EURURO Vol. 72 No. 5

853 860

Words of Wisdom
Re: Association Between Direct-to-consumer Advertising
and Testosterone Testing and Initiation in the United
States, 2009– 2013
Layton JB, Kim Y, Alexander GC, Emery SL
JAMA 2017;317:1159–66
Experts’ summary:
Layton et al reported on the association between direct-to-
consumer advertising (DTCA) and testosterone testing and
initiation. Monthly television ratings for branded testosterone
advertisements and low T condition awareness ads were ob-
tained for 75 of the largest designated market areas in the USA
from 2008 to 2013. These ratings were correlated with indi-
vidual-level testosterone use data from commercial insurance
claims within each designated market area from 2009 to
2013. Multivariable models to predict the association between
DTCA and testosterone testing and initiationwere adjusted for
age, race, physician density, socioeconomic status, seasonality,
and trend in overall increase in usage. For each month of
advertisement exposure, they demonstrated increased rates
of testosterone tests, initiations in testosterone therapy, and
initiations in therapy without a recent test.
Experts’ comments:
With a rise in DTCA for low T since the mid-2000s, this article
uses epidemiologic data to highlight its impact on patient and
physician behavior. This study focuses on DTCA from televi-
sion and does not address DTCA from the internet, radio,
billboards, and newspapers/magazines. In the current era,
as many as 70% of patients receive their health care informa-
tion through the internet . The authors did not cite specific
rationale behind the chosen 2-mo lag period, but did note that
their statistically significant findings were not appreciated at
1-mo and 3-mo lag times.
DTCA is the marketing of products to consumers, rather
than to product providers. The inconvenient truth is that
physician judgement and actions are influenced by their
patients’ demands. The data from Layton et al suggest
that DTCAs galvanize patients to seek testosterone testing
and engage in conversations with physicians about de-
creased testosterone levels. In the UK, the number of men
detected with low testosterone levels has increased, while
the proportion of men started on testosterone therapy
after testing has decreased . Unfortunately, increased
awareness in the USA has resulted in increased initiation of
testosterone therapy with normal testosterone levels and
without recent testosterone tests . This suggests that
patients are beginning a treatment without properly consult-
ing a physician about its risks. Although controversial, the
risks of cardiovascular events, such as myocardial infarction
and stroke , are still a concern that have not been effectively
dismissed. Similarly, exogenous testosterone use suppresses
the hypothalamic-pituitary-gonadal axis by suppressing
follicle-stimulating hormone and luteinizing hormone, which
may permanently cause infertility .
While physicians may never be able to control the actions
of manufacturers such as advertisements, physicians can
control their own actions. This begins with renewing pro-
vider perceptions of patients as patients and not consumers.
Providers owe it to their patients to provide them with the
current standard of care, to discuss risks and benefits of
medications, and to allow shared decision making.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
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[2]
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[3]
[4]
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[5]
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Joshua S. Jue, Ranjith Ramasamy*
Department of Urology, University of Miami Miller School of Medicine,
Miami, FL, USA
*Corresponding author. Department of Urology, University of Miami
Miller School of Medicine, 1600 North West 10th Avenue 1140, Miami, FL
33136, USA.
E-mail address: (R. Ramasamy).
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
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