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A Painful Cancer Advertisement

There’s an op-ed in the New York Times that makes tough reading, and it’s something that we’re going to be seeing more of. The author, Matt Jablow, lost his wife Ronna to non-small cell lung cancer, undiagnosed until a late stage, which is bad enough. Worse, they got to find out about it during a family vacation to Italy, and she was dead within two years of rapidly progressing disease. She was given Opdivo (nivolumab), the anti PD-1 therapy which has been much in the news, but this did nothing for her at all.

And now, as Jablow says, he gets to watch commercials for Opdivo talking about how it can extend lives, ask your doctor, and so on, and he’s (understandably) not happy about it. I’d find it painful, too – who wouldn’t?

It would be incredibly uplifting if it weren’t so utterly misleading and exploitive. To date, only about one in five patients with Stage 4 non-small cell lung cancer has seen any measurable response to Opdivo; and, in those patients who do respond, the median increase in life expectancy is only about three months compared with standard chemotherapy.

The overall five-year survival rate for people with Stage 4 lung cancer is between 1 and 5 percent. Instead of a “chance of living longer,” a more truthful narrator would have said, “Opdivo provides an outside chance for people with advanced lung cancer to live just a few months longer.”

Hmm. With all respect to Mr. Jablow, and to the memory of his wife, his statements aren’t completely correct. The response rate he cites is not in all Stage IV NSCLC patients, but just in those who have failed other therapies. His response rates need some clarification, too: as that NEJM article he links to shows, patients in this category have a survival rate of 22% at one year and 5% at two years. That Bristol-Myers Squibb trial demonstrated that Opdivo/nivolumab changes this to 41% at one year and 19% at three years. We don’t have five-year survival rates yet, because it hasn’t been around that long.

Another key factor (as the recent failed trial for this drug showed) is whether or not a given patient has a form of NSCLC that’s driven by the PD-1 signaling pathway. If so, the response rate seems far better. This is tied up as well in a fight between Bristol-Myers Squibb and Merck, makers of a competing antibody, Keytruda. Keytruda’s clinical trials were set up in patients who strongly expressed PD-1 L1 protein, and their FDA approval thus requires testing for it. Opdivo’s trials were not set up in that way – they did look at PD1-L1 expression, but have been going for a broader patient population. Merck, on the other hand, can well argue that that approach isn’t as relevant, because it’s really the high PD-1 L1 population that should be getting a drug like this anyway, and so on.

It would seem clear the Ronna Jablow was not in that category, because Opdivo (or Keytruda) would very likely have shown a much more pronounced effect if that had been the case. It’s important to note that the survival rates quoted above were enough to blast this drug through the FDA approval process, because, frankly, they’re so damn impressive. This is what “impressive” looks like in oncology. We’ve been redefining that over the years, and that redefinition is still going on (fortunately), but the PD-1 antibodies are indeed a real advance. The op-ed goes on to note the recent failed trial as dashing “the highest of hopes”, but those were the highest of hopes for people who haven’t been following the biology closely (which includes many investors as well). The data were already clear that these drugs work best in specific patients, not in the broad population, and Bristol-Myers Squibb’s attempts to work around that are not coming through for them.

All this is of little consequence to someone who’s lost someone close to them after such a drug has done nothing to help, though. I understand that – I am, in fact, for some years now the only one left standing out of my own birth family, so I understand it pretty well. I can see how Mr. Jablow is offended and distressed by the ads for Opdivo, and for my part I would rather that they mention getting tested for PD-1 L1, or at least say something like “for some patients” rather than giving an impression that this is going to help everyone. (But to be fair in that direction, in combination therapy with other agents, adding Keytruda, Opdivo or similar agents may well extend the lives of patients in the lower-expressing categories as well; we don’t really know yet). At the same time, though, there are people who are indeed going to be helped by these drugs, helped a great deal, and a great deal more than Mr. Jablow’s op-ed would suggest. I’m sorry that his wife wasn’t one of them.

As better therapies come along (and they’re coming along faster than usual these days), this problem is going to occur more often. It’s going to be increasingly painful to lose people to cancer when there are more treatments and better treatments than in years past. Immuno-oncology, in its various forms, has pulled some people practically out of the grave by current treatment standards, and we’re going to see more of that in the years to come. But we’re also going to see people who aren’t helped by it, not yet, and losing them will be harder than ever. I have no good advice for those affected in this way, and no consolation for them. We’re trying.

 

75 comments on “A Painful Cancer Advertisement”

  1. Some idiot says:

    No offence whatsoever to anyone working in the field (damn hard area, and good luck to you all), but, I have always been an in-principle opponent of allowing pharma to advertise directly to the public, and this is (unfortunately) another reason… Even if (with all respect to the person involved) he doesn’t quite have his facts straight.

    1. Duncan Bayne says:

      The alternative to allowing direct to consumer advertising – with all its inherent pitfalls – is to treat patients like ill-informed children, withholding information from them and disallowing them to make decisions about their own treatment.

      There’s certainly more scope to prosecute misleading advertising, though.

      1. Some idiot says:

        It is not a question of witholding information from patients (and thereby treating them like children)… The information is there if they want to get it. The question (as you infer at the end) is whether or not pharma should be allowed to give patients a somewhat distorted, sugar-coated version of the truth or not. I do not believe they should be allowed to do so.

        Disclaimer: I work in pharma (have done so for decades), and am (believe it or not!!!) still a believer that pharma can make a real difference. That’s why I am here. I just believe that the marketing folks should be held to the facts…

        1. John says:

          The main issue is that these ads are exploitative and cruel, and they offend a lot of people, even those who haven’t been diagnosed with cancer (like me). Where is the FDA and FCC in this? Have they been bought off by the drug companies like everyone else (read, the Government)? I recently had an argument with an Astrozenica salesman who is retiring at age 45. He thinks the ads are great and justified. He claimed the ads prompted patients to confront their doctors about these new “beta” drugs, and therefore coercing them into trying them. He said the patients who switched were in effect clinical trials, and their outcomes gave the drug companies useful data. In other words, the patients are Guinea Pigs.

      2. Hugo says:

        No commercials leads to treating patients as uninformed children, withholding information from them and disallowing them to make decisions? This is the longest slippery slope argument I’ve ever seen!

        Direct to consumer marketing is a silly Americanism, and I think it’s one of the worst investments of health dollars from a societal point of view. If it’s banned it’ll be just one less source of incorrect / biased information for patients to find.

      3. fajensen says:

        “… is to treat patients like ill-informed children, withholding information from them and disallowing them to make decisions about their own treatment.”

        So, what? … Steve Jobs might have made it if he hadn’t made poorly informed decisions on his own treatment.

        Patients, who are not medical doctors and who are by coincidence not incapacitated by their disease, just happens to be, in actual fact, truly ill informed and incapable of most decisions about their own treatment – even if patients are very smart in one area, they are not trained in medicine or pharmacology – they are just dabblers and amateurs and they will get the results that go with that.

        Society pays specialists quite handsomely to be the informed and capable ones “in case” so IT-developers, plumbers and carpenters won’t have to sit and watch a 10000 hour block of 30 second TV-ads to learn how to cure themselves. Assuming, of course, that advertising and 95% of the Internet content actually “informed” … which it totally doesn’t.

    2. biotechy says:

      I, WADR, think, WADR, we can, WADR, leave out WADR, all these disclaimers and just comment on the facts and the issues. WADR.

      Now what was misleading about the Opdivo ad? I didn’t see any evidence presented in the oped that it was misleading. Did any of you?

      If it gives a CHANCE at getting a response (and with long survival curve tails, there seems to be a small chance of a really impressive and durable response), how is that ad not honest?

    3. Dr Whitcomb says:

      There are patients who have extended life of 5-6 years with Opdivo so it does work on some patients. With the drug there is hope.

    4. joeylawn says:

      “Some Idiot” – You can’t call yourself that when you make such a great statement like that.

      Couldn’t agree with you more.

  2. Some Dude says:

    Just on the point of the ads: maybe the US should follow the example of most civilized countries and ban advertisements on prescription drugs. This might also bring drug prices down.

    1. biotechtoreador says:

      “This might also bring drug prices down.”

      Or improve on the current pharmacopeia by not diverting money from R&D to advertising. Maybe the failure rate of marketing (“I know half my ads work, I just don’t know which half”) versus the failure rate of R&D makes this appealing, but it seems to me a very cynical way to do business.

    2. ben sears says:

      i also believe that prohibiting DTC would bring drug prices down. i’ve witnessed the staggering sums that pharmaceutical companies spend on commercial budgets (sales conferences, incentives, holiday parties with tier-one musical acts, etc). from my perspective, these sums would be much better spent in the medical and R&D organizations.

      1. Some Dude says:

        There would be another thing at work as well: insurances would have an easier time negotiating prices without immediate pressure from patients who are all asking their doctor if the newest miracle drug is right for them.

        1. ben sears says:

          great point, thank you.

    3. Jistuce says:

      Fun fact: we USED to ban drug ads. That restriction was, of course, lifted at the behest of the pharmaceutical companies who certainly had only the patients’ best interests at heart by congressmen who were serving their constituents to the best of their abilities. No money was involved at all, I assure you. Even if it was, it was merely in recognition of all the good it would do to be able to tell people to ask their doctor for “the purple pill”.

      Disclaimer: I am sarcastic and jaded.

    4. Dr Whitcomb says:

      The facts are that some patients are living months longer with Opdivo not weeks. As an Oncologist I know that there is no such thing as a cancer moonshot as each cancer and patient is different. DTC ads help my patients understand that there are options but more than that they give them hope.

      1. UudonRock says:

        I agree with this. The idea of providing hope in itself is a benefit to patients. Modern medicine in America has placed greater emphasis on patient involvement and taken a much more rounded approach to overall patient health. There is no silver bullet for cancer, but without any hope patient response to any therapy is usually subverted.

  3. Selena says:

    Derek – The correct nomenclature is “PD-L1”, not “PD-1 L1”.

    1. not to nitpick says:

      Also, PD-1 signaling doesn’t drive NSCLC. It’s an immune suppressive pathway and the signaling occurs in tumor infiltrating T-cells, not the cancer cells themselves.

  4. dearieme says:

    I think Mr Lablow is being rather precious.

    1. Some idiot says:

      Oh I dunno… I have lost some of my family to slow, painful diseases, and if I saw an ad for a “wonder cure” where the benefits were (to put it politely) overstated, then I could probably get a bit warm under the collar too…

  5. Old says:

    DTC has NEVER been good for the industry’s reputation and with the latest ad’s with all sorts of new creatures, silly slogans and hours of side effects it even further reduces the credibility and difficulty of what we do for society. That said, the genie is out of the bottle and as long as lawyers, marketers and finance people run the drug business we will see more walking intestines, talking bladders and unfulfilled hopes of people looking for relief and in some cases unfortunately a cure.

  6. AmILloyd says:

    I think DTC was one of the worst things that ever happened to the drug industry. It really incentivized them to focus on marketing and wringing the last penny out of marginally better therapies than to put most of their resources into the hard work of actually developing new drugs. Drugs are not ketchup. My sincere condolences to Mr. Jablow, and I share his frustration about DTC.

    1. no one in particular says:

      Agree with the statement that DTC is the worst thing ever to happen to the pharmaceutical industry, my solution to the personal annoyance factor, however, is simply not to watch TV. What is the need to be bombarded with ads when there is so much streaming content available? I actually wait to watch the latest season of shows I like until they come up on Netflix or Amazon (and if you can’t wait then order the disk from Netflix), once you’re there, you will never go back.

      1. John Wayne says:

        DTC isn’t a good thing, most people will agree. The problem is that marketing campaigns have a higher return on investment than research campaigns. Eventually, the remaining pie will not be worth enough to squabble over.

        I agree about advertising. My wife and I got rid of cable two years ago, and we haven’t looked back. We watch everything on Amazon, Hulu or Netflix (streaming or disk). When football season starts I’ll be perplexed that people watch that much advertising; some of it is funny and it gives you a chance to chat, get some food or go to the bathroom. I also can’t listen to the radio anymore; its just one add after another.

  7. nmoss says:

    So, I believe there is a correlation between when “big pharma” went from its “hero/noble business” status to “villain/profiteer” in the eyes of the public…The fall from grace occurred/coincided with the approval of DTC drug advertising as well as the release of the Harrison Ford movie “The Fugitive” where the pharma company executives were the bad guys. What do you think?

    1. no one in particular says:

      Totally agree, once again.

    2. Nick K says:

      Couldn’t agree more. I was going to point out the close correlation between DTC and the collapse of the public’s trust in Pharma, but you got there before me.

  8. CMCguy says:

    I too am not a fan of DTC ads as potential for confusion with attractive sound bite messages plus not where pharma efforts could be directed however I see it is one way to force MDs to learn about new alternatives. My impression is that far too many are too busy to effectively keep abreast of all the advances and directly or indirectly prohibit sales calls where they might gain such education hence backdoor pressure from the patients becomes effective option. A number of PC barriers have been built to isolate MDs from Pharma, sometimes in reactions to past abuses, yet the industry and medical community really has to work collaboratively to identify, develop, apply and continuously improve treatments because this appears to be another example illustrating that while proud of successes the gaps involve real people and families with devastating consequences.

  9. MarkV says:

    I lost my wife to rheumatoid arthritis not too long ago, after blowing through most every available prescription, with little to no effect, including all the big advertisers.

    The Humira ads, the Enbrel ads, the Xeljans ads. They all bothered me while she was still with, getting no help from any treatment plan. It was easy to see how utterly useless the marketing was for people who had actual need for biologics.

    They really pissed me off right after she was gone. I couldn’t watch TV (thank god for DVRs). Now, they still suck, and occasionally hit at exactly the wrong moment. But still, whether they should be banned, I dunno. They’re just ads. Ads don’t work, right?

    The RA chemotherapy drugs are generally more effective in more people than cancer chemotherapy drugs. And I still can’t reconcile selling drug efficacy with the same words as laundry detergent, but adding “ask your doctor” and pretending it makes a difference.

  10. Jumbo says:

    It is worth noting that his wife entered a clinical trial for Opdivo. That probably means she had a chance of receiving placebo (I haven’t looked up the protocol to see the design, but it is very unlikely it didn’t have a placebo arm = “standard of care”). So we don’t actually know if “the drug didn’t work” in her case. That is the gamble of entering a clinical trial. You may not get anything.

    1. John Harrold says:

      The study may have used a historical control.

  11. luysii says:

    ” I am, in fact, for some years now the only one left standing out of my own birth family”

    That being the case, get some weight off and get some daily exercise. Probably 2 drinks a day isn’t a bad idea. I know you don’t smoke. We all must play the genetic hands we are dealt, but don’t spindle and mutilate the cards (said the man whose father lived to 100).

  12. Drug Developer says:

    Without disputing the perception issues with DTC ads, it should be noted that they work, or companies wouldn’t use them. Money spent on DTC doesn’t compete with R&D spending — it enables it, by generating revenue greater than the ad cost, some of which then goes to R&D (and of course some to the bottom line). Derek has made that point here in the past.

    1. Eric Nuxoll says:

      I don’t think I can let that statement pass. There are only three ways that DTC marketing can increase funds for R&D: 1) They induce people who are not actually sick to somehow purchase the drug anyway. That’s reprehensible. 2) They actually somehow increase the number of people who are sick, and therefore need the drug. Sounds ridiculous, but I’m not ruling it out. That is also reprehensible. 3) They take market share from a competing drug which treats the same disease. That’s a zero-sum game where any increase in R&D funds at one place must be offset by a decrease in R&D funds at another, plus the cost of the marketing. Overall, R&D spending is decreased by the amount spent on marketing. This is like claiming that the more you spend on your military, the more you can spend on everything else, too. That only works if your military is successfully pillaging someone else. Net civilian production does not increase.

      1. MrRogers says:

        What about 4) informs a patient about a therapeutic option for a condition he’s been living with because he thought none were available.

      2. George Sheppard says:

        Eric, I’m afraid your argument only holds if patients and their health care providers are fully aware of what treatments are available. I don’t think that is actually the case. Yeah, I hate seeing most of those ads, but there is “some” value to the information they contain and the conversations with doctors they presumably inspire. I don’t trust busy docs to read the literature, and I sure as hell don’t trust the PBM formulary to decide what the best choice for me is!

        1. Some idiot says:

          Hmmm… There is an excellent point in here somewhere… Has anyone demonstrated that real health outcomes have actually been improved by DTC? And at what extra cost? And how does that extra cost compare to money spent in other ways in the health budget?

          This is probably an impossible question to answer in the real world, but I think it is a useful thought experiment…

        2. tangent says:

          There is some value to DTC, yeah — speaking of the “positive-sum” kind of value here, bringing people up to the standard of care, rather than zero-sum patient-stealing between equivalent treatments. There is value to DTC, but there’s got to be far more of that value in advertising to prescribers, and value even in all the sleazy sales rep stuff. Making one doctor aware of the treatment affects 100 or 1000 patients; making one patient aware affects 1 patient, maybe 10 by word of mouth? Yes, it’s true the patient cares more deeply, and it’s true that patients bring in treatment improvements sometimes.

          But multiplying out those factors, I think the bottom line is you’d spend 95% of your ad dollars on prescribers, before you saturated them to the point where the ROI going to consumers became higher — if you were interested in “growing the pie” and delivering more total treatment, and had no interest in fighting over pie.

          1. tangent says:

            If the industry could act collectively, maximizing “pie size” while ignoring the slices, it probably would cut way back on DTC. At least I can’t imagine it’s a high-ROI way for the industry to grow the total patient awareness that they should ask a doctor if there’s a treatment for their angina.

            But if they tried that, and even if the big players could keep out of a cheating race, some hedge fund putz would jump in and do it — leveraged buyout of a company holding a drug, advertise to get a large % of the drug’s market, profit. The old gentlemen’s agreement against DTC can’t survive the securitization of the industry. (That was a real historical thing, right, not a myth I was told?)

  13. Barry says:

    For decades, Drug Companies abided by a gentleman’s agreement to restrict advertising of prescription drugs to physicians only. It was perceived (but never proven in court) that a statutory ban on DTC advertising would run afoul of First Amendment guarantees of free speech. All that broke down with minoxidil. Once a prescription drug was approved for the vanity market/balding, DTC advertising was irresistible to Upjohn.
    It wasn’t clear at the time, but this probably does mark the turning point, when Drug Companies were no longer run by scientists, but increasingly by marketers, and–as others have commented above–when they lost the public respect.

  14. Billy says:

    How about we eliminate all advertising? I find it frustrating when I see ads for products that I know are worthless (from personal experience) but are described as revolutionary. Though I do sympathize with Jablow, the world of marketing/advertising is all about making people feel good about a product, not about the science of what makes it improve your life. This is (unfortunately) true of prescription drugs.

    1. Crocodile Chuck says:

      “the world of marketing/advertising is all about making people feel good about a product”

      In reality, the world of marketing/advertising is all about making people feel BAD about themselves, in order to compel them to purchase the product.

      FIXED!

      1. Jim Hartley says:

        For the truth about advertising in 4 minutes, try Jerry Seinfeld’s video, https://www.youtube.com/watch?v=uHWX4pG0FNY.

  15. gippgig says:

    “get some weight off” is an invalid generalization. Most people aren’t obese. Note that repeated studies have shown that on average overweight people live longer than normal weight or obese people and far longer than the underweight.

    1. luysii says:

      It isn’t a generalization in this case

      1. Phil says:

        luysii: If you know Derek well enough to make such a personal comment, I’m surprised you would do so in public.

        1. luysii says:

          Probably a mistake on my part. But I spent decades seeing the effects of obesity. For the distinction between overweight and obesity, please see
          https://luysii.wordpress.com/2016/06/19/overweight-is-good-obesity-is-not/

  16. MoMo says:

    DTC medicine ads are the new snake oil salesman of the 21st century. Yet the FDA does’nt see it that way. Ask any nurse in the US how overprescribed their patients are, and its fully allowed by law. The medicines don’t have to work, can be obscenely overpriced, and can be broadcast into your craniums by all media at any time.

    And most are embecilic and stupid too. If any one advertising methodology was evil and deserved physical retribution for its repugnant properties, this would be it, and Jablow has a right to be angry.

    So next time at a professional pharmaceutical conference with the Pharma Mega-Booths call out these ridiculous ads and tactics, get in the Reps faces and invade their personal space. I know they do the same with their ads to the US public and make scads of money doing it.

  17. Chrispy says:

    DTC advertising must work or companies wouldn’t pay for it.

    Unfortunately, patients in the US are often in the position of having to advocate for their own care. Insurance companies and HMOs are motivated to do the least expensive care options, and patients are rightly suspicious of exactly what metrics went into their treatment decisions. DTC advertising plays right into this dysfunctional system, and apparently doctors are willing to play along, prescribing things for no better reason than their ill-informed patient saw it on television.

    Fixing this mess requires more than a ban on DTC advertising (although that would be a start). The profit motive needs to be removed, probably requiring a single-payer health system. Doctors need to be legitimate advocates for their patients; only then will their patients not feel the need to second guess them.

    1. tangent says:

      I’d be really curious if you poll people in the U.S. on whether they want a single-payer system, what do you see for people who work in pharma, versus the general public? Or for doctors, nurses, people who work in medical insurance?

      I see some 2008 poll of doctors with 59% pro-single-payer, somewhat higher than the public depending on what wording is used, but 2008 was a long time ago now. From the doctors I know, my guess is they have strong opinions that are *not* so tightly tied to their general left/right stance, but might be tied to how Medicare reimburses in their specialty. The one person I know in medical insurance thinks the industry should be hurled into the sun.

  18. FK says:

    I have not seen any overlap or co-ordinated trials between pharma and other methods of fighting cancer in the biomedical sector – focused u/s, dissolved oxygen micro bubbles, not to mention surgery and drug combinations. Seems like a missed opportunity.

  19. Anonymous says:

    I’m not a fan of DTC for many reasons, not least clinical. Another reason is that it turns into a costly arms-race where companies feel they have to pay-to-play.

    However, it’s disingenuous to suggest that money spent on marketing would necessarily be available to R&D. Marketing is a multiplier that increases sales, and if it didn’t result in increased sales above the cost of the marketing, the suits wouldn’t pay for it. In theory, though perhaps unlikely for the big boys, spending less on marketing could even result in a smaller R&D budget.

    For the same reasons, directly comparing an R&D budget to a marketing budget makes for great (negative) publicity but isn’t in reality necessarily valid.

  20. Druid says:

    Great debate on DTC. Maybe room for an MBA student to explore its ethical and commercial values.
    Derek also touched on another point. A smart CMO wants to target the patients where the cost-benefit and risk-benefit ratios are best, mostly because this is the cheapest and most reliable to demonstrate efficacy. Many trials have been ruined by including too many patients for whom the drug has little or no chance of helping. The crafty CFO loads lots of cost onto the proprietary approved diagnostic test. The lazy CFO likes the idea of selling the drug to as many people as possible, whether they will benefit from the drug or not, including people who don’t even have the indication but can be persuaded to think they have it. Pester-power!
    However, there are two problems. One is that tissue biopsies are required for most biomarkers. This can be conveniently added onto surgical section, but that is often not the case for metastasized cancers. Secondly there are thousands of mutations and over/under expressions which define specific cancer types. The good news is that efforts such as NCI-MATCH (Molecular Analysis for Therapy CHoice) are making a start to deliver panels of assays for characterizing cancers. Meanwhile the R&D industry needs to work out how to provide specific treatments which are affordable for the very small patient populations which are typical in personalized medicine.

  21. Li Zhi says:

    There is zero doubt that DTC can work. Apparently, the people who look on it with disfavor also believe other information which can have a large impact on a person’s life should go through a “truth commission”. I’ll volunteer for that, I need the money. Either people should be allowed to gather all the information possible to make, in consultation with their medical advisors, their decisions or we need momma and pappa to make them for us. Removing it as an option is clearly paternalism. It’s just like the best form of government. The best form of government is a dictatorship with me as dictator. The worst form of government is a dictatorship with anyone else as dictator. No sort of filter is benign and unbiased when it comes to making difficult health decisions. The best any of us can do is 1) educate ourselves as best as possible and 2) seek out the best medical advice we can find.
    With my sincere condolences to Mr Jablow, feeling pain at a personal loss doesn’t qualify anyone to pose as critic – unless they know what they’re talking about. If I understand what Derek wrote, Mr Jablow was just plain wrong. The NY Times, by giving him a pulpit to broadcast his false assertions, is certainly not doing its job. It reminds me of the local news outlets cornering the family of someone who has just died and asking them what they think and whether they’re upset with anyone’s behavior. That’s not journalism, its tabloid sensationalism. So, if we need to compare the NYT Editorial Pages as a source for medical information to a FDA approved advertisement, which do you think would generally be a superior source? There are two tragedies here: Mrs Jablow’s death, and the OpEd which may well lead to people who could benefit not pursuing it as an option. In fact while Mr Jablow may have recently buried his wife, if he misinformed the public, he is potentially morally responsible for further loss of life. Grief ought to be a private affair, his mixing those emotions into a contrafactual OpEd isn’t excusable. It’s not acceptable behavior, and he should be condemned for it, along with the NYT who saw fit to publish it without, apparently, fact checking. Allowing a highly biased and unbalanced OpEd to go unanswered isn’t good journalism.

    1. anon says:

      The problem with advertisement is, that its job is not to allow you to make an informed decision. Its job is to sell you things.

      1. Druid says:

        That is true for over-the-counter meds, though it is still sensible to ask a pharmacist for advice, but advertising prescription-only medicines with “Ask your physician about “Qurit”” is pester-power. I imagine physicians can handle it, and I thought the insurers usually make the decisions about prescribing patterns, in which case advertising will not make much difference. Likewise, the industry does not like NICE (National Institute for Healthcare and Care Excellence) – they will insist on being so damned objective and refuse to be swayed by emotional arguments! Meeting today on nivolumab as it happens …

      2. Isodore says:

        One shouldn’t buy a car or a computer based on its ads alone, and in fact most people wouldn’t, they’d collect additional information from various disinterested sources, like friends who had bought cars recently and possibly also some expert, like their mechanic or their company’s IT professional. So why would a patient not seek the advise of his/her doctor for something that could make the difference between health and illness or, more severely, between life and death?

        1. luysii says:

          Isadore — because frightened people are often not rational. Trust me, I’ve seen this many times in practice. Intelligence and education are no guarantee against this.

          1. Isidore says:

            I get that! I was on that boat a few years ago, although not with medications but with different surgical procedures I had to chose from. Since there are no surgery adds I looked online lot in addition to seeking second and third opinions from doctors. With prescription medications one has to get a physician to write the prescription. Isn’t the physician responsible for advising the patient before prescribing something, even if it is a drug the patient demanded? Of course in the end we are free to make our choices, including listening or not listening to expert opinion. And as others have pointed out, it is not the government’s job to protect us from ourselves. In any case, the FDA has the power to take action in cases of factually incorrect drug ads:
            http://www.fda.gov/Drugs/ResourcesForYou/Consumers/PrescriptionDrugAdvertising/

  22. anon says:

    There has been some work in economics on the effects of direct-to-consumer advertising of prescription drugs. It appears to increase utilization a bit. Some people interpret this as a good thing because it indicates that the ads may have informed patients who had not been getting treated. Others claim that the utilization increase occurs because physicians are pestered into submission. A time honored response is that physicians ought to be able to deal with patient queries and explain why drug X is not good for a particular patient.

    Companies seem to advertise more in the least competitive drug classes. The reasons for this make sense to economists and marketing people, but I won’t bore you with them. A first approximation seems to be that drug advertising is no more socially detrimental than advertising for any other complex product, and that it may have value simply because it informs the average person that something new exists. It is possible that it also helps to keep all the players in the market–pharmaceutical companies, insurers, physicians, and patients–honest by providing another source of information, especially in a era where third party payers seek to reduce utilization by hook or crook.

  23. Blabl says:

    Or you could just join the civilised world and ban direct to consumer marketing or prescription medication? Nah…..

    1. ab says:

      Yes. Because it’s always best to do what everyone else does.

      1. Phil says:

        No, the best thing to do is ignore everything that goes on in other countries and make our own rules based on magical thinking and ‘MURICA! PAY MORE THAN ANY OTHER COUNTRY FOR WORSE HEALTH OUTCOMES! F*CK YEAH!!!!!!

        1. ab says:

          Take it easy with the caps the curse words. You’ve set up a false dichotomy; it doesn’t have to be either/or. We’re all well aware of the rules regarding DTC advertising in other countries. There are other answers to why this choice has been made besides “magical thinking” and “‘MURICA! F-YEAH!…”

          1. Phil says:

            I was responding to (and one-upping in over-the-top fashion, I admit) your glib and sarcastic response.

            I don’t think anyone is making a serious argument that we should or shouldn’t ban DTC advertising based solely on what other countries do. An appeal to the bandwagon is of course fallacious.

            However, there is a credible argument that the “answers to why this choice was made” are A) the increasing power that finance/marketing types have within pharma companies and B) the influence that lobbyists have in the US vs other countries.

            The story might have been that consumers are smart and can process this information meaningfully, and corporations should be free to exercise the first amendment, but the *real* motivation is to eke out a few more prescription sales, whether it’s good for patients or not. Because of A) pharma companies had no qualms pursuing DTC advertising, and because of B) they got what they wanted in the US.

  24. Doug Steinman says:

    Sorry. Late to the party again. I just wanted to add that DTC advertising does serve a purpose in educating the patient as a consumer. However, I have found that while trying to help a friend navigate through Stage 4 pancreatic cancer, that clinical oncologists seem to have NIH syndrome. I searched through recent clinical trials and results only to have all of my suggestions shot down by the comment, Where are you getting this crap from?” Since I was not a family member I backed off but I felt a total lack of respect for this jerk who did not seem to have his patient’s best interests at heart.

  25. MoMo says:

    There is no supporting DTC ads for prescription drugs. What’s next, DTC surgical procedures? And if you have a disease and are treated by a doctor, and need information from television to help them treat you, its time to find a new doctor.

    What do you call a doctor graduating at the top of his class, and one that just barely passed his exams? Doctor!

    A little levity while Pharma poisons our Great Nation, its water supply, and threatens the future health of our children.

  26. tangent says:

    I’d forgotten a lot of the details of the history of pharma DTC.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278148/

    1981 – first DTC print ad, Merck, Pneumovax in Reader’s Digest
    1983 – a trial balloon of a DTC broadcast ad, Boots
    1983 – followed by FDA request for a voluntary(?) moratorium
    1985 – FDA ruling that effectively opened the floodgates for print ads, but not broadcast (can’t put the risks in three-point font in quite the same way)
    1997 – ruling opened up broadcast ads too

  27. ab says:

    @Phil:
    An appeal to the bandwagon is exactly what Blabl and others are doing. There is no other reasonable way to interpret, Lets “join the civilized world and ban DTC marketing.” The only magical thinking is to assume Europe gets it right every time. Thalidomide, anyone?

    DTC pharma commercials are the ONLY commercials that cause me to hunt frantically for the remote so I can mute the TV immediately. Well, maybe that douchey Mazda guy too. [Seriously, does he have the douchiest voice ever??] I find it quite insulting to see my life’s work reduced to capitalist drudgery. At the same time, I recognize it’s POSSIBLE they do some good. I frankly don’t think you or anyone else has convincing data showing the net effect of DTC advertising on patients is positive or negative. I DO find the correlation between the advent of Viagra TV adds and the tanking of public opinion of pharma to be pretty compelling. Public opinion is not the same as net health outcome, though.

    All of the points in your 4:25 comment are reasonable. But you should also admit that it is possible for pharma to have a lot of influence in Washington, make a lot of money, and for finance to influence pharma direction, all while the industry as a whole positively benefits society. They are not mutually exclusive.

    Finally, these DTC TV adds… Has anyone actually watched any of them, including the one for Opdivo? The adds all spend roughly half the time saying the drug is pretty good, and the second half listing the dozen different ways taking it might permanently disable or kill you. I don’t see how anyone could come away from one of these adds thinking, This drug is a panacea! And without risk! They’re scary.

    1. Phil says:

      ab: Thanks for continuing the conversation. I missed your response since it was buried.

      Re: Washington, money, finance – all of these can POSSIBLY coexist while society benefits; however, in practice I don’t see finance contributing positively until the mindset of the average investor changes from short-sighted and greedy to patient and responsible (don’t hold your breath).

      And yes, it’s POSSIBLE that DTC ads do some good, but as you state, no one has conclusive evidence one way or the other. But what DTC advertising does without question is compete with R&D spending. Weighing dollars spent on something that has no conclusive benefit versus R&D (long-term but measurable benefit) should be a no-brainer, but the financiers/marketers are compelled by the possibility of short term gain (again, whether or not it’s in patients’ best interest).

      “I find it quite insulting to see my life’s work reduced to capitalist drudgery.” Cheers to that. In addition to fueling my rage, this sentiment has steered my career away from the lab and toward infiltrating the business side. Someone needs to stand up for the work of scientists and the value it creates.

      Also, I speak above in generalizations. To be clear, there are investors who are in fact patient and responsible, just as there are finance and marketing people who value R&D. They just don’t seem to be carrying the day very often.

  28. Hap says:

    For the most part, my assumption when I see ads for drugs on TV is that the makers of the advertised drug are either 1) trying to get people to buy something when it has no competitive advantage over other drugs for the same indication (or, in a worst-case scenario, trying to subtly expand the target population) or 2) trying to get people to request a drug from doctors that insurance companies won’t cover to put pressure on them to cover it (it’s also possible that people could be buying the drug on their own, but with the costs it’s unlikely). In no case do I see them and believe them.

    Someone before noted that drug ads may help in getting patients to renew prescriptions for medications that they’re already on. I don’t think, though, that that outweighs the damage that DTC has done to the drug industry. Their management has monetized the reputation of the drug industry, and now the companies and the customers will be left holding the bag. It is likely more expensive to put drugs through trials because customers and the FDA can no longer trust companies to behave reasonably (the FDA exists because people are people, and well, there were lots of liars before DTC). I don’t think caring about what other countries do is a relevant reason to dislike DTC – lots of people can be wrong. What it’s done here, though, seems like a pretty good reason to dislike it. It could have been OK for society and drug companies, but I don’t think it has; it has probably been bad for both – it’s just that it allowed some to make a lot of money, and what happened afterwards was not their problem.

  29. sgcox says:

    Advertised as “currently the best compound to treat tumors” by the guy administrating it for $11,000 :
    http://www.sciencemag.org/news/2016/08/candidate-cancer-drug-suspected-after-death-three-patients-alternative-medicine-clinic

  30. loupgarous says:

    As someone battling metastatic paraganglioma, I went from essentially not being diagnosed properly because my general practitioner (who was being paid by Aetna not to refer me to costly specialists in oncology) sent me to endocrinologists who insisted that if I-131 MIBG (the “gold standard”) didn’t image my cancer, it didn’t exist.

    Seven years of severe pain and wildly fluctuating catecholamine levels later (paraganglioma ranges from indolent, inert tumors to aggressive tumors which for which the apt analogy is “pheochromocytomas on steroids”), a birthday lunch featuring liberal ingestion of wine and beer put me in bed with terrible pain; MRI and CT imaging revealed tumors in my liver; In-111 octreotide scans which my insurance company paid my GP and specialists not to request revealed the tumors to be metastases from the original paraganglioma excised from between my heart and spleen. Eight years of another “gold standard” for paragangiioma, depot octreotide therapy, allowed the tumors to spread to the cardiac notch of my stomach and Lord knows where else.

    It was after it became clear octreotide wasn’t cutting it that one of the oncologists I was consulting advised me to seek clinical trials, and I found a group in Houston investigating Lu-177 octreotate (which carries the radiation to my rare tumors, which have an affinity for octreotide). The smaller tumors responded well to the therapy, which left the big guy which had set up shop in and around my vagus nerve and part of my stomach – that was removed during exploratory surgery – and several hard-case tumors in my liver which hadn’t been fazed by the radiation. Those seem to be responding well to local treatment via transluminal catheter with mitomycin and daunorubicin, followed by embolization of the blood vessel through which they were accessed.

    I mention all this because oncology has progressed just from the time I was first diagnosed over 15 years to the point where the diagnosis and treatment of my exceedingly rare tumors has gone from ineffectiveness to great diagnostic and therapeutic power. I took part in the Lu-177 octreotate study despairing of doing more than contributing data which might be useful in someone else’s treatment, only to emerge with a significant reduction in pain and morbidity after surgery, embolization, internal targeted radiation, more surgery, and chemo-embolization.

    My pain is manageable with less pain medication and less toxic pain medication now. We’ll see what happens.

    But I freely admit, I’m lucky. I could have been gullible enough to fall for “chelation therapy” being hawked by a friend of my wife’s parents, or simply have accepted what can only be called malpractice for fun and profit by indifferent practitioners and greedy insurance companies and allowed myself to die in increasing pain.

    I’m of two minds about TV ads for drugs which have significant toxicity and therapeutic value which can be debatable depending on the disease for which they are prescribed. The current funding model of the pharmaceutical industry (in which I worked for years as a consulting analyst) seems to be a vicious circle in which half the expense of a new drug’s roll-out is marketing – purchase of advertisements in expensive prime-time TV slots and the usual largesse distributed by drug company reps to physicians. Eliminate the marketing, and half the expense of the roll-out disappears – along with whatever incentive drug companies may have to aggressively pursue innovative targets for drug therapy.

    I feel for the man who can’t stand to watch ads for a medication which didn’t do his wife much good. But Derek’s right in that the man’s grief led him to misinterpret the statistics surrounding Opdivo, and that it’s one of an increasing number of drug therapies for cancer which give their patients not just more life, but more enjoyable life. Bristol-Myers Squibb did well with Opdivo, and their advertising of the drug is actually one of the very least objectionable examples of prime-time TV drug advertising; the ads I saw presented the data soberly and thanked the patients and investigators in the clinical study in a dignified manner.

  31. RoyS says:

    I lost my (active, never-smoked) father to lung cancer about 4 months ago… the Opdivo didn’t work and chemo options were gone. On the other hand I have a friend that Opdivo is working very well for.

    In my family, it was understood that Opdivo only works well in ~20% of cases (dad and brother both being scientists might have helped with that– years ago dad wrote Derek about his nickel carbonyl TIWWW entry as he had worked with it).

    It was convenient while he was on the treatment to point to the ads and tell other people that was what he was trying. Today the ads don’t move the needle for me one way or the other.

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