Getting real about NCI-designated Cancer Center advertising

The 69 National Cancer Institute-designated Cancer Centers are premier academic institutions that place significant value on research integrity and an ethic that rigorous evidence should guide patient care and define expectations. Recent patient-focused advertising has strayed from these values, obscuring valid reasons for seeking care at these centres.

Turn on the TV, surf the Internet, or drive down a billboard-laden highway in the USA, and you are likely to be exposed to an advertisement by one of the 69 National Cancer Institute (NCI)-designated Cancer Centers. These include claims that research excellence results in superior medical care. Examples of the catchphrases include 'science saving lives', 'more science, less fear', and 'the promise of discovery'. Emphasizing research excellence in patient-focused advertising is complex because research integrity depends on long-term processes of rigorous data analysis and reproducibility. Thus, inappropriate marketing can create false hope and might divert patients from the most important and immediate reasons for seeking care at an NCI-designated Cancer Center.

NCI-designated Cancer Centers differ from community health-care providers in that their mission includes research and education, the quality of which is certified by the NCI. These centres are typically associated with major medical schools, and often combine in-patient hospitals, out-patient clinics, and research institutes. NCI-designated Cancer Centers provide quality clinical care, although the NCI designation criteria focus on research that spans basic laboratory science, clinical trials, and the study of current practices. Such centers strongly subscribe to the ethos that rigorous evidence should guide medical practice and define patient expectations; inappropriate advertising can compromise this ethical obligation.

Growth in NCI-designated Cancer Center advertising is only one component of overall growth in general health-care and cancer-care advertising1. NCI-designated Cancer Centers have a special challenge: advertising in a manner that maintains the academic standards they cherish and that provides the rationale for extensive governmental and philanthropic support. The core problem with many of their advertisements is that current research efforts have limited impact on contemporary patient care: successful laboratory developments typically take years, or even decades, to reach the clinic and involves combining advances, recalibrations, and replication of results from multiple institutions. Even clinical-outcomes research needs to be replicated and tested over a long time period.

A clinical trial conducted at an NCI-designated Cancer Center might have more immediate impact on a patient, but designing advertisements appropriate to promote trial participation is a complex task. Undeniably, some cancer trials, including targeted therapies2, and immunotherapy trials3, have produced dramatic results in certain patient subgroups. These successes are the exceptions, however, and patient expectations regarding their treatment are often unrealistic. A panacea cure is almost never the goal of a trial, and improvements are typically incremental, even at NCI-designated Cancer Centers. Early phase clinical studies seek only to document the safety of treatment; very few late-phase randomized clinical trials demonstrate marked differences in long-term overall survival4. Moreover, every experimental therapy carries the risk of serious adverse effects5.

In addition to overemphasizing the implications of ongoing research, NCI-designated Cancer Center advertising has strayed from the ethical responsibility for objectivity. One recent televised advertisement featured a long-term survivor of pancreatic cancer, and gave the impression that the superior expertise and experience of the oncologists at the centre could considerably enhance the chances of curing the disease; however, supportive evidence was not presented. In reality, metastatic pancreatic cancer remains a deadly disease, for which aggressive systemic therapies typically provide only short-term survival advantages6.

Is ethical medical advertising possible? Research on medical advertising ethics is sparse. Larson and co-workers at Dartmouth's Geisel School of Medicine noted that 62% of academic medical centre advertisements appealed to the viewers' emotions7. For advertisements involving single therapeutic interventions, 38% promoted treatments of unproven effectiveness, and none of these promotions provided quantitative evidence for the positive claims; notably, only one mentioned potential harms. A communication from the Society for Healthcare Strategy & Market Development of the American Hospital Association included a checklist that stipulates that an advertiser should be able to assert 'yes' to the question: “If the communication features results that may be atypical or specific to a single patient, does it also include a description of typical results?” (Ref. 8). NCI-designated Cancer Center websites often feature individual patient stories of treatment successes but omit details of typical outcomes. Such exceptional responders might relate to their specific favourable underlying disease biology, rather than benefiting from a recent research advance9.

“Experience and breadth of care, not miracle cures or long-term scientific research, are valid promotional attributes”

Do NCI-designated Cancer Centers offer advantages for patients? Outcomes research has shown consistently that one of the most important quality measures is the number of procedures performed — a high-patient volume results in health-care practitioners well-versed in treating the disease10. In this regard, NCI-designated Cancer Centers excel because they are among the busiest cancer-treatment centres in the USA, and see more patients with the most difficult-to-treat tumour types and the rarest cases. The scale of these centres enables expanded service provision. For example, treatment services might not cure metastatic pancreatic cancer, but many NCI-designated Cancer Centers have innovative palliative-care programmes. Experience and breadth of care, not miracle cures or long-term scientific research, are valid promotional attributes.

Why is NCI-designated Cancer Center advertising so undisciplined? One reason is the urgency of maintaining large patient populations to support clinical excellence, medical education, and clinical research. With competing community health-care providers launching advertising campaigns, there is temptation to stray from core values. A second consideration is organizational complexity: NCI-designated Cancer Centers are huge enterprises, and executives responsible for finance and advertising may have minimal knowledge of research and evidence-based medicine. A third explanation is more troubling. Many hospitals no longer behave as non-profit entities; rather, they maintain absurdly high clinical charges and levels of executive compensation, while earning large financial 'margins'. In general, cancer care is profitable and unchecked advertising helps maintain these excesses.

“...exaggerated advertising can erode the mission as easily as revenue shortfalls”

NCI-designated Cancer Centers are unique because of the elaborate governance and organizational structure the NCI demands. Nonetheless, the NCI has not yet required structures to monitor advertising and tame hospital executives. Just as Institutional Review Boards protect patients from imprudent research, cancer centre External Review Boards (ERBs) could help protect the public from inappropriate advertisements, as noted in this article11. ERBs should be multidisciplinary, and include patient advocates, as well as experts in marketing, finance, medicine, ethics, and science. Crucially, they should insure that the public is appropriately informed and that advertising is consistent with core values of the centre: more facts and less emotion are needed. NCI-designated Cancer Centers have special roles in our health-care system that require large patient populations. Many such centres see a need to advertise; however, they should proceed cautiously, recognizing that exaggerated advertising can erode the mission as easily as revenue shortfalls.

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Correspondence to David Rubenson.

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Rubenson, D., Kapp, D. Getting real about NCI-designated Cancer Center advertising. Nat Rev Clin Oncol 14, 195–196 (2017). https://doi.org/10.1038/nrclinonc.2017.28

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