Direct-To-Consumer Internet Promotion Of Robotic Prostatectomy Exhibits Varying Quality Of Information

Abstract

Robotic surgery to remove a cancerous prostate has become a popular treatment. Internet marketing of this surgery provides an intriguing case study of direct-to-consumer promotions of medical devices, which are more loosely regulated than pharmaceutical promotions. We investigated whether the claims made in online promotions of robotic prostatectomy were consistent with evidence from comparative effectiveness studies. After performing a search and crosssectional analysis of websites that mentioned the procedure, we found that many sites claimed benefits that were unsupported by evidence and that 42 percent of the sites failed to mention risks. Most sites were published by hospitals and physicians, which the public may regard as more objective than pages published by manufacturers. Unbalanced information may inappropriately raise patients’ expectations. Increasing enforcement and regulation of online promotions may be beyond the capabilities of federal authorities. Thus, the most feasible solution may be for the government and medical societies to promote the production of balanced educational material.

In addition to traditional sources such as one’s physician, family members, and friends, the Internet has become an important medium for medical information.^1,2 In a 2008 survey, 83 percent of adult Internet users in the United States reported that they searched for health information online.³ Another study found that patients were twice as likely to use information on the Internet in making decisions regarding certain surgeries as they were to use online information in decisions about medications and cancer screening.⁴

It is therefore not surprising that Intuitive Surgical of Sunnyvale, California—the sole manufacturer of the da Vinci Surgical System for robot-assisted laparoscopic prostatectomy, also called robotic prostatectomy—has developed a marketing site (http://www.daVinciMarketingToolkit.com) with materials for providers to use in promoting robotic prostatectomy on their own websites. Although medical misinformation is not unique to robotic prostatectomy, this study demonstrates important aspects of the procedure’s online promotion that claimed benefits unsupported by evidence and frequently failed to mention risks. This study also highlights the broader challenges of providing high-quality, comprehensive information to patients to support informed decision making.

This year more than 230,000 men in the United States will be diagnosed with prostate cancer. Approximately a third of them will opt for surgical treatment.⁵ For the better part of a century, open radical prostatectomy, or open prostatectomy, was the standard surgical approach in men with localized, early-stage disease.⁶ In open prostatectomy, the surgeon removes the prostate by directly manipulating the surgical instruments with his hands while viewing the surgery through the incision.

In the past decade, however, robotic prostatectomy has become an increasingly popular alternative to open prostatectomy. In this surgery, often described as minimally invasive surgery, robotic arms are controlled by the surgeon at a separate console that shows the surgical site via an internal camera. The camera and robotic arms are inserted into the patient by small incisions, each approximately an inch long.

The use of robotic prostatectomy rose substantially between 2003 and 2007.⁷ Moreover, recent estimates suggest that in 2009 approximately 90,000 prostatectomies were performed robotically, representing a 23 percent increase from the previous year.⁸ Although the da Vinci Surgical System, the only machine used for robotic surgery, is used for a number of different types of surgeries—including nephrectomy, or removal of one or both kidneys; hysterectomy; gastric bypass; and thyroidectomy—approximately half of all robotic surgeries are prostatectomies.⁸ One study found that between Ocotber 2008 and December 2009, 61 percent of prostatectomies were performed with the robot in a sample of more than 1,000 hospitals in 44 states.⁹

The comparative effectiveness of open prostatectomy and robotic prostatectomy is a subject of much debate. In the absence of a large randomized trial, evidence regarding the outcomes of these procedures comes primarily from population-based observational studies, single-institution cohort studies, and two recent systematic reviews.^7,10–16

Some evidence suggests that compared to open prostatectomy, robotic prostatectomy is associated with less blood loss, shorter hospital stay, greater chance of negative surgical margins (the absence of cancerous cells along the border of removed tissue), and fewer anastomotic strictures (narrowing of the urethra caused by scarring). For other clinical and functional outcomes—including urinary continence, erectile function, and cancer recurrence—evidence is limited and does not demonstrate a clear advantage of one procedure over the other.^{7,10–12,17,18}

Prescription pharmaceuticals and so-called restricted medical devices—those that can be sold, distributed, or used only on the order of an authorized health care provider, commonly referred to as prescription devices—are required to have premarket approval from the Food and Drug Administration (FDA), which also regulates direct advertising to consumers by the manufacturers of those products. In contrast, the promotional activities of health care providers, particularly on the Internet, are subject to less careful scrutiny. Advertising by physicians and hospitals, for example, is regulated by the Federal Trade Commission, which monitors nearly all advertising in the United States and has a less strict definition of what constitutes inappropriate advertising than the FDA does.

Even the FDA’s regulation of manufacturers’ advertising of medical devices, such as the da Vinci Surgical System, is less restrictive than its regulation of prescription pharmaceutical advertising. FDA regulations require drug manufacturers to present a fair balance of risks and benefits, but manufacturers of restricted medical devices need provide only a brief description of the device’s use and risks.¹⁹ For medical devices, there is no further requirement regarding the number of risks that must be mentioned. Furthermore, although advertisements for pharmaceuticals must be submitted to the FDA at the time of publication, ads for medical devices do not need to be submitted.

Promotion of the da Vinci Surgical System for robotic prostatectomy has been discussed anecdotally by many writers in the lay and academic literature.^7,10,20–24 Our objective was to find and categorize Internet-based marketing of robotic prostatectomy and to assess whether claims about it on individual websites were consistent with evidence in the medical literature. Internet promotion of robotic prostatectomy provides a case study in a loosely regulated environment of promotion by manufacturers, hospitals, physicians, and not-for-profit advocacy groups that are widely considered reputable sources of information.

Study Data And Methods

Search Strategy and Sample

We used the Google search engine to identify websites related to robotic prostatectomy. Google searches constituted 66 percent of all US Internet searches in January 2012.²⁵

We used the Google Insights for Search tool²⁶ to select search terms related to robotic prostatectomy. This tool provides the top ten related search terms, based on the keywords most commonly searched for immediately before and after the keyword of interest. Based on these results, we used the following terms in our Internet search, in addition to robotic prostatectomy: radical prostatectomy robotic, radical prostatectomy, robotic surgery, robotic prostatectomy surgery, da vinci prostatectomy, robotic laparoscopic prostatectomy, laparoscopic prostatectomy, robotic prostate surgery, robotic assisted prostatectomy, and prostate surgery. Because searchers primarily use the first page of results, we analyzed only the results provided on the first page returned for each search, using default search settings.²⁷

We considered only large-title hyperlinks with plain-text summaries to be unique results. (Sometimes Google provides multiple small-text links to other pages within a website. We did not include these in our sample.) We included sponsored links—that is, links whose owners paid Google to have them turn up in search results. We conducted searches between March 19 and April 7, 2010, and we saved all web pages for review.

From the initial cohort of results, we removed duplicate results and web pages whose primary content was academic research, news, or user-generated (that is, material that can be edited by anyone visiting the site, such as Wikipedia entries), as illustrated in the exhibit in the online Appendix.²⁸ We also excluded web pages that were medical or general encyclopedias or did not explicitly mention robotic prostatectomy. Our search strategy was intended to identify the most easily accessible web pages that patients would be the most likely to encounter.

Although patients may use online resources such as medical journals, news outlets, and encyclopedias, those resources did not fit well into an analysis of a product’s claims. The validity of journal articles is based primarily on their methodology and analysis, not on their conformity with external evidence. News sources and encyclopedias often report claims by third parties with opposing views and maintain a neutral tone, which made analysis difficult.

Content Analysis

Our unit of analysis was a unique landing page on a website—that is, a page that a search engine linked to. We characterized the source, content, and layout of each page using a standardized content analysis instrument developed for this study, which is available in the online Appendix.²⁸

We reviewed only information presented on the landing page, with one exception. We reviewed information about the benefits and risks of robotic prostatectomy on the landing page and pages that were only one click away from the landing page. We analyzed the benefits and risks one level away from the landing page to allow for the “one-click rule.” We made this exception because some organizations, such as Yahoo! and Pharmaceutical Research and Manufacturers of America (PhRMA), have argued that the FDA ought to allow a health care product’s manufacturer or other publisher to present the item’s risks one click away from a description of its benefits.²⁹ This is not current FDA policy, but we opted to analyze web pages one click away from the landing page in case publishers were following this standard. We used specific words and phrases related to risks and benefits to select hyperlinks on the landing page that were likely to direct the average user to claims about robotic prostatectomy.

The content analysis included assessments of whether the page mentioned specific outcomes of interest in terms that were favorable, unfavorable, or neutral toward robotic prostatectomy. A favorable or unfavorable claim could directly compare robotic prostatectomy to open prostatectomy (for example, “Robotic prostatectomy is less painful than open surgery”) or could be a declarative statement (such as “Robotic prostatectomy is painless”). Neutral statements used keywords but did not present them as benefits or risks (for example, “Some people worry about incontinence”).

In addition, we measured the readability of information about risks and benefits using the Microsoft Word 2007 word-processing application of the Flesch-Kincaid Grade Level formula.³⁰ The formula approximates the number of years of education that the average reader needs to comprehend a passage. It is a function of the number of words per sentence and number of syllables per word.

We also reviewed web pages for verbal and visual marketing strategies by searching for keywords such as safe or state-of-the-art and classifying the types of images presented. One of us reviewed all of the web pages. Two others reviewed a random sample of pages to assess interrater agreement with the content analysis instrument. Agreement among reviewers was 78 percent, which is within the normal range for this type of study.

Limitations

Several limitations of this study should be noted. First and foremost, the study is not meant to determine whether promotions of robotic prostatectomy are better or worse than promotions of open prostatectomy or any other prostate cancer treatment. Moreover, robotic prostatectomy is not the only medical service that has been found to be inappropriately marketed. A number of studies have shown misleading and incomplete information aimed at consumers regarding orthopedic procedures,^31,32 HIV antiretroviral medications,³³ and mesothelioma.³⁴

An additional limitation is that our online search reflected the state of the Internet at a particular point in time. Website content can change rapidly, and new pages can be added at any time. Moreover,Google’s search engine uses a dynamic search algorithm. This means that searches performed at different times and locations can return different results, even if all available content remains static. Many of the web pages reviewed in this study were still active as of this article’s date of publication, although a number of them have changed their content or layout.

Because search results are tailored to the location where they are performed, our search probably favored websites from the New York metropolitan area. Nevertheless, our results included pages from publishers located in California, Florida, Michigan, Ohio, Texas, and other states, which suggests that our sample was geographically diverse.

Finally, we used a standardized content analysis instrument to review web pages in a systematic and objective manner. Nonetheless, because of the numerous ways publishers could present information, the classification of web pages involved judgment calls, which introduced some subjectivity.

Study Results

Our Internet searches produced 218 results, including 115 duplicate landing pages, 4 pages of academic research, 6 error-message or sign-in pages, 7 news pages, 11 encyclopedic reference pages, 12 pages that consisted mainly of user-generated content, and 27 pages that did not mention robotic prostatectomy (2 pages were classified as both encyclopedic and user-generated). That left thirty-eight unique pages for analysis (Exhibit 1).

Exhibit 1.

Characteristics Of Thirty-Eight Unique Web Pages Mentioning Robotic Prostatectomy, 2010

Characteristic	Number of pages	Percent of pages
TYPE OF PUBLISHER
Intuitive (da Vinci manufacturer)	5	13
Other medical device manufacturer	0	0
Hospital	17	45
Hospital as a whole	11	65
Department of urology	4	24
Unidentified part of hospital	2	12
Private practice or individual physician	10	26
Not-for-profit advocacy organization	2	5
Academic (not health care provider)	0	0
Other	4	11
PUBLISHER PERFORMS ROBOTIC PROSTATECTOMY
Yes	27	71
No	10	26
Cannot determine	1	3
TOPIC OF PAGE
Robotic prostatectomy	27	71
Other robot-assisted surgery	0	0
Other specific prostate cancer treatment	1	3
Prostate cancer treatment options	5	13
Prostate cancer in general	2	5
Other cancer topics	1	3
Other	2	5
SPECIFIC CONTENT
Mention of other treatments	31	82
Equal or more space for treatments other than robotic prostatectomy	10	26
Description of another aspect of prostate cancer	10	26
Intuitive’s website template	0	0
Hyperlink to an Intuitive website	4	11
Mention of da Vinci, Intuitive, or EndoWrist	25	66
Description of robotic prostatectomy or da Vinci as “high tech”	23	61
Mention of safety	10	26
Mention of the publisher’s quality	18	47
Celebrity testimonial	0	0
Expert testimonial	6	16
Patient testimonial	14	37
Video	13	34
Hospital logo	19	50
Picture from Intuitive	6	16
Picture of da Vinci robot	14	37
Picture of people in an outdoor setting	10	26
Picture of people in any nonmedical setting	21	55
LOCATION OF MENTIONS OF RISKS
Landing page	17	45
Page one click away from landing page	5	13
Does not mention risks	16	42
FONT SIZE FOR MENTIONS OF RISKS
Risks in smaller font than benefits	3	14
Benefits and risks in same size font	18	86

SOURCE Authors’ analysis. NOTES Da Vinci is the da Vinci Surgical System. EndoWrist is a brand name for some of the instruments attached to the arms of the da Vinci robot.

Forty-five percent of the websites mentioned at least one risk on the landing page (Exhibit 1). At least one risk was mentioned on the landing page or a page one click away in four of the five Intuitive Surgical pages, seven of the seventeen hospital pages, six of the ten physician or private practice pages, both of the not-for-profit advocacy group pages, and three of the four pages with miscellaneous publishers.

The average Flesch-Kincaid Grade Level³⁰ of statements of benefits was 14.7, while the average grade level of statements of risks was 13.1. In other words, the average statements of benefits and risks were both written at a college reading level, hypothetically requiring almost fifteen years of education.

The most common claims favorable to robotic prostatectomy were that patients undergoing the procedure would experience a shorter recovery and less pain than patients undergoing other treatments. Both of these claims were mentioned on twenty-five pages (Exhibit 2). The most frequent potential outcome mentioned unfavorably with respect to robotic prostatectomy was impairment to normal sexual functioning, cited on eight pages. Four outcomes of interest were mentioned by fewer than five pages: Bladder obstruction appeared on four pages; survival rate appeared on one page; and no page mentioned mortality rate or painful urination (data not shown).

Exhibit 2.

Terms Used To Refer To Robotic Prostactectomy On Web Pages, 2010

			Type of mention
	Any mention		Favorable		Unfavorable		Neutral
Term	No. of total pages	% of total pages	No. of pages with mention	% of pages with mention	No. of pages with mention	% of pages with mention	No. of pages with mention	% of pages with mention
Precise/precision	22	58	21	95	0	0	1	5
Duration of procedurea	5	13	1	20	1	20	3	60
Incision	24	63	22	92	0	0	2	8
Scarring/cosmetic results	19	50	16	84	1	5	2	11
Spares nerves/nerve sparing	12	32	10	83	0	0	2	17
Shorter/longer hospital stay	16	42	15	94	0	0	1	6
Shorter/longer recovery (time)b	27	71	25	93	0	0	2	7
Recurrence/additional treatment/cure rate/surgical margin	5	13	1	20	3	60	1	20
Erectile (dysfunction)/erections/potency/impotence/sexual function	27	71	17	63	8	30	2	7
(In)continence/urinary control/bladder control	23	61	15	65	6	26	2	9
Blood loss/bloodless/transfusion	23	61	22	96	1	4	0	0
General/medical/surgical complications	13	34	8	62	5	38	0	0
(Days of) catheterization	12	32	4	33	7	58	1	8
Pain/comfort	27	71	25	93	1	4	1	4
(Less/more) anesthesia	8	21	3	38	3	38	2	25
(Risk of) infection	19	50	15	79	4	21	0	0

SOURCE Authors’ analysis. NOTE Percentages might not sum to 100 because of rounding.

^aSpecific keywords were not searched for because the phrasing for duration of procedure was too variable.

^bOr return to normal activity.

Web pages that appeared at least once as a sponsored link were more likely than other pages to avoid mentioning risks (57 percent versus 33 percent). However, this difference was not significant.

Discussion

Current evidence suggests that compared to open prostatectomy, robotic prostatectomy is associated with less blood loss and shorter hospital stays, and possibly with better surgical margins and fewer anastomotic strictures.^7,10,12 The evidence regarding other outcomes is limited and often conflicting.^{7,10–12,17,18} Nonetheless, most of the web pages we reviewed claimed that robotic prostatectomy was superior to open prostatectomy, providing greater comfort and lower risk of infection, incontinence, and impotence. Forty-two percent of the pages listed no risks of robotic prostatectomy on the landing page or a page one link away.

These findings raise concerns about the quality of information that prostate cancer patients are likely to find when using the Internet to learn more about treatment options. Misleading, unbalanced, or exaggerated claims about the relative benefits of robotic prostatectomy may inappropriately raise patients’ expectations about their outcomes and recovery. In a survey of 400 men who had open prostatectomy or robotic prostatectomy, 24 percent of those who had robotic prostatectomy expressed regret with their treatment choice, while only about 15 percent who had open prostatectomy expressed similar regret.³⁵ Unrealistic expectations may account for some of this disparity.

On a positive note, when a page mentioned both risks and benefits of robotic prostatectomy, those mentions were typically written at about the same reading level. Experts generally recommend that material aimed at the general public be written at an eighth grade reading level, or a Flesch-Kincaid Grade Level of 8.³⁰ Most notably, Institutional Review Boards often require consent forms to be written at this level. Information about risks and benefits on the web pages we examined was written at a college level—13.1 and 14.7, respectively. The use of largely unavoidable words such as prostatectomy and incontinence may be responsible for the elevated reading levels.

In an earlier study of promotion of robotic surgery, Linda Jin and colleagues randomly sampled the websites of 400 American hospitals.³⁶ Fifty-eight percent of the pages in our study—and 41 percent of pages published by hospitals—mentioned at least one risk of robotic prostatectomy. However, Jin and colleagues found that no hospital website provided this information.

John Mulhall and colleagues systematically reviewed the websites of seventy robotic and twenty open prostatectomy centers to assess the presentation and quality of sexual health information.²¹ They found that half of the robotic prostatectomy websites suggested that erectile dysfunction rates were lower after robotic prostatectomy than after open prostatectomy, while only 5 percent of open prostatectomy sites claimed lower erectile dysfunction rates after that procedure than after robotic surgery. The authors concluded that the accuracy and comprehensiveness of erectile dysfunction information presented on the medical center websites was poor. They also reported that these deficiencies might be worse on sites promoting robotic prostatectomy than on those promoting open prostatectomy. Our analysis characterized robotic prostatectomy advertising along more dimensions, but it supports some of the deficiencies elucidated by Mulhall and colleagues.

Peter Steinberg and Reza Ghavamian analyzed forty-one websites to assess the overall favorability of claims along five outcome measures: potency, continence, cancer control, recovery, and blood loss. Their sample—which included hospital, surgeon, manufacturer, and miscellaneous websites—was based the first fifty results of a single Google search for the term robotic prostatectomy.³⁷ Although these authors did not explicitly report the presence or absence of risk statements, 56–85 percent of the sites they reviewed claimed that robotic prostatectomy was superior to open prostatectomy, depending on the outcome measure. No site claimed that it was worse in any measured respect.

Our search strategy was designed to mimic the experience of an actual patient seeking information about robotic prostatectomy using more search terms than past studies and using only first-page results. It returned 218 nonunique results. The thirty-eight unique web pages that received a full review came up many times in our search method, representing 121 of those 218 results. An important finding of our study is that the most easily accessible online information about robotic prostatectomy is concentrated in a small number of web pages.

The inclusion of risk information was more common in our analysis than in prior studies: 58 percent of the web pages in our sample mentioned at least one risk of robotic prostatectomy. Although this could be attributable to different sampling strategies or definitions of what constitutes a risk, the difference between our results and those of Jin and colleagues, in particular, is very large.

Hospital and Physician Promotion of Robotic Prostatectomy

The majority of web pages that we reviewed—twenty-seven out of thirtyeight—were published by hospitals or physicians. Fourteen of these pages did not mention any risks of robotic prostatectomy on the landing page or a page one click away.

The da Vinci Surgical System costs between $1 million and $2.5 million, with $100,000 to $200,000 per year in maintenance fees.⁸ Thus, the equipment represents a substantial capital investment, and hospitals that purchase it have a strong incentive to promote its use, perhaps by overstating its benefits or minimizing its risks.^38,39 A recent analysis in seven states suggests that acquisition of the equipment is associated with increased numbers of radical prostatectomies at both the hospital and regional levels.⁴⁰

Many people probably understand that they should not put stock in health information found on user-generated websites. However, it is not as obvious that sites published by members of the medical community may also be subject to concerns about quality, completeness, and bias. Although these publishers may have conflicts of interest, their public reputation and medical background may imply to many people that they are balanced and objective.

Overall, there was a wide range in the tone and presentation of the web pages were viewed. Some pages used a direct, informational tone; others used excessively ornate prose about the wonders of life without cancer, with fairly little substantiative discussion of robotic prostatectomy. One site directly stated that there were no risks associated with robotic prostatectomy, then proceeded to list a number of risks lower on the page. We found information of poor quality presented on many sites in our sample, not just those that might be considered outright advertising.

Regulatory Implications

FDA regulations govern the content of direct-to-consumer advertising by manufacturers, packers, and distributors of restricted medical devices. However, these regulations do not apply to health care providers who prescribe or use such devices. The Federal Food, Drug, and Cosmetic Act of 2005 states that a restricted device is misbranded—that is, inappropriately marketed—if “its advertising is false or misleading in any particular” or does not include “a brief statement of the intended uses of the device and relevant warnings, precautions, side effects, and contraindications.” The law gives the FDA authority to enforce sanctions against manufacturers, packers, and distributors who violate these rules.¹⁹

Promotional messages from other entities, however, are subject to Federal Trade Commission regulations that find them “deceptive if there is a misrepresentation, omission, or other practice, that misleads the consumer acting reasonably in the circumstances, to the consumer’s detriment.”⁴¹ Although the commission has jurisdiction over the promotional materials from physicians and hospitals that we reviewed, it usually focuses on the largest businesses that commit the most egregious advertising violations. It concentrates its enforcement this way because its purview is so broad, and it could not possibly regulate all advertising in the United States.⁴²

Even if restricted medical devices were subject to the stricter FDA rules for pharmaceutical advertising, the agency would have a hard time enforcing requirements for hospitals and physicians to present a fair balance of risks and benefits of the product¹⁹ and to provide a complete description of all side effects. It would also be very difficult for the agency to review all advertisements at the time of publication.⁴³ The FDA already has difficulty monitoring the promotional activities of medical device and pharmaceutical manufacturers within its jurisdiction.⁴⁴ Extending its activities to thousands of physician and hospital websites would be nearly impossible.

Furthermore, applying those regulations to smaller hospitals and physician practices could unintentionally curtail the availability of useful health information. Smaller groups may lack the financial and legal resources to ensure that their advertisements comply with the requirements. Although online medical information published by health care providers needs to be improved, increased regulation might not be the most effective mechanism.

As advertising shifts from traditional media to the Internet, the regulation of advertising content becomes increasingly difficult. The amount of print and broadcast advertising is limited by the high cost of these media. In contrast, Internet promotion expands the opportunities for inexpensive, direct-to-consumer marketing. Thus, the volume of material promoting specific medical procedures, devices, and drugs may be impossible for any single entity to monitor. Proposals to increase regulation of direct-to-consumer medical care promotion may also be limited by legal and ethical considerations associated with restricting free speech.

Instead of creating new regulations and strengthening enforcement, it may be more feasible for the FDA and medical societies to promote the creation of responsible, balanced educational material. These organizations could produce and distribute guidelines intended for physicians and hospitals that describe how to develop educational materials in a balanced and patient-friendly manner. Additionally, specialty societies could provide template descriptions of risks and benefits to help doctors describe the medical products and procedures they use.

Conclusion

To make informed decisions about their medical care, patients need unbiased, evidence-based information about the benefits and risks of different treatment options. The Internet is a major source of information for prostate cancer patients. However, our findings suggest that websites about robotic prostatectomy—even those from generally reputable physicians and hospitals—are often unbalanced and inconsistent with published evidence. In addition, a substantial proportion of the sites fail to mention risks associated with the surgery.

A balanced presentation of outcomes expected after radical prostatectomy is necessary to allow patients to make informed treatment decisions and to help them set realistic expectations, which will improve their satisfaction and minimize any regret.

Biographies

Joshua N. Mirkin is a medical student at the State University of New York (SUNY) Downstate College of Medicine.

In this month’s Health Affairs, Joshua Mirkin and coauthors report on their analysis of claims made in online promotions of robotic surgery for prostate cancer. The authors previously collaborated on a number of studies investigating the clinical effectiveness and cost-effectiveness of prostate cancer surgery. In this study they conducted a crosssectional analysis of web pages that mentioned the procedure. They found that many pages claimed benefits that were unsupported by evidence, while 42 percent of pages failed to mention any risks. The authors call upon government and medical societies to promote more balanced promotional materials.

Mirkin is a first-year medical student at the State University of New York (SUNY) Downstate College of Medicine. From 2009 to 2011 he was a data assistant at the Health Outcomes Research Group and the Center for Health Policy and Outcomes, both at Memorial Sloan-Kettering Cancer Center. His research investigates payment reform, direct-to-consumer advertising, and comparative effectiveness.

Mirkin is a member of the Osler Society of New York and the Manhasset-Lakeville Fire Department. He is a volunteer at, as well as the incoming chair of continuous quality improvement for, the Brooklyn Free Clinic. He has a bachelor’s degree in biological sciences and economics from Dartmouth College.

William T. Lowrance is an assistant professor at the Huntsman Cancer Institute and University of Utah School of Medicine.

William Lowrance is an assistant professor in the Division of Urology at the Huntsman Cancer Institute and University of Utah School of Medicine. His clinical practice focuses on treating prostate, bladder, kidney, testicular, and penile cancers, while his research focuses on comparative effectiveness and cost-effectiveness studies of treatments for cancers of the reproductive system and urinary tract.

Lowrance completed his medical degree at the Medical University of South Carolina. During his urologic oncology fellowship at Memorial Sloan-Kettering, he obtained a master’s degree in public health from Harvard University.

Andrew H. Feifer is a urologic oncologist at the Credit Valley Hospital and Carlo Fidani Cancer Centre.

Andrew Feifer is a urologic oncologist at the Credit Valley Hospital and Carlo Fidani Cancer Centre at the University of Toronto, in Ontario, Canada. Clinically, his interests include the surgical management of prostate, bladder, renal, and testicular tumors. His current research interests include aspects of quality of care in urologic oncology, population health, and comparative effectiveness, as well as disparities in the delivery of cancer care. Feifer is a fellow of the Royal College of Physicians and Surgeons of Canada. He completed his medical school and urology residency at McGill University. He then completed a urologic oncology clinical and research fellowship at Memorial Sloan-Kettering, as well as a master’s degree in public health at Harvard University.

John P. Mulhall is director of the Male Sexual and Reproductive Medicine Program at Memorial Sloan-Kettering Cancer Center.

John Mulhall is director of the Male Sexual and Reproductive Medicine Program at Memorial Sloan-Kettering. He is a board-certified urologist and a microsurgeon who specializes in sexual and reproductive medicine and surgery. He received his medical degree from University College Dublin, in Ireland, and completed a fellowship in male sexual and reproductive dysfunction at Boston University Medical Center.

James E. Eastham is chief of the urology service at Memorial Sloan-Kettering Cancer Center.

James Eastham is a professor and the chief of the urology service in the Department of Surgery at Memorial Sloan-Kettering. Previously, he was an associate professor in urology at Louisiana State University in Shreveport and chief of urology at Overton Brooks Veterans Affairs Medical Center, in Louisiana. Eastham received his medical degree from the University of California, Los Angeles, and completed a fellowship in urologic oncology at Baylor College of Medicine.

Elena B. Elkin is a health services researcher at Memorial Sloan-Kettering Cancer Center.

Elena Elkin is a health services researcher in the Center for Health Policy and Outcomes at Memorial Sloan-Kettering and an assistant professor of public health at Weill Cornell Medical College. She studies the determinants of cancer screening, treatment and outcomes using population-based observational data analysis, decision analysis, and patient surveys.

Elkin received a doctorate in health policy from Harvard University and a master’s degree in public administration, with an emphasis in health policy and management, from New York University.