Caveat Patiens: American Cancer Marketing (part 2)

This is the second post about dubious marketing techniques newly-diagnosed cancer patients are likely to encounter. 

TargetdHypodermic copyCaveat patiens means “patient beware.”  A newly diagnosed man or woman is an attractive target for companies and institutions that can subtly (or not) exploit the natural fear induced by the word “cancer” as they market treatments that promise the best possible outcomes.

In the first post, we examined how attractive technology and self-serving educational websites can negatively impact rational decisions about which treatment to choose and from whom.  Here, we examine two other practices in wide circulation.

Outcome Data Manipulation.  We cancer patients understandably seek the best possible  outcome—typically measured as “overall survival,”  i.e. beating back the disease and living as long as possible.  No one capitalizes on that desire more aggressively than Cancer Treatment Centers of America (CTCA), a private for-profit corporate with five centers in the US.

One laudatory web article lays out CTCA’s marketing arsenal in candid detail (albeit in ‘marketingese’) as it enthuses, “Not only do they [CTCA] understand the core tenets of media-making and content distribution…for driving significant organic web traffic, you’d have to live under a rock to escape their robust, ongoing television and radio advertising presence. This barely touches on CTCA’s full arsenal of resources, tools, tactics, and strategies used to feed their well-oiled business development machine.”(1)  That statement alone should be warning enough. But there’s more.

Pre-diagnosis, they may have just been background noise, but post-diagnosis, you or a family member will doubtless pay close attention to CTCA’s ubiquitous TV ads.  These 30-second spots feature patient testimonials about how well they were treated and how they are now pretty much cancer-free.  However, you’re likely to miss the little “results not typical” disclaimer at the bottom of the screen because it’s there for only about a second.  But even that really does not detract from the emotional impact of the testimonial’s joyful enthusiasm.

In addition to upbeat ads, CTCA presents carefully manicured outcome data that positions it as being far more effective than those “average” cancer centers like Dana-Farber or MD Anderson.  For example, CCTA has claimed breast cancer survival at 3 years out as 14% better than what is recorded in the SEER Database(2), lung cancer 11% better at 18 months, pancreatic cancer 8% higher at 18 months, and so on.

A Reuters investigation of these numbers in May 2013 (3) underscores the truth of Mark Twain’s assertion about “three kinds of lies: lies, damned lies, and statistics.” CTCA statistical achievement is accomplished by refusing to treat patients with advanced disease, and thus, more likely to die, as well as any patients on Medicare (they are old, after all) or Medicaid, as well as defining very short survival measurement timeframes.  (Most survival statistics are measured more conservatively at five years out.)  

To further purify their data, CTCA then calculates survival outcomes for only some of the patients it eventually accepts for treatment.  As a biostatistician quoted by Reuters observes, this “is a huge bias and gives an enormous advantage to CTCA.”  In 1996, CTCA entered into a consent decree with the Federal Trade Commission (FTC) and agreed not to make unsubstantiated outcomes claims without admitting fault.  When Reuters asked if CTCA’s current ads meet the terms of the consent decree, the FTC would say only, “No one at the commission can comment on non-public information.”

The bottom line of this cautionary tale: investigate data and testimonials that sound too good to be true.  They doubtless are.

Unacknowledged self-referral.  Along with surgery, electron beam radiotherapy (EBRT) to treat prostate cancer is big business, especially its more advanced form, IMRT, which is reimbursed by insurers and Medicare at substantially higher dollar amounts than conventional radiation or even surgery.  In my own situation, my urologist referred me to a radiation oncologist at an independent practice.  However, IMRT’s tantalizingly high payments have motivated many urology practices to expand into direct ownership of this equipment.

Since urologists are invariably the ones performing the initial diagnosis of prostate cancer, and if they then decide that surgery may not be the best option for the patient, it is easy to hang on to those insurance and Medicare dollars by referring the patient to the in-house radiation center–a practice called “self-referral.”

Authors of a study on self-referral point out that one company, Urorad, in its marketing materials directed at urologists, claims “that treating 1.5 new patients monthly with IMRT could generate more than $425,000 in additional revenue per physician each year.”(4)  Nearly one in five urology practices in the US now own IMRT machines.  The allure of increased profit and the frequent failure to acknowledge the tight financial connection between urologist and radiation oncologist too easily trumps the patient’s best interests.

Self-referral has become sufficiently widespread that the American Society for Radiation Oncology (ASTRO) is concerned for its reputation.  Eager to avoid investigation by outsiders, it is “supporting a Georgetown University independent analysis of the effect of physician self-referral on urologists’ use of IMRT for prostate cancer patients.” (5)  We’ll see.

Caveat Patiens. A reasonable question at this point is, is this kind of marketing really legal?  The answer is, “Mostly.”

In an article titled, “Cancer Center Ads Use Emotion More Than Fact,”(6) the New York Times notes that “…federal agencies cannot limit the ad claims made by nonprofit medical centers about their ability to cure people of diseases like cancer, according to the government’s main ad regulator, the Federal Trade Commission.”  Centers may freely make unsupported statements such as “highest cancer cure rates with the lowest risk of side effects,” even though the same NYT article states, “Cancer experts interviewed for this article say there are no comprehensive statistics showing that any one elite medical center has better overall cancer success rates than its competitors.”

For-profit corporations such as CTCA fall under the purview of the Federal Trade Commission (FTC), which exercises stricter control over claims and causes things like the little disclaimer to appear in the TV ad.  This is also why CTCA uses testimonials and carefully groomed data rather than simple declarative statements of superiority.

The tricky forest of which ad claims are legal and which are not is probably one reason why Intuitive Surgical does not advertise its robots directly to end customers, rather allowing its generally non-profit hospital clients to do it for them.  On the other hand, you will never see claims of superiority coming from pharmaceutical companies because the FDA won’t let them.

How do we arm ourselves against the subtle and not-so-subtle marketing pitches?

Unfortunately, given the emotions of a cancer diagnosis, not everyone is likely to perform a steely-eyed cost/benefit analysis of treatment alternatives as we might do when purchasing a new car.

Our best defense against claims made in ads, on TV, and on billboards is remaining steadfastly alert (along with a modicum of cynicism) about claims and even data.  Even though our overwhelming desire is to get that disease out our bodies as fast as we can, we need to pause, take a breath, and not let our guard down just because we’ve heard those dreadful words, “you have cancer.”  Difficult, but necessary.

None of this is fair and it isn’t very nice, but as long as there is profit to be made in delivering cancer treatment, marketers will surely be there casting their nets.  And as we’ve seen, our best interests as patients do not always align with theirs.  But remember: we’re the ones who are emotionally vulnerable–and they are not.

FOOTNOTES:

(1) http://fontherapeutics.com/blog/cancer-treatment-centers-of-america-800-pound-marketing-gorilla/ accessed 2/1/14

(2) The Surveillance, Epidemiology, and End Results (SEER) program run by the National Cancer Institute that tracks cancer incidence survival in the US.

(3) http://www.reuters.com/article/2013/03/06/us-usa-cancer-ctca-idUSBRE9250L820130306  accessed 2/1/14

(4) Excerpted from “Growth of high-cost intensity-modulated radiotherapy for prostate cancer raises concerns about overuse” published in the April 2012 issue of Health Affairs

(5) ASTRO Press Release, April 10, 2012 accessed 2/4/14 at http://www.urotoday.com/UroToday/Prostate-Cancer/astro-responds-to-study-on-growth-of-imrt-for-prostate-cancer.html

(6) http://www.nytimes.com/2009/12/19/health/19cancerads.html (12/19/2009) accessed 2/3/14.

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