Breast thermography heat is on
Allison Roe put her reputation on the line when she endorsed a breast health check that mainstream cancer doctors consider a potentially harmful waste of time. As the row over breast thermography heats up, Adam Dudding investigates the pitfalls of celebrity endorsement.
AFTER THOSE two stunning marathon victories in New York and Boston back in 1981, Allison Roe signed deals to plug running shoes, an airline, a clothing label, even a brand of decaf coffee. There were many offers, and she quickly worked out her ground rules.
If you're going to endorse a product, she told Metro magazine in 1983, there are two things to get right. Most importantly, you have to believe in it, "otherwise I can't be convincing". And the other thing is the money.
"You don't endorse a product if no one is going to pay you. You're putting yourself in a position where people can criticise you and you're putting yourself out to do it."
That was decades ago, when everyone was vying for a piece of the young and beautiful Kiwi champion (when she appeared on the front of US magazine The Runner in April 1983, sales trebled). But those comments still seem sound – especially the bit about being exposed to criticism.
Since May this year Roe has been the face of, and a paid spokeswoman for, Clinical Thermography, a company that, controversially, assesses the health of women's breasts by taking infrared photos of them. The assessment costs $199, though various promotions have lopped a bit off the fee.
But her endorsement labours – from posing for print ads, to plugging the product in soft interview pieces for the likes of the NZ Woman's Weekly – stepped up a notch in September, when she fired off an angry press release in response to heavy-duty criticism from mainstream breast cancer organisations and doctors who believe thermography has little value and may undermine New Zealand's "world class" mammography screening programme.
None of the criticism has been made about Roe personally, but there is no doubt that she is central to their concerns. Though breast thermography has been in New Zealand and on the fringe for almost a decade, Dr Mike Baker, the radiologist who has led the recent criticism, says it was only from the beginning of this year that he started getting significant numbers of women coming to his practice either worried because of an "abnormal" thermogram but in fact free of cancer, and, conversely, women with "clear" thermograms who did have cancer.
He doesn't know how many women Clinical Thermography are seeing (and last week the company wouldn't give patient numbers to the Sunday Star-Times), but at times he sees up to two such women a day and believes the technique has "gathered momentum with more and more marketing. And having a prominent ambassador certainly has changed that".
And what an ambassador. Roe is a fantastically fit woman who positively oozes health, who has been banging on about healthy diet and sensible exercise and chemical-free sunscreen and environmental toxins for decades. Just last week she was elected to the Waitemata District Health Board on a platform that included promoting a "new paradigm in health care" and more "integration" in the health system.
If you can't turn to Allison Roe for a bit of guidance about how to keep your breasts healthy, who can you turn to?
THERE'S NEVER any shortage of famous faces willing to put their name to a product, company or cause. From TV larrikin Marc Ellis plugging a home ventilation system to cyclist Sarah Ulmer explaining the benefits of Purina dog food, McDonald's salads and slabs of red meat, there's barely a TV ad break that goes by without a familiar, trustable face encouraging us to spend our money somewhere.
It works, says Owen Scott, a technology marketing consultant with Christchurch firm Concentrate, because "when people we respect and admire go and touch a product, some of that value must pass on to the product". And it works particularly well when there's a good match of person and product (which explains why Ulmer got a lot of stick for lending her healthy, sporty image to McDonald's).
The nature of the deals varies widely. Many charitable endorsements will involve little or no cash changing hands: think John Kirwan's depression ads for the Mental Health Foundation, numerous women's endorsement of the Breast Cancer Foundation (including Allison Roe in the past) or the various campaigns pleading with us not to smoke and not to bash our families.
Other deals are simply commercial, involving flat fees or, sometimes, bonuses and royalties linked to the subsequent sales performance of the product.
Last year a Massey University study estimated celebrities are typically paid 10-25% of the total advertising expenditure for an advertising campaign. Thus a big international endorsement by a Kiwi with global appeal, such as Jonah Lomu's support for sports firm adidas, can earn the celebrity millions of dollars. For a campaign within New Zealand only, the figures are much lower: a million-dollar ad campaign budget (which is about as big as they get) might devote $100,000 to its celeb.
The numbers change again for a medium-sized campaign, because you factor in the value a celeb can bring in the form of "news" coverage. Consider that an advertiser will pay around $10,000 to place a double-page spread ad in the NZ Woman's Weekly – if your spokesperson can be interviewed about how product X has changed her life, you've scored that same space for free.
As one insider described it, "instead of spending $500,000 on a TV campaign, you spend $150,000 on TV and pay $50,000 to the endorser, for the same final result". For smaller campaigns the payments are far smaller, but the basic principles remain.
But celebrity endorsement comes with risk, both for the company and the endorser, because if the reputation of one gets damaged, so does the other. That's why some of Tiger Woods' sponsors pulled the plug after the golfer's serial adultery hit the headlines. Children's charity KidsCan took on rugby player Doug Howlett as a front-man in 2007 but he was arrested for drunkenly stomping on cars at Heathrow Airport later that year.
Equally, a product that turns out to be problematic can leave the endorser looking stupid. The collapse of New Zealand's finance companies left egg on the face of former newsreader Richard Long, whose soothing voice had helped persuade many that Eric Watson and Mark Hotchin's firm Hanover was indeed a business with "the size and strength to withstand any conditions". Along with his credibility, Long lost a $50,000 investment after Hanover crashed.
You could argue that both company and endorser have made their bed and should now lie in it, but there is a third party to the deal: the public. Vicki Hyde of the NZ Skeptics says the human tendency to follow people "gets us into all sorts of trouble". She keeps an especially close eye on endorsements that are linked to health or medical products, because of the potential for real harm. Some endorsed products are just a waste of money, says Hyde. But others aren't as harmless as they seem.
Squash player Susan Devoy's chirpy ads for Centrum multivitamins might seem benign, but most research shows supplemental vitamins are of little value, and "vitamins aren't necessarily healthy under any and all circumstances", says Hyde.
After all, last year Professor Rod Jackson at Auckland University called for all multivitamin brands to carry health warnings, based on "quality randomised controlled trials of 160,000 people worldwide", which he said showed healthy people taking multivitamins increased their risk of premature death by up to 16%.
There would be harm too, says Hyde, in the potential disruption of a national breast cancer screening programme, if women see a service such as breast thermography as a credible alternative to mammography.
And that's where the stoush over Clinical Thermography comes in.
Last week Roe told the Star-Times that she had approached Clinical Thermography soon after it launched last year, having previously travelled regularly to Tauranga for her thermograms. Six months ago her role as an official spokesperson was formalised, but the contract's terms are "confidential".
She says she is "extremely fussy" about what she endorses, turns down many offers (including opportunities to flog light beer and tampons), and unlike in the 1980s, "this is not about the money". Rather, this is about doing something for women's health. For years she helped raise money for the Breast Cancer Foundation but that war on cancer went nowhere – now she's placing her faith in thermography.
Clinical Thermography spokesman Jamie Newman, whose family runs the company, seems bewildered by the caning it has been getting. He considers the calls for the entire thermography industry to be shut down to be "extreme". He thinks the dismissal of breast thermography by the Ministry of Health's National Screening Unit, by the Cancer Society, by the Breast Cancer Foundation and by the College of Radiologists is based on inadequate research, and on the wrong-headed idea that thermography is setting out to replace mammography.
He accepts that some dodgier thermography operations in the US have done just that, earning themselves warning letters from the FDA, and, in the case of one Oregon clinic, being shut down by the Department of Justice. But Clinical Thermography, he says, is merely offering an "adjunct" to mammography and other testing. His company's website and literature are littered with clear statements to that effect.
FOR TAURANGA radiologist and breast specialist Dr Deborah McMurtrie, this doesn't wash. The basic flaw with thermography, she says, is the unacceptably high level of false positives (where the test says something is wrong when there isn't) and false negatives (where the test misses a problem).
And while thermographers might try to say they're "adjunctive" to mainstream tests, and are monitoring "breast health", rather than "breast cancer", the fact is, says McMurtrie, that "nobody gives a toss if their breasts are healthy. They want to know if they've got breast cancer".
Mammography, which involves x-raying breasts to look for cancers, is far from perfect, says McMurtrie. It is particularly poor at finding cancers in young and dense breasts, and it has its own failure rates. It involves a small amount of radiation, and is uncomfortable for some women. But crucially, it has been shown to be vastly more effective at finding cancers than thermography.
Aside from taking note of a review of thermography performed in 2004 by Massey University which concluded it was of little benefit in finding cancer, McMurtrie has some first-hand insight.
In 2002 a number of women came to her brandishing "abnormal" thermograms from Tauranga doctor Mike Godfrey, the pioneer of thermography in New Zealand (who has since merged his business with Clinical Thermography). Almost all of those women had no cancer, but it got McMurtrie thinking. The basic idea – that the presence of a cancer will be reflected in changes to the surface temperature of the breast – is not entirely unreasonable, and she was always on the lookout for better techniques. So McMurtrie sent a number of her patients – all of whom had already been confirmed as having breast cancer by biopsy, but whose diagnosis using mammograms and ultrasound had proven to be tricky – to Godfrey.
The results shocked and disappointed her: three of the first four patients she sent, all women who definitely had breast cancer, came back with thermograms which did not reveal the severe thermographic abnormalities expected. McMurtrie abandoned her ad hoc study, and reported her findings to other radiologists at a breast imaging conference in 2005.
(Last week, Newman said Godfrey's slightly different version of events was that "one of the first three or four women [McMurtrie] sent through had a small heat signature that was not identified by Mike which turned out to be cancer".)
McMurtrie says she is uncomfortable at speaking publicly – "there's a reluctance for all of us to put our head above the parapet" – but like other people in the field, she was concerned at the recent growth, and national spread, of thermography. "It had got to the point when people we respect, like Allison Roe, are promoting it. It gives it a de facto authority."
Newman won't reveal patient volumes at Clinical Thermography's two permanent clinics in Auckland and Tauranga and its temporary clinics nationwide, because "there's lots of misinformation out there, and we get misquoted", but he says they have indeed increased since Roe's endorsement began. But the uplift has been "hard to quantify, given the active campaign against thermography that's been going on".
That campaign isn't over yet. Last week College of Radiologists representative Mike Baker said the issue "isn't personal", and isn't even about any particular company.
"It's about a technique that's not recognised as a tool for picking up breast cancer, but is being promoted as an examination that looks after breast health. But if it doesn't pick up breast cancer, why use it?"
Like McMurtrie, Baker says he hasn't relished going public like this – it's the first time in his career he's done so – but "I feel very strongly about it".
Roe sees something rather different behind what she calls the "deliberately orchestrated campaign" to "sling mud" at thermography at a time when concerns have been raised worldwide about the efficacy of mammography screening campaigns.
"The cancer industry basically works on fear. They try to put the fear into women about breast cancer. They raise enormous amounts of money which they channel into promoting mammography. They're worried about their own patch and they fear anything that might [be] competition... because mammography around the world is under the microscope."
That version doesn't gel with McMurtrie's stance. She says she'd be delighted if any test one day replaced conventional mammography.
If patients ask about thermography she points them to the Breast Cancer Foundation's condemning position statement, but if people want to throw money at a thermogram that's OK, as long as it doesn't affect their commitment to regular mammograms. "They can buy a pair of shoes, they can have thermography.
"I'd love it if there were a test that didn't use radiation and didn't squish women," says McMurtrie. "But I don't think thermography is it."
What's it like to undergo clinical thermography? Monique Farmer reports.
MY SECOND least favourite day of the year is my annual mammogram. No matter how well the radiographer warms her hands before grabbing and positioning your breasts, or how many tropical island photographs adorn the walls, there's nothing more unpleasant than having a highly sensitive part of your body squashed between two glass plates. Repeatedly.
My least favourite day of the year is the anniversary of my mother's death. She was first diagnosed with breast cancer at the age of 39, when she hadn't yet reached menopause, which is reason enough for me to have mammograms for the last 10 years, since the age of 30.
Preparing for thermography is very different to a mammogram, where all you have to remember is not to book at a sensitive stage of your cycle, and not wear deodorant. There are 11 "pre-appointment instructions" – no exercise four hours prior, no underarm shaving on the day, no lotions, no shower or hot drink one hour before. No physical stimulation of the breasts for 24 hours before the appointment, "sexual or otherwise".
The most challenging instruction is "do not wear restrictive clothing such as a bra before the appointment".
In a small, upstairs medical suite in Remuera, I'm ushered into a windowless room with a laptop on a desk, a black stool positioned in front of a camera on a tripod, and a big stainless steel basin perched on a small table. I remove my jewellery, strip to the waist and sit on the stool for 15 minutes while my body adjusts to the room's 18-20C temperature. I must sit with my hands on my hips (to ensure my armpits cool down) and not touch my chest.
I hoped that the technician would leave the room as it's an awkward position, but she stays and talks, maintaining eye contact. She explains the different poses I'll do (all with hands resting on the top of my head, some with arched back, at different angles to the camera), then shows me through a typical report so I know what to expect when it is posted out in about a week. (You can also ask for a report to be copied to someone else, like a GP or naturopath.) Photographs of the breast show a rainbow of colours – with cool areas in blues and greens, and areas of increased vascular activity in reds and oranges. These hotter spots could indicate a range of things, from injury to cysts, not just cancer. But the theory is that a tumour has an increased blood supply, and therefore the temperature in the surrounding tissue will be higher.
There is no mention of any risks of thermography – but she says that screening should be done annually, to build up a picture of changes in the breast tissue. I ask if she makes diagnoses and she says no, the next step if there was a high risk rating in my report would be a referral for an ultrasound, followed by the usual course of a biopsy if there's anything sinister.
As promised in the advertisements, there is no touching and no discomfort. The technician demonstrates poses or points which way to face.
Then the stainless steel basin is filled with water chilled to 10 degrees, and she tells me to immerse my hands up to the wrists for one minute. This is tougher than it sounds, as with each second your hands ache with the cold. The technician explains that the cold water will trigger my "fight-or-flight" response, which will constrict the blood vessels in my peripheries. We repeat the photographs after she dries off my hands, and this time the infrared camera will capture any "non-responding blood vessels", as in the early stages of tumour growth, abnormal blood vessels do not constrict.
The most entertaining part comes at the end, when the technician turns the laptop around to demonstrate how I look on-screen – my clothes and bracelet are cool colours, while under my arm is bright red. She tells me to press my hand to my face, and when I take it away there's an outline on my cheek.
I pay $200 and leave the empty waiting room, none the wiser about whether there's an issue until I get the results in a week (it costs $30 more to receive within 48 hours).
There's no question that the experience of thermography is more pleasant than mammography, but that's not hard. As a believer in science, I think the opposition to thermography – from the medical establishment through to insurers such as Southern Cross who won't pay for it – is too compelling to ignore. I'll be sticking to mammography as my first line of defence.
The Sunday Star-Times did thermography anonymously and paid for the session.
HIGHS AND LOWS OF CELEBRITY ENDORSEMENT
2003: Cycling champion Sarah Ulmer fronts the McDonald's "Eat Smart, Be Active" campaign, which seeks to convince the nation that the fast-food giant is interested in healthy eating. Nutritionists criticise the campaign, prompting McDonald's to claim that it was all about healthy living, and "not about promoting the company".
2006: Home ventilation company HRV tells the Waikato Times sales have leapt 800% since former All Black Marc Ellis began appearing in their ads. Despite Ellis's minor fall from grace over drug charges in 2005, the company kept him on.
2007: A TV ad by former One News presenter Richard Long, right, says Hanover Finance has "the size and strength to withstand any conditions". It didn't (indeed it had a relatively unimpressive Fitch credit rating of BB+) and in mid-2008 it froze repayments of $500m to investors.
2007: Puff Daddy agrees to endorse Ciroc vodka, or rather, signs on as their "brand manager" in exchange for a 50% share of profits. Either way, the deal is touted as potentially being worth as much as $US100m ($126m) to the US rap star over the contract's term.
2009: Mike King turns his back on six years of lucrative TV ads for the Pork Board, and presents a hard-hitting documentary on the cruelty of pig farming.
2009: Tiger Woods, who earns an estimated $US100m a year from endorsement deals alone, confesses to multiple affairs, and sheds a number of sponsors. An estimate by Sports Illustrated said his endorsements would earn him $US22m less this year than last.
Sunday Star Times