Patient education? Or marketing?

The distinction between marketing and patient education can be very subtle.  Or not.

When offered a free meal in return for listening to a presentation about time-shares in Hawaii, everyone understands this to be a marketing ploy, pure and simple. The same is true with the offer of a free lottery ticket or a 20% discount coupon on a purchase of over $100. What about health care organizations offering free or discounted services?

Picture yourself at your doctor’s office for a routine annual health evaluation or a blood pressure follow-up visit. The nurse putting you in a room (or the receptionist checking you) out hands you a flier and tells you that, as a former smoker, you might be interested in a new free service: free CT screening for lung cancer.  The very professionally done flier offers free low-dose CT scans for current or former 30+ pack-year smokers between 55 and 74, and says:

“A recent study of more than 53,000 current or former heavy smokers revealed that those who received low-dose CT scans had a 20-percent lower risk of dying from lung cancer than participants who received standard chest x-rays.”

Is this an altruistic educational service, a crass marketing ploy, or some of both?

Until very recently, multiple studies had all failed to show a benefit from screening for lung cancer. Then, in 2011 the NEJM published (here   and  here) results of a large and well done study (NLST) comparing chest x-rays with low dose CT scans in 53,000 patients and the USPSTF felt that the study showed enough potential benefit that it should be offered to selected high risk patients after a discussion of the potential for both benefits and harms. 

The flier certainly does alert patients to the availability of a free screening service which has been shown to have a potential benefit: reducing deaths from lung cancer. However, the claim of a 20% reduction in lung cancer mortality is incomplete and extremely misleading. Consider the following additional information:

  • The study showed a benefit in patients who had 3 annual low dose CT scans and were followed for 5-7 years. 
  • The study population was 91% white, and was younger, healthier, and better educated than the average US population of smokers. The results may not apply to all groups.
  • The lung cancer mortality benefit dropped from 20% to 16% with an additional year of follow-up.
  • The benefit is presented only in terms of deaths from lung cancer. The reduction in all cause mortality was 6.7% (This is still a very significant benefit.)
  • The benefit is presented as a relative risk reduction. Marketers love relative figures because they overemphasize the effects of tests and treatments. Experts in informed decision-making universally recommend avoiding relative risk/benefit information and presenting instead either absolute risk/benefit information or numbers needed to screen/treat. The absolute risk reduction is much smaller than the relative risk reduction: for death from lung cancer, the risk of death drops from 21/1000 to 18/1000 or an absolute risk reduction of 3/1000 patients screened annually for three years. The absolute risk reduction for all-cause mortality (the true net benefit in the study population) was 6.7/1000 patients screened annually for three years.  The NNS to prevent a lung cancer death is ~ 320, meaning that 320 patients had to be screened annually for 3 years to prevent one lung cancer death. The NNS to prevent a death from any cause is ~ 220. These are real and valid benefits, and should be presented in real and understandable terms.
  • Not all smokers and former smokers stand to benefit equally. Within the screened population, the potential benefit (lives saved/patients screened annually x 3) ranged from 1/100 to 1/5000 depending on risk stratification.  (Publication by the NLST group in NEJM July 2013.)
  • This (large and well done) study reflects what can be done in academic medical centers but has not been replicated in non-academic community environments. 
  • Four out of ten (39%) of patients screened by low dose CT had at least one abnormal CT that required further evaluation, one out of every 4 CT scans was abnormal, and 96% of the abnormalities were not lung cancer (were false positives). 
  • Two thirds of abnormal CT's required further evaluation. This was usually by repeat scanning at varied intervals, but 2.5% underwent an invasive procedure like bronchoscopy or biopsy (18/1000 patients) and about 1% (3/1000) had a major complication from their procedure. Deaths were rare but occurred.
  • The study was not designed to show harms and does not allow ‘numbers needed to harm’ (NNH citation) to be calculated.
  • Overdiagnosis (more here) was not specifically addressed or calculated in the study, but other studies of CT screening, autopsy studies, and analysis of the data from NLST suggest that this is not insignificant. The USPSTF estimated a 10% over diagnosis rate. The NLST over diagnosis study group estimated it could be as high as 18% in a February 2014 publication in JAMA Internal Medicine. At 18% over diagnosis, the risk of being treated unnecessarily is about the same as the potential for having one’s life saved: 1/300.
  • General health status, but especially the presence of pulmonary or cardiovascular disease, will alter the risk of cancer and affect the risks associated with both diagnostic and treatment interventions. This is best addressed before screening.
  • The majority of lung cancers will not be found by screening, not all cancer diagnoses will be early and improve outcomes, and there was no mortality benefit shown with the most aggressive form of lung cancer (small cell).

The goal of patient education is to provide fair, comprehensive, balanced and understandable information in a way that patients can use to make good quality informed decisions about their health.  There are both potential benefits and harms from screening, and the nature and likelihood of both benefits and  harms for an individual patient should be discussed before a patient undergoes screening.

The goal of advertising is neither education nor improved clinical outcomes, but the creation of consumer demand by showing only the positives, presented in the best possible light. Advertising has no obligation to present balanced or complete information.  Seen as marketing, this handout makes perfect sense as a 'loss-leader.'  Based on the NLST study cited, one thousand free CT screens will likely generate 250 follow-up CT studies, 400 office visits and  25 procedures (bronchoscopies, biopsies and surgeries), none of which will be free.

The irony is that it is easy to combine marketing and patient education in a responsible and ethical way. Imagine if the flier said:

A recent study of more than 53,000 current or former heavy smokers showed that early detection of lung cancer using low-dose CT scans saved lives, but like all medical interventions, was associated with potential risks and harms. More information is available here: <link to complete and balanced information on the institution’s web site>. You may find it useful to discuss screening with your primary care clinician.

What do you think? What is the primary purpose of this flier? Will it do more good or more harm? Who stands to benefit? Is this flier patient education or marketing? Does it enhance your trust or undermine your trust of the organization?




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