Cancer Patient Use and the Marketing of Cancer Patient Use and the Marketing of Herbal SupplementsHerbal Supplements

K. Simon Yeung, MBA, PharmD, LAcK. Simon Yeung, MBA, PharmD, LAcJyothirmai Gubili, MSJyothirmai Gubili, MS

Barrie Cassileth, MS, PhD Barrie Cassileth, MS, PhD

Society for Integrative Oncology ConferenceSociety for Integrative Oncology ConferenceBoston, MABoston, MA

November 11, 2006November 11, 2006

Integrative Medicine Service Integrative Medicine Service

PurposePurpose

To uncover popular dietary supplements To uncover popular dietary supplements currently sought by cancer patientscurrently sought by cancer patients

To determine the scientific basis for To determine the scientific basis for promoter claimspromoter claims

To determine if there is an association To determine if there is an association between popularity and marketing between popularity and marketing intensityintensity

BackgroundBackground

Cancer patients tend to use multiple dietary Cancer patients tend to use multiple dietary supplements in hopes of cure and for symptom supplements in hopes of cure and for symptom reliefrelief

Many of these products have adverse effects Many of these products have adverse effects and can interact with conventional drugsand can interact with conventional drugs

These products are not regulated by the FDA These products are not regulated by the FDA and are promoted heavily, primarily to cancer and are promoted heavily, primarily to cancer patientspatients

PrevalencePrevalence

Centers for Disease Control survey in 2002:Centers for Disease Control survey in 2002: 38 million Americans use botanicals38 million Americans use botanicals

A survey by Gupta et al,* on 227 cancer patients:A survey by Gupta et al,* on 227 cancer patients:– 71% used dietary supplements 71% used dietary supplements

– 53% did not consult a healthcare professional53% did not consult a healthcare professional

– 25% of supplements identified might have adverse 25% of supplements identified might have adverse interactions with chemotherapyinteractions with chemotherapy

*Gupta, D., et al., Support Care Cancer. 2005.

The AboutHerbs Web siteThe AboutHerbs Web site

An MSKCC Integrative Medicine Service An MSKCC Integrative Medicine Service Information Program Information Program www.mskcc.org/aboutherbswww.mskcc.org/aboutherbs217 monographs 217 monographs 4,700,000 hits from health professionals 4,700,000 hits from health professionals and public internationally since 2002and public internationally since 2002This website is in FOCUSThis website is in FOCUS• FFree accessree access• OObjective informationbjective information• CCancer relatedancer related• UUpdated frequentlypdated frequently• SSearchable databaseearchable database

Advisory BoardAdvisory Board

Barrie Cassileth, PhDBarrie Cassileth, PhDChief, Integrative Medicine Service, MSKCCChief, Integrative Medicine Service, MSKCC

Charlie Lucarelli, MS, RPhCharlie Lucarelli, MS, RPhDirector, Department of Pharmacy, MSKCCDirector, Department of Pharmacy, MSKCC

Nai-Kong Cheung, MD, PhDNai-Kong Cheung, MD, PhDHead, Neuroblastoma Program, Department Head, Neuroblastoma Program, Department

Of Pediatric Oncology, MSKCCOf Pediatric Oncology, MSKCC

Gary Deng, MD, PhDGary Deng, MD, PhDAssistant Attending, Integrative MedicineAssistant Attending, Integrative Medicine

Service, MSKCCService, MSKCC

James Dougherty, MDJames Dougherty, MDPresident, Arcus GroupPresident, Arcus Group

Donald Garrity, RDDonald Garrity, RDNutrition Specialist, Integrative Medicine, Nutrition Specialist, Integrative Medicine, MSKCCMSKCC

Robert Kurtz, MDRobert Kurtz, MDChief, Gastroenterology and Nutrition Service, Chief, Gastroenterology and Nutrition Service, MSKCCMSKCC

Michael Krychman, MDMichael Krychman, MDCo-Director, Sexual Medicine Program, Co-Director, Sexual Medicine Program, MSKCCMSKCC

MethodsMethods

1.1. Page view data compiled by Web site statistics Page view data compiled by Web site statistics tracking programs were analyzedtracking programs were analyzed

2.2. The five most visited monographs in the first The five most visited monographs in the first six months of 2006 were identifiedsix months of 2006 were identified

3.3. Medline data on the safety and efficacy of these Medline data on the safety and efficacy of these five supplements were extractedfive supplements were extracted

4.4. The distributor Web sites for these five The distributor Web sites for these five products were searched for marketing and products were searched for marketing and promotion practices promotion practices

Top 5 MonographsTop 5 MonographsJan – June 2006Jan – June 2006

Total Hits % of Top 5

1. “JuicePlus+” 26584 32%

2. Lycium 15681 19%

3. Reishi 14232 17%

4. Aloe 13379 16%

5. Mangosteen 13195 16%

Top 5 MonographsTop 5 MonographsJan – June 2006Jan – June 2006

Total Hits % of Top 5

1. “JuicePlus+” 26584 32%

2. Lycium 15681 19%

3. Reishi 14232 17%

4. Aloe 13379 16%

5. Mangosteen 13195 16%

•In contrast, the top 5 dietary supplements used by the general public: echinacea, ginseng, ginkgo, garlic, and glucosamine*

*CDC Advance Data No. 343. May 27 2004

Results: Top 5 Products Results: Top 5 Products

Top 5 Products by Popularity Rank

1. “JuicePlus+”

2. Lycium

3. Reishi

4. Aloe

5. Mangosteen

Results: Top 5 Products Results: Top 5 Products

Top 5 Products by Popularity Rank

Medline Articles by

ProductName

1. “JuicePlus+” 1

2. Lycium 145

3. Reishi 162

4. Aloe 796

5. Mangosteen 43

Results: Top 5 Products Results: Top 5 Products

Top 5 Products by Popularity Rank

Medline Articles by

ProductName

Clinical Trials on Medline

1. “JuicePlus+” 1 1

2. Lycium 145 4

3. Reishi 162 9

4. Aloe 796 24

5. Mangosteen 43 0

Results: Top 5 Products Results: Top 5 Products

Top 5 Products by Popularity Rank

Medline Articles by

ProductName

Clinical Trials on Medline

Cancer Related Clinical Trials

1. “JuicePlus+” 1 1 0

2. Lycium 145 4 1

3. Reishi 162 9 6

4. Aloe 796 24 10

5. Mangosteen 43 0 0

Results: Top 5 Products Results: Top 5 Products

Top 5 Products by Popularity Rank

Medline Articles by

ProductName

Clinical Trials on Medline

Cancer Related Clinical Trials

Adverse Effects:

low + moderate ++

high +++

1. “JuicePlus+” 1 1 0 +

2. Lycium 145 4 1 +

3. Reishi 162 9 6 ++

4. Aloe 796 24 10 +++

5. Mangosteen 43 0 0 ++

Results: Research in CancerResults: Research in CancerReishi studied in cancer patientsReishi studied in cancer patients

Aloe vera:Aloe vera:– Aloe for radiotherapy-induced skin damage: Aloe for radiotherapy-induced skin damage:

conflicting dataconflicting data– Injections of Acemannan, extracted from aloe, Injections of Acemannan, extracted from aloe,

resulted in several cancer patient deaths resulted in several cancer patient deaths

Lycium used in one observational studyLycium used in one observational study

Mangosteen and “Juice Plus+” no research Mangosteen and “Juice Plus+” no research in humans in humans

Results: MarketingResults: Marketing

Top 5 Products by Popularity Rank

Cancer related Info

“Product name” AND “Cancer”

(# of web pages per Google)

1. “JuicePlus+” 29,000

2. Lycium 47,000

3. Reishi 196,000

4. Aloe 1,280,000

5. Mangosteen 388,000

Results: MarketingResults: Marketing

Top 5 Products by Popularity Rank

Cancer related Info

“Product name” AND “Cancer”

(# of web pages per Google)

Marketing Intensity“Product name” AND “Independent

Distributors”

(# of web pages per Google)

1. “JuicePlus+” 29,000 19,000

2. Lycium 47,000 50,000

3. Reishi 196,000 1,000

4. Aloe 1,280,000 183,000

5. Mangosteen 388,000 95,000

Results: Marketing, concludedResults: Marketing, concluded

Reishi and aloe have been in common use for Reishi and aloe have been in common use for decades and are available through conventional decades and are available through conventional channels, including pharmacies and health-food channels, including pharmacies and health-food storesstores

““Juice Plus+”, lycium, and mangosteen became Juice Plus+”, lycium, and mangosteen became popular in the US only in the last few years and popular in the US only in the last few years and are promoted mainly via network marketing are promoted mainly via network marketing schemesschemes

LimitationsLimitations

Number of visits may be due to increase in referral Number of visits may be due to increase in referral sites and hyperlinkssites and hyperlinks

Do not have breakdown by visitors and by referral Do not have breakdown by visitors and by referral sitessites

Only reflect the demand on information, not usage Only reflect the demand on information, not usage

Sales figures of these products are not available for Sales figures of these products are not available for comparisoncomparison

Data have not been subjected to statistical analysisData have not been subjected to statistical analysis

ConclusionsConclusions

Cancer patients tend to seek information on Cancer patients tend to seek information on specific herbal supplementsspecific herbal supplementsIn vitro and animal studies suggest beneficial In vitro and animal studies suggest beneficial effects for some supplements effects for some supplements Clinical trials to support their uses for cancer Clinical trials to support their uses for cancer are limitedare limitedMany products have adverse effects and may Many products have adverse effects and may interfere with cancer treatmentsinterfere with cancer treatmentsThese supplements are sold through network These supplements are sold through network marketing and are promoted as alternative marketing and are promoted as alternative treatments for cancertreatments for cancer