Health, Hope and Hype

With the pharmaceutical industry spending around $3 billion a year advertising its products directly to consumers, you can't open a magazine, watch television or read a newspaper without stumbling over a pitch for this or that drug. So when an editor first alerted me to a series of ads being run by the pharmaceutical giant Novartis, I assumed it was just more of the same. Each ad shows a photo of an actual cancer patient, under headlines such as, "Stunning Success. Deadly cancer at 23. Complete remission at 24," or "To life! Novartis and Rabbi Sklarz drove his cancer into remission in just 56 days." I knew the company was touting its new wonder drug, which can snatch certain cancer patients from death's door and put them into remission.

But on closer inspection, I realized these ads can't be aimed at consumers, not simply because they never mention the drug, Gleevec, by name, but also because there's not much point in the company spending hundreds of thousands of dollars on marketing a drug that benefits at most only a few thousand patients. Gleevec works on chronic myeloid leukemia and an exceedingly rare intestinal tumor, which together afflict only about 5,000 to 8,000 Americans a year. Colon cancer, by contrast, is diagnosed in 149,000 people annually. Every oncologist in the country with a patient who needs Gleevec is surely aware of the drug, if not already prescribing it.

Then I read the tag line: "Think what's possible." Aha. These are corporate "feel-good" ads aimed at burnishing the company's image in the eyes of investors, company employees, and especially Congress, which is hammering out the details of a Medicare prescription drug benefit. The ads aren't selling a product; they're selling hope.

Now there's a commodity that seems to be in great abundance these days, at least in the fields of medicine and biomedical research. Magazines are chocka-block with full-page ads such as the one for a New York hospital that reads, "Another day, another breakthrough," and so-called advertorials, tricked-up advertising for hospitals and drugs that is practically indistinguishable from the editorial content of the magazines in which they appear, except for the requisite word "advertisement" that's printed at the top of the page in small type. The headline on one recent eight-page advertorial on heart disease: "From Cause to Cure." Oh, really? If there's a cure for heart disease, I'd like to know what it is.

Forgive me if I sound cynical. It's just that, as a journalist, I'm a recently reformed hope pusher myself. The medical stories I used to write always had a strong element of hope, and the same goes for the majority of the articles produced by my colleagues around the country, who collectively serve as a kind of pep squad for biomedical research and medicine.

Here are just a few headlines from an Internet search that turned up 939 stories containing the words "breakthrough" and "medicine" from the month of June alone: "Saving Lives with Living Machines," from Technology Review; "Beat the Clock: Local Scientists May Be on the Verge of a Cancer Breakthrough," in Washingtonian; "Life Saver; There's a Revolutionary Blood Test That Can Predict the Future," in the London Mirror. With all those breakthroughs, you'd think nobody would have to die of cancer any more and we should all be running marathons into our eighties.

But we aren't running marathons in our eighties and we are still dying of cancer and heart disease and you name it. Do you think maybe that's because a lot of what passes as medical journalism contains a bit of hype?

This issue came into sharp relief for me in 1998 during the flap that ensued after the New York Times printed a story about the potential for new compounds known as "anti-angiogenic factors" to treat cancer. The story appeared on a Sunday, on the front page, above the fold, and it quoted Jim Watson, co-discoverer of the structure of DNA, saying, cancer would be cured "in two years." This was a patently ridiculous prediction, and any reporter who has ever interviewed Watson is well aware that he -- how shall I put this? -- has been know to shoot from the hip. But lots of readers and editors didn't know that. Later the New York Times would say it was shocked, shocked, when headlines around the world blared "Cancer Cure," stock prices of half a dozen biotech companies with patents on the compounds hit the stratosphere, and cancer patients clogged the phone lines of every oncologist and cancer center in the country, begging for a shot at the new miracle drugs.

In reality, the compounds hadn't yet been tested on a single human being, and they existed in such tiny quantities that there was scarcely enough to treat a few cancer-ridden mice. That meant that dozens of medical writers around the country, including me, would spend the week pulling together stories to set the record straight and disabuse readers of the notion that anti-angiogenic factors were going to cure anybody's cancer any time soon.

And yet, when the time came to decide how to package the magazine story that a colleague and I had written, somebody hit on the bright idea of running a photo of the breed of mouse that was used in the experiments, under the words, "Meet the Mouse That Beat Cancer." When we writers objected that this headline would further fuel the hype, the editors added "A Cure?" With that, the cover was printed with a wink and nod to what we all knew: Hope sells magazines.

Don't get me wrong. I'm all for hope. It's a good thing to feel when your doctor hands you a scary diagnosis. And I am deeply hopeful -- no, convinced -- that science will one day cure cancer, Alzheimer's, multiple sclerosis and so on. But hope is not the same as information. Good journalism is supposed to shine light into dark corners, not help sell this or that new drug or treatment.

One of the sorriest examples of the latter involves the way journalists covered high-dose chemotherapy for breast cancer -- a risky, expensive treatment that was performed on only 100 women a year in the mid-1980s. By 1994, that number had jumped to more than 4,000 a year. Patients with advanced breast cancer were clamoring for high-dose chemo, which was also known as bone marrow transplant, even though there was scarcely a shred of evidence that it kept anybody alive longer than standard treatment. Why? At least part of the treatment's popularity was due to the hundreds of articles and television segments that appeared in the 1990s. I can't pretend to have read or seen every last one, but I have looked at about 200 of them, and with a few notable exceptions, practically every story portrayed high-dose chemotherapy as an advanced breast cancer patient's only hope.

The stories tended to follow a formula guaranteed to tug at readers' heartstrings: Tell the tale of a frightened patient, preferably a young one with children, who has exhausted all other options and is fighting her insurance company for a shot at life. (Many companies refused to pay for high-dose chemotherapy, which initially cost $150,000 and up.) Most reporters threw in a warning or two about the fact that the treatment was still unproven -- clinical trials didn't get underway until 1992. And it was extremely risky, killing 20 percent of patients in the early days. But the risk was part of the drama, and I think it's safe to say that many if not most breast cancer patients skipped right over the caveats about the lack of scientific evidence. The upshot was that we in the media helped sell a pricey, unproven, vile treatment to some of the most vulnerable readers imaginable.

At the very least, we should have given a little more thought to ulterior motives. For one thing, high-dose chemotherapy was hugely profitable. A single procedure could net a hospital a minimum of $18,000 to $20,000. No wonder hospitals began building entire wings devoted to this treatment. For another, most of the doctors who were administering it were too busy making names for themselves in their profession, enriching their institutions, and gosh, saving lives to look critically at the data.

Many of my colleagues will undoubtedly be crying foul right about now. I can almost hear them pounding their fists on the breakfast table and telling their spouses, "We were just reporting the news as we heard it from the doctors!" True enough, and therein lies the problem. We have this symbiotic relationship with the industry we are supposed to scrutinize, so much so that we often get our story spoon-fed and pre-digested from the medical journals, which send out embargoed copies of the top scientific papers each week. That means the editors and publicists of those journals, rather than reporters, are deciding what constitutes news. Funny, but those digests never seem to include the (rare) editorials that criticize the medical industry.

The newest little twist on this time-honored practice is the "video news release," which is pre-packaged footage for television stations to use in producing medical stories. A recent example: ThinPrep, a new way of preparing Pap smears that the manufacturer claimed was more accurate than the old method. But because ThinPrep was also more expensive, insurers and HMOs didn't want to pay for it. Five years ago, the company put together a video news release, featuring doctors who swore by the new technology and a patient named Peggy Smith saying it saved her life. Smith was a publicist's dream come true, a medical technologist who happened to see her own abnormal cervical cells in the microscope while using ThinPrep. Gasp! What many of the television and print stories failed to disclose was that Vanderbilt University, where Smith and the doctor-experts worked, was being paid by the company to test the new technology.

So much for journalistic skepticism. Like the rest of America, we medical journalists seem to think that if it's new it must be improved. And the market for happy talk is only growing. There's an unwritten rule in mass-market magazines and television: If your ratings are low run a medical story. If your ratings are really low, run two. If I want to dish out yet another hope-filled piece about how biomedical research is going to make us live for a century, there are plenty of editors to lap it up. In general, editors love stories about the bright, bold future of medicine, undoubtedly because that's what readers love.

What readers don't seem to like is ambiguity, or probabilities, or uncertainties, which in the end are the very stuff of science. They don't seem to want to hear that whole-body CT scanning will almost undoubtedly lead to unnecessary treatment, or that the Chinese herb ephedra won't help them lose weight without having to exercise or cut out the super-sized Cokes -- much less that it could kill them. They don't like the idea that they might have to participate in a clinical trial to determine whether this or that new test or treatment actually works.

When I recall the saga of high-dose chemotherapy, which turned out to be no more effective than standard chemotherapy, I feel both sad and humbled. Sad for all the women who suffered, but also a little sad because I can't bring myself to write hopeful stories any more. Lately I've been digging into the darker side of the medical-industrial complex -- the conflicts of interest, the money, the failure to protect patients -- and I have to tell you it's a lot harder than writing about the newest breakthrough, and a lot less fun.

But mostly I feel humbled by the power of my profession. Fifteen years ago, the budget for the National Institutes of Health was just barely over $7 billion, and the nation's total health care bill was $500 billion. This year we will spend more than $1.4 trillion on the two combined, yet we are only moderately healthier than we were back in 1988. While health and biomedical research are clearly two of the best investments we can make as a nation, at least part of our willingness to pour money into this behemoth system has been fueled by the rosy picture of it the media have painted -- and by the selling of hope.