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Direct-to-consumer ads: helpful or harmful?

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If it seems like you have been seeing an awful lot of advertisements for the new cancer immunotherapy medications lately, it’s not your imagination. Ad spending for the new cancer drugs Keytruda® (pembrolizumab) and Opdivo® (nivolumab) has exploded onto the scene in a big way. Drug makers Bristol Meyers Squibb (Opdivo) and Merck & Co. (Keytruda) spent $132 million on TV advertising in the first nine months of 2016, and more than $33 million just in February of this year.1,2

At OptumRx, we have been following the rise of cancer immunotherapy drugs for several years. They are considered specialty medications, since they require special handling, and are administered via infusion under medical supervision.3

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Drug makers spent $132 million on TV advertising for Opdivo and Keytruda in the first nine months of 2016

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When Bristol-Myers Squibb (BMS) launched its Opdivo TV commercial in fall 2015, it was the first time the company had run a branded cancer drug ad.2 Merck waited until February of 2017 to release their own DTC ad for Keytruda. This set the stage for a very public duel featuring competing claims about these sophisticated immunotherapy treatments.4

The recent blizzard of ad dollars has placed Opdivo and Keytruda second and third in pharma TV advertising spending for the early 2017 period. This is a stunning development for a DTC ad category that didn’t even exist on national television two years ago.2

Power to the patient?

Traditionally, direct-to-consumer (DTC) advertising was the province of more conventional over-the-counter drugs, like analgesics and stomach acid reducers. Then we began to see advertising for drugs to treat more complex conditions like depression, irritable bowel syndrome, and plaque psoriasis. But until quite recently, cancer drug marketing has focused on educational marketing aimed at physicians and health care providers.1

At the broadest level, the recent advertising blitz for immunotherapy has re-awakened an argument that goes back to the earliest days of direct-to-consumer advertising for pharmaceuticals. Prior to 1997, it was illegal to publically advertise prescription drugs. At that time, doctors – and even pharmaceutical executives – argued that marketing sophisticated medicines would disrupt the doctor-patient relationship, and could not be done safely.5

Of course, eventually the drug industry changed its mind. Reacting in part to a new feeling that consumers need to be empowered to make their own health care decisions, pharmaceutical companies now promoted the idea that patients had the right to know all their options.5 By this yardstick, marketing prescription drugs on TV would actually benefit the public.6 Eventually, the Food and Drug Agency (FDA) agreed.

We all know what happened next. Spending by drug companies on TV ads shot from around a half billion dollars per year in the late 1990’s to over $6 billion each year today. As a result, there now are more than 80 DTC ads for drugs on TV every hour.7

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Chart showing DTC ad spending by pharmaceutical companies

Television still rules

Increasingly, we hear that social media is the real future for marketers who want the best way to reach their audience.8 However, total advertising dollars still heavily favor television. In fact, the graph below shows a pronounced increase in the proportion of the total DTC budget going to television ads – now nearly 70%:

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Chart showing that TV direct-to-consumer advertising spend as a percent of total is on the rise

One possible explanation for the huge emphasis on TV ads is demographic. Simply put, older Americans watch much more TV than younger groups. Recent Nielsen figures show that those aged 50-64 spend three times more hours watching television than the 18-24 group; while those over age 65 watch even more than that.9

Not coincidentally, many of the top advertised drugs treat conditions that affect mostly older people (e.g., erectile dysfunction, Alzheimer's, cancer). Overall, patients aged 50 and up accounted for 70% of all dispensed prescriptions in 2016.10

Perhaps someday our TVs will become as smart as our computers, and learn to display only ads that are relevant particularly to us. However, at least for the near future, as the population keeps getting older we can probably expect to see the lion’s share of the pharma advertising dollar going to TV.11

A look at the products

Now that we have a sense for how much money is in play, let’s spend a moment looking at the two drugs that are the beneficiaries of all this attention: Opdivo and Keytruda. Both of these new drugs have seen rapid additions to their initial FDA approvals. In just the first full year, they obtained seven new approvals between them (three for Keytruda, four for Opdivo).12

By the summer of 2016, Opdivo was considered the cancer immunology market leader, with indications for melanoma, second-line non-small cell lung cancer, renal cell carcinoma, classical Hodgkin lymphoma, and squamous cell carcinoma of the head and neck.13 Opdivo sales quickly jumped to blockbuster status (at least $1 billion) in 2015, the first full year. From there sales increased rapidly, to nearly $4 billion in 2016.13, 14

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Chart showing rising Opdivo sales vs. decreasing Keytruda sales from 2015 to 2016

As these sales results indicate, doctors and patients are excited about the demonstrated clinical advantages of immunology. However these drugs share a common trait of many modern specialty medications: They are extremely expensive, with an average cost of over $100,000 per year. That figure can increase to over $200,000 per year when they are used in combination with other drugs, as is increasingly common.15 In addition, immunotherapy drugs come with their own set of potential side-effects.16

Changing environment

The new emphasis on DTC advertising comes just as the tone and focus of the conversation around immunotherapy has begun to change. Previously, as the above linked article reflects, much of the early commentary reflected the excitement that these new treatments were generating.

This excitement extended not only to patients and doctors, but also to the scientists who were creating them. In 2013, immunotherapy was called the science “breakthrough of the year,” while in 2014 its ability to reduce cancer was called “remarkable.”17, 18

What has changed today is that we now know much more about how much improvement most patients can realistically expect. Furthermore, we also know much more about who – exactly – can benefit from these drugs. And that definitely does not include everyone.16

To DTC or not to DTC?

Unfortunately, these new complexities are coming to light just as a thunderous publicity campaign is saturating the airwaves. Some doctors are concerned that the nuances of when, and who to treat are being lost in the noise. Others are taken aback by the seemingly blanket promise in these ads of “the chance to live longer,” when the reality may be much more complicated.19

So is all this advertising a problem, or not? The question boils down to whether one believes DTC advertising is harmful, or beneficial. There are advocates on both sides.

One stance is that DTC ads work to drive up drug costs. The American Medical Association (AMA) believes that the growing proliferation of DTC ads is driving demand for expensive treatments – despite the clinical effectiveness of less costly alternatives. In 2015, the AMA announced its support for a ban on DTC ads of prescription drugs and medical devices. Their logic is that a ban would help make prescription drugs more affordable.20

Turning specifically to DTC ads for cancer immunotherapy, two oncologists recently argued that marketing cancer-related drugs directly to the public can be harmful in many ways.21 They believe that patients can misunderstand whether a new drug is appropriate to treat their own case, or gain a false impression of how much good it might do for them. In addition, these doctors argue that DTC advertising boosts patient interest in new drugs whose toxic effects may not be fully known, while failing to present other treatment options that may be less toxic or less costly.21

The pro-DTC camp points out that there is actually little economic evidence that DTC advertising drives up prescription drug prices.7 They point out that, while it is true that advertising does cause increased drug sales, this is not always a bad thing. For example, if a DTC ad motivates someone with depression to see a doctor and receive treatment, that’s arguably a net positive.7

Also regarding increased sales, it appears that DTC advertising not only increases sales for the specific drugs they advertise, but for other drugs in the same category. This can include drugs that are much less expensive, such as those favored on PBM formularies.7

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There is even some evidence that drug ads can actually help patients stay adherent to medications they’ve already been prescribed. One study found that, for every 10% increase in viewership of drug ads, between 1 and 2.5% more people stayed adherent to their prescribed drug regimen.7

DTC advertising also has its defenders when it comes to the doctor-patient relationship. A sociologist at the University of Miami (Florida) has presented research showing that, in general, DTC advertising works to open lines of communication between patients and doctors.22 The research showed, for example, that when patients saw a DTC ad for a drug they felt was relevant, they would talk to their doctor about it. These were conversations they would not necessarily have otherwise had.22

One very interesting finding regards the perception among doctors that patients are going to push to request for a prescription drug that they have seen advertised. This perception is actually false.19 While such patients do exist, for the most part patients do trust their doctor's opinion and expertise. Furthermore, patients seem to trust their doctors more than they do the pharmaceutical industry. Patients are canny enough to understand that they are being targeted by a sales pitch, not just useful information. If their doctor tells them that an advertised drug is not necessary, “9 times out of 10, patients will accept their doctor's opinion and they don't push."19

Clinical landscape for immunology

While concerns about whether DTC advertising is a good or bad for cancer immunology are important, ultimately they are secondary. In the U.S., certainly for the foreseeable future, we must acknowledge that DTC advertising is deeply entrenched in our culture, and is unlikely to end anytime soon.

The real questions around cancer immunology revolve around the drugs themselves: Are the new cancer immunology drugs living up to their initial promise? Are cancer patients pinning unrealistic hopes to these new therapies?

This is the subject of our next installment: Marketplace of hope

OptumRx and BriovaRx specialty pharmacy programs offer a wide range of management tools and strategies designed to deliver the right care, at the right time, to the right individuals. If you have questions about how to be sure that your plan is correctly administering these complex new drugs, be sure to talk to your consultant or OptumRx representative.

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References

  1. Medical Marketing & Media. Merck's DTC ad for Keytruda hints at more cancer brands turning to TV. Feb. 12, 2017. Accessed at: http://www.mmm-online.com/commercial/mercks-dtc-ad-for-keytruda-hints-at-more-cancer-brands-turning-to-tv/article/637538/ on 04.14.2017.
  2. Fierce Pharma. Keytruda's head-to-head against Opdivo rockets meds to Nos. 2 and 3 in ad spending. Mar 15, 2017. Accessed at: http://www.fiercepharma.com/marketing/merck-keytruda-and-bms-opdivo-competition-rockets-cancer-drugs-to-nos-2-and-3-ad-spending on 04.13.2017.
  3. Specialty Pharmacy Times. 2015: The Year in Oncology Drugs. February 10, 2016. Accessed at: https://www.specialtypharmacytimes.com/publications/specialty-pharmacy-times/2016/february-2016/2015-the-year-in-oncology-drugs/p-4 on 04.14.2017.
  4. BioPharma Dive. Merck unveils new Keytruda DTC ad. Feb. 1, 2017. Accessed at: http://www.biopharmadive.com/news/merck-unveils-new-keytruda-dtc-ad/435270/ on 04.13.2017.
  5. Vox.com. What 20 years of drug commercials are doing to Americans’ health. Aug. 29, 2016. Accessed at: http://www.vox.com/2016/8/29/12685026/american-drug-ads-tv on 04.21.2017.
  6. Los Angeles Times. Direct-to-consumer drug ads: A bad idea that's about to get worse. Feb. 15, 2017. Accessed at: http://www.latimes.com/business/la-fi-lazarus-drugadvertising-20170215-story.html on 04.24.2017.
  7. New York Times. Ban Drug Ads on TV? Some Positive Outcomes Would Be Lost. March 14, 2016. Accessed at: https://www.nytimes.com/2016/03/15/upshot/ban-drug-ads-on-tv-some-positive-outcomes-would-be-lost.html?_r=0 on 04.24.2017.
  8. Advertising Age. TV Budgets Shifting to Social? Yes, It's Time to Worry. May 23, 2016. Accessed at: http://adage.com/article/digitalnext/era-multilingual-communications/304106/ on 05.04.2017.
  9. MarketingCharts. The State of Traditional TV: Updated With Q4 2016 Data. April 24, 2017. Accessed at: http://www.marketingcharts.com/television/are-young-people-watching-less-tv-24817/ on 05.04.2017.
  10. QuintilesIMS Institute. Medicines Use and Spending in the U.S. A Review of 2016 and Outlook to 2021. May, 2017. [PDF]
  11. Pharma Marketing Network. Annual Spending on Direct-to-Consumer Drug Advertising Ties an All-Time High. March 03, 2016. Accessed at: http://pharmamkting.blogspot.com/2016/03/annual-spending-on-direct-to-consumer.html.
  12. IMS Institute for Healthcare Informatics. Global Oncology Trend Report: A Review of 2015 and Outlook to 2020. June 2016. [PDF]
  13. Drugs.com. Development History and FDA Approval Process for Opdivo. Accessed at: https://www.drugs.com/history/opdivo.htmlon 04.14.2017.
  14. BioPharma Dive. How biomarkers cost Bristol-Myers the lung cancer market. Feb. 13, 2017. Accessed at: http://www.biopharmadive.com/news/biomarkers-bristol-myers-opdivo-lost-lung-cancer/435891/on 04.14.2017.
  15. Healthline News. The Value and Cost of Immunotherapy Cancer Treatments. Oct. 12, 2016. Accessed at: http://www.healthline.com/health-news/value-and-cost-of-immunotherapy#2on 05.05.2017.
  16. STAT. Beware the hype: Top scientists cautious about fighting cancer with immunotherapy. Sept. 25, 2016. Accessed at: https://www.statnews.com/2016/09/25/cancer-immunotherapy-caution/on 04.24.2017.
  17. Cancer Immunotherapy Named Science ‘Breakthrough of the Year’. Available at: http://www.livescience.com/42102-cancer-immunotherapy-breakthrough.htmlon 03.04.2014.
  18. Memorial Sloan Kettering Cancer Center: Cell Therapy Shows Remarkable Ability to Eradicate Cancer in Clinical Study. February 19, 2014.
  19. Medscape Medical News. Cancer Drug Direct-to-Consumer Advertisements -- Good or Bad? Sept. 1, 2016. Accessed at: http://www.medscape.com/viewarticle/868276#vp_1on 04.14.2017.
  20. American Medical Association. AMA Calls for Ban on DTC Ads of Prescription Drugs and Medical Devices. Nov. 17, 2015. Accessed at: https://www.ama-assn.org/content/ama-calls-ban-direct-consumer-advertising-prescription-drugs-and-medical-deviceson 04.24.2017.
  21. JAMA Oncology. Viewpoint: Disadvantages of Direct-to-Consumer Drug Advertising in Oncology. Nov. 2016. Accessed at: http://jamanetwork.com/journals/jamaoncology/on 04.28.2017.
  22. JAMA Oncology. Viewpoint: Direct-to-Consumer Advertising of Prescription Drugs Can Inform the Public and Improve Health. Accessed at: http://jamanetwork.com/journals/jamaoncology/article-abstract/2542921on 04.28.2017.
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STATEMENT REGARDING FINANCIAL INFLUENCE:
This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article.