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Aug 4, 2020

Dr. Fay Hlubocky, a clinical psychologist and ethicist at the University of Chicago Medicine Comprehensive Cancer Center, discusses ethical dilemmas associated with direct-to-consumer-advertising in the cancer setting and shares guidance on promoting ethical marketing of services to patients.



ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. I'm delighted to welcome Dr. Fay Hlubocky to the podcast today. Dr. Hlubocky is a clinical psychologist and ethicist at the University of Chicago Medicine Comprehensive Cancer Center, and the past chair of the ASCO Ethics Committee. She joins me today to discuss ethical dilemmas associated with direct-to-consumer- advertising in the cancer setting, and efforts to promote ethical, quality marketing information to patients with cancer. Dr. Hlubocky reports no conflicts of interest relating to the issues we'll discuss in the podcast. Full disclosures can be found on our episode pages. Dr. Hlubocky, it's great to have you on the podcast today.

Dr. Fay Hlubocky: Thank you, Geraldine, for your lovely invitation, and wonderful to join you and all our ASCO friends out there to discuss this important issue.

ASCO Daily News: This year, spending on advertising by pharma companies, hospitals, and cancer centers directly to consumers is projected to reach $173 billion according to the Agency for Healthcare Research and Quality. That's about three times more than was spent on advertising 20 years ago. Patients with cancer, as we know, are a very vulnerable patient population. So as an ethicist, what are your biggest concerns about direct-to-consumer advertising in the cancer setting?

Dr. Fay Hlubocky: As an ethicist, our concern is that we are promoting balanced and fair data-based information to patients and their families. However, we're also very concerned that this marketing is used as a powerful tool that can entice patients in such a way to seek out treatment that might not be appropriate for them. The psychology of advertisements very much works on people's emotions, especially in the cancer setting, with the vulnerable cancer patient that tends to have hope, and is also fearful because of his/her disease.

So these ads work very powerfully because they're very relevant to the patient. As well, that content of the ad, particularly if it's visual ad or an auditory, by their words, by phrases, can be very persuasive. So we really have to balance this marketing information.

Again, as many have described, including cancer center directors, the goal of marketing is to increase the market share for many cancer center advertising. And now that there's a shortage of patients seeking treatment, especially clinical trials, there is this boom, this increase in marketing. So our goal in the community is to have an open dialogue with the cancer centers, with pharma, with all of us, to be able to truly and really talk about this issue and provide balanced, honest, fair information for patients and their families.

ASCO Daily News: Well, direct-to-consumer advertising really is a controversial issue, but are there benefits to it in the oncology field? Does the research show that direct-to-consumer advertising truly improves access to care and clinical trials?

Dr. Fay Hlubocky: So there are several advantages. It's actually a great mechanism to be able to inform and educate and bring awareness to the patient and family who might be seeking, say, clinical trials or other treatments that aren't close to home. We know that it can help to not necessarily, "improve the care" directly, but definitely, there has been a great deal of research by, for example, Vater et al.,  in 2014, that it does-- a benefit is that it does increase access to, say, clinical trials. But that said, because there is such a shortage of patients going into, say, trials, we have to be very careful that that clinical trial is also not just a tool, a mechanism, to invite cancer patients in that might not be appropriate for such trials.

So there are advantages. We are able to engage clinicians with the use of these tools, either through billboard, social media, to engage clinicians who might not be aware of new medications, say, new trials out there. Patients are also alerted to cancer symptoms through some of these ads, so might be more willing to go to a physician to say, 'I have this symptom,' and through testing, may find out that it is a cancer or where that cancer may have spread or originated. And so there are true advantages. Education is key.

But we have to be also wary of the cons. Many ads are not data-driven. They may not mention the negative outcome of the particular treatment. Patients may actually have to access more tests and use a lot more tests. False hope-- patients actually might be very hopeful when they see this advertisement but then, come in, become very anxious and upset because that specific ad and that specific treatment or service might not fit that specific cancer patient's needs.

And the use of patient testimonial-- again, another powerful tool in that tool box, where patients could be misled, where these ads do not mention, the patient eligibility, say, for trials? So within these testimonials, again, the visuals and that relevancy to the patient can be quite enticing and very persuasive. That may cause the patient to then travel long distances, spend a lot of money on travel and housing.

So we really have to balance this advertising, which, now, 56% of is actually through social media, web-based platforms, internet, TV, as well as print. Just even driving down the expressway on a billboard, we see these ads. So again, although there are significant benefits, we also have to be cautious of the significant cons and disadvantages.

ASCO Daily News:  Right. And so what's at stake for oncologists who have a responsibility to educate their patients and provide the best possible care while also supporting the business interests of their institutions and managing the influence of other parties?

Dr. Fay Hlubocky: So oncologists are placed at a unique position. First and foremost, their obligation has to be to the patient to provide patient-centered, quality care. So of course as patients will, say, come to the cancer center, it's vital to be able to talk about whether or not that cancer treatment or the service that they are seeking is ideal for them, to truly talk about the data that's associated with it, the risks and benefits.

As I mentioned, in the study by Vater, and there have been many studies, that really looked at the information on risks and benefits; how these ads tend to infrequently provide that information. So really going through that in an informed consent discussion, a very rigorous informed consent discussion, to describe the purpose, the risks and the benefits, as well as the alternatives -- it's very, very vital, whether it's a physician where the patient is seeking treatment or maybe even the patient's physician, say, in the community who's seeking out this information, to really truly sit down with the patient and the family member and go through, step by step, why this treatment or trial is right or not right for them. So in that aspect, the obligation is always to the patient.

The challenge is, of course, for many, that the cancer center is the place of business, the place where physicians are employed. As well, the oncologist has an obligation to provide the appropriate information on the treatments provided by their cancer center to patients, to work and collaborate with the cancer center to be able to communicate this information, and actually work with cancer leadership, actually, in using these tools.

So that, as I think of the future direction, it is for the oncologist to work with marketing to really convey the right information, work with the cancer center so that that information is balanced, it's fair, it's appropriate, it's ethical, that the entire community feels that the right information is being provided.

ASCO Daily News: Are there resources out there for oncologists and patients to verify information, to verify whether the information they're hearing is accurate about treatments, about drugs, medical devices, et cetera?

Dr. Fay Hlubocky: We know the NCI has a great reputation; has a wealth of information on their website when it comes to, say, trials or treatments. And also, the cancer center, I think, can be a fabulous resource in that aspect, to really educate them, the patient, as consumer. But again, balancing it with that information by talking about potential risks, talking specifically about the data that was presented, and patient eligibility-- I think that's the only, appropriate way that we will feel confident in conveying the importance of this information to our patients.

ASCO Daily News: So how do you foresee the future direction of direct-to-consumer advertising in the cancer setting? And perhaps you'd also like to talk about the article that you've published in the Educational Book and any other work you're doing in this area?

Dr. Fay Hlubocky: Yes. It's our hope that cancer centers and the cancer community will adopt ethical guidelines that can help the cancer center. Because truly, what is the best mechanisms for advertising and marketing-- it has to really be uniform.

So for us to truly adopt policies, uniform policies, that all cancer centers can utilize is the most ideal. And we discuss this, actually, in our article on the ethical implications of a cancer center advertising for the ASCO20 Education Program in August. And we really did quite an in-depth review of the literature out there on, what are some of the issues that cancer centers need to address?

And again, it's also even the physician communication. Physicians have to feel empowered by their cancer centers to be able to talk about these issues, and talk about it both with the patient, as well, more broadly, for us to have greater discussions. And that's actually a wonderful thing that we've been able to do with ASCO. And we're so grateful to ASCO leadership on the Education Committee that they have allowed us a platform to have an open dialogue so that the cancer center, physicians, patients, all of us within the community, can have an open dialogue on how to best market cancer center services and treatments to patients and families as a whole. So that's part of the future.

Part of the future, I think, will be also an increase in some of these advertisements through social media, which tends to be the primary source of a lot of these ads. As well, future research needs to really look at the link between these ads and patients' expectations for benefits. So how are these ads really, truly influencing patients' decision-making? And I think with that information, more longitudinal information, more rigorous testing and research through patient interviews and really following the patient experience -- it's our only way to identify what type of harms, what types of benefits are patients experiencing from that? But we can only do this together as a community and a partnership as a whole within oncology.

ASCO Daily News: Absolutely. I'm afraid we'll have to wrap things up now. But I thank you for sharing your insights and your work to address this important and controversial issue.

Dr. Fay Hlubocky: Thank you. Thank you so much, Geraldine. And thank you to all the listeners out there.

ASCO Daily News: And I'll just remind our listeners that they can find the article in the Educational Book, entitled "Direct-to-Consumer Advertising for Cancer Centers and Institutes: Ethical Dilemmas and Practical Implications."


Dr. Fay Hlubocky: Thank you, Geraldine. Thank you, everyone.

ASCO Daily News: And thank you to our listeners for joining us today for this episode of the ASCO Daily News podcast. If you're enjoying the content on the podcast, please take a moment to rate, review, and subscribe.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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Dr. Fay Hlubocky - No Relationships to Disclose