Ethicists and experts in health-care marketing are expressing criticism of how some hospitals are marketing their oncology services. Hospitals are promoting proceduressuch as lung-cancer screening using spiral computed tomographythat have not been fully validated in clinical trials. Others are turning to celebrity endorsements (see related story, p. 8) or are touting their high patient-satisfaction scores while failing to mention clinical success rates.
"The best marketing is marketing that educates," noted Rhoda Weiss, a Los Angeles-based consultant and speaker on health-care marketing and strategy. "Marketing can be great in terms of educating people and letting people know whats out there. But it can also mislead people and take advantage of people who are hypochondriacs or who are vulnerable because theyre ill."
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In an interview, medical writer Christine Blackett Schlank, author of Medicine and Money (Silver Lake Publishing, 1999), explained that hospitals are driven by competitive pressure to purchase expensive instruments, the costs of which then have to be amortized. "In order to get donations or to get money [hospitals] have to have some of the newest procedures and technology. And if they dont have it, I would assume that theyd have more trouble attracting patients and attracting money to the institution. Once they have it they have to use it. They have to get their money back. So theyre making patients think that its something they want."
And its not just hospitals that are advertising the latest in medical technology directly to patients; instrument manufacturers are doing so as well. General Electric, for example, has touted its digital mammography system in television commercials as a "major breakthough," although theres some question about whether digital mammography is any better than its analog predecessors (see News, March 15, 2000, p. 442).
Another technology that has come under scrutiny involves lung cancer screening with spiral CT (see News, April 19, 2000, p. 592). Using spiral CT, radiologists can acquire images of the entire chest in about 10 or 15 seconds, compared to about 20 minutes with a standard CT. As radiologist Albert Lee, M.D., of Glendale Memorial Hospital in Glendale, Calif., explained, "In lung cancer screening you want to be able to detect small lesions, and you want to be able to do the exam in a reasonably short period. You want to cover a big area in a small amount of time. Do it fast, do it cheap."
But critics have pointed out that the Early Lung Cancer Action Projectthe main study supporting the use of spiral CT for lung cancer screening (Henschke C et al., Lancet 354:99105, 1999)was not a randomized trial. The National Cancer Institute is planning a large multicenter trial of spiral CT that is both prospective and randomized, but that trial is only in its feasibility phase. Among other questions, the NCI-sponsored study is designed to determine rates of false positives and false negatives and to determine whether using spiral CT produces a decrease in morbidity and mortality.
Marketing the Technology
Nevertheless, years before the results of this study are likely to become available, some hospitals and clinics are urging at-risk patients to get the test, even though few if any health insurers will reimburse their members for it. A Web-based search on "spiral CT" reveals several hospitals marketing this service, including Boca Raton Community Hospital in Boca Raton, Fla.; the Sharp Oncology Center in San Diego, Calif.; and Glendale Memorial Hospital, which encourages patients at risk for lung cancer to pay $300 for spiral CT. This information appears in several places on Glendale Memorials Web site, and in addition patients hear an advertisement for the procedure when they telephone the hospital and are placed on hold.
According to Peter A. Clark, S.J., Ph.D., the McShane Professor of Ethics at St. Josephs University in Philadelphia, such marketing activities fail a critical ethical test. "I dont think it would pass the test of beneficence," noted Clark. "With one clinical trial, I dont think thats enough. Therefore, unless we have enough data from long-term clinical trials on the accuracy and the false positives and the false negatives, I dont see how a hospital could advertise this in good conscience. They certainly wouldnt allow that with medications."
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Amy deBlaise-Kasai, the clinical research coordinator of Glendale Memorials cancer center, noted that patients willing to pay for spiral CT are asked to sign a consent form that alerts them to the risk that the test might miss their cancer. She acknowledged, however, that the risks of false-positive results, which sometimes lead to invasive procedures such as biopsies, are not spelled out. In the hospitals defense, she noted that mammography has a high false-positive rate, and in addition "mammography is screening all women and the lung cancer study is looking at an at-risk population."
Weiss has been a proponent of lung-cancer screening ever since a close friend benefitted, in her opinion, from an early diagnosis after spiral CT. Yet she is troubled by some of the language Glendale Memorial uses on its Web site. A page on health screening reads, in part, "Regular screening for persons at-risk could increase chances of a cure. All past and present smokers, people with occupational exposure to asbestos, chemicals, fumes or dust are encouraged to participate."
"I think the words that bother me are are encouraged, " said Weiss. "The word cure also concerns me."
deBlaise-Kasai denies that the wording of the Web page implies that the test has been proven to decrease morbidity or mortality. "Certainly were not saying that. Were talking about detecting lung cancers at an earlier stage. We dont know that answer, and [the Early Lung Cancer Action Project] doesnt know that answer because the data arent mature enough."
That same Web page points out that while the test costs $300, some patients may qualify for a clinical trial, which would allow them to receive spiral CT at no charge. According to deBlaise-Kasai, the hospital has received funds from a private foundation to conduct its own nonrandomized trial of 100 patients, modeled on the Early Lung Cancer Action Project. And she said that Glendale Memorial hopes to be part of the NCI-sponsored randomized trial as well.
Ethical Questions
Clark said he believes that additional ethical questions are raised when a hospital conducts a clinical trial while offering the same service for a fee. "How can they be doing these two things at the same time?" he asked. "It just seems like theyve already made their decision that its positive. So are they going to skew the results here? Are they looking at the accuracy of this from an objective standpoint, or have they already made their decisions, and theyre just kind of going through the motions?
"Im surprised the hospital is doing this," he continued. "Arent they opening themselves up to litigation? Lets say that we find out that it had a high percentage of false positives or false negatives. At that point couldnt people come back and sue them for offering a procedure that wasnt fully tested?"
Other marketing practices, in addition to touting unproven technology, also come under criticism by marketing experts. "Sometimes Ill see marketing from small hospitals with small cancer programs, and they talk about how good their program is based on their patient satisfaction," said Weiss. "Does that mean that its clinically excellent?"
In addition, said Weiss, "We sometimes use celebrities or individuals to market miracles. What makes news is miracle stories, so we market these miracle stories, and yet not everyone is going to have a miracle. We concentrate on stories of patients who survive and do well, but we dont balance it with more of the norm."
Weiss said that even though health-care marketing associations do publish codes of ethics, individual hospitals rarely if ever have their marketing efforts audited. "How do we make the tough decisions?" she asked. "I think as marketers we have to have a conscience about what we do. And sometimes in the name of trying to please health-care executives, marketers can go over the edge."
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