Cancer Drug Direct-to-Consumer Advertisements -- Good or Bad?

Fran Lowry

September 01, 2016

Marketing cancer-related drugs directly to the public can be harmful in many ways, two oncologists write  in a "Viewpoint" article published online August 11 in JAMA Oncology.

While there is little evidence "so far" that cancer-related, direct-to-consumer advertising (DTCA) causes inappropriate treatment recommendations, the practice does have the potential to foster patient misinterpretations of expected efficacy and toxic effects of drugs, with concomitant harm to the patient-physician therapeutic relationship, write Lowell E. Schnipper, MD, from Beth Israel Deaconess Medical Center, Harvard Medical School, and Gregory A. Abel, MD, from Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.

Such advertising also boosts patient interest in new drugs whose toxic effects may not be fully known, and it also fails to present other treatment options that may be less toxic or costly, Dr Schnipper and Dr Abel write.

However, an opposing view is published alongside in the journal.   "Prescription drug advertisements spread valuable educational information about the promoted product and conditions associated with the drug," writes  Crystal Adams, PhD, a sociologist at the University of Miami, Florida, in an accompanying article.

Doctors in general seem to be against DTCA. A story from Medscape Medical News announcing the American Medical Association's call to ban DTCA attracted hundreds of comments from readers who agreed with the AMA's stance.

The "Opdivo in Lung Cancer" Advertisement

In their article, Dr Schnipper and Dr Abel cite the recent example of the television ad for nivolumab (Opdivo, Bristol-Myers Squibb) for patients with squamous non-small cell lung cancer, which has also been previously reported   by Medscape Medical News.

"The text is announced over uplifting music and features people who ostensibly have cancer and their families enjoying excellent quality of life in a beautiful city at sunset. Positive messages about the drug are projected on buildings as patients and families look on. Later, these same people are watching a baseball game, walking a dog in a lovely park, and playing with grandchildren. No one is filmed being infused, and no one seems to be experiencing significant toxic effects," they write.

Dr Schnipper and Dr Abel note that the ad for Opdivo does not state the proportion of patients likely to tolerate and benefit from the drug. Nor does it mention alternative forms of immune-modulatory therapy or the cost of treatment.

Cost is particularly important, they write, "because patients are increasingly responsible for substantial copayments for cancer treatments."

Presenting patients with cancer enjoying an excellent quality of life may also lead patients to have unrealistic expectations that the drug will work even before they see their oncologist, they write.

The authors also take issue with the way the ad for Opdivo presents efficacy data.

"The following text is provided on the screen: 'In a clinical trial, Opdivo reduced the risk of dying by 41% compared to chemotherapy (docetaxel).' While technically true, this statement is incomplete. In the cited clinical trial, the extension of median progression-free survival was 0.7 months (21 days when compared with docetaxel) and overall survival was 3.2 months longer," they write.

It can also be dangerous to promote drugs before the full scope of any toxic effects are known, the authors write.

As an example, they cite the initial enthusiasm for recombinant erythropoietin-alfa for the fatigue associated with chemotherapy.

"The patient-directed and physician-directed marketing campaigns soon after approval undoubtedly helped lead to a large increase in the use of these agents.

"Although haemoglobin level was higher following recombinant erythropoietin-alfa administration, subsequent studies demonstrated higher mortality in patients with advanced cancer after using the agents. It is uncertain how many patients were harmed by the explosion in erythropoietin-alfa use in oncology before they were understood to carry a higher mortality risk," Dr Schnipper and Dr Abel write.

Opposing View

In the opposing "Viewpoint" article, Dr Adams writes that DTCA has been roundly condemned for "so-called disease mongering," but, in fact, the practice can encourage the adoption of healthy behaviors, foster a new sense of patient empowerment, and emphasize personal responsibility for individual health.

"Early in my career I was very critical of direct-to-consumer advertising, and I used to be in favor of a ban, but then, as I started to conduct research into the content analyses of DTCA and as I started talking to patients directly, as well as doctors and representatives from the pharmaceutical industry, I realized that the question should not be 'Should there be a ban on DTCA?' Instead, the better question should be 'How can we regulate DTCA to maximize patient benefit?'" Dr Adams told Medscape Medical News.

"The positive effects of DTCA include greater involvement in medical decision-making, increased compliance with prescription medication intake, and improved patient-physician communication," she said.

"My positive comments about DTCA extend to cancer-related drugs," she said.

"Patients are very savvy, and when I was doing my research I got a lot of feedback from patients that they were very aware that the information they were receiving from pharmaceutical companies was biased. They don't necessarily take it for granted that the messages that are coming are not skewed, and are aware that the depictions of patients on prescription drugs is not necessarily reflective of reality," Dr Adams said.

DTCA opens a line of communication between patient and doctor, she argued.

"This is particularly the case for minority populations. We found that when patients felt that a prescription drug was relevant to their life in some way they would talk to their doctor about it, and that these conversations were new courses of conversations they would not necessarily have had if they had not seen that prescription drug advertised. There is scant research related to health disparities and DTCA, but we did see that minority populations are more likely to go to their doctor after they have seen a drug ad to seek care," Dr Adams said.

There is a general perception, particularly among doctors, that patients are going to go to them and push their request for a prescription drug that they have seen advertised, but this is false, she said.

"This is not what we are finding in our research. Yes, such patients do exist, but for the most part, patients trust their doctor's opinion and expertise, and they trust their doctors more than they do the pharmaceutical industry. What often happens is, they go to their doctor and the doctor says, ok, we can try this, and maybe it will work better for you, or else the doctor will tell them that the drug is not necessary, and 9 times out of 10, patients will accept their doctor's opinion and they don't push," Dr Adams said.

DTCA of pharmaceuticals is so entrenched now in our society that invoking a ban would be futile, she added.

"We live in an information age, and patients can very readily go to the Internet and search for whatever they want to search for. I think that DTCA strengthens the doctor-patient relationship because it helps patients have discussions with their doctor. It opens that line of communication, and this is especially true for minorities," Dr Adams said.

Dr Schnipper reports that he is the co-editor-in-chief of UpToDate and is a member of the advisory board of NanteHealth Inc. Dr Abel and Dr Adams have disclosed no relevant financial relationships.

JAMA Oncol. Published online August 11, 2016.  Schnipper/Abel abstract   Adams abstract

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