TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week's topics include interferon for COVID infection, adverse pregnancy outcomes and heart disease, low-value drugs and pharma advertising to consumers, and minimizing surgery for lung cancer.
Program notes:
0:40 Interferon lambda for acute COVID infection
1:40 Return to ED or hospitalization
2:40 Works on different variants of COVID
3:40 Would look for its use
4:00 Lung resection in non-small cell lung cancer
5:00 Lobar versus sublobar surgery
6:01 Direct-to-consumer ads and drug impact
7:02 134 top selling drugs in U.S.
8:03 When a patient sees an ad
9:02 Other purveyors are hospitals and insurance companies
9:40 Adverse pregnancy outcomes and premature heart disease
10:40 Coronary calcium scan
11:40 Take a careful history
12:45 End
Transcript:
Elizabeth: Does it help to add interferon to COVID-19 treatment?
Rick: In people with lung cancer, does minimal surgery give the same result as bigger surgery?
Elizabeth: How much money are drug manufacturers spending on direct-to-consumer advertising relative to the characteristics of the drug?
Rick: And adverse pregnancy outcomes results in heart disease decades later.
Elizabeth: That's what we're talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I'm Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I'm also the dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, let us turn right to the New England Journal of Medicine and taking a look at this study on early treatment with pegylated interferon lambda for COVID-19 infection. COVID, of course, is still with us. I looked at the numbers this morning and it seems to have plateaued, but the deaths are also still in the 400s.
This is a study taking a look at what happens if we give people with acute symptomatic COVID infection a single dose of pegylated interferon lambda. These were all outpatients. They looked at this issue among people who had predominantly been vaccinated, who had COVID and lived in Brazil and Canada. These outpatients who came with their acute clinical condition consistent with COVID-19 were treated within 7 days after the onset of symptoms. They received either this single subcutaneous injection of the pegylated interferon lambda or a placebo, whether that was an injection or oral. Their outcome measure was, "Did you come back to the ED or did you have to come to a hospital within 28 days after your randomization?" They had 933 patients in the interferon arm and just over a thousand in the placebo arm. Eighty-three percent of their folks had been vaccinated.
What they found -- and this I think is really great news -- is that only 2.7% of the folks who have received the interferon had a primary outcome event, while 5.6% of those in the placebo group did. It's sounding to me like why not give interferon to people who present with COVID infection?
Rick: Type III interferon is an early line of defense in upper respiratory tract infections. Unfortunately, the COVID virus just elicits a very weak interferon response. If we can give it subcutaneously via single injection, we actually can boost that. It's an antiviral agent, but it's not really very specific. The good news is therefore it works on different variants of COVID. We have a long history of using interferon, especially in people with hepatitis. It's expensive.
When you look at the major complications in this group -- death from COVID -- it was less than 1%. The interferon decreased it, but it wasn't very high. Most of the things that prevented it was hospitalizations for COVID. There is a benefit. There is no doubt about it. I guess you have to weigh the cost-benefit. If you're going to give interferon to 100 people at let's say $4,000 a piece and you're going to prevent 3% of the hospitalizations but very few deaths, is it worth it on a societal level?
Elizabeth: From my view from the bleachers, I would say it absolutely is worth it. If we take a look at the cost of hospitalization, that's one factor. The other factor I think would be really interesting, which isn't examined here, would be what about the development of long COVID symptoms?
Rick: Those are points that are very well taken, Elizabeth. It allows a study like this that shows that it is efficacious and then we can do a more in-depth analysis.
Elizabeth: I would say that if I developed acute COVID symptoms, not only would I be looking for Paxlovid, but I'd also be looking for an interferon injection.
Rick: You get the biggest bang for the buck for those individuals that are most likely to have a severe infection. I would say certainly in high-risk individuals, yes. In a 15-year-old or 16-year-old that gets COVID, are you going to give them pegylated interferon? Probably not.
Elizabeth: In the New England Journal of Medicine, then, let's turn to yours about resection of lungs in people with non-small cell lung cancer.
Rick: When we talk about non-small cell lung cancer, small cell lung cancer is one type. The other major type would be adenocarcinoma.
Oftentimes those cancers start in the very peripheral part of the lung. Typically what's been done is you remove if you detect it, and there are no metastasis or metastasis that are limited, taking out the entire lobe of the lung.
As a result of our screening techniques, we are now looking at a number of individuals that have non-small cell carcinoma in the very early stages. It's less than 2 centimeters - that is, it's less than an inch and often it hasn't even metastasized.
The question is, could we do less lung resection and still get the same result? That means looking 7 years down the road, are you just as unlikely to have recurrence or you're just as unlikely to have died if you do a more minimal resection than if you do the bigger lobar resection?
That was a question that they addressed in 700 patients. Half the individuals got the lobar resection, the other the more minimal or sublobar resection. They followed them for 7 years and the outcome was the same. That means that you can do less surgery. Most of these surgeries are done through videoscopy or through a thoracoscope, not through a major incision, and get just as good a result.
Elizabeth: This is really excellent news. I'm so happy to hear it. I had thought previously that the argument for lobectomy was really largely anatomic. The lungs have sort of these functional units and those are the lobes. That if you remove the whole thing that it was somehow easier.
Rick: A couple things. One is these tumors sit on the outside of the lung, not near the central part. In the more central part, you have to do a much wider-wedge resection and now the surgical techniques are so good. Again, even using laparoscopic surgery or videoscopy, where the acute complications are really very low, they are no different than doing the lobar and it looks like the long-term results can be just as good. Again, I want to focus on the fact that we have to choose the patients carefully to get this kind of a positive outcome.
Elizabeth: Let's turn now to JAMA and let's take a look at this issue of direct-to-consumer advertising on the part of pharmaceutical companies.
This has been a long-standing issue. It's one that we've talked about a lot. In this case, they modified it a little bit. They took a look at the 150 top-selling, branded prescription drugs in the U.S. in 2020, and they asked the question of how did advertising relative to these drugs relate to clinical benefit of these drugs. A way to say, are we trying to sell more of these drugs that really don't work as well? That's the way I would modify that particular question.
What they found is that of the total advertising budgets of pharmaceutical companies, 13.5% of their promotional spending was allocated -- the median -- to direct-to-consumer advertising. They were only able to analyze this issue of how clinically beneficial were these drugs in 134. Of those, they spent a lot more money on advertising for drugs that had low added clinical benefit than for those with the higher added clinical benefit.
They also had an editorial that's written by an economist. This economist basically kind of says, "Yeah. Yeah. We see this thing, but I'm not sure that it's really the smoking gun that you all are painting it as."
Rick: Elizabeth, again, I was fascinated by the editorial comments because I thought, "OK, a drug company's spending a lot of money directly in advertising to consumers." By the way, there are only two countries in the world that allow that to happen. That's the U.S. and New Zealand, and especially for what are considered to be low-value medications. Now by those low-value, that's not assessed by us. That's by Canada and France because they actually do that. We don't do that in the U.S. yet.
But as the editorialist mentions, high clinical benefit drugs, you don't need to advertise, because the physicians already know and the patients already know. Secondly, there is a halo effect: that is, when a patient sees an advertisement -- let's say it's for an antidepressant -- not only is there an increase in the use of that antidepressant, but in antidepressants in general for people that need them, even for what are to be considered to be high clinical benefit [drugs].
Finally, the drug companies try to sell their drugs in a number of ways. This is one of them. Sometimes they detail physicians. They pay for them to use drugs or pay for them to go to conferences. I do think it's helpful for patients to have conversations with physicians, and hopefully the physician is well versed enough to know what the best clinical medication or the best clinical treatment is for a patient and isn't swayed by something that somebody sees on TV.
Elizabeth: Once again, let's return to that editorial for a second and just note a couple statements in here. He says physicians are not perfect agents for their patients in arguing for a role for direct-to-consumer advertising. That's an interesting thing. I don't think he means that as an indictment as much as he says that while drug manufacturers might have a vested interest in this, other purveyors of that kind of information include hospitals and health insurance payers that can all have a role in improving patients' health. Maybe we shouldn't be fingering the pharmaceutical industry quite as much as we are. Your point is well taken that sometimes this precipitates a big conversation between patients and physicians and then renders a better fit.
Rick: Absolutely. Elizabeth, I would say one of the major decision makers in deciding who gets what medications actually is the insurance companies. They will put something on a formulary, so there are a lot of things that go into this.
Elizabeth: Remaining in JAMA then, let's turn to our final one for this week.
Rick: Many people may not realize when women have adverse pregnancy outcomes, these are women usually in their 20s and 30s, they are more likely to develop heart disease prematurely than those women that didn't have adverse pregnancy outcomes. I'm talking about women have had preeclampsia, hypertension during their pregnancy, preterm delivery, or had an infant that was small for their gestational age, or even had gestational diabetes. Probably that knowledge has just come to fruition over the last several years.
Well, this is a really interesting study to try to find out if we can identify one or more of the causes. It's a cross-sectional study of a population-based cohort out of women in Sweden. As you know, they have a terrific database. They follow everybody and have a lot of information.
They looked at over 10,000 women that had had one or more deliveries since about 1973. They followed them over the course of about 30 years -- and many of these women, by the way, had had a coronary CT scan as well. That detects calcium in the coronary arteries. We know how much calcium a person has for a particular age. We know what's in the normal range and outside the normal range.
They compared the women that had had pregnancy outcomes that were adverse versus those who did not. They noticed that they were much more likely to have calcium in their arteries and more likely to have blockages, even though they hadn't had an adverse cardiac event yet.
Some of these pregnancy issues are associated later with more risk factors in that group. They were more likely to have diabetes, hypertension, and obesity. But even for those women that don't have very many risk factors, they still were more likely to have abnormal coronaries. It's probably because pregnancy adverse outcomes are related to some vascular problem. These women are 4 to 11 years older in terms of their vasculature, just as a result of being pregnant, compared to women that didn't have an adverse pregnancy outcome.
Elizabeth: Do we need to start looking for, what would this vascular abnormality be?
Rick: What we need to do is first of all recognize it's a risk factor because it doesn't fall in the regular risk calculations of the equations that we have. We got to take a careful history. As a physician now, I need to ask the women tell me about your pregnancies and were there any adverse outcomes? If so, I need to be extremely vigilant about making sure that we address other risk factors that she may have. I need to drive her cholesterol lower, make sure her blood pressure is well controlled, make sure that her diabetes is well controlled, if she has it, and she exercises. Then if she complains of cardiac symptoms, I need to take them seriously and not dismiss them saying, "Oh, she is a woman and she doesn't usually develop heart disease till later." Because they can develop it earlier, especially if they have had adverse pregnancy outcomes.
Elizabeth: Of course, we know that coronary calcium scans are really quick and quite revelatory. Does this suggest to you that one of those might be indicated?
Rick: Perhaps -- certainly if it's going to affect the treatment or how you're going to address risk factors or behaviors, then you should have it. If it's not going to change anything, I wouldn't do it.
Elizabeth: On that note then, that's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.
Rick: And I'm Rick Lange. Y'all listen up and make healthy choices.