Update on Direct-to-Consumer Marketing in Oncology

Postgraduate training in Cancer Genetics-a cross-specialty survey exploring experience of clinicians in Ireland

BACKGROUND

As genomic profiling of constitutional and tumour-derived DNA becomes increasingly critical in cancer risk estimation, prognostication and treatment, there is a growing need for clinicians involved in cancer care to up-skill in Cancer Genetics. In the Republic of Ireland (ROI), this is particularly crucial, given a paucity of vocationally trained Clinical Geneticists per capita compared to other European countries.

AIMS

We aimed to assess the self-reported confidence of postgraduate medical/surgical trainees in ROI in requesting, interpreting, and managing genomic data in patients with cancer, and to assess their selfreported experience, and demand for future training in this area.

METHODS

A cross-sectional survey of postgraduate trainees in four specialties (Medical and Radiation Oncology, Surgery, and Obstetrics and Gynaecology (O&G)), training in ROI, was undertaken. A bespoke electronic questionnaire was designed to capture data regarding preceding experience, and confidence across several hypothetical clinical scenarios involving genomic testing. The survey was circulated to eligible participants by training programme administrators, after relevant institutional ethical approval. Data was collected anonymously.

RESULTS

The study cohort included 62 respondents. A paucity of cancer genetics training at every level was demonstrated, with "hardly any" or "none at all" reported by 47(76%), 62(100%), and 50(81%) during undergraduate, core specialty, and higher specialist training, respectively. A relative lack of confidence in all clinical scenarios was apparent, particularly among Surgery/O&G trainees. Most respondents would value more training in Cancer Genetics.

CONCLUSIONS

This study demonstrates an unmet need in dedicated Cancer Genetics training for postgraduate specialty trainees in ROI.

The Commercialization of Genetic Research: A Pilot Study

With the development of molecular genetics, the field of personalized medicine based on genetic data has been growing at a phenomenal pace. Genetic tests can identify health risks, ancestry, and genealogy, as well as the prediction of drug responses. However, very limited research exists about the marketing practices of companies, which promote and sell DNA ancestry and health-related genetic tests directly to the public.

Aim. To evaluate the awareness and attitude about genetic testing in the population of a large industrial city in Russia (on the example of Irkutsk).

Materials and methods. A total of 305 respondents – 265 of them were students of higher educational institutions of Irkutsk. The study was conducted on condition of anonymity. The questionnaire was available on the Internet on the basis of the Google Forms service. All basic concepts were explained to the participants during the survey.

Results. 94.1 % are interested in conducting genetic testing on a commercial basis. Of the total number of survey participants, 72.8 % expressed a desire to undergo the analysis “Hereditary predisposition to diseases”, 61 % – “Monogenic diseases”, 52.1 % – “Ethno”. In addition, out of the total number of respondents surveyed, 36.7 % want to undergo genetic testing for research: features of metabolism and food intolerance “Diet”, 22 % – susceptibility to injuries and speed of recovery of physical form “Sport”, 18 % – to hereditarily determined susceptibility to drugs “Pharmacy”. It follows from the answers that the greatest interest among the surveyed people is the determination of predisposition to cardiovascular diseases – 72.5 %, to Alzheimer’s disease – 48.3 % and diabetes mellitus – 40.3 %.

Conclusion. The results obtained indicate an interest in the study of predisposition to cardiovascular and neurodegenerative diseases. There is a high need to analyze the assessment of the clinical usefulness of genetic research, to assess the impact of research results on human behavior and the system of regulation of genetic testing in healthcare in general. 

Direct-to-Consumer Advertising for Cancer Centers and Institutes: Ethical Dilemmas and Practical Implications

In the United States, many cancer centers advertise their clinical services directly to the public. Although there are potential public benefits from such advertising, including increased patient awareness of treatment options and improved access to care and clinical trials, there is also potential for harm through misinformation, provision of false hope, inappropriate use of health care resources, and disruption in doctor-patient relationships. Although patient education through advertising is appropriate, misleading patients in the name of gaining market share, boosting profits, or even boosting trial accrual is not. It is critical that rigorous ethical guidelines are adopted and that oversight is introduced to ensure that cancer center marketing supports good patient care and public health interests. Patients with cancer have been identified as an especially vulnerable population because of fears and anxiety related to their diagnosis and the very real need to identify optimal sources of care. Cancer organizations have a fiduciary duty and a moral and legal obligation to provide truthful information to avoid deceptive, inaccurate claims associated with treatment success. In this article, actionable recommendations are provided for both the oncologist and the cancer center's marketing team to promote ethical marketing of services to patients with cancer. This tailored guidance for the oncology community includes explicit communication on (1) ensuring fair and balanced promotion of cancer services, (2) avoiding exaggeration of claims in the context of reputational marketing, (3) providing data and statistics to support direct and implied assertions of treatment success, and (4) defining eligible patient groups in the context of marketing for research. These recommendations for cancer centers are designed to promote ethical quality marketing information to patients with cancer.

Quantitative Information on Oncology Prescription Drug Websites

Our objective was to determine whether and how quantitative information about drug benefits and risks is presented to consumers and healthcare professionals on cancer-related prescription drug websites. We analyzed the content of 65 active cancer-related prescription drug websites. We assessed the inclusion and presentation of quantitative information for two audiences (consumers and healthcare professionals) and two types of information (drug benefits and risks). Websites were equally likely to present quantitative information for benefits (96.9 %) and risks (95.4 %). However, the amount of the information differed significantly: Both consumer-directed and healthcare-professional-directed webpages were more likely to have quantitative information for every benefit (consumer 38.5 %; healthcare professional 86.1 %) compared with every risk (consumer 3.1 %; healthcare professional 6.2 %). The numeric and graphic presentations also differed by audience and information type. Consumers have access to quantitative information about oncology drugs and, in particular, about the benefits of these drugs. Research has shown that using quantitative information to communicate treatment benefits and risks can increase patients' and physicians' understanding and can aid in treatment decision-making, although some numeric and graphic formats are more useful than others.

Medical Oncologists' Experiences in Using Genomic Testing for Lung and Colorectal Cancer Care

PURPOSE

Genomic testing improves outcomes for many at-risk individuals and patients with cancer; however, little is known about how genomic testing for non-small-cell lung cancer (NSCLC) and colorectal cancer (CRC) is used in clinical practice.

PATIENTS AND METHODS

In 2012 to 2013, we surveyed medical oncologists who care for patients in diverse practice and health care settings across the United States about their use of guideline- and non-guideline-endorsed genetic tests. Multivariable regression models identified factors that are associated with greater test use.

RESULTS

Of oncologists, 337 completed the survey (participation rate, 53%). Oncologists reported higher use of guideline-endorsed tests (eg, KRAS for CRC; EGFR for NSCLC) than non-guideline-endorsed tests (eg, Onco typeDX Colon; ERCC1 for NSCLC). Many oncologists reported having no patients with CRC who had mismatch repair and/or microsatellite instability (24%) or germline Lynch syndrome (32%) testing, and no patients with NSCLC who had ALK testing (11%). Of oncologists, 32% reported that five or fewer patients had KRAS and EGFR testing for CRC and NSCLC, respectively. Oncologists, rather than pathologists or surgeons, ordered the vast majority of tests. In multivariable analyses, fewer patients in nonprofit integrated health care delivery systems underwent testing than did patients in hospital or office-based single-specialty group settings (all P < .05). High patient volume and patient requests (CRC only) were also associated with higher test use (all P < .05).

CONCLUSION

Genomic test use for CRC and NSCLC varies by test and practice characteristics. Research in specific clinical contexts is needed to determine whether the observed variation reflects appropriate or inappropriate care. One potential way to reduce unwanted variation would be to offer widespread reflexive testing by pathology for guideline-endorsed predictive somatic tests.

Marketing of personalized cancer care on the web: an analysis of Internet websites

Internet marketing may accelerate the use of care based on genomic or tumor-derived data. However, online marketing may be detrimental if it endorses products of unproven benefit. We conducted an analysis of Internet websites to identify personalized cancer medicine (PCM) products and claims. A Delphi Panel categorized PCM as standard or nonstandard based on evidence of clinical utility. Fifty-five websites, sponsored by commercial entities, academic institutions, physicians, research institutes, and organizations, that marketed PCM included somatic (58%) and germline (20%) analysis, interpretive services (15%), and physicians/institutions offering personalized care (44%). Of 32 sites offering somatic analysis, 56% included specific test information (range 1-152 tests). All statistical tests were two-sided, and comparisons of website content were conducted using McNemar's test. More websites contained information about the benefits than limitations of PCM (85% vs 27%, P < .001). Websites specifying somatic analysis were statistically significantly more likely to market one or more nonstandard tests as compared with standard tests (88% vs 44%, P = .04).

A Study of the Frequency and Social Determinants of Exposure to Cancer-Related Direct-to-Consumer Advertising Among Breast, Prostate, and Colorectal Cancer Patients

Cancer-related direct-to-consumer advertising (DTCA) is controversial because cancer treatment is complex and entails more risks and costs than typical treatments that are advertised for other conditions. Drawing from the Structural Influence Model of Communication, this study explores communication inequalities in DTCA exposure across social determinants among a population-based sample of 2013 patients diagnosed with breast, prostate, or colorectal cancers. Three survey items assessed patients' frequency of encountering ads concerning treatment alternatives for cancer, dealing with side effects of treatment, and doctors or hospitals offering services for cancer following their diagnosis. The analysis showed that overall exposure to DTCA in this study population was modest (median was once per week). Breast cancer patients reported significantly higher exposure to all three ad categories and overall DTCA exposure than prostate and colorectal cancer patients. Older patients consistently reported lower overall exposure to DTCA across the three cancer types. Other significant correlates included ethnicity (higher exposures among African American prostate cancer patients vs. White; lower exposures in Hispanic colorectal cancer patients vs. White) and cancer stage (higher exposures in Stage IV prostate cancer patients vs. Stages 0-II). Education level did not predict patients' DTCA exposure. The implications of these observed inequalities in DTCA exposure on cancer outcomes are discussed.

What are cancer centers advertising to the public?: a content analysis

BACKGROUND

Although critics have expressed concerns about cancer center advertising, analyses of the content of these advertisements are lacking.

OBJECTIVE

To characterize the informational and emotional content of direct-to-consumer cancer center advertisements.

DESIGN

Content analysis.

SETTING

Top U.S. consumer magazines (n = 269) and television networks (n = 44) in 2012.

MEASUREMENTS

Types of clinical services promoted; information provided about clinical services, including risks, benefits, costs, and insurance availability; use of emotional advertising appeals; and use of patient testimonials were assessed. Two investigators independently coded advertisements using ATLAS.ti, and κ values ranged from 0.77 to 1.00.

RESULTS

A total of 102 cancer centers placed 409 unique clinical advertisements in top media markets in 2012. Advertisements promoted treatments (88%) more often than screening (18%) or supportive services (13%). Benefits of advertised therapies were described more often than risks (27% vs. 2%) but were rarely quantified (2%). Few advertisements mentioned coverage or costs (5%), and none mentioned specific insurance plans. Emotional appeals were frequent (85%), evoking hope for survival (61%), describing cancer treatment as a fight or battle (41%), and inducing fear (30%). Nearly one half of advertisements included patient testimonials, which were usually focused on survival, rarely included disclaimers (15%), and never described the results that a typical patient may expect.

LIMITATION

Internet advertisements were not included.

CONCLUSION

Clinical advertisements by cancer centers frequently promote cancer therapy with emotional appeals that evoke hope and fear while rarely providing information about risks, benefits, costs, or insurance availability. Further work is needed to understand how these advertisements influence patient understanding and expectations of benefit from cancer treatments.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Potential spillover educational effects of cancer-related direct-to-consumer advertising on cancer patients' increased information seeking behaviors: results from a cohort study

Spillover effects of exposure to direct-to-consumer advertising (DTCA) of cancer treatments on patients' general inquiry about their treatments and managing their illness are not well understood. This study examines the effects of cancer patients' exposure to cancer-related DTCA on subsequent health information seeking behaviors from clinician and non-clinician sources (lay media and interpersonal contacts). Using a longitudinal survey design over 3 years, data was collected from cancer survivors diagnosed with colorectal, breast, or prostate cancer who were randomly sampled from the Pennsylvania Cancer Registry. Study outcome measures include patients' information engagement with their clinicians and information seeking from non-medical sources about cancer treatment and quality of life issues, measured in the second survey. The predictor variable is the frequency of exposure to cancer-related DTCA since diagnosis, measured at the round 1 survey. The analyses utilized lagged-weighted multivariate regressions and adjusted for round 1 levels of patient-clinician engagement, information seeking from nonmedical sources, and confounders. Exposure to cancer-related DTCA is associated with increased levels of subsequent patient-clinician information engagement (B = .023, 95% CI = .005-.040, p = .012), controlling for confounders. In comparison, exposure to DTCA is marginally significant in predicting health information seeking from non-clinician sources (B = .009, 95% CI = -.001-.018, p = .067). Cancer-related DTCA has potentially beneficial spillover effects on health information seeking behaviors among cancer patients. Exposure to DTCA predicts (a little) more patient engagement with their physicians.

Impact of oncology-related direct-to-consumer advertising: association with appropriate and inappropriate prescriptions

BACKGROUND

Little is known about the impact of direct-to-consumer advertising (DTCA) on appropriate versus inappropriate prescribing. Aromatase inhibitor (AI) therapy for breast cancer provides an ideal paradigm for studying this issue, because AIs have been the focus of substantial DTCA, and because they should only be used in postmenopausal women, age can serve as a simple surrogate marker of appropriateness.

METHODS

Data regarding national DTCA spending for the AIs were obtained from TNS Multimedia; hormonal therapy prescription data were obtained from IMS Health. Time series analyses were performed to characterize the association between monthly changes in DTCA spending for the AIs and monthly changes in the proportion of all new hormonal therapy prescriptions represented by the AIs from October 2005 to September 2007. Analyses were stratified by age, considering prescriptions for women ≤ 40 (likely premenopausal) to be inappropriate and those for women > 60 (likely postmenopausal) to be appropriate.

RESULTS

Monthly dollars spent on AI-associated DTCA varied considerably ($118,600 to $22,019,660). Time series analysis revealed that for every million dollars spent on DTCA for the AIs, there was an associated increase 3 months later in the new AI prescription proportion of 0.15% for all ages (P < .0001) and 0.18% for those > 60 years (P < .0001), but no significant change for those ≤ 40 at any time from 0 to 6 months.

CONCLUSIONS

DTCA for the AIs was associated with increases in appropriate prescriptions with no significant effect on inappropriate prescriptions, suggesting that DTCA may not foster inappropriate medication use for certain drug classes.