In Part 1 of this article, in the March 10 issue, we reported that it has been difficult to get cancer centers to discuss their advertising programs, at least the cross section of those approached for the article. Since there is no external oversight of hospital advertising, some medical facilities have been able to make claims that would otherwise require substantiation from so-called evidence-based institutions.
We also learned that an article in the New York Times on the topic, “Cancer Center Ads Use Emotion More than Fact” (12/19/09), had prompted some hospitals and related professional organizations to consider beginning a dialogue about the issue.
The Times story dealt with the lack of regulation of hospital advertising and the fact that some ads' anecdotal claims, such as “highest cure rates, or lowest risk” would not be considered statistically valid by medical science, “but ads for nonprofit medical centers are not held to scientific standards of evidence.”
To get a sense of cancer center advertising protocols I called the five NCI-designated comprehensive cancer centers followed last year for OT's series about how the cancer community was affected by the recession.
The institutions—City of Hope, Ohio State University/James, Johns Hopkins, M. D. Anderson, and Roswell Park—were chosen again because they reflect diverse structures and regional differences.
City of Hope
“It's important for people diagnosed with cancer to be aware of comprehensive cancer centers and to be able to access them,” said City of Hope Senior Vice President of Communications Brenda Maceo.
In a telephone interview, she characterized her institution's advertising as falling into two “awareness tracks”—(1) regional for southern California, describing clinical services that can be accessed by patients, 97% who come from California; and (2) national, with advertising awareness about its research mission geared toward reinforcing philanthropic support, since City of Hope has more than 200 grassroots chapters for fundraising throughout the nation, a development not necessarily appreciated by development officers at competing cancer centers who find a physical City of Hope presence in their backyards.
And to add insult to injury, Ms. Maceo accomplished something of an advertising coup when Fox Sports designated City of Hope as the official charity of the National Football League this past season, a designation that included public service announcements playing for free throughout the country as well as mentions by announcers.
“We have a unique City of Hope model with our media partnerships with Fox, Clear Channel, Ladies' Home Journal, and others.
“We do very little TV advertising in California because it is so expensive; we rely mostly on radio and print and some outdoor ads in this region, but this type of model using donated media means we're able to reach national audiences without a national budget.”
As for its vetting process, Ms. Maceo said that when an ad is under development the clinical marketing team works with institute physicians in that area. The ad then goes to the appropriate clinical department chair and then to the chief medical officer. Once reviewed and possibly revised, the content is finally seen by the legal team and compliance office before it is released to the public.
Ohio State University Comprehensive Cancer Center/James Cancer Hospital and Solove Research Institute
When I originally contacted Ohio State, the designated spokesperson was out sick but another medical center communications official said he'd try to expedite things, noting that OSU would provide its budget information because it was required to do so as a state institution, even though he doubted the other centers would comply.
However, when OT spoke with OSU's chief communications officer for the cancer program, Theresa DiNardo-Brown (while she was still ill at home), she said that I'd have to go through a Freedom of Information Act request to get the proprietary budget information.
Ms. DiNardo-Brown said that Ohio State University's Cancer Center and James Hospital uses advertising along with media relations, outreach, education classes, and other means to reach the public.
“We're in a very competitive market here in central Ohio, with some large community health systems that are very competitive.
“What we use really depends on what our goal is. For example, advertising is an effective tool if it's a prevention message for community education, which is part of our mission, or to educate consumers about our research-based care options.”
The center's advertising covers traditional print and broadcast, billboards, digital Internet advertising, and on occasion, direct mail, and provides overall awareness about OSU to referring physicians and oncologists, she said.
“We have a process to determine whether to use advertising based on whether it would be advisable and feasible. Our marketing program directors work with administrators and disease chairs on a core key message to make sure they are comfortable saying it and that it's on target and accurate.”
For certain ads the center may use a committee of patient and family advisors, a voluntary group of patients, survivors, caregivers, and family members who provide their perspective to help determine needs and ensure that messages are understandable.
“And when we run prevention messages encouraging people to get mammograms or screened for prostate cancer we sometimes will hold a screening event at the hospital as well,” she said.
Two cancer centers did actually volunteer to provide information on much they spend annually on advertising:
Johns Hopkins Kimmel Cancer Center
Dalal J. Haldeman, PhD, MBA, is Vice President for Marketing, Communications, and Business Development for Johns Hopkins Medicine, which comprises the entire Hopkins medical enterprise, including the Kimmel Cancer Center.
Yet, she said her entire annual advertising budget for print and TV is between $500,000 and $600,000.
“I'm a believer that health care institutions spend too much money on advertising,” she said during a telephone interview.
She cited an independent study done in 2008 that compared the advertising budgets for print and television of several leading medical centers, with one institution's budget more than 10 times greater than that of Hopkins.
“I believe it is okay to use advertising for education or information, or to increase awareness, and it should be very truthful so that a relative or friend would find it compassionate.”
She cited a situation in Hopkins's pancreatic cancer clinic where some 20% of patients referred for second opinions were misdiagnosed—that is, they either did not have pancreatic cancer at all, or were not told how advanced their stage of cancer actually was.
“But the bottom line is, if you spend money for public relations or media for physician services, make sure that what you are doing is what you need. The measure of success is ‘why am I doing this ad,’ and then establishing measurements.”
Hopkins does not advertise nationally, she noted, but relies largely on its news media placement. The advertising is largely limited to the Baltimore area and parts of the Mid-Atlantic States.
As an academic evidence-based medical center, Hopkins would not make any statements or claims that its faculty was not comfortable with, and a team approach is often promoted, she said. The vetting process involves an internal group of health care professionals—doctors and sometimes nurses— involved in the particular disease site, as well as the marketing and public affairs team, department administrators, and legal counsel.
University of Texas M. D. Anderson Cancer Center
The Houston-based M. D. Anderson Cancer Center does a lot of marketing research, said Associate Vice President for Marketing Alicia Jensen.
“This is a very competitive and confusing market with a lot of options. We use market research to understand patients and their communities and how they make decisions about cancer, both those who have cancer and those who may be future patients. We view this as part of our educational mission.”
She described the center's demographic audience as those age 35 to 60 with insurance who are able to come to M. D. Anderson, adding that psychographics would consider them “fighters” or people who do their homework and speak with family and friends in an active effort to seek information about their cancer care. About two-thirds of these patients come from Texas.
“Folks who have already chosen us are aware of what we can do for them, and we seek to build a latent awareness so that when others are at the point of needing care they will consider us,” she said.
Advertising is mostly regional, although a national effort has begun using key strategic publications, including Smithsonian magazine, some in-flight magazines, and even Travel+Leisure.
Direct-to-consumer advertising was first introduced at the center in 1996 when the Texas legislature permitted patient self-referral and M. D. Anderson established a marketing department to reach the community through brand advertising.
“Our institution is very evidence-based and data-driven, and that is reflected in our advertising. We make an effort to understand our market and how they make decisions so we can best serve them.”
Ms. Jensen said her annual advertising budget is slightly more than $4 million, and that the strategy is to keep it at the same level, since “unfortunately cancer happens, regardless of the economy.”
The advertising process begins with the marketing team meeting with the center's business planners to look at areas that can be differentiated to offer the best hope for patients, and then deciding how to educate the public about the medical services being offered.
“We sit down with management on the business and medical sides, and plan strategy, key messages, distribution, audience, and return on investment. We work with an advertising agency to come up with the creative and messaging, the medical side vets everything for accuracy, the executive committee [the center's president and executive vice presidents] reviews all strategies, and business and legal experts make sure everything is consistent with our branding, and the messages we are communicating are those we can fulfill.”
Roswell Park Cancer Institute
The Buffalo, NY-based center (disclosure note: I am involved in an oral history project with RPCI) also relies heavily on marketing research, according to Laurel A. DiBrog, Vice President for Marketing, Planning, and Public Affairs.
“Our target market is women aged 45 and older—the decision makers who will get their family members to the doctor and will select the health plan.
“We want to know our constituents in western New York State, and our biggest message involves once you've been diagnosed with cancer you should know all your options, take your time, and don't have a knee-jerk reaction about rushing into what could be unnecessary treatment.”
Ms. DiBrog talked about a situation that was brought to her attention in 2008 by oncologists in Roswell Park's prostate cancer program, who were concerned about the number of men coming in for second opinions who either did not have cancer at all or were being rushed into treatment by community urologists.
“We held focus groups with our own prostate cancer patients and with men who did not get their treatment here to learn how much of a problem this was, and then decided to develop a marketing campaign to raise awareness about options related to prostate cancer. And we found many men felt rushed into treatments, and were not told about various options, with surgeons advocating surgery and radiation oncologists advocating radiation, and very few advising them about active surveillance when it was appropriate.”
Ms. DiBrog said that the institute didn't rush into its awareness campaign and that more than a year elapsed before it was released.
The process involved concept approval from senior leadership; bringing the faculty together to develop the concept and discuss the look and feel of the campaign; holding focus groups with patients, members of a support group, and the general public; and vetting the campaign for content and appropriateness to ensure it would not create fear. All advertising and marketing services were provided in-house.
The campaign featured former Buffalo Sabres hockey player Mike Robitaille, whose family had a long history of prostate cancer, in a series of local commercials (http://bit.ly/RPCIprostate)
“If we make a claim about quality of care we want to be sure we have the data to support it, and unless it's published [in the literature] then we consider it as false advertising,” she said, also expressing concern about the potential for claims in some of the slick medical-device marketing materials made available by for-profit manufacturers to hospitals and community practices.