CAVEATS

Direct-To-Consumer Advertising: Let the Pharmacist Beware

Recently, the Food and Drug Administration approved the use of Nolvadex (tamoxifen citrate) as a preventive treatment for certain types of cancers. The drug's manufacturer, Zeneca Pharmaceuticals, has rolled out an innovative advertising campaign that focuses on the risk of developing cancer rather than on the qualities of the product, and communicates the message that consumers can do something about their cancer risk.

These ads depart substantially from celebrity-endorsed, "feel-good" ads for some pharmaceuticals, providing instead a host of information that fights commonly held myths about breast cancer. The goal of the campaign is to get the consumer to ask questions, and Zeneca has provided the answers, brochure-style, for pharmacists everywhere to discuss with patients. I hope these ads have peripheral effects and start a dialogue between health care professionals and patients with, or at risk of developing, cancer. There couldn't be a downside to that, could there?

Well, perhaps. Will Rogers, who made famous many quips and quotes during his lifetime as a humorist and philosopher, once made a statement that may help clarify this downside. Many historians have described the flight of Oklahomans from the dust bowl toward the promise of prosperity in California during the Great Depression of the 1930s, but none as succinctly and humorously as Rogers, who said, "When the Okies left Oklahoma and moved to California, they raised the average intelligence levels of both states."

What in the world does this have to do with direct-to-consumer advertising? Strange as it sounds, this epidemiological phenomenon (commonly called stage migration) has a lot to do with how we treat cancer sufferers. In an article by Alvan R. Feinstein et al.,¹ the authors report on a study that compared patients treated at the same institution for lung cancer-one cohort treated between 1953 and 1964, and another treated in 1977. The authors demonstrated how improved diagnostic techniques had allowed cancers to be detected earlier in the latter group. This more recent cohort appeared to have a much more favorable survival rate. However, further analysis showed this to be an artifact of new diagnostic and imaging procedures, producing a stage migration. As the authors explained: "Many patients who previously would have been classified in a `good' stage were assigned to a `bad' stage. Because the prognosis of those who migrated, although worse than that for other members of the good-stage group, was better than that for other members of the bad-stage group, survival rates rose in each group without any change in individual outcomes." However, when the two cohorts were classified according to stages that were immune to diagnostic technique advances, the cohorts had similar survival rates.¹

Simply put, we have to wonder about the integrity and applicability of the information we as pharmacists receive from pharmaceutical companies for use in patient education. Although the risk-reduction claims of Nolvadex are sound, questions about other cancers have yet to be researched. Early detection of new cancers will be a great service if we can treat the cancers more effectively. However, unless treatments actually improve survival rates, early detection may simply increase resource utilization without yielding substantial benefit.

In direct-to-consumer advertising, pharmaceutical companies seek ways to differentiate their pharmaceuticals as commodities. If a market hasn't fully developed for the product, manufacturers will apply time-tested marketing methods to create stronger demand. These efforts may lead consumers to seek information that will confirm or refute the manufacturer's claims that differentiate its product from its competitors. This is happening now and will become more prevalent quickly. Consumers are turning to the most trustworthy and accessible sources of information-including, and perhaps especially, pharmacists-for answers to their questions.

This means pharmacists will be on the front lines processing these information requests. Exercise caution, make your evaluations prudent and wise. Advertisements such as those from Zeneca will bring questions about other cancers, and the information you need to answer those questions may not be neatly packaged in those brochures you received. Express your concerns to the consumer and qualify your answers. In this manner, you serve the autonomy of patients, lead them to ask more questions, and encourage their own caution.

Embrace the coming opportunities to help your patients. Enhance your knowledge and understanding of the information laid before you, and beware of advertisements bearing gifts.

Woodie M. Zachry III, R.Ph., M.S.
The University of Texas at Austin,
College of Pharmacy
Division of Pharmacy Practice
and Administration

References

1. Feinstein AR, Sosin DM, Wells CK. The Will Rogers phenomenon, stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. N Eng J Med 1985 (Jan 20); 312(25): 1604-08.