bias as current literature published by benefactors demonstrates low quality and highly positive conclusions towards approval of the robot” (6). Danielle Wenner and Carol Ashton reported in JACS 2018, in “Do surgical trials meet the scientific standards of clinical trials?”, they concluded that “Our findings indicate failure on the part of investigators, independent review boards and peer reviewers (7).
At the risk of sounding trite by repeating bromides, one cannot dismiss statements by Pr. John Ioanidis from Stanford (medicine and statistics) who stated that “… false findings are the majority or even the vast majority of published research claims” (8). Barbour observed in PLoS Medicine that “…Journals may increasingly become close to works of fiction, telling stories dictated by lobbyists, rather than works of science” (9) while Steen in 2010, revealed “that the United States leads the world in retracted Journal articles and its scientists were cited as the most prone to engage in deliberate fraud” and questions whether “authors commit deliberate research fraud” (10). Carl Heneghan from Oxford University (who leads ‘Evidence Based Medicine”) reminds us that ”…but with the questionable integrity of much of today’s evidence …” (11) and in December 2018, he adds: “It’s unacceptable to keep maintaining this system”(12). Cherla & Olavaria et al. reported an “Investigation of Financial Conflict of Interest among published Ventral Hernia Research” in JACS and concluded that “70% of articles have a COI. Self-reporting COI is discordant in 63% of the articles and 25% of relevant COI are not disclosed”. Significantly, they reveal in “Comparison of conflicts of interest among published hernia researchers…” that there is substantial discordance between self-reported COI in published articles compared with those in the Centers for Medicare and Medicaid services Open Payment data base” (13). A review by Patel et al. (14) in Annals of Surgery (2018) confirmed that “where authors did not declare a COI, they were 4.3 times more likely to be more favorable to robotics than papers with declared COIs! An investigation by the BMJ (October 11-2018) reveals how “vaginal mesh implant manufacturers "aggressively hustled" their products into widespread use, how regulators approved them ‘on the flimsiest of evidence’ and how the medical profession failed to set up registries that might have picked up problems far sooner” and “It also names prominent individuals—all on mesh guidelines committees—who take money from mesh manufacturers for various activities including research grants, speaker honorarium and consultancy, as do the medical royal colleges, creating a potential for bias”. Further and a shattering thought, “But it isn't only individual clinicians who have financial links with industry, says the BMJ article, which cites links between some of the leading mesh device companies and several royal colleges, including the Royal College of Surgeons (15,16,17,18,19)). A last comment from the same publication by Dr. Fiona Godlee, The BMJ's Editor in Chief and Professor Carl Heneghan of Oxford University's Centre for Evidence Based Medicine: “the postmarketing assessment of vaginal mesh has been ‘a shameful episode in the history of implantable devices’." .
But regardless of the perceived or actual effect of such extensive industry influence within specialist branches of the medical profession, “none of this information is freely or easily available to the public in the UK” (19). In Canada, our minister of Health, Ginette Petitpas Taylor has reacted as one would expect from a conscientious minister, with utmost concern for the public and is passing legislation aimed at making Health Canada transparent and free from encumbrances by red tape and lobbies. A web site already established will give access to types of devices, known complications to anyone about to undergo surgery. Hopefully, Canada Health should supplant the FDA, at least in Canada.
Some surgeons remain oblivious if not naïve as observed in the words of A. Wright in a General Surgery News debate on conflicts of interest when he declares that “…the number of physicians who are truly industry shills is thankfully quite small” (20). This view is tantamount to staring at climate change and perceiving it as a sprinkle of rain!
It is an ironic fact that the first attempt at creating an “American Hernia Society” was mapped out in the classic pattern of an egregious Conflict of Interest if not a poorly calculated attempt at collusion or corruption!
In August 1996, eight established surgeons: Raymond Read, Arthur Gilbert, John Skandalakis, Ira Rutkow, Parviz Amid, Lloyd M. Nyhus, Stephen Scott and myself were invited by a prominent mesh manufacturer with an intent of creating a hernia society. An additional four surgeons, absent, not known to any of us were also added to the final list to make up a proposed board of directors for the nascent hernia society. The funds provided amounted to $220 000. A manager was appointed by the mesh company who would draw a salary of $45 000/year for three years from the said grant, leaving essentially a budget of $85 000 for three years of operation!
The only requirement by the mesh company was that no other mesh manufacturer was to participate in any activity of the society for at least three years. Enough time, I assumed, to promote a recently released polypropylene device for the treatment of adult inguinal hernias. Annual meetings would have been devoted entirely to the said company, essentially a single, monopolistic device-fest! A truly sweetheart deal for the mesh company if it were to be. And all for a song!
Lloyd Nyhus was the first to leave as he was not interested in such an organization. Back in our own homes, I took up the discussion with Dr Shouldice who agreed with Lloyd’s attitude. I called Lloyd at home and asked him whether he would favour an organization without the industry. To this, Lloyd Nyhus replied with a resounding yes and Dr Shouldice offered to host the first meeting in Toronto.
I set to work calling all the colleagues who had been neglected by the industry and all agreed that the offer by the mesh company was unethical, unconscionable and called for trenchant criticism. Gilbert and Rutkow persisted in remaining with the original proposal and manufacturer. Someone suggested that a meeting in balmy Miami in February would be more desirable than in Toronto and this suggestion was taken up.
All the fifteen surgeons whom I contacted were colleagues whom I felt would be influential through their academic accomplishments to form a society, de novo, free from any industrial entanglements, COI and lobbying by a ravenous industry. Arthur Gilbert, seeing the writing on the wall finally decided to join us. He offered to incorporate the new society in Florida and his dogged devotion in seeking out new members convinced all that perhaps he should be awarded with the first presidency and this was duly voted on and carried out. The inaugural picture included 13 members while Guy Voeller and Marty Arregui were absent. The AHS was founded on January 11-1997. I duly notified the mesh company that their offer had been rejected. Ira Rutkow on the other hand, simply disappeared from the face of the earth!
Conflict of Interest
What constitutes a conflict of interest is not easy to define because it is a subjective evaluation by a recipient of the industry’s largesse while it is an objective opinion by an unbiased observer. To be sure, many surgeons will develop a certain blindness to it by deceiving themselves especially if money, renown, authority among their peers will result from such conflicts. Perhaps TS Eliot described such characters best …” Half of the harm that is done in this world is due to people who want to feel important. They don't mean to do harm but the harm does not interest them”. T.S. Eliot, (1888-1965).
Who is to blame for this existential volte-face which ails our own field of surgery? The final common pathway always leads to the surgeons, most of whom are not aware of the subliminal messages or the beam in their eyes. That is not to say that the societies, the industry, editors, reviewers, authors and the FDA are without sin. Each deserves our attention if briefly.
The Hernia Societies
Some Hernia Societies have consolidated all the shortcomings surrounding the conflicts of interests. They reflect the temporary leaderships rather than the unbiased judgement of a membership that feels left out. Annual meetings are but a bazaar where all the companies display their polypropylene wares and devices, most of which have never been scientifically, ethically or reliably tested or proven to be safe. The FDA simply depends on the 510k clause which grandfathers anything made of polypropylene and relying on confirmation by surgeons who are ill-equipped to handle honestly the issue of informed consent. “Lunch and Learn” are herd culls given by a “collaborative” surgeon who will be paid handsomely for his effort. Most objectionable is the presence of the industry on the board of the AHS and its constant influence especially with research, grants and sponsorships which generally must promote the companies’ interests. The funding of registries, Guidelines have always been generous as they are the cheapest and a most effective method to advertise through supposedly competent opinion leaders. Especially if one is the president of the society or a board member who will use his authority to defend his pale, as happened when Carbonell removed an associate editor of HERNIA because of his opposition to the International Guidelines (which have never gone through the time hallowed blind, peer review and were elaborated by surgeons with foregone conclusions and fealty to the industry). For good reasons, as we shall see, through the payments obtained from the industry and gleaned from the Open Payment Data base: https://www.cms.gov/. Those Guidelines were sponsored and funded by Ethicon, Bard, Medtronic.
A German watchdog, <guidelinewatch.de>, which assesses the transparency and independence from the industry) found that only 11% of the 165 “guidelines” in medicine rated as good with enough transparency and no conflict of interest. (21). <(https://www.leitlinienwatch.de,)>. It is also unethical to use the good offices of the AHS, by harnessing its logo, its fame, its assumed authority to promote the interests of an individual surgeon or a hernia centre with which that surgeon may be associated. The most recent such a foray is a course offered by a group, through the AHS’ offices, to surgeons unfamiliar with robotics but who have access to a robot!
Another egregious abuse of authority is the setting up of the AHS Practice Advisory Committee which promotes the use of mesh in all patients as decided by its panel of 25 surgeons, all of whom had already concluded, before issuing a statement, that there is no better way but mesh for all hernias. Led by Yuri Novitsky who received the sum of $809 000 from 2013 to 2017, according to the US Open Payments Data Base. He could become the poster boy for bias and COI. His appointment as an associate-editor to the journal HERNIA could explain the malignant nature of dissemination of mesh techniques by the bidding industry and their collaborative surgeons at a time when chronic-post herniorrhaphy pain has become the most common and most serious complication of groin hernia surgery. Recent studies and reviews by Urbach, Köckerling, the Mayo Clinic, totalling a population of almost 1 million patients have proven that recurrences are just as frequent or higher with mesh techniques and perform no better than pure tissue repairs (22,23,24).
Adding chronic severe inguinodynia (12%; range 6% to 75.5%), dysejaculation (3.1%), pain during sexual activity 10.9% to a mesh recurrence rate of 5 - 11%, certainly negates any perceived advantages of mesh in a groin repair (25, 26, 27, 28, 29,30).
Last but certainly not least are the declared conflicts of interest at annual meetings of the Americas Hernia Society. The year 2014 was reviewed (31) and there were 42 surgeons (49.4%) who declared a COI while 36 (42.4%) declared no COI, 7 (8.2%) who should have declared a COI but did not. Those with a COI spoke on behalf of 145 companies. There were 23 surgeons who acted as consultants to 54 companies (1 at least and 8 at most). There were 22 surgeons who received grants from 44 companies (1 at least, 4 at most) and 21 surgeons listed on the speaker’s bureau for 47 companies (1 at least and 8 at most). It would be difficult to conceive that there would be no bias in their presentations.
The Europeans, unlike Americans and Canadians, do not have a system in place to declare income from the industry so that a COI may be more difficult to identify.
Some surgeons long known to be sponsored generously by or working for the industry do not appear anywhere on the US Open Payments data base!,
Mesh producing corporations, in principle, have a fiduciary duty towards patients. However, in this role, those corporations have failed dismally. All the necessary information about polypropylene (PP) mesh, its nature, its behavior and complications have been obtained through US courts of law. Much of the knowledge about PP is propagated by surgeons instead of chemists or polymer engineers who are best qualified to confirm that PP is NOT inert and degrades readily at a speed which varies with the presence, type, quantity of antioxidants, stabilizers, hindered phenols, hindered amines, phosphates, thioesters etc. Such antioxidants can be used up in controlling free radicals within the polymers and weaken the nature of the PP. This explains why a Marlex® mesh could in fact become resorbed within 4-6 years and lead to “mesh fracture” or breakdown (32).
While the mesh industry has had us convinced that mesh shrinkage is due to changes brought on by the patient’s scar tissue, the reality is more scientific, chemical and the explanation is found in the nature of the mesh fibres which undergo changes in what is called “post-crystallization” and is an inherent step in the manufacture of PP and occurs during the transition from the amorphous to the crystalline states. A state much affected by temperature, humidity and aging (33).
What is of greater concern is the sinuous route which Bard and others have insisted on in order to maintain the sale of polypropylene mesh and devices. These implants were never meant to be used in humans, according to evidence obtained in courts with a statement by Chevron Phillips, the makers of the polypropylene resin. That warning dates back to 2004 (34) though the industry had been aware of this shortfall much earlier. An additional and serious drawback of the industry is the lack of a registry for complications. Usually, these companies will demand from patients an explanted mesh for analysis (not always available) and if it were available, checking the “stock number” reveals the mesh to be normal and therefore, the complication is always due to a “technical mistake by a surgeon who has not been properly trained in the use of mesh”, a common reply to patients’ complaints. The choice of key surgeons by the industry within societies or university departments has facilitated their invasion of research departments through which they can acquire a semblance of respectability and accelerated diffusion of their message. In the UK, Johnson and Johnson (Ethicon) was one of 83 global firms to have direct access to the cabinet or to a senior minister through what has been termed a “buddy scheme” (35). This scheme denotes lobbyism as a most cultivated political tool and strategy.
The influence of industry has been pervasive and ubiquitous as can be observed in the funding of registries, guidelines, courses of indoctrination, hernia “schools” where diplomas will be awarded to candidates. Though still unofficial and in the planning stages, the industry will be funding three “hernia schools” in Spain, Italy and Germany.
Most disappointing is the fact that 9 out of the top 10 companies spend much more on marketing than in research. The “biggest spender, Johnson and Johnson, shelled out 17.5 billion in marketing in 2013 compared to 8.2 billion for R & D” (36).
It would be apt at this juncture to quote the most respected economist of all time: the British born Adam Smith (1723-1790): “The interest of [businessmen] is always in some respects different from, and even opposite to, that of the public ... The proposal of any new law or regulation of commerce which comes from this order ... ought never to be adopted, till after having been long and carefully examined ... with the most suspicious attention. It comes from an order of men ... who have generally an interest to deceive and even oppress the public” (37).
In 1938, Franklin D. Roosevelt signed the Food, Drug and Cosmetic Act into law, following 100 deaths from the drug Sulfanilamide. A federal agent investigating the S.E. Massengill Company, revealed: “there was a complete lack of testing facilities, apparently, they just throw drugs together, and if they don’t explode, they are placed for sale” (38)! It would seem that things have not changed much from the pre-Roosevelt days at the FDA! In 1976, Gerald Ford signed the Medical Device Act into law which was prompted in part by the injuries to 900 000 women by the Dalkon Shield. If one considers the severe chronic post herniorrhaphy pain, estimated to range from 3% to 75.5% (25,26,27,28,29,30), and if one accepts the very conservative estimate of the EHS International guidelines (39), the incidence of such pain is 12%. Since over one million hernias are handled per year in the US alone (40), this would mean that 120 000 patients a year, at least, would run into the problem which is becoming a more frequent entity and for which surgeons are beginning to effect mesh removals successfully. Both, groin (80%) and ventral/incisional hernias (20%) are affected in the same manner and proportion (10-12%) albeit that the latter present a different set of complications eg: erosions into bowel, fistulas etc. This data is to be shortly published by our group. This means that since the mid - 1990s, when mesh use began its vertiginous climb, there would be more than 3 million such injuries for which the FDA has dubious records, if any. An investigation by “more than 250 journalists in 36 countries representing more than 50 media organizations (International Consortium of Investigative Journalists) … spent nearly a year examining the safety of medical devices. They found that more than 1.7 million injuries and nearly 83 000 deaths had been reported to the FDA over a 10 year period”. By its own admission, the FDA has “the most sophisticated adverse event reporting system in the world but acknowledges that its data is “inconsistent and incomplete” (41).
A common source of criticism aimed at the FDA is the 510k issue. Anything made of polypropylene in any shape, form, configuration has been approved when it is the polypropylene which has fed the controversy of mesh as an adjunct to hernia repair. General surgeons are quick to point (as did the Practice Advisory Committee of the AHS) that the problem with hernia is “different” from vaginal and pelvic organ prolapse operations. That statement is inaccurate. The problem is identical with the exception that the vaginal wall and urethra are adjacent to the mesh, thinner, readier for erosions and perforations, infections, irritation by loose, solidified spicules of mesh fibres. These findings were confirmed by Iakovlev et al (42).
Looking at the FDA website, reporting complications by surgeons, hospitals and the industry is recommended but as one can read, a patient has to have died or come close to dying before it is recorded and there is no legal imposition to do so.
In Canada, the federal ministry of health has promised more transparency as a result of the reports of the International Consortium of Investigative Journalists. A website is now available for anyone to consult about devices and implants, complications etc… All the information which any surgeon should objectively and honestly discuss with patients before signing a consent which then would be truly informed. But we know that a surgeon is too ready to put his spin on his favourite mesh and technique (as is often seen without full disclosure) so that the Health Canada website will provide the facts correctly which are likely to be at odds with the recommendations of most surgeons.
Editors, Reviewers, authors.
A strange phenomenon of the last 20 years is that the new generations of surgeons have never seen a pure tissue repair, much less done one!
Bassini, Mc Vay & Shouldice have been relegated to antiquity with an arrogance which can only betray ignorance. Can one be a true hernia surgeon who cannot do a herniorrhaphy unless a mesh is used? There is no doubt that reason has succumbed to advertising. Less than 20 years ago, reports by Nyhus, Stoppa, Flament, Rives, Berliner, Shouldice reported recurrence rates of less than 2%, a much lower rate than seen with mesh today (43).
Of particular interest is that Francis Usher, who introduced Marlex®, wrote a chapter for Lloyd Nyhus’ first edition of HERNIA in 1964 and described the use of Marlex only for direct inguinal hernias. Indirect hernias were never mentioned, since they rarely recur when properly handled without the need for mesh. (44).
To perpetuate the anomaly of mesh for all is the emergence of surgeons as journal reviewers with no knowledge of pure tissue repairs. They seem to think that polypropylene has been in use for 60 years without any problem and have become oblivious of its complications, no doubt obnubilated by the thick clouds of industrial sponsorship. The climb in the use of mesh has paralleled the appearance and steep climb of chronic pain, starting in the mid-1990s.
It is worthwhile to note that Hernia Surge released its “EHS International Guidelines for the treatment of adult hernias” in February 2018 and by March 2018, the entire editorial staff was relieved of its functions and HERNIA will no longer be the voice of the AHS/EHS. No explanation was offered for this turnabout but surely, issue #1 of The Hernia Letter predicted this sudden demise simply on the basis of such teeming of maundering COI by all the participants of the steering and working committees. Why the guidelines appear on the AHS website is beyond me but, the influence of Carbonell, while he was president of the AHS betrays a certain unfettered loyalty to the industry.
While the creation of registries was well intentioned, they have become a tool of the industry which can afford to appear uninvolved and at arm’s length since the registries play so well into the industry’s plans, schemes and promotions. Most registries are sponsored by the industry except the one in Denmark which is funded by the state. However, those who make use of the Danish data are a group of constant authors whose conclusions would seem to have been written by the industry. Personally, and I insist on this being personal, I have given up reading or trusting Danish reports from their data base. They have been instrumental in convincing the world that there is more CPIP associated with pure tissue repairs than with mesh (unheard of except with collaborative surgeons and certainly negated by older authors such as Nyhus, Ponka, Devlin etc… in their textbooks, that all women regardless of the type of hernia must be treated with mesh laparoscopically (65% of women have an indirect inguinal hernia which need the simplest operation since they rarely recur) and that mesh is no danger to fertility with a study in which unilateral hernias (92%) and bilateral hernias (8%) were illogically combined as one group with an inadequate follow-up which should be in terms of years (9 years and beyond) (42,45)! The Danes have been relying on Gedankenexperiment and Deiknymi where the proof lies with a conceptual rather than an experimental confirmation (46,47,48,49,50). Simply said: "I thought it out therefore it must be right"! I have had reasons to criticize them at conferences as well as through letters to the editor. Close examination of the Hernia Surge International Guidelines published in February 2018 shows the influence that the Danish Hernia Data Base has had on the recommendations of those guidelines which have never been vetted by blind peer review. Nor have they adhered to COPE (Committee On Publishing Ethics) standards which emphasize transparency and best practice. These deficiencies should have been reason enough to forbid their publication.
It is a sad commentary that the Europeans do NOT have to declare any COI or any income from the industry as do the Americans and Canadians, a blunder which facilitates any covert activity on the part of collaborative surgeons, a disservice to unsuspecting patients and to a profession which is, more and more, looked upon as a shill for the industry.
Sadly, journal editors are not exempt from involvement in COIs. A British Medical Journal study by Bell and Cram (BMJ-2017) have reviewed “52 influential journals”, “Of 713 eligible editors, 361 (50.6%) received some (>$0) general payments in 2014, and 139 (19.5%) received research payments” and “the mean general payment was $28 136, and the mean research payment was $37 963” (51). These are minor payments compared to those recorded for promoting devices in hernia and sling operations and the effect on public trust cannot be overestimated.
The appalling extreme to which some editors will reveal their duplicity has no limit. In a recent issue of the International Journal of Abdominal Wall and Hernia Surgery (November 2018), a colleague, John Morrison submitted a paper entitled: “A case for open inguinal hernia repair”. One would expect a routine acceptance (or not) and the appearance of the article in print. Two associate editors: Reinhard Bittner (head of the European section) and David Chen decided to review Dr Morrison’s text and replied with a 5 page editorial of their own which consisted of shredding any and all good faith statements by Dr Morrison without any supporting evidence nor touching upon the main objections (CPIP, erosions into bladder, adhesions to iliofemoral vessels etc.) of laparoscopic techniques while vaunting all its wonderful attributes. A rebuttal was called for but that will be the topic of the next Hernia Letter! (52,53)
How does one control and regulate the influence of industry in defense of patients who could never, despite the most detailed information, make an informed decision which has not been swayed beforehand by industry and its collaborative surgeons? Industry whose policy is dictated by marketing strategies rather than honest, transparent scientific evidence and conviction, or a government health agency bent on promoting industry (through 510k policies) with utter disregard for a public which is venting its ire through the courts.
A possibility would be that COI come under the control of licensing bodies for each state or province. There ought to be a code issued by these licensing bodies which would determine what constitutes COI. Where transparency is not evident, where COI is not declared or bandied with would constitute reason enough for a disciplinary action which would garner the support and enforcement by civil and criminal courts. COI must be recognized for its deleterious effects, its dangers, its pernicious nature and for its unprofessional principles which Hippocrates would condemn.
When you deceive yourself, there is no one else left in the world to deceive. R. Bendavid.
Surgeon’s Income, directly from the industry, according to the US Open Payments Data Base. Data collected by Dr Kevin Petersen MD. Some surgeons outside this time span have been known to receive up to $1 million and beyond.
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