Letters from work, child care, and transportation could also improve 4. Unger JM, Coltman CA Jr, Crowley JJ, et al. Impact of the year 2000 access to clinical trials for lower-income patients. Future Medicare policy change on older patient enrollment to cancer clinical trials. J Clin Oncol. 2006;24(1):141-144. research should investigate how to overcome financial barri- 5. Zafar SY, Peppercorn JM, Schrag D, et al. The financial toxicity of cancer ers to clinical trial participation. treatment: a pilot study assessing out-of-pocket expenses and the insured The identification of patient income level as an indepen- cancer patient’s experience. Oncologist. 2013;18(4):381-390. dent predictor of trial participation is important for multiple 6. Dickert N, Grady C. What’s the price of a research subject? approaches to reasons. If income is associated with health status, then im- payment for research participation. N Engl J Med. 1999;341(3):198-203. proving representativeness of lower-income patients in trials would improve the generalizability of study outcomes. Also, The Use of Superlatives in Cancer Research greater participation of lower-income patients would allow The language used in oncology practice and research may elicit trials to be conducted more quickly, speeding the develop- important connotations.1 Whereas most new cancer drugs af- ment of new treatments. Crucially, since clinical trial treat- ford modest benefits,2 approved drugs or those in develop- ments represent the newest available treatments, access to this ment may be heralded as “game changers” or “break- vital resource should be available to individuals of all income throughs” in the lay press. These news articles may be important levels. sources of information to patients, the public, and investors— with a broader reach than medical journal articles. However, Joseph M. Unger, PhD omission of medical context or use of inflated descriptors may 3 Julie R. Gralow, MD lead to misunderstandings among readers. Kathy S. Albain, MD We sought to investigate the use of modest and superla- Scott D. Ramsey, MD tive descriptors in contemporary news articles regarding can- Dawn L. Hershman, MD cer drugs. We sought to determine who uses this inflated lan- guage and what classes of drugs were most heralded. Author Affiliations: SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, Washington (Unger); Seattle Cancer Care Alliance, University of Methods | We searched 10 superlative terms in conjunction with Washington, Seattle (Gralow); Loyola University, Chicago Stritch School of “cancer drug” in Google’s news search (http://news.google Medicine, Maywood, Illinois (Albain); University of Washington Medical Center, .com) between June 21, 2015, and June 25, 2015. Superlative Seattle (Ramsey); Fred Hutchinson Cancer Research Center, Seattle, Washington (Ramsey); Columbia University, New York, terms included “breakthrough,” “game changer,” “miracle,” New York (Hershman). “cure,” “home run,” “revolutionary,” “transformative,” “life Corresponding Author: Joseph M. Unger, PhD, SWOG Statistical Center, saver,”“groundbreaking,”and “marvel.”Terms were prespeci- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M3-C102, fied and identified through discussion. PO Box 19024, Seattle, WA 98109-1024 ([email protected]). All articles resulted were read in full by one reviewer Published Online: October 15, 2015. doi:10.1001/jamaoncol.2015.3924. (M.V.A.). The following information was extracted: drug de- Author Contributions: Dr Unger had full access to all of the data in the study scribed, mechanism of action, class of medication, whether the and takes responsibility for the integrity of the data and the accuracy of the data agent described had already received US Food and Drug Ad- analysis. Study concept and design: Unger, Ramsey, Hershman. ministration approval, whether the data described con- Acquisition, analysis, or interpretation of data: Unger, Gralow, Albain, Ramsey, cerned human trial results or preclinical (eg, mouse or cell cul- Hershman. ture) data, and the quoted individual (physician, journalist, Drafting of the manuscript: Unger, Hershman. industry expert, or patient). An academic hematologist- Critical revision of the manuscript for important intellectual content: Unger, Gralow, Albain, Ramsey, Hershman. oncologist (V.P.) researched mechanism of action of all drugs Statistical analysis: Unger. and coded their class as cytotoxic, targeted, immunotherapy— Obtained funding: Gralow, Ramsey. checkpoint inhibitor, immunotherapy—therapeutic vaccine, ra- Administrative, technical, or material support: Gralow. Study supervision: Ramsey, Hershman. diotherapy, gene therapy, or other. Conflict of Interest Disclosures: None reported. Results | We found 94 news articles from 66 distinct news out- Funding/Support: This work was supported by a Breast Cancer Research Foundation grant and by the National Institutes of Health, National Cancer lets that made 97 superlative mentions that fit our criteria, re- Institute (NCI) Community Oncology Research Program Research Base grant ferring to 36 specific drugs, with 3 articles not naming the drug. 5UG1CA189974-01. The most common class of drugs referenced was targeted therapy Role of the Funder/Sponsor: The funding organizations had a role in the design (17 of 36 [47%]). Nine (25%) cytotoxic drugs were discussed, fol- and conduct of the study and in the collection and management of the data but lowed by 5 (14%) immunotherapy checkpoint inhibitors, 3 (8%) had no role in the analysis and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit for publication. cancer vaccines, 1 radiotherapy, and 1 gene therapy. 1. Murthy VH, Krumholz HM, Gross CP. Participation in cancer clinical trials: Among 97 superlatives used, 39 (40%) referred to a tar- race-, sex-, and age-based disparities. JAMA. 2004;291(22): geted therapy, 37 (38%) referred to an immunologic check- 2720-2726. point inhibitor, 10 (10%) referenced a cytotoxic drug, 5 (5%) 2. Unger JM, Hershman DL, Albain KS, et al. Patient income level and cancer discussed a therapeutic cancer vaccine, 3 (3%) did not name clinical trial participation. J Clin Oncol. 2013;31(5):536-542. the drug, 2 (2%) referred to a radiotherapy, and 1 (1%) referred 3. Javid SH, Unger JM, Gralow JR, et al. A prospective analysis of the influence to gene therapy. of older age on physician and patient decision-making when considering enrollment in breast cancer clinical trials (SWOG S0316). Oncologist. 2012;17(9): Precisely half (18 of 36) of drugs described had not re- 1180-1190. ceived Food and Drug Administration approval (as of July 15, jamaoncology.com (Reprinted) JAMA Oncology January 2016 Volume 2, Number 1 139 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Letters Table. Frequency and Characteristics of Cancer Drugs Described With Superlatives Superlative Frequency, No. (%)a Superlative(s) Drug FDA-Approved Clinical Drug (N = 97) Used (Frequency) Classification Drug(s) Data? Ipilimumab and 20 (21) Breakthrough (7), Immunotherapy— Yes Yes nivolumab miracle (5), game checkpoint inhibitor (Yervoy-Opdivo changer (5), combination) revolutionary (2), groundbreaking (1) Pembrolizumab 12 (12) Revolutionary (5), Immunotherapy— Yes Yes (Keytruda) game changer (2), checkpoint inhibitor groundbreaking (2), cure (2), miracle (1) Palbociclib (Ibrance) 10 (10) Groundbreaking (6), Targeted therapy Yes Yes game changer (2), revolutionary (1), miracle (1) Trastuzumab 7 (7) Revolutionary (4), Targeted therapy Yes Yes emtansine (Kadcyla) miracle (3) Dinutuximab 4 (4) Game changer (1), Targeted therapy Yes Yes (Unituxin) groundbreaking (1), Abbreviation: FDA, Food and Drug breakthrough (1), Administration. miracle (1) a MPDL3280A 3 (3) Game changer (2), Immunotherapy— No Yes Drugs with 1 (1%) superlative: revolutionary (1) checkpoint inhibitor ABT-199, acelarin, ALM201, Olaparib (Lynparza) 3 (3) Revolutionary (2), Targeted therapy Yes Yes bortezomib (Velcade), brentuximab breakthrough (1) vedotin (Adcetris), Cimavax, T-VEC 3 (3) Breakthrough (3) Immunotherapy— No Yes docetaxel (Taxotere), doxorubicin vaccine with vinorelbine, epidaza (Chidamide), eribulin (Halaven), Pertuzumab (Perjeta) 3 (3) Groundbreaking (3) Targeted therapy Yes Yes figitumumab, G1 T-28, ibrutinib Unnamed 3 (3) Breakthrough (1), ………(Imbruvica), ipilimumab, NeuVax, miracle (1), nivolumab (Opdivo), OH14 game changer (1) compound, OTS964, PENAO, Radium-223 2 (2) Game changer (2) Radiotherapeutic drug Yes Yes protein-bound paclitaxel dichloride (Alpharadin or Xofigo) (Abraxane), rociletinib, TargomiRs, TRXE-009, vemurafenib (Zelboraf), BPM31510 2 (2) Revolutionary (2) Cytotoxic therapy No Yes ZL105. 2015) for at least 1 indication. For 5 of 36 (14%) drugs, super- cology conference; as such, it may not reflect the use of these latives were used in the absence of clinical data (ie, based solely terms at other times, as well as in other years. on mouse, cell culture, and/or preclinical work). The specific A range of speakers used superlatives, but the majority drug mentioned, superlative used, and other characteristics were journalists (55%), who may not have the expertise to iden- are described in the Table. tify the most promising medical therapies, or what magni- A variety of speakers were credited with using the super- tude of benefit warrants a superlative. The use of superla- lative (53 journalists [55%], 26 physicians