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When ads subtract

DII small banner By Warren R. Heymann, MD
Aug. 2, 2018

“Could the skin lesion you’re seeing…actually be a deadly blood cancer?….Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is an aggressive and deadly hematologic cancer with skin lesions that may be mistaken for other skin disorders…When biopsying skin lesions, ask your pathologist to test for CD 123. Refer patients early.”

Although this is a commentary about advertising, it is imperative to have a rudimentary knowledge of BPDCN. It is rare, accounting for less than 1% of all cutaneous lymphomas. BPDCN was formerly known as blastic NK cell lymphoma or CD4+/CD56+ hematodermic neoplasm. CD4, CD56, and CD 123 expression are characteristic of BPDCN. It predominantly affects the skin and has a high risk of leukemic dissemination. The disease usually affects older men (median age 67 years), however, its has been rarely reported in children. Clinical manifestations are variable, and include single or multiple, nontender, sometimes pruritic, erythematous to violaceous papules, plaques , nodules., or ecchymotic lesions. The long-term prognosis is poor, and worse in adults, with a median survival of 12-16 months . Induction chemotherapy similar to high-risk acute lymphoblastic leukemia is utilized followed by hematopoietic stem cell transplantation. (1,2,3)

Direct-to-consumer advertising (DTCA) became legal in the United States in 1985, however, it escalated in 1997, after the FDA loosened risk information disclosure requirements. Billions of dollars are spent on these ads. Proponents defend the educational components of the ads, while detractors consider the information biased and misleading. Applequist and Ball performed a content analysis of prime-time direct-to-consumer ads across 4 major cable television networks. The ad content (n = 61) was coded for factual claims made regarding target conditions, appeals used, portrayal of medications, and lifestyle characteristics shown. The authors found a substantial decrease in the percentage of ads that conveyed information about the conditions being targeted, such as risk factors (16%) and prevalence (16%). Positive emotional appeals (94%) continued to be emphasized; yet there was decreased use of negative emotional appeals (51%), pointing to an overall more positive portrayal of a patient’s experience with a medication. The lifestyles portrayed in the sample largely featured how products can enable more recreational activities (69%) and fewer ads (7%) presented alternatives to product use. They concluded that DCTA promotes prescription drugs above educating the population. They contest that improvement in the educational value of DTCA is likely to require regulatory action rather than reliance on self-regulation by the pharmaceutical industry. (4)

Direct-to-consumer information (DTCI) campaigns, without mentioning specific drugs have been demonstrated increase prescription rates. Zaitsu et al confirmed this in a DTCI campaign for patients with overactive bladders. (5)

I no longer think twice about these ads on television — I even have learned to enjoy the creativity. On my recent trip to Glacier National Park, I was thrilled to see a moose cross a river. I felt badly for the TV woman on her camping trip where a giant overactive bladder blocked her view of a moose.

Over the years, I have become adept at handling patient requests for what they have seen on television or print ads, quickly stating why the drug may or may not be appropriate for them, and move on. (In this age of prior authorizations, good luck getting them anyway!)
I am delighted for dermatologists to learn about BPDCNs and become familiar with its diagnostic immunohistochemistry.

So why did this print ad about testing for CD123 leave me aghast?

Maybe I would not have been offended if the ad was directed to dermatopathologists asking for consideration to include CD123 in immunohistochemical panels for assessing atypical lymphocytic infiltrates.

What perturbed me was the blatant push for dermatologists to biopsy lesions and request immunohistochemistry for CD123 “because you play a critical role in early and accurate diagnosis of BPDCN”. I have not — and will not — biopsy every ecchymosis for the remote chance of diagnosing BPDCN. Of course competent dermatologists are going to biopsy violaceous papules and nodules suspicious of lymphocytic infiltrates. I expect that any reputable dermatopathologist will request a panel of markers to determine the precise nature of any lymphomatous process.

I anticipate that next week there will be an ad warning us that seborrheic dermatitis could be Langerhans cell histiocytosis — biopsy it and check a CD1a stain to be sure!

Madison Avenue knows no shame.

1. Żychowska M, et al. Blastic plasmacytoid dendritic cell neoplasm: A rare lymphoma of extremely aggressive course. Postepy Dermatol Alergol 2017; 34:504-506.
2. Dreyer S, et al. Skin lesions serve as clues to relapse of pediatric blastic plasmacytoid dendritic cell neoplasm. Pediatr Dermatol 2018; 35: e132-5.
3. Rai MP, et al. Blastic plasmacytoid dendritic cell neoplasm. Clin Case Rep 2018; 6: 770-2.
4. Applequist J, Ball JG. An updated analysis of direct-to-consumer television advertisements for prescription drugs. Ann Fam Med 2018; 16: 211-6.
5. Zaitsu M, et al. Impact of a direct-to-consumer information campaign on prescription patterns for overactive bladder. BMC Health Serv Res 2018; 18:325.

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