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:
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:
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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