Journal of the National Cancer Institute Advance Access originally published online on October 7, 2008
JNCI Journal of the National Cancer Institute 2008 100(20):1424-1426; doi:10.1093/jnci/djn377
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© Oxford University Press 2008.
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Media's Influence Extends to Cancer Care
The media is a major source of cancer information for the public. Although news reports can educate readers about advances in cancer research, the media are often criticized for spreading inaccurate and hyped stories about the disease. Three recent analyses examine whether cancer news coverage in the mainstream media has influenced the policy and practice of cancer care in three different countries.
A report published in the June issue of the Journal of the Royal Society of Medicine revealed how the Australian media's news coverage of trastuzumab, a drug used in HER2-positive breast cancer, affected the government's decision to include the drug in a state-subsidized drug list.
With the publication of the trastuzumab trial results in the New England Journal of Medicine in October 2005, demand for the drug by the media and cancer advocacy groups surged in many countries even though the drug was not yet licensed for treatment. France bypassed its approval process to release the drug; many Canadian provinces fast-tracked its approval; and the UK's department of health announced the acceleration of the assessment process of trastuzumab. After the release of the trial results, there was also a flurry of news reports on trastuzumab in Australia.
According to the Australian media study, which was conducted by researchers from the University of Sydney from October 2005 until the drug became subsidized in August 2006, 43 television news reports with 239 direct or attributed statements about trastuzumab were identified during the period. "The predominant discourse running across these news stories was the ‘wonder drug’ trastuzumab being made unavailable to HER2-positive breast cancer women due to the government's intransigence and its lackadaisical nature," said Simon Chapman, Ph.D., one of the report's authors and a professor of public health at the University of Sydney.
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More than half of news coverage revolved around one overwhelming image: desperate sick women in double jeopardy. They were afflicted by a potentially fatal disease, but the hefty price of the treatment would spell their financial ruin. "Most news reports on trastuzumab overwhelmingly focused on the fact that the drug was unaffordable to many women with HER2-positive breast cancer and cited government callousness and mean-spiritedness as reasons behind this roadblock," Chapman said.
The researchers found that the media painted only a rosy picture of the drug and often exaggerated its real benefits. Trastuzumab after standard chemotherapy reduces the risk of disease recurrence for women with HER2-positive breast cancer by about 50%. However, the researchers found that in several news reports that figure was inflated to 90%.
"The Australian media unambiguously aimed at forcing a shift in government policy by running news reports about trastuzumab with predominant attention on some issues while eschewing others over this 11-month period," Chapman said. The researchers found that media reports did not discuss the debates surrounding the trastuzumab trial—questions about optimal duration of trastuzumab, sequencing of treatment, and the long-term benefits and risks. Only 8% of the total statements about trastuzumab mentioned the government's rationale for not listing the drug, namely, inadequate evidence. The research also revealed that none of the news reports questioned the price being charged by the drug manufacturer, which the government would have to pay for trastuzumab. (Patients had to pay $1,000 for the weekly dose of trastuzumab before it was approved for government subsidization, which lowered the cost to $30.)
"The case study of how trastuzumab was covered on Australian television showed the ‘rule of rescue’ in operation," Chapman said. The rule of rescue refers to the way that health care policy gives priority to rescuing identifiable individuals from health plights over efforts to bring benefit to populations of ‘statistical’ victims. "Australian media, by invoking the rule of rescue in its news coverage, provided an unavoidable backdrop that paved the way to the subsidization of the drug by the government."
Influence on Doctors’ Prescriptions
In another study, published in the Japanese Journal of Clinical Oncology, researchers discuss how a special news program about oxaliplatin on the Japan Broadcasting Corporation (NHK) might have influenced whether Japanese physicians prescribed the drug. NHK aired the program, called Questioning Cancer Treatment in Japan, on April 30 and May 1, 2005. Oxaliplatin was approved in Japan in March 2005 for use against advanced and recurrent colorectal cancer. After the approval, a postmarketing clinical trial that enrolled 1,200 patients was conducted in Japan to monitor patients treated with oxaliplatin.
The study found that the number of patients registered in the postmarketing clinical trial increased sharply after the NHK program, reaching a peak in the first week of June. The pharmaceutical company researchers conducting the trial enrolled enough patients 44 weeks sooner than they had estimated.
According to the study authors, apart from the NHK program, three national newspapers and one weekly magazine ran stories on oxaliplatin between April 6 and June 6. However, unlike NHK, which got high viewer ratings and covered many aspects of the drug, the other reports were minor with only brief discussions of the drug. Before the surge in oxaliplatin use, there were no meetings of any oncological societies in Japan that discussed the drug, so the possibility that scientific meetings in Japan influenced the increase in oxaliplatin use can be discounted, the authors concluded.
"Our study demonstrates the chronological association between the NHK special and the increase in the number of oxaliplatin prescriptions, suggesting a potential impact of TV on prescriptions by medical specialists," said Koichiro Yoji, M.D., Ph.D., assistant professor of hematology and oncology at the University of Tokyo and one of the study authors. "Though it could not demonstrate exact causal association between the NHK special and the increase in oxaliplatin prescription, the study has brought a crucial issue like the possibility of media's influence on prescription behaviour to the limelight, which needs to be addressed by further research."
After the program aired, more than 400 Japanese doctors sent a written opinion to NHK stating that the program had spread misperceptions and confusion about oxaliplatin to the public and that they felt it exerted an inappropriate influence on clinicians’ prescriptions of oxaliplatin. "Clinical oncologists who viewed this NHK TV program, which presented a life-prolonging anticancer drug like oxaliplatin as the curing drug, feared for the potential hazard that misinformed patients would bring; this program made viewers expect too much from the new anticancer drug. In fact, the extravagant expectation of the new drug from the patients clouded the judgments of the front-line physician," Yoji said.
Covering a Celebrity's Illness
Another way by which the media seems to influence cancer care is through portraits of celebrity illness. Capitalizing on the interest generated by celebrities’ illnesses can provide an opportunity to promote public health objectives that would otherwise require huge sums of money. Journalist Katie Couric's televised colon cancer awareness campaign, for example, increased public participation in a screening campaign in the U.S., according to a study in the July 14, 2003, issue of Archives of Internal Medicine. The recent breast cancer diagnosis for 36-year-old actress Christina Applegate provided the opportunity for many medical societies and media outlets to discuss the risks and myths associated with breast cancer in premenopausal women.
However, coverage of celebrity illness can also undercut the appropriateness of the public health budget prioritization or promote its irrational use. A recent study in the International Journal of Epidemiology examined the effect of Australian singer Kylie Minogue's breast cancer diagnosis on screening for the disease among Australian women aged 25–44 years. Australian researchers who conducted the study looked at whether the publicity surrounding Minogue's diagnosis influenced doctor-referred breast imaging, biopsy, and surgery rates among low-risk Australian women. Her diagnosis was made in May 2005; the study looked at the period from October 2004 to June 2006.
Doctor-referred breast imaging in women aged 25–44 years increased in Australia after the media coverage of Minogue's diagnosis. The odds of a woman aged 25–44 years undergoing imaging procedures increased by 20% in the first and second quarters after the news reports. The increase never returned to the baseline level during the study period. "With no evidence of increasing linear trends of breast imaging in the preceding quarters, the study suggests that media reports of Kylie's diagnosis prompted the upward trend of imaging in Australian women after May 2005," said Margaret Kelaher, Ph.D., from the school of population health at the University of Melbourne and the lead author of the study.
The absolute number of breast biopsies also increased during the study period and did not return to the earlier levels over the following year. But the increase in biopsies did not translate into an increase in cancer diagnoses. The odds of having surgery after positive biopsy decreased compared with the 6-month period before the announcement of Minogue's diagnosis.
"Our study showed that increased awareness in the wake of celebrity illness can affect doctors’ and consumers’ decision making in a way that undermines rational guidelines. The implications of such events may be even greater in relation to cancers with a lower public profile, particularly where there is increased potential for adverse consequences associated with screening itself," Kelaher said.
When a celebrity gets ill, people may think, ‘If it can happen to them, it can happen to me.’ "So for the best interest of those ‘worried well,’ consultation between a celebrity's public relations team and public health agencies on how to shape and disseminate the information could help create a message with the best chances of furthering the quality of care and sound public health practice," Kelaher said.
Mark Fendrick, M.D., a professor of health management and policy at the University of Michigan Medical Center in Ann Arbor, also agrees. Because celebrities profoundly affect public health behavior, "it is important for media stories to accurately report recommended screening practices for preventive care to avoid unnecessary, costly, and potentially dangerous overuse of screening tests for whom they are not clinically indicated."
Not Just the Media
Despite these studies, many argue that the media is not entirely to blame. "On the one hand, several studies suggest that cancer news stories, most of the time, do not misrepresent factual information. Nevertheless, as these studies demonstrate, some aspects of studies about cancer are highlighted while others are not. The aspects that receive greater attention are often those that invite conflict between groups or those that are particularly novel and thus not yet validated by scientific replication," said Jeff Niederdeppe, Ph.D., assistant professor in the department of communication at Cornell University.
The problem seems to lie in the inherent differences between journalistic and scientific values. "Journalistic norms value novelty and conflict, whereas scientific norms value replication and the development of a cumulative body of evidence over time. Most complaints about health news coverage are rooted in the conflict between these norms," he added.
Chapman argues that it's not necessarily the function of the media to send out public health messages. The news media should not be seen as some arm of government or the health professions, lining up alongside health communicators to bring audiences comprehensive, balanced, and evidence-based messages, he said. "They are profit-driven entities, whose first service is to their shareholders by delivering advertising revenue. Advertising revenue is attracted to media that attract large audiences, and large audiences are typically more attracted to human-interest stories than to long, detailed facts on health and medicine."
The scientific community is also partly to blame, he said. "Overhyping is a dance for two: Many scientists and their institutions flagrantly overhype developments to attract publicity and investment."
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