Health News Review

We’ve been following claims for Cyberknife “knife-less surgery” for a long time.  See search results from our blog. We’ve seen billboards promoting it in the metropolitan health care market we live in.

 

And big East Coast medical centers promoting it at subway stops.

But only recently did we start noticing many TV commercials promoting the technology, which was described recently in this way:

Rohit Inamdar, a senior medical physicist and senior associate in the Applied Solutions Group at the ECRI Institute in Plymouth Meeting, Pa., a nonprofit organization that evaluates medical products and processes, agrees that the clinical evidence on the use of the CyberKnife for prostate cancer is “a little early … and a little weak. It’s still developing and cannot stand on its feet.”

You don’t get that sense in TV spots airing in Minneapolis:

Or in New Jersey:

Or in TV, print, or outdoor ads from another medical center in New Jersey:

This is undoubtedly just a smattering of what’s happening across the U.S.  But it was enough for me to seek the opinion of Harold DeMonaco, MS, one of our expert story reviewers and guest bloggers. He looked at some of the ads and here is his analysis:

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In Minnesota: Turn Devastation Into Hope

In New Jersey: The Ray of Hope You Have Been Searching For

Elsewhere in New Jersey:  Cancer Doesn’t Fight Fair, Neither Should You

The three quotes above are the ending statements made in videos promoting the Cyberknife radiation therapy system and its availability at some hospitals.  These ads are clearly aimed at patients with cancer, as vulnerable a patient population as there is.  At best, these ads are incomplete and misleading.  But, then again they are advertisements.  We don’t expect full disclosure in any other advertising.  Should we expect more from healthcare providers?  Should we hold hospitals and healthcare networks to a higher standard in their advertising? And what is the legitimate role of local journalists in response to this type of advertisement?

Unfortunately, excessive claims in medical advertising have been around since the dark ages.  Given the high economic stakes of a competitive healthcare market, we may be seeing the beginnings of the 21st Century version of “snake oil” promotions. The Cyberknife system is not the issue here.  Like most new technologies, the Cyberknife system can play an important role in improving the treatment of many cancer patients.  It is the advertising that is the issue.  Does a hospital really need to resort to phrases like, “turn devastation into hope,” to promote the use of a new treatment option?

I want to be clear up front, I am a technogeek.  I like new technology and am an advocate for its use when and where it can best benefit the patient.  I am however simply dismayed at the lengths to which some hospitals and healthcare systems will go to promote their new technology.  While some hospitals do a very good job, promoting the Cyberknife, others apparently see the need to distort the reality of the device as it relates to the published evidence for its superiority.  I am also dismayed that journalists seem perfectly willing to ignore the increasing excesses of hospital promotions.

Wikipedia defines “Advertising as a form of communication for marketing and used to encourage or persuade an audience (viewers, readers or listeners; sometimes a specific group) to continue or take some new action. Most commonly, the desired result is to drive consumer behavior with respect to a commercial offering, although political and ideological advertising is also common. In Latin, ad vertere means “to turn the mind toward.”

Advertising is clearly not meant to educate.  “Education in its general sense is a form of learning in which knowledge, skills, and habits of a group of people are transferred from one generation to the next through teaching, training, research, or simply through autodidacticism….,” according to Wikipedia.

Can there be any doubt then that these promos are intended to “turn the mind of cancer patients toward” these local institutions? That, in and of itself, may not be problematic.  The clinicians at these institutions likely practice good clinical care.  It is also likely that patients with cancer who are not eligible for treatment with this form of radiotherapy would be managed appropriately by some other means.  But, that being the case, why then must the marketing folks distort their message?

I appreciate the fact that hospitals are in fact businesses.  Although most hospitals are structured as “Not for Profits,” all must generate a profit to survive.  The key to survival for hospitals like any business is the margin between costs and revenues. In a low margin business, volume is the key.  Like any business in a competitive market, identifying an advantage over your competitors and exploiting it is the key to either maintaining or increasing market share.  And that is where advertising comes into play. This is especially true when a local hospital invests millions of dollars in a new technology like the Cyberknife. Those large sunk costs need to be turned into at least a financial “break even” quickly.  So, patient volume is critical.  The same is true for any new and expensive technology from a proton beam center to a surgical robot and is not unique to the Cyberknife.  What does appear to be unique is the length to which some would go to drive volume.  Unless they have been living in a cave somewhere, is there anyone who has not seen a billboard, local news story or press release about a DaVinci Robot system or a Cyberknife?  I assume that there a couple of reasons for this level of marketing of a product.   The first is the large investment made by local hospitals into these technologies and the subsequent need to increase volume to pay for them.  The second is the marketing support provided by the companies themselves.  A visit to the websites will give you an idea of how polished and complete the marketing support is.

The Cyberknife system is an impressive device that was first approved by the FDA over a decade ago.  Whether it is truly an advantage over Intensity Modulated Radiation Therapy (IMRT) is still in question.  It may be more convenient, requiring fewer treatment sessions than IMRT, but the long term outcomes seen in prostate cancer, for example, in comparison to IMRT are still in question.  Published studies are few in number and I am not aware of any comparative trials in the literature. The majority of studies published to date have been in low and intermediate risk prostate cancer patients and have not been randomized, comparing it to IMRT. At this point, it appears that the Cybeknife provides similar results to IMRT in the short term and is certainly more convenient.  We simply don’t know if the precision of the device is in fact an advantage in the long run. We also don’t know if the side effect profile is better. This is not a new phenomenon nor is it unique to the Cyberknife.  In reality, IMRT became the dominant method for delivering radiation therapy to patients long before any trials demonstrated its superiority.

Comparative trials are not required for FDA approval.  No manufacturer needs to demonstrate that their new device is in fact superior to existing technology.  The marketplace will define the eventual role of most new technologies.  But, newer, even when it is intuitively obvious that there is a technical advantage, may not be better clinically. For example, a recent article published in the Journal of the American Medical Association concluded that IMRT was superior to conventional radiation therapy in patients with prostate cancer.  This is a validation of the underlying assumption and in the market’s faith in the technology.  Interestingly, proton beam therapy, the presumed gold standard for radiation accuracy did not appear to offer any advantage and had a higher likelihood of producing gastrointestinal damage than IMRT.  The authors used administrative data to draw conclusions and the results while interesting are not form a randomized controlled trial.  But they do point out that newer may not in fact be better.  An ongoing clinical trial may provide somewhat more definitive answers.

Some local hospitals appear willing to push the envelope in their advertising while the local media seems to be silent on the issue.  Or worse, as evidenced by a recent story Gary highlighted from a Dallas radio station.  I was able to find an excellent story on a newly installed Cyberknife system at Georgetown University Hospital* from several years ago by Rob Stein. Why are there not more?

Every hospital and healthcare network in the US has a pubic relations/news and media department.  Most do an excellent job in highlighting the advantages of care at their particular institutions.  Some perhaps stretch the truth.  And a minority appear to be willing to stretch the truth until it breaks.

As always, these comments reflect my views only on the topic.  I am interested to see what journalists have to say.

(* We originally wrote only Georgetown University.  But we were subsequently advised by a Georgetown University Medical Center employee that “the hospital is not operated or owned by Georgetown University.  It is owned by MedStar Health and in fact, the hospital recently changed its name to MedStar Georgetown University Hospital.” So we have made a correction.)

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Comments

Bob Foster posted on January 3, 2013 at 4:37 pm

Full disclosure: I work for an ad agency. My specialty is radiation oncology marketing.

Excesses? Oh, my word. You should sit in on hospital marketing meetings where the subject of cuts in budgets is discussed. Healthcare systems will experience another in a series of marketing budget decreases in 2013. Reimbursement rates for certain radiation oncology procedures fell again in 2013.

As for the efficacy of CyberKnife for early stage prostate cancer being “a little early … and a little weak. It’s still developing and cannot stand on its feet.” That is blatantly not true. I recommend you read Dr. Katz’s ASTRO abstract on the subject.

CyberKnife is a promising alternative for people who have reached their lifetime limit of radiation, have an inoperable tumor or are experiencing pain from a tumor putting pressure on nerves. Talk to a lung cancer patient who has had a portion of one lung removed and the other lung treated with CyberKnife. They will tell you how amazing CyberKnife is. I could list numerous advantages to CyberKnife over gantry-based IMRT systems. That is why spreading the word about CyberKnfie has become my mission in my professional life.

With the siloing up of physicians, the only way numerous patients will hear about CyberKnife is through advertising. There is no good reason why qualified patients should endure surgery and 30 to 40 IMRT treatments when they can have the same, if not better, results with 3 to 5 CyberKnife treatments.

Bob Foster, Marketing Consultant

    Gary Schwitzer posted on January 3, 2013 at 5:13 pm

    Bob,

    I’m going to ignore my own comments policy, which clearly states that I will delete any comment that makes any kind of product pitch. You lead with your obvious conflict of interest – thank you for that – so I’ll let you have your say herein one time.

    But this isn’t paid-for advertising space, so you don’t get to say whatever you want here without being challenged as you do when you buy ad space or commercial air time.

    Regarding efficacy, you frame this as amazing. The quote about Cyberknife evidence being “weak…still developing and cannot stand on its feet” came from a senior medical physicist with similar thoughts in the Radiology Today piece from a well-known and respected urologist. Clearly, some learned people don’t think the technology is quite ready to be framed as amazing.

    We’d love it if hospital marketing budgets were submitted to the site so we could post them and help readers understand the excesses described in the blog post.

    Finally, there may be many good “reasons why qualified patients should endure” – your words – other treatments rather than your pet radiation approach. Data, evidence, complete information about benefits and harms, outcomes that matter in peoples’ lives, a shared decision-making encounter with one’s physician – to name just a few.

Peter Kirkbride posted on January 4, 2013 at 3:29 am

I write as the author of the UK national report on SBRT (stereotactic body radiotherapy) and the point I would like to make is that what is being described in the article is the use of SBRT, and that Cyberknife is just one platform which can deliver SBRT – you can perform the same treatment using other machines, included some ‘standard’ linear acclerators provided they have the right software.

In the UK we are trying to get the patients, press and politcians to understand that, yes SBRT is an exciting new development which has the potential to revolutionise cancer treatment BUT apart from early-stage lung cancer, the evidence for its wholesale use is simply not yet available AND, relevant to this article, that you do not have to have a Cyberknife to deliver SBRT – there are alternatives, some of which are cheaper and can be used more flexibly

Harold DeMonaco posted on January 4, 2013 at 7:45 am

Dear Bob,

I am familiar with Dr. Katz’s work. I would recommend that you re-read my comments. The issue is not the Cyberknife, it is the utter nonsense that you and others seem to think is necessary to promote the use of the device. How could you possibly justify, ” Turn devastation into Hope?” How does that advertising advance a patient’s understanding of options?

You note, “Excesses? Oh, my word. You should sit in on hospital marketing meetings where the subject of cuts in budgets is discussed. Healthcare systems will experience another in a series of marketing budget decreases in 2013. Reimbursement rates for certain radiation oncology procedures fell again in 2013. ” Is this then your rationale for the over the top advertising for the Cyberknife? Then we would seem to agree. Many hospitals are caught in a closed loop with the ever present need to purchase the latest device in advance of their neighbors in an attempt to maintain market share. As I noted, patient volume is the key to their short term survival. That is until the next device comes on the scene. Those fact still don’t justify some of the advertising messages that clutter the landscape.

Don’t you think that patients, especially those with cancer, deserve something more than standard advertising hype?

Greg Pawelski posted on January 4, 2013 at 11:26 am

I believe that you are “spot on” on this issue Harold: It is the “advertising” that is the issue. And the same is true for any other new and expensive technology, from proton beam and DaVinci robot, to RT-PCR and Microarrays. It is not unique to Cyberknife. Academics are besides themselves over the promise of new technology. It seems so cool that it simply must be good for something. But a “cool” technology is no different than “cool” computer technology – it’s not worth much without some very good applications (“apps”), and personalized cancer medicine is still waiting for its first killer app.

As for the “efficacy” of Cyberknife, we got the same “end-run” from Pet Scans in oncology. There was a large collaborative trial in 2006, with CMS and ACRIN (American College of Radiology Imaging Network) to gather data shared with CMS gleaned from the National Oncologic PET Registry (NOPR), what was thought to determine “efficacy” of the Pet Scan in cancer treatment management. This was not “efficacy.” Efficacy means that the use of the modality in question improves clinical outcomes, compared to patient management in the absence of such testing.

The alternative to getting a Pet Scan is to rely on the use of much less expensive imaging (CT Scan, MRI, ultrasound, plain X-rays, etc.) or just to manage patients on the basis of history and physical examination. All the CMS/ACRIN data showed is that the doctors pay attention to the test results. This didn’t prove efficacy. Efficacy means that you prove that patient “outcomes” are improved as a result of the changed treatment decisions. It hasn’t been proven to improve outcomes and that is what is meant by “efficacy” in this context also.

kgapo posted on January 6, 2013 at 5:46 pm

In Europe as you know, medical ads are not allowed. What then? In Greece, only three private hospitals in Athens have three different brands of the stereotactic radiation surgery equipment. All patients needing this type of therapy manadatorily go to one of them. The social insurance refunds the therapy cost at 6.500euro. I thought you might like to see what the HCPs state on their websites as arguments for preferring this type of therapy.
1.CyberKnife http://www.iatropoli.gr/en/cyberknife/
2.SRS/SRT-BRAINLAB-Νovalis6D ROBOTICS http://bit.ly/Wl3Gql -Varian (no Engish translation)
3.Gamma Knife http://www.hygeia.gr/services.aspx?p_id=20