This article was written by Michael Wilkes, MD, PhD, Professor of Medicine at the University of California, Davis and its Director of Global Health.
As poets and writers have known for millennia, the use of specific words can lead to imagery, meaning, feelings and emotions that transcend the narrow definition of the word. A study I did several years ago showed that changing just one word in the sentence from “Is there anything else you want to address in the visit today?” (ANY condition) to, “Is there something else you want to address in the visit today” (SOMETHING condition) had a significant impact on overall patient satisfaction. Words matter a great deal, and so do visual images.
It’s hard to escape from direct-to-consumer promotions these days, be they on TV, radio, at sporting events, jumping out of the program at a concert, or on a billboard at the airport. Directing promotional material to physicians who are better able to evaluate the claims and distortions is so old school. It is far more effective to advertise directly to the consumer and appeal to his or her emotions and desires and let the consumer convince the doctor.
In the advertisements, the use of superlatives – words like “breakthrough”, “game changer” or “something this big” — that exaggerate the benefits of a drug, images that suggest greater benefits than can actually be achieved, and videos that tug on the heart strings of the viewer all suggest that if you don’t try the drug being promoted, you aren’t really trying your hardest. Recently researchers at Oregon Health Sciences University showed that the use of superlatives to describe cancer drugs is common, particularly in describing a new class of drugs called immunotherapies. These direct and subliminal messages intended to increase demand for a drug are particularly worrisome when the drug at hand is new and relatively untested, when the drug carries significant risks that balance out the promoted benefits, and when the drug is exceedingly expensive.
A case in point is the drug nivolumab marketed under the trade name Opdivo. It is manufactured by Bristol-Myers Squibb to treat certain types of lung cancer – but only after the sick person has failed conventional chemotherapy. Over half the patients taking the drug experience severe side effects – some are so severe the patients stopped taking the drug. Still the drug is being heavily promoted on prime time TV with an advertisement that begins with a surprisingly healthy-looking father and his son sitting at a baseball stadium. Dad, presumably the one with cancer, is smiling and clearly enjoying himself.
The narrator begins, “For adults with an advanced lung cancer called squamous non-small, previously treated with platinum based therapy, it’s not every day that something this big comes along”. The scene changes as we watch the father and son look around a city scene where flashed across the city’s buildings is a bright sign that reads, “A chance to live longer.” We then see other healthy middle aged men and their spouses looking up and smiling at the “A chance to live longer” sign.
Technically, the advertisement is accurate. Clinical trials showed that compared to a group who took conventional chemotherapy, those taking the drug nivolumab lived an average of 90 days longer. Is this a huge clinical advance? Well, it depends on your perspective. Some patients feel 90 days doesn’t sound like much, while others say they would give their right arm to live another 90 days – but only if their quality of life was high. But, before you decide if would you take the drug, also consider that the drug costs about $150,000 for the initial treatment, and then about $14,000 a month. Not all insurance will cover the cost.
Oncologists and other physicians I’ve spoken with reflect the same attitudes as cancer patients. Some report that this is a remarkable drug that gives them a new tool to extend life, others see this as a smoke screen that distracts from important work that needs to be done around end of life issues, and others feel the cost of the drug is outrageous when we can’t afford even basic health care for all such as aggressive prevention around smoking cessation.
These are interesting times, and much depends on one’s perspective and motivation.
What is clearly long overdue is a public discussion about what constitutes meaningful patient-oriented outcomes and how to use society’s limited resources.
“Bristol-Myers Squibb’s closely watched new drug Opdivo, one of the first of a new wave of cancer medicines that boost the immune system, has been rejected as too expensive for treating lung cancer by Britain’s cost watchdog.
In draft guidance issued on Wednesday, the National Institute for Health and Care Excellence (NICE) said using Opdivo, or nivolumab, in non-small cell lung cancer after chemotherapy did not represent a cost-effective use of resources.
The U.S. drugmaker said the NICE decision was “deeply disappointing”.
However, the head of Britain’s leading cancer research center said companies needed to do more to bring down the cost of such treatments.”