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Hospital ads for the latest novelty treatment tell patients nothing about what matters

Hospital ads for the latest novelty treatment tell patients nothing about what matters

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(Photo by drcabl3 via Flickr)
An ad for for the CyberKnife from NYU Winthrop Hospital at the entrance to a New York City subway stop.

All of us have seen them — those ubiquitous TV hospital ads that are designed to impart a warm and fuzzy feeling about the medical facilities they are promoting. In New York City, where I live, the ads have reached a new level of silliness.

This winter a subway ad for Mount Sinai Hospital advised riders, “When researching hospitals, consider how much research they do.” It went on to say, the research “we do today drives medicine we will do tomorrow,” and noted that the hospital was proud that it “ranked in the top four medical schools in the country in research dollars per investigator.”

If I were looking for a hospital for a surgical procedure or if I were taken to a facility in critical condition as I was in 2017, the last thing I’d care about was that the hospital was ranked highly for “research dollars per investigator,” whatever that means for patients. I can think of several other measures, such as a hospital’s rates for blood stream or surgical site infections or its readmission rates, that are far more useful for indicating the quality of care.

But you’re not likely to see those measures touted in any ads for your local hospital. Instead you’re likely to see ads promoting unique treatments such as the CyberKnife for prostate cancer from NYU Winthrop Hospital. The ads usually convey something special about the hospital and sometimes the miraculous cures they enable, like a recent Cleveland Clinic commercial featuring a woman whose heart was failing. “No one else could figure out what was wrong with me,” she said. The Clinic saved her life, she added. An ad for Vanderbilt University Hospital promises patients they can “get everything that medical science has to offer,” and for kidney and heart transplant patients, “we can now test your DNA to give you a more precise dose of a common anti-rejection drug.” For some patients, the commercial says, “It’s the difference between life and death.”

What’s wrong with these dramatic testimonials?

I checked in with Arthur Caplan, a professor of bioethics at New York University Langone Medical Center, who has made a practice of questioning those medical miracle ads. Caplan says they may not be giving a realistic picture to people who have serious life-threatening cancers and other diseases, and the narrative suggests that survival, if not certain, is at least likely. That is, if you go to the hospital sponsoring the ad.

The ads are misleading, Caplan explained. He said many ads push individualized or personalized medicine. “They give the impression there’s a pharmacy up in the attic brewing a medicine just for you,” Caplan said. They aren’t, he added. “It’s cruel to suggest you’re getting something special or unattainable when that’s not the case. You’re deceiving them.”

Caplan’s comments on the ethics of hospital advertising and the current genre of hospital miracles that permeate the advertising space invite a much larger discussion: Namely, what are the right metrics to judge a hospital’s performance, how useful are such metrics in emergency situations, and how could you possibly refer to them once you are in the hospital as a patient?

The steps a hospital takes to ensure that medication errors don’t occur or that its staffing ratios are sufficient to protect patients are not the stuff of local advertising. Billboards and TV ads are for CyberKnives and cancer miracles. No hospital I know is promoting the how many nurses it has on the night shift.

Meanwhile, the hospital business is changing. What were once individual facilities historically run by charitable and religious institutions are now more likely to be part of mega-conglomerates where patients are now treated as customers and doctors are known as providers. “Hospitals are being treated like a business,” Caplan told me “You’d be a sap if you don’t advertise.”   

As hospitals buy up other hospitals and establish satellites in cities near and far to trade on the hospital name and attract new patients, it’s fair to ask whether the satellites deliver the same kind of care as the mother ship. Presumably the hospitals with marquee names hope the impression of excellence — fostered by the ads, of course — rubs off on their affiliates.

But does real or perceived excellence in a particular medical specialty such as prostate cancer treatment shown by the mother ship mean the satellites will provide the same kind of care?

Most potential patients don’t know, and they’re likely to equate the two based on little evidence. A recent study published in JAMA Network Open reported that the likelihood of surviving complex cancer surgery appears to be greater for those who had the procedure at the top-ranked hospital than at their affiliates.

Researchers said their study had limitations and that they might not be able to generalize their observations to all scenarios in which hospitals extend their brand. They concluded that whatever the public’s perception is, “there is currently no evidence to support or refute assumptions of care equivalency within cancer networks.”

What do patients want from a hospital stay aside from getting well and getting out? Assuming they get the right treatment, patients want to be safe and avoid any surprise bills at the end that can send them to the poor house. They want to feel like they’re in trusted, skilled hands. Those dimensions, however, are usually unknown to patients before they are hospitalized. The steps a hospital takes to ensure that medication errors don’t occur or that its staffing ratios are sufficient to protect patients are not the stuff of local advertising. Billboards and TV ads are for CyberKnives and cancer miracles. No hospital I know is promoting the how many nurses it has on the night shift.

Even Zuckerberg San Francisco General Hospital, which recently ended its controversial practice of balance billing — when a hospital sends patients bills for a balance that an insurer won’t pay — has seemed less than eager to publicize its far-reaching changes to help its patients, according to Vox’s health policy writer Sarah Kliff. Kliff deserves a lot of credit for pushing the balance billing story into national prominence by collecting more than 2,000 emergency room bills from October 2017 through April 2019. Although balance billing is outlawed by Medicare, it has become commonplace among privately insured patients in the last few years.

“I hear from patients with bills they are not aware of the policy changes,” Kliff told me. “I have no evidence they are advertising it widely. They made a decision not to send out notices to patients.”

I asked the hospital if they ever advertised their new billing policy. “We don’t buy ads or have an advertising budget,” said Rachael Kagan, director of communications at the San Francisco Dept. of Public Health. “There’s been extensive local and national media coverage, as well as press releases and public meetings of the health commission. There’s information posted on our website.”

While this is all to the good, these steps aren’t likely to capture the public’s imagination or burnish the brand the way that miracle cures or the CyberKnife have. But how great it would be if some hospital that was really improving safety, for instance, or designing more humane billing practices would take the giant step of shouting it from the roof top.

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.

Comments

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Letter to the Editor (Annenberg)
Dear Center for Health Journalism,
As the hospital responsible for the CyberKnife ads in New York City, we take serious issue with both the methodology and conclusions reflected in the recent article from May 21 by Trudy Lieberman titled, “Hospital Ads for the Latest Novelty treatments tell patients nothing about what matters.” The article is based on what we believe is a flawed, biased approach—grouping all medical advertising into a single bucket, with the premise that such advertising communicates no information that is important and/or promises “miracle cures” that do not exist. By lumping together healthcare-related ads in this manner, the Center for Health Journalism becomes the entity that is misleading, and, in fact, the article borders on slander. To place our advertising next to an editorial comment about the “silliness” of medical advertising in general is, at best, unprofessional and, at worst, libelous. The article is personal opinion masquerading as serious journalism. You should be ashamed to have this published under your banner.
Our CyberKnife advertising is directed at men with prostate cancer, which will affect approximately one in nine men during their lifetime. It is also one of the leading causes of cancer death among men, although with early screening and detection it is highly treatable.
CyberKnife (a patented, trademarked technology from a company called Accuray—their name, not ours) is a form of Stereotactic Body Radiation Therapy (SBRT), which has been accepted as a standard of care by both the American Urologic Association (AUA) and American Society for Radiation Oncology (ASTRO). Our physicians have made several peer-reviewed presentations at ASTRO illustrating the efficacy of CyberKnife treatments for prostate cancer.
There is not a single statement or claim in any of our CyberKnife advertisements that cannot be backed up by extensive, peer-reviewed research and data. CyberKnife is not, contrary to the insinuation of your author, a “novelty treatment.” Rather, it is a major advancement in radiation oncology which we have been using successfully for 14 years, with proven, documented results.
For many men, CyberKnife is a very desirable alternative to radical prostatectomy. Our hospital offers both options, as well as several other forms of prostate cancer treatment. We make patients who come to us for treatment aware of these options. For prostate cancer that can be treated with surgical removal, radiation therapy has been shown to be equally effective as surgery, yet with fewer side effects. No other treatment, including surgery, demonstrates a greater reduction in impotence than CyberKnife, and CyberKnife virtually eliminates the prospect of incontinence, which occurs more frequently after surgery.1,2,3,8 Accepted multi-institutional studies of the outcomes for CyberKnife prove this out, showing that its effectiveness matches the effectiveness of surgery, yet with the lowest incidence of side effects.4 ** This peer-reviewed data spans over 10 years.5 Industry-accepted studies have also shown that the stereotactic body radiation therapy (SBRT) used in CyberKnife is as effective as conventional image-guided radiation therapy (IGRT), but that the accuracy of SBRT significantly reduces radiation exposure to healthy tissue.6 That is a key demonstrable difference in the two technologies.
In addition, fractionated, high-intensity doses of SBRT radiation over a shorter period of time than conventional IGRT have been shown to be as effective as IGRT, with at least equal outcomes, but obviously SBRT is more convenient – a course of five brief daily treatments versus eight to nine weeks of conventional treatment. A newer, alternative treatment, proton therapy, also typically takes eight to nine weeks. Proton treatment over the course of a short period of time is, we believe, currently being investigated. However, there is no research on Proton therapy for prostate cancer, at least that we are aware of, that has tracked a decade of data on efficacy, as has CyberKnife. Furthermore, data has shown that protons for prostate cancer have a higher risk of GI complications compared to other forms of radiation, 7 so the jury is still out on that therapy for prostate.
CyberKnife’s technology tracks the motion of the prostate and adjusts treatment in “real time” to that movement, thereby delivering a continuous radiation treatment6,9-12 that more accurately locks on the prostate and avoids irradiating surrounding healthy tissue that might be exposed due to this motion. We are not aware of any other technology that can make that claim regarding accuracy of treatment. This is not a “miracle” claim. It is simply a statement about the efficacy of a treatment relative to other forms of treatment.
Our CyberKnife advertising also states that it is the most advanced treatment for prostate cancer in a decade. We submit that since no other treatment in the last 10 years has exceeded the performance of CyberKnife in terms of outcomes, convenience, and the significant reduction in side effects, coupled with the accuracy and precision that have resulted in a lower exposure of radiation to healthy surrounding tissue, this in fact supports the claim that it is the biggest advance in the treatment of prostate cancer in the last 10 years. We submit that it is verifiable.
We have never made a claim that the science did not support. It is our mission to point men seeking treatment to what is demonstrably a better option. We never say perfect, we never say it can accomplish everything. We say that, given other options, it is a “better treatment.” And we back it up!
We think it is important to note that our direct-to-consumer advertising program began nine years ago because many clinicians, who did not have access to CyberKnife technology, distorted the facts about CyberKnife, in favor of the technologies or service to which they had access. Certain groups of urologists, for example, misrepresented the validity of CyberKnife by telling their patients it was “experimental,” or that it was not FDA-approved, or that insurance would not cover it. This behavior was, at best, misleading, but it was done. Which, in your author’s view, is truly misleading – advertising supported by scientific data, or disingenuous claims by practicing physicians recommending a treatment to their patients simply because that was all they could offer.
So we have been extraordinarily careful to make certain that every CyberKnife claim is backed by fact and science, and we defy anyone to cite a single example of that not being the case. In fact, we offer to provide to any man who asks a complete packet of information about the benefits of CyberKnife (I will happily provide that very large packet of data to anyone who asks).
In short, the things that matter most to men who have been diagnosed with prostate cancer that requires treatment are, above all, efficacy, minimizing side effects such as impotence or incontinence, convenience, both in terms of treatment time and return to normal activities, and reduced exposure of healthy tissue to radiation. If your author had bothered to check, she would never have cited our advertising as an example of telling men “nothing about what matters.” Moreover, our data fully demonstrates the quality of our process and the safety of our technology. In 14 years we have NEVER administered an excessive dose of radiation.
As we have stated above, we have never made a claim in our advertising that cannot be supported by accepted, verifiable research data. If our advertising messages help men identify a highly effective solution to treat early-stage prostate cancer, we are delighted that we have done our job and created outstanding, effective advertising.
We demand an immediate retraction of this cavalier and scurrilous article which, using a broad brush and sophomoric generalizations, paints a very unfair picture of our CyberKnife advertising.

Very truly yours,

J. Edmund Keating
Senior Vice President
NYU Winthrop Hospital
References
1. Donovan JL, et al. N Engl J Med. 2016 Oct 13;375(15):1425-1437
2. Woo JA, et al. Front Oncol. 2014 May 26;4:122
3. King CR, et al. Int J Radiat Oncol Biol Phys. 2012 Feb 1;82(2):877-82
4. Meier, RM, et al. Int J Radiat Oncol Biol Phys. 2018 Volume 102, Issue 2, Pages 296–303
5. Katz, A. Cureus. 2017 Sep; 9(9): e1668.
6. Hossain S. et al. Int J Radiat Oncol Biol Phys 2010;78(1):58-63.
7. Sheets NC, et al. JAMA. 2012 Apr 18; 307(15): 1611–1620.
8. Hamdy, FC et al. N Engl J Med 2016; 375:1415-1424
9. XieXie Y. et al. Int J Radiat Oncol Biol Phys 2008;72:236-246.
10. Mutanga, FT. et al . Int J Radiat Oncol Biol Phys 2012;83(1):400-407.
11. van de Water S. et al. Int J Radiat Oncol Biol Phys 2012;88(5):1154-1160.
12. Lei S, et al. . Front Oncol 2011; 1:48
13. ** To date, no randomized trials comparing surgical outcomes to CyberKnife have been conducted; however, the Accuray company is sponsoring such a trail in the UK, called the PACE study, which should also provide very useful scientific information on the efficacy of CyberKnife versus surgery as a treatment for prostate cancer.

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Good analysis Trudy, thumbs up. Every hospital should be responsible to take care of their brand and what's the most important. It sounds like the issues on healthcare are endless. Everyday, we are facing challenges and difficulties to solve those issues. It's good to know your thoughts, this can be read by many and a good source as well to improve the system.

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