Jalali, Rakesh

Pareek, Puneet

Bioline International

131J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2Free full text available fromwww.cancerjournal.netRakesh Jalali,  Puneet PareekDepartment of Radiation Oncology, Tata Memorial Hospital, Mumbai, India For correspondence:Dr. Rakesh Jalali, Department of Radiation Oncology, 125, Tata Memorial Hospital, Parel, Mumbai-400 012, India.  E-mail: rjalali@tmc.gov.inDOI: 10.4103/0973-1482.65228 PMID: *****EditorialIs there a need to regulate health care advertisement for lay public?While waiting at Delhi’s new spanking airport lounge, a sleek billboard advertising the virtues of “Cyberknife” as a new age revolutionary treatment is bound to seize your attention. As an oncologist, it may even almost take your breath away, for such in-your-face advertisement is a relatively new phenomenon, at least in our country. You may have encountered similar instances in various public forums including lay press, all forms of print and electronic media. Medical advertisement about healthcare chains, hospitals, occasional pharmaceutical product, alternatively medicine (and of course countless quacks) is admittedly not new. Brandishing one specific product with such brazenness accompanied by a sustained, well-organized media blitzkrieg is, however, unparalleled. One has of course witnessed similar instances in the mother of capitalistic nations, the United States (the healthcare woes of community there well known necessitating Obama’s recent reforms and a different subject altogether). Such phenomenon in our country is indeed a new one.Witnessing all this mayhem, one does get buoyed into a wonder. Why do it? What is the need? Advertising in essence can lead to social welfare when it is truthfully informative and even reduces the cost of search involved for the product for the consumer. Traditionally, medicine has by and large refrained from espousing its products directly to lay public. And thankfully physicians, scientists and manufacturers have recognized that propagation and growth of medical products/techniques are most optimally accomplished within their communities, without too much exposure to the lay public. Advertisements very much in the public eye in the form of big billboards on common public places including airports, bus stands and streets, to our mind represent a genuine concern. It appears that it becomes a moral duty of the manufacturers and concerned parties to apprise every living soul in the society about the incredible powers the product possesses almost covertly implying in the public psyche that deprivation of advertised product would be grossly detrimental to their care and healing. It can have serious implications in a typically challenging and often desperate situation as in “oncology care”. Concerned parties often argue and sometimes dangerously actually believe that they are in fact doing a great service to the society by filling gaps and information. They also proudly proclaim that they do not utilize the product indiscriminately and indeed advise the consumers (hate the word consumer for a patient/caregiver, but have no choice for that is the state we are talking about) about the suitability, etc. What is often forgotten, however, is that there will be always a bias for a business styled advertised product and often evidence is manufactured and convoluted to suit the applicability.[1] We are tempted indeed to discuss the merits and demerits of “cyberknife”, which sort of triggered this piece but will refrain from doing so. Fortunately, a large number of professionals are increasingly becoming aware of the gap between advertised promise and factual evidence. Indications for “radical” cure with such technique is alarmingly low that it does not even comprise 1% of the oncology burden that we have and it remains largely a “fancy”, ultra-precise treatment for recurrent/palliative situations.A few discerning minds in the public do actually perceive a ring of desperation in public advertisement attempts by the manufacturers and concerned parties and can smell something amiss. Concerned parties, although cognizant of this counter-productive reaction, are happy in the notion of overwhelming majority who buy their claims. A big concern is that as the treatment is so expensive, a vast majority of patient population does not even contemplate and of course afford to inquire about its indications and if it is suitable for his particular instance. Yet, in view of frenzied advertisement in lay public, he has witnessed the proclaimed miracle cures and is burdened with stress and guilt of not been able to access the particular heavily advertised product. Invariably, instances of such massive public advertisement campaigns are related to expensive technologies and treatments. One also wonders and wishes 132 J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2that a similar zeal and enthusiasm be devoted to propagate in public well-known treatments, public education, awareness and disease prevention.[2]Interestingly, while we are puzzled in the intricacies of innovations and their evidence and fine nuances, etc., in the peer reviewed scientific literature, our patients are persuaded by frank advertisements and the seemingly innocent informative articles on health care mentioning names of drugs and radiation machines! The concern about “Direct to Consumer Advertising (DTCA)” or simply the advertising to patients is as old for radiation oncologist as is for any other physician.[3] X-rays were sold to cure any number of ills, as were numerous concoctions. In the era of kilovoltage radiation therapy, it was heavily advertised as a cure for all sorts of conditions from headaches, tinea capitis to get rid of a hairy mole! Are we witnessing a rebirth of such outdated, almost laughable and ill-conceived phenomena of the past?There have been similar instances reported in the literature. Kravitz et al in a randomized trial published in Journal of American Medical Association (JAMA) showed how the brand-specific demand for an advertised brand of antidepressant paroxetin was more frequently met for adjustment disorder for which it is not indicated (P < 0.001).[4] Viale et al reported that out of 221 oncology nurses surveyed, an alarming 74% said that patients asked for inappropriate medications after watching advertisements.[5] In 2004, GlaxoSmithKline spent $157 million on advertising for its erectile dysfunction medication vardenafil, which in that year had only about $250 million in sales. We should never forget the story of Merck’s Rofecoxib which was heavily advertised highlighting having less gastric adverse effects, later fined and withdrawn because of increased cardiac morbidity,[1] of erythropoietin becoming a hot sale after being advertised directly to patients for relief of “fatigue” and now proven to be dangerous as it can lead to reduced survival. In the year 2008-2009, 76% of the advertisements were withdrawn from the 249 complaints resolved by the Advertising Standards Unit of UK.[6] Often the drugs and devices are marketed and promoted for the uses not yet scientifically proven, i.e., for off label uses. This has resulted in a number of important litigations such as the following: Intron A (Schering-Plough) for bladder cancer, Actimmune (InterMune) for misleading press release about its indication in idiopathic pulmonary fibroses, Trisenox (Cell Therapeutics) for cancers other than PML, Abilify (Bristol-Myers Squibb) for pediatric use and for dementia related psychoses. The Food and Drug Administration (FDA) had sent a notice of violation to a company, CATscan2000, for illegally promoting unapproved procedure of screening for heart disease in asymptomatic people. No wonder the drug and device manufacturers are accountable for sheer profit and thus team up with the equally evolved science of advertising and marketing management.The debate on whether the advertising is desirable or not is a long one, with extreme opinions. In the economics literature, Chamberlin[7] explains that advertising increases demand “‘by altering wants themselves’. This is a manipulative form of advertising as it exploits ‘the laws of psychology’ with which the consumer is unfamiliar and, therefore, against which he cannot defend himself ”. In their classic work, Dixit and Norman[8] have put clearly that when advertising changes tastes, any increase in consumer surplus is illusionary and, therefore, does not contribute to social welfare. Most advertisements are not balanced or accurate. The philosophy of the advertising agencies can be understood by what Wolfe[9] has written in The Lancet about an agency asserting that its “communications are focused on making the hippocampus respond positively to your product how your product is superior and unique.”Let us examine the fundamentals of medical advertisement. Simplifying the marketing management jargon, if an emotional, unrealistic and persuasive advertisement of a drug or medical device, which is yet to pass the scientific rigor of its utility and indications, is advertised directly to the patients, the patients tend to request for it and often buy it. For approval, they discuss with the “significant” people in their life, the relatives, friends and the physician. Dangerously, the friends and relatives of the patient who in the past have browsed through the advertisement even though without much involvement, already have changed perceptions (cognitive processing) about the product. Blind acceptance of new technologies by the medical profession is a major determinant of their rate of diffusion. Physicians expand the number of patients deemed eligible for new procedures more rapidly, in part because it generates revenues for the hospital already overburdened with the purchase of new products. It not only increases its consumption but also adds up the costs of advertising to the already high cost of the product and thus the patient ends up paying a lot more! Such blatant advertising in open public necessitates serious thinking and an appraisal from the national professional bodies and apex medical governing forums to deliberate and put forward regulations, taking into account all the moral, ethical and legal issues in these scenarios. One could take a leaf out of existing forums such as in UK and many other European countries to address these issues.The ethos and conflict of the views expressed have been eloquently captured by Angell[10] who says “For profit, businesses are pledged to increase the value of their investors’ stock. That is a very different goal from the mission of medical schools”.REFERENCES1. Jalali R. Particle therapy in clinical practice: Is there enough evidence to justify the current surge in interest? J Cancer Res Ther 2008;4:54-6.2. Jagsi R. Conflicts of interest and the Physician-Patient relationship in the era of Direct-to-Patient advertising. J Clin Oncol 2007;25:902-5.3. Sarin R. From 3D to 5D Radiotherapy: A blitzkrieg of DTH. J Cancer Res Ther 2009;5:223-4. 4. Kravitz RL, Epstein RM, Feldman MD, Franz CE, Azari R, Wilkes MS, et al. Influence of patient’s requests for direct-to-consumer Jalali and Pareek: Health care advertisement in lay public133J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2advertised antidepressants: a randomized controlled trial. JAMA 2005;293:1995-2002.5. Viale PH, Sanchez Yamamoto D. The attitudes and beliefs of oncology nurse practitioners regarding direct-to-consumer advertising of prescription medications. Oncol Nurs Forum 2004;31:777-83.6. Annual Report September 2008-August 2009, Advertising Standards Unit Vigilance and Risk Management of Medicine Division, Medicines and Healthcare products Regulatory Agency, UK. 7. Chamberlin E. The theory of monopolistic competition. Cambridge, MA: Harvard University Press; 1933.8. Dixit A, Norman V. Advertising and welfare. Bell J Econ 1978;9:1-17.9. Wolfe S. Drug advertisements that go straight to the hippocampus. Lancet 1996;348:632.10. Angell M. Is Academic Medicine for Sale? N Engl J Med 2000;342:1516-8.Jalali and Pareek: Health care advertisement in lay public

Is there a need to regulate health care advertisement for lay public?

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