Arguments against proactive MRI scanning always seem to have a whiff of status quo bias to them. Yes, right now MRIs are expensive and false positives are common, but if regular scans were widespread, it's likely this result in innovations that would drive down costs, improve accuracy, as well as producing a much larger corpus of data with which to guide diagnosis and reduce false positives.<p>To use a software analogy, if your downtime detection system kept producing false negatives, would your solution to be just turn it off? You'd get some better night's sleep, but you'd pay for it when the system really went down and you had no idea.
> it's likely this result in innovations that would drive down costs, improve accuracy, as well as producing a much larger corpus of data with which to guide diagnosis and reduce false positives.<p>Why is it likely? We already have a lot of MRI data. There are already a lot of incidental findings. It might also be an issue of the MRI not being able to produce enough information to discriminate.<p>> To use a software analogy, if your downtime detection system kept producing false negatives, would your solution to be just turn it off? You'd get some better night's sleep, but you'd pay for it when the system really went down and you had no idea.<p>The analogy is rather something like this: your downtime detector is not just a "ping" but a full web browser that tests everything and it sometimes flags things that are not actually issues. So you don't turn it off, but you only use it when you have another signal that indicates that something might be going wrong.
There's a softer component to healthcare which is that people can overreact to medical results. If a doctor administers a scan, finds a handful of likely benign things but wants to administer another scan later on down the line, I'm probably much more likely to look for a second opinion that tells me to cut them out (even if it may not be medically necessary) than trust my doctor that "it's probably fine".<p>It's probably more accurate to use a software analogy about performance metrics. We measure random request spikes now and again that strain the system. It's probably fine, but later on down the line, something could change that results in an outage during one of these spikes. Do we proactively fix the problem even if no change is expected? Or do we wait till there is definitely a problem before taking action?
But surely this would decrease as we learned more from more frequent MRI scanning. Doctors and patients would be less likely to overreact, and we'd settle in on something better?<p>I'm not an expert though.
No, this is more like disabling logging because people are concerned the server is going down.<p>“Don’t worry about it, I don’t think it’s a real issue so we’re just going to ignore it”
> Arguments against proactive MRI scanning always seem to have a whiff of status quo bias to them<p>More and more European countries are currently adopting Lung Cancer screening programs. It's usually limited to people with a certain amount of cigarette-pack-years, but still gives the opportunity for driving more of the innovation you're talking about. I think the main challenge at the moment is that nothing in healthcare is prepared of looking at those scans effectively, a radiologist has full medical education + additional specialization - without effective procedures you'll never be able to provide full-body scans with any meaningful impact.
False positives trigger more diagnostics some of which can be harmful, not just psychologically but physiologically as well.<p>If false positives are ok, why not build a down time detector that rolls a die every 5 mins and alert on hitting a 6.
Additional diagnostics can also be very expensive. Articles like this don’t seem to understand the overall costs to a health system with decisions like these. And that cost eventually does go down into the pockets of patients one way or another.
Harmful to shareholder value.<p>Personally I’d rather have cancer checked out rather than have a “wait and die” approach
But medicine isn't quite the same feedback loop as downtime monitoringg
“ One study in 2020 found that 95% of asymptomatic patients had some type of "abnormal" finding, but just 1.8% of these findings were indeed cancer.”<p>This has been my experience. And I’ve had oncologists echo exactly this. In the words of one: MRIs find too much.<p>The CT and the PET/CT are the gold standards for finding cancer, finding recurrences, and staging cancer. The trouble is the radiation dose.<p>MRI provides very inconclusive results. You’ll see something but it’ll be unclear what it is. And often what you see is not even visible on a CT. Or it’s visible on a PET/CT and is showing metabolic activity indicating its cancer.<p>MRIs are great for certain things like herniated disks in your back. They suck at cancer.
It's not that MRIs suck at cancer. They provide fantastic structural and functional data.<p>The problem is the specificity of the results and the prior.<p>A full body MRI by definition will provide detailed views of areas where the pretest probability for cancer is negligible. That means even a specific test would result in a high risk of false positives.<p>As a counter point, MRS means that you can now MRI someone's prostate and do NMR on lesions you find.<p>Lets say someone has lower urinary tract symptoms. And is 60 years old. An MRI could visualize as well as do a analysis that would otherwise require a biopsy. With the raised prior you can be quite sure suspicious lesions are cancerous.<p>Similarly for CNS tumours. Where fine detail. Subtle diffusion defects can mark csncers you couldn't even see if you cut the person open.<p>No sensible doctor would give you a whole body CT unless there was a very good reason. That very good reason is probably "we already think you have disseminated cancer". That pushes the prior up.<p>And less so for a PET/CT. Lets flood you with x-rays and add some beta radiation and gamma to boot!<p>The danger of an unnecessary CT/PET is causing cancer, the danger of an unnecessary MRI chasing non existent cancer.
> MRIs are great for certain things like herniated disks in your back.<p>I have had a lot of experience with MRIs on both myself (back and knee [1]) and my dogs with herniated discs. The doctors always make it sound like MRIs are great to confirm what's suspected because of other symptoms like pain, but a point in time MRI alone is not that valuable. Everyone's bodies (including animals!) are surprisingly different inside making normal be somewhat unique. I think what would be interesting is if scanning technology like MRIs could be made so inexpensive and easy that everyone had one done 4x/year. That way it's the differential being checked and I'm guessing it would be way more valuable. Normalization such as this could also lower anxiety around findings.<p>[1] Even when I tore my ACL the MRI came back only as probable.
Do you know which MRI you used? Not all are equal.
Most MRI are 1.5T powered, and you can’t get fine details until you hit 3T. And there are differences even in the 3T power range. There are higher powered MRI which are mostly only used in research, whilst it is a bit scary thinking about the sheer power of them but a 7T machine doing a full scan of you, would be guaranteed nearly to find anything wrong with you.<p>When I last looked the full body scans for sale seemed to used 1.5T setup, which seems like a waste. The 3T advanced scans looks much more detailed, but it just depends on where you live - I couldn’t find any around.
>One study in 2020 found that 95% of asymptomatic patients had some type of "abnormal" finding, but just 1.8% of these findings were indeed cancer.<p>That can also be reframed as 1.71% of asymptomatic people having cancer, which is a really good argument for better screening.
The argument for better screening would require that finding those asymptomatic cancers actually improves survival rates. There are several reasonable scenarios where early screening doesn't improve it:<p>* The cancer is aggressive and resistant to treatment. Chemo/radiation only pause the growth for a bit, but ultimately the cancer keeps growing and the total survival time is the same (only that the patient spent more time knowing they had cancer).<p>* The cancer is susceptible enough to treatment that it's still curable when it becomes symptomatic and found through other means.<p>* The cancer is slow enough that the patient dies from other causes before.<p>Early screening brings benefits only when the cancer ends up causing issues and responds differently to treatment between the "early screening detection" time and the "normal detection" time.<p>It's impossible to know beforehand which of the scenarios have more weight, specially because we have very little data on what happens way before cancer is detected via the usual methods. We need better studies on this, and for now the evidence doesn't really point out to these large, indiscriminate screenings being actually helpful.
That’s not the correct framing - your assertion first lacks evidence about why we should screen better. In fact, we aren’t improving longevity in many early diagnoses, and may be treating people whose immune system would resolve the cancers.<p>Further, the denominator is asymptomatic people <i>who were able to get MRI’s they didn’t need</i>. That doesn’t tell us anything about the normal world.
I wonder how biased the group is though, is the sample truly representative of the general population or is it a group of people who are already undergoing screen for some other health-related reason?
Spot on. And dealing with false positives sucks.<p>One caveat is that regular PET isn't so good in the brain - there is so much metabolic activity that everything glows. So I get an MRI Brain to go with my regular full body PET/CT (cancer 5 years ago with recurrence 18 months later, currently NED).
I had a CT scan last year for some stomach issues they wanted to look at.<p>Doctor warned me up front that the odds the images find <i>something</i> that looks weird is high but not to panic because of how many false positives there are when looking inside someone’s body.<p>While I am happy to report they didn’t find anything serious, I do take slight offense to the following at the top of my results:<p>Last name, First name: Unremarkable<p>(Kidding of course but still got a chuckle out of me)
2.5 years in of regular PET scans. At this point, I’m almost humored by what gets flagged as suspicious by the radiologist - usually mosquito bites and stomach bugs (kids in daycare means I’m almost always sick). I have a scan Monday and two weeks ago had a re-excision so there’s a two inch gash healing on my back. This week I got three vaccines. And then tonight my toddler bit me hard enough to draw blood. I had asked the oncologist if it made sense to delay the scan because of the re-excision and he said not to worry because he’d know why there’s inflammation in that area. I’m thinking the bite and the shots will probably get flagged too. I just hope I don’t forget any other maladies or mishaps that might get flagged that I can’t explain.
> I do take slight offense to the following at the top of my results:<p>No offense for me, just confusion. One of the status reports started as follows:<p>> OptionOfT is a very pleasant 36-year-old gentleman 6 weeks status post left anterior total hip arthroplasty done by Dr. _ on _.<p>I asked my wife whether I was particularly friendly (I sometimes fail to adjust my demeanor in certain situations).<p>She said: nah, they write that for everybody.
I had a nurse chart “patient ‘feels like a million bucks’” while I was getting an immunotherapy infusion.<p>She said “It’s just not often I hear that here.”
Some RIS systems make semi form reports with ‘Dear <referrer> thank you for sending <patient> to see us for their <type of imaging> etc etc.<p>Then you can just tab from field to field when doing the report.
The bar is really low for patient behavior. Tbh I find anyone not screaming at me to be pleasant in comparison.
That’s completely and 100% false. It’s much easier to characterize things on MRI and MRI is indeed phenomenal for cancer! The problem is with screening, not actual staging or follow-up, and whole-body screening in ct and pet/ct is even worse than MRI screening even if you ignore radiation.
Anecdotal evidence to confirm: I had two false alarms from an unrelated MRI scan, and beside wasting a lot of time on diagnosing them - it was also extremely stressful.<p>My father is a part of "full body PET scan every 3 years" program as part of post - cancer treatment, and it worked twice: early detected lung and prostate tumors, both removed.
> My father is a part of "full body PET scan every 3 years" program as part of post - cancer treatment,<p>These treatments are wonderful and it is great that they exist. But many people fail to understand the difference in terms of pretest probability, etc.<p>I can absolutely see the heavy psychological impact pending biopsy results may have. People are quick to discount these issues when you raise them as a concern, but only if they never went through this stress themselves
> My father is a part of "full body PET scan every 3 years" program as part of post - cancer treatment, and it worked twice: early detected lung and prostate tumors, both removed.<p>My mum gets scanned a little more frequently than that, following treatment for an inoperable tumour in her lung around five years ago. During treatment she was getting scanned every three months or so, and it was remarkable watching this thing go from the size of a tangerine, to actually expanding a bit and looking "fuzzy" once the drugs kicked in, to being the size of a plum, then the size of a grape attached with a little thin thread of tissue, to being a thing the size of a pea. Now there's a tiny ripple of scar tissue that no-one wants to investigate further, because if it's not doing anything let's not poke at it.<p>There is a roughly pea-sized "thing" on her adrenal gland that was a bit worrying because anything like that is going to get intimately involved with your lymphatic system and then it's going to metastasise like hell. But it neither got bigger nor smaller in the nearly six years since the first scan, so it can't be that important.<p>This is one of the great things about the NHS, especially here in Scotland where we have (possibly as a result of the weirdly high levels of cancer) some of the best oncology services in the world.<p>If we'd lived in the US, the insurance companies would have taken one look at an 83-year-old about to become a grandmother and sent her home with a bottle of morphine to die. As it is, she's doing very well and got to see both her grandchildren start school.
But saying MRIs "suck at cancer" feels off. They're actually first-line or gold standard for certain cancers
I feel that label is actually deserved. Yes, some cancer types are easier to detect with MRI, in particular inside of a body, but at the same time MRI in and by itself isn't great at predicting all cancer types. How could it help with regards to leukemia, for instance? What exactly could MRI detect here better than other diagnostic tools? One has to keep in mind that diagnosis also takes time - plus the cost; and the overdiagnosis problem which means that some cancer that are not really relevant, are hyped up by MRI to be the end of the world for a patient. So there is a trade-off.<p>IMO MRI needs to become cheaper; and more reliable too.
“MRIs…suck at cancer”<p>Wrong? I understand MRIs are the standard for certain types of cancer like brain and spinal tumors.<p>With respect to whole body MRI they can be less effective because it’s not optimized, accuracy can be traded for area.<p>But as a general statement MRIs do not suck at cancer.
MRIs are good if you know what you’re looking for, and usually with contrast, which in a situation like cancer where you need to do them often can result in allergic reactions.<p>In a full body situation, they are looking for mets, and the uptake of radioactive sugar by the tumors will let a PET scan find them.
>MRIs are great for certain things like herniated disks in your back. They suck at cancer.<p>MRIs are fine for certain kinds of cancer like liver cancer.
hmm that is still around 1.5% of ppl having cancer. not trivial. Even more if you include false negatives.
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And yes getting frequent full body MRIs is still overwhelming the right thing for the patient.
No? The point of the article, and of the preceding comments, echoing a pretty common tenet of evidence-based medicine, is that frequent full-body MRIs are a bad idea for the patient.
Here in NZ an Australia, the college of radiologists disagree and say ‘don’t do it’ for screening the worried well.<p><a href="https://www.ranzcr.com/college/document-library/2024-position-statement-on-whole-body-mri" rel="nofollow">https://www.ranzcr.com/college/document-library/2024-positio...</a>
Seems like their main concern is "substantial downstream healthcare costs"
Yes, and needless biopsy can be a big deal.<p>It’s a great document, I’m an MR tech and we now have something to lean on when we say no to these scans. We can then scan people with problems rather than people with too much money.
Great document? I just read the entire thing, it contains no evidence or justification for their claims.<p>> We can then scan people with problems rather than people with too much money.<p>Right, this is what it's really about. MRIs are a scare resource and providers need to manage cost. Fortunately I can afford to pay out of pocket, but I'm just annoyed that doctors are so irrational about this<p>To be clear, it's up to a doctor whether or not to do a "needless biopsy". That has nothing to do with a scan.
NZ doesn't have the screening capacity for when it's medically necessary, much less optional.
This guy has never heard the term 'scanxiety'. Go ask what it means on a cancer forum. The real OG's are the VHL folks. Bet we have a few here on this thread. Respect.
I have, it's the fault of how medicine is practiced to reduce cost. It's completely avoidable, you can just not tell people their scan results if they have no symptoms and the detection is less than 95% likely to be cancer. This is strictly better than the status quo because the only difference is some people who almost certainly have cancer learn that they have cancer and nothing else changes
I much prefer tests with low false positive rates.<p>I recently had such a cancer-related test. A cousin had a BRCA2 mutation and I was concerned I could have it also. Insurance would not pay for the testing, but one can get a panel of such genetic tests for just $250 now, so I went ahead. And it was negative. This is reassuring not just to me, but also to my children, and (somewhat) my sibling (the relevant parent is no longer alive).<p>Had this test been positive, the chance of pancreatic cancer would have gone way up, so frequent scans (I think annual MRI and ultrasound?) would have been justified.
Answering the question in the title...<p>> One study in 2020 found that 95% of asymptomatic patients had some type of "abnormal" finding, but just 1.8% of these findings were indeed cancer.<p>So a bit less than 1.8% of the time in this study<p>> Prenuvo's recent Polaris Study followed 1,011 patients for at least one year following a whole-body MRI scan. Of these patients, 41 had biopsies. More than half of the 41 were diagnosed with cancer.<p>That's 2.0%<p>Note that this doesn't mean that 1.7~2.0% of people have cancer without knowing it. It could be more:<p>> A negative scan doesn’t mean you’re disease-free. Some cancers and conditions simply aren’t visible yet or aren’t reliably detected on a one-time full-body MRI."<p>But also perhaps less, in a way:<p>> "You're finding something that never would have caused you any problem in your life, and in cancer, we call that overdiagnosis," Vickers says.
Yep, I have experience with both. It found cancer for my wife and she was able to treat it immediately. Fully recovered.<p>It found a weird spot on me that turned out to a pancreatic rest.<p>The only reason we did the scans were because we were making a significant life decision that we didn’t want to have to backtrack if either got diagnosed with cancer within a year . We knew nothing was guaranteed but we wanted to do some tests.
> You're finding something that never would have caused you any problem in your life<p>Is it though? Isn't it possible you could be early-detecting something serious that is much easier to treat now vs when symptoms appear?
There's a theory that the first-stage cancer is way more common than we think, it's just doesn't develop further most of the time, cause no symptoms and remains undiagnosed throughout the lifetime.<p>There's some support for this view because agressive screening for thyroid and prostate cancers increases the number of surgeries a lot but doesn't seem affect the mortality rates.<p>Risks from a surgery are non-negligible, if you perform it to treat a low-risk condition it may be a net loss in the end.<p>So you're technically right about the "early-detecting" part, but the "much easier to treat" step is problematic because it's unclear what a net-positive treatment looks like for low-risk cases. Probably it comes down to yearly monitoring of whatever was detected, not the actual treatment.
Yes, you could early-detect something, but the likelihood of this thing being life-threatening are extremely low. If you choose to manage this thing aggressively anyway, you have to undergo more invasive testing (e.g., biopsies, surgery, anesthesia, etc.) that all have small risks of catastrophic events. In most cases, the risks of more invasive testing outweigh the risks of just not pursuing any further workup.<p>Nothing in medicine comes for free—everything is a tradeoff.
> Isn't it possible you could be early-detecting something serious that is much easier to treat now vs when symptoms appear?<p>It could be. It could also be the cade that you undergo invasive surgery for something that would have never caused you problems within your life. The problem is that cancer isn‘t cancer. Even if it originates from the same tissue, some tumors behave <i>very</i> different from others.
Yeah a 2% risk of having something which can easily kill you and is very expensive to treat, especially if you're not elderly and still have lots of life ahead of your, is not exactly trivial. I would want to know about this
Doctors here are cognitively captured by a system designed to limit cost (and that's mostly a good thing)<p>But scanning frequently is overwhelmingly good for the patient. The problem is the doctors. Imagine two possibilities.
1. You scan every six months and a doctor reviews your scans but never tells you anything no matter what
2. You scan every six months and a doctor reviews your scans and only tells you results if you have an obviously growing mass that has a probability greater than 95% of being cancerous<p>Obviously #2 is better for the patient than #1, but #1 is equivalent to never testing if you ignore cost.<p>So the actual reason we don't have effect frequent scans combined with effective diagnostic techniques is cost, and doctors cope with this reality by saying clearly wrong things about "over diagnosis". It's a local minimum of the payer/provider dynamic that has nothing to do with scans per se.
I don't think this is doctors being captured by the system so much as medicine being cautious about scaling interventions without strong outcome data
Why is it good for the patient? I think that to claim this, you'd need to show a difference in outcomes.<p>Here, you have a tool with a ~100% false positive rate, so if we start administering it to everyone, it will almost certainly cost lives. Botched biopsies, unnecessary treatments, other complications. Not to mention the huge cost that would divert money from other welfare programs. So you need to show that when it actually detects something, it saves at least as many lives. And I doubt that's the case.
I wouldn't argue we should roll this out to everyone. But I am glad it exists. I commented earlier in this topic about how it caught cancer in my wife at the age of 44. She didn't have to go through chemo or radiation treatment because it was caught so early. Surgery removed the whole cancer.<p>Additionally for me, I have a scan that shows what my body currently has. I had something show up that I did get a scope to check out that was a pancreatic rest. No big deal. Now, if I ever have another MRI and somethings is somewhere else, we have a baseline to compare against. Everything is a risk calculation. When I did my MRI, I also had other procedures done like a heart calcium score.<p>I will get a little more personal. We didn't do it out of the blue. My wife and I decided we want to live on a sailboat. That was a big purchase for us and boats take a long time to sell. We didn't want to commit to such a purchase then 1 year later find out either of us had cancer then we have the stress of cancer and the stress of trying to sell a boat.<p>I would never suggest everyone do it, but I am happy we did.
Did you read my two options? Do you agree option 2 is better than option 1? If so, then scans are better than no scan<p>You don't need to show that it's possible to avoid false positives. That's doctors being irrational.<p>You only need to show that it's possible to build a diagnostic system that's better than no testing, and I have shown that already
No. To argue for the benefit of the procedure, you <i>need</i> to show a difference in outcomes. Not that it can detect something, even if it could (which whole-body MRIs clearly don't). That the detection improves your chances of survival.<p>If you have an growing mass in your body, then if it's cancer, after a year, it might be too late for treatment. Or it may turn out to be nothing: a benign tumor / cyst / fat deposit in an unusual place. Or it may be slow-growing prostate cancer that you can live with for another 20 years, and maybe it's the chemotherapy that will do you in. It's really not that clear-cut in medicine.<p>To give you have another example: let's say that the risk of appendicitis in people who have an appendix is 1%. And the risk in people who had an appendix removed is 0%. Does this justify proactively removing the appendix? No, because the consequences of complications are much higher than the harm you're preventing. The same applies here: detection, even if 100% accurate, doesn't mean anything. You need to show that what you do with the result actually helps.
The difference in out come is<p>With my change: 95% of people who are shown scans have cancer and are treated earlier. 5% of people do not have cancer and get CT scans. 0.5% of people get useless biopsies
Without my change: many of those 95% die, the 0.5% do not get useless biopsies<p>And the beauty of this is you can pick the percentage!<p>> If you have an growing mass in your body, then after a year, it may very well no longer make a difference whether you treat it or not. Or it may be that you would have lived another 20 years just fine<p>This is just wrong for many parts of the body. In your brain? Your lungs? Growing for a year between 3 scans 6 months apart? Extremely unlikely to be benign<p>> The same applies here: detection, even if 100% accurate, doesn't mean anything. You need to show that what you do with the result actually helps.<p>This is wrong. If you had a 100% accurate cancer detector, fewer people would die of cancer with no downside
> With my change: 95% of people who are shown scans have cancer and are treated earlier. Without my change: many of those 95% die<p>Why? What happens if the cancer still doesn't respond to treatment even when detected early? Or, to the contrary, if the cancer also responds to treatment when it starts becoming symptomatic?<p>That's why we have studies to understand if screening is a good practice or not. It's not that clear cut.
> With my change: 95% of people who are shown scans have cancer and are treated earlier. 5% of people do not have cancer and get CT scans. 0.5% of people get useless biopsies Without my change: many of those 95% die, the 0.5% do not get useless biopsies<p>You assume that treating cancer automatically improves the outcome. Treating cancer often kills you, so treating a non-fatal tumor can easily be a bad decision. And a lot of the tumors found by agressive scans are like that, but we don't know yet how much exactly and how to tell one from the other. It's a new question that requires decades-long observations to answer.<p>> This is wrong. If you had a 100% accurate cancer detector, fewer people would die of cancer with no downside<p>You're saying it as if detection somehow cures cancer, it doesn't.
> You're saying it as if detection somehow cures cancer, it doesn't.<p>No, I didn't say the detector would cause cancer to be cured.
I said fewer people would die with no downsides. If treatment is sometimes harmful then the detector also fixes that, you'd never treat people without cancer
No, the detector doesn't fix that, that problem is not treating people without cancer. The problem is treating people with cancer that won't kill or harm them during their lifetime. In this case even a low risk treatment becomes harmful, let alone cancer treatments.
So if this is true, it seems that we must accept that many people will die of cancer we could have detected and cured with frequent scans, because doing frequent scans will overall cause more harm to people who didn't need treatment. So the overall death/harm rate would be worst with more frequent scans?<p>Isn't that then just a problem with the scan and diagnosis? With more frequent scans it seems highly unlikely that we wouldn't improve this process and end up in a better place.
You are deep in the cope here.<p>There is no world in which biopsies cause more harm than detecting every cancer at stage 1 prevents.<p>> Not to mention the huge cost that would divert money from shareholders<p>Ah, that explains it
No.<p>When there is low prevalence of a condition, but a non-zero false positive rate of a test, the false positives generated by universal testing can in fact be a net dis-benefit (worry, invasive further procedures, etc) to the patient population as a whole, regardless of cost. This is a well understood statistical phenomenon, and is carefully considered by healthcare systems when advising on testing.
Best comment here
Can someone ELI5 why false positives on a MRI are so bad?<p>From a pure Bayesian PoV, you're better off with a noisy additional observation. At worst it doesn't get much weight.<p>At a pragmatic level, can't you say, hey here's something thats probably nothing, let's scan it again in 6 months? Why does an MRI necessarily lead to invasive follow ups?<p>I get that ideally we'd have a crystal ball with 0 type I / type II errors but short of that, why is a noisy predictor bad?
> At a pragmatic level, can't you say, hey here's something thats probably nothing, let's scan it again in 6 months<p>If a doctor even _hints_ there might be cancer, the patient will have a terrible 6 months (with actual, measurable negative health impacts of the added stress). Also, at some uncertainy-level (say, 10% chance of cancer) the doctor _has_ to say something and has to schedule expensive followups to not risk liability, even though in 90% of the cases it is not only unnecessary, but actively harmful to the patients.<p>When, on average, the cost of the screening + the harm done by a false positive outweighs the benefits of an early detection, you shouldn't do the screening in the first place.
Because the patient is usually unable to handle such information correctly (the medical system sometimes too). And the whole-body-scan type of tests additionally pre-select for the high anxiety types.
My understanding is it's liability, if the doctor decides not to look into it then they could be blamed for it if it turns to cancer.
In real life, every additional data point has a cost...
I 100% agree. The UK recently recommended to not scan for prostate cancer because it sometimes detects cancers that don't need treatment:<p><a href="https://www.bbc.com/news/articles/cm20169gz44o.amp" rel="nofollow">https://www.bbc.com/news/articles/cm20169gz44o.amp</a><p>This seems super dumb to me. If the test detects cancer that doesn't need treatment, don't treat it!! It's still better to know it's there and that you need to monitor it.<p>> Before you know it, you are on the operating table having your prostate removed – and we see examples of that all the time,<p>Well fix <i>that</i> problem then. If someone puts a smoke detector above a toaster you don't just pull the battery and call it a day.
> If the test detects cancer that doesn't need treatment, don't treat it!!<p>How do you know which ones to treat and which ones to leave?
> Well fix that problem then. If someone puts a smoke detector above a toaster you don't just pull the battery and call it a day.<p>I think what's happening here is that the smoke detector is indicating the possibility of fire, but the toaster is always being immediately doused in water. Which as we know would cause more damage than good unless there truly was a raging inferno.<p>The suggestion here seems to be moving the smoke detector to somewhere where there's a higher chance of it ringing means a higher chance of a damaging fire. Which seems quite reasonable.
The question is how can you know if it needs treatment or not. I guess you either need to do a biopsy, or check if it's grown after N months (leaving patient scared and anxious during that time). Neither are great if most cases end up not needing treatment.
If the test provides you <i>zero</i> information about whether it needs treating then it was never a useful test. Presumably it's more like "there's a X% chance this needs treatment". In which case you just set reasonable thresholds for X. E.g. if it's 5% you monitor it, 10% you do a biopsy, 70% you operate, etc.<p>This is much more sensible than just not testing at all and letting people die from cancer.<p>> leaving patient scared and anxious during that time<p>This seems to be the actual motivation. We don't want to scare people with test results so we're just not going to test them. I think that should be up to the patient.
> This is much more sensible than just not testing at all and letting people die from cancer.<p>This is not what happens. You're assuming that if the cancer does not get detected by the screening then it never gets detected. What actually happens is that the test gives information that might actually be redundant and obtainable in less risky way. What the studies are showing is that waiting until there are other, more specific signs and symptoms of the prostate cancer results in the same survival rates.
> One study in 2020 found that 95% of asymptomatic patients had some type of "abnormal" finding, but just 1.8% of these findings were indeed cancer<p>So that would be 1.71% of people getting a full body MRI catching cancer early.<p>That seems like an astoundingly good return to me. What does late cancer treatment and lost lives cost? Many times these MRI’s.<p>If everyone did this, would there be any significant number of late stage cancer discoveries anymore?<p>Obviously, reducing the cost of false positives is important. But if 1.7% of us have cancer - wow. My guess is that percentage can be tuned up and down by demographics. So maybe there is still an argument against everyone doing it.
There are two points in MRIs that limit or (better) regulate their use:<p>* financial cost vs level of care. A full body MRI costs a huge sum but it is the most detailed non-invasive diagnosis we have for any disease that can lead to earlier therapy. Used as a screening method, does it worth to save one patient in tens/hundreds tests performed? You answer, but public health authorities, health insurances and medical societies are negative.<p>* MRI shows some minor findings that would never cause symptoms and better not be known to the patient due to the stress they bring and cost of ongoing follow up (eg in the brain small meningiomas or angiomas). This might bring more harm than good and limit their net value.
For some reason, I always found the arguments for "it's better to not know" for these tests to be strange and slightly infantilizing. But of course this must not be the end of it, and there might be some more well thought out arguments from bioethicists that go beyond "the patient can't handle the truth". Because this argument seems like it's doing a lot of heavy lifting without much evidence.
One important point is that many people die WITH cancer but not OF cancer. So even for the 1.8%, only a fraction of those people were going to die of the disease (or even suffer significant symptoms) - the rest were just going to die of natural causes anyway.<p>But now you've found it you pretty much have to remove it, which has significant quality of life implications.
This seems like a wild statement.<p>Age is a big factor in the with/of cancer factor. If someone is 80 years old then there's good chance it won't be cancer that kills them (assuming they aren't already in a late stage).<p>But if you are 40 and you have cancer, there's a good chance you'll die of that cancer if it's left untreated.<p>I'm personally of the opinion that cancer screening should happen earlier for younger people and less frequently for older people. Like, if you hit 80, there's really basically no reason to screen for cancer.
It does, doesn't it! This is basically the reason scepticism in screening has risen (amongst scientists and medics, not the general population) - research seems to show that screening catches much more cancer but doesn't save many more people.<p>Rohin Francis does a good video on it, which you don't have to watch because it has references underneath you can click straight through to (the video is good though): <a href="https://youtu.be/yNzQ_sLGIuA" rel="nofollow">https://youtu.be/yNzQ_sLGIuA</a><p>I am frustrated by this because it seems obvious to me that "more data == better" but I guess it makes sense if you think of the scans as having high amounts of noise, and us having a poor understanding of the system we're monitoring (this never happens in tech, of course :)).
I pay an extra $60 a year to have my ophthalmologist take a digital image of my retina. It comes back as normal every year, but if something does change we can diff the image against the baseline.<p>Maybe I don't want to look for cancer right now but if I spend $1,000 every 5 years to take an image for later use... isn't that useful?
Might be, but in the context it's also worth asking what better options you have for your health with that $1000.<p>(for some people that question may not apply, of course, but at a population level it does, and we have population-level questions about effective use of MRI time.). And if there's something better, you should spend it on that and then ask the question _again_. So it could be that getting a whole-body MRI is something like $30k down the list of best ways to spend money for improved health.<p>I'm not sure what the best use of $1k is from a health standpoint is, just noting that it's good to have a comparator.
> I'm not sure what the best use of $1k is from a health standpoint is, just noting that it's good to have a comparator.<p>Spending 1k on a gym membership and more fresh vegetables would be a pretty high return on investment, if one isn't in shape and eating healthy already.
Yes, and it seems like its purposefully ignored in the "body scan" debate. full CT scans would be more problematic, and MRI's (especially no contrast ones) don't pick up a lot of things... but having annual comparisons over a few years would likely fill in some of those gaps. literally and figuratively.
Er wait is retinal cancer a thing?
Yes. Like OP, I do a picture every year. Three years ago there was a scare, that turned out to be nothing.
Family history of glaucoma and macular degeneration. Also had a semi detached retina when I was a kid.
Retinal imaging is used to detect damage from glaucoma or other eye disease, by "diffing" the fine blood vessels and nerves.
Yes. You can also have melanoma on your uvea
theres a ton of degeneative stuff too that's not strongly age corrilated.
Can one solution be always doing two scans, N months apart, before drawing any conclusions (excluding things that can be reliably detected from a single scan)? Initial scan could affect N (if you find something potentially aggressive, you can schedule the second scan sooner). And then do a follow up every M years.<p>That should exclude benign or very slowing growing things
> The tests range from several hundred to several thousand dollars, depending on which sections of the body are scanned, and are not covered by insurance.<p>Even ignoring the overdiagnosing problem (I don't understand how they can determine from MRI when a cancer is a cancer; there are also benign growth and often when they are a certain size, people notice them, but how would MRI help here? Too small areas could be classified as malign; any further procedures can be dangerous - see that Dawson Creek actor recently, the cost of clinical intervention did not help), I think that medicine is increasingly becoming a "only affordable for those who have money". You can see this with regards to gene therapy too - if we ignore the success ratio, many of these therapies are impossible to acquire for Average Joe. Granted, the prices will go down for various reasons (we saw this with Moore's law and many other inventions too), but at the end of the day I feel we are stepping closer and closer to a very unfair society model - more and more superrich, but prices also go up immensely for average people. That model is not sustainable; people will be angry since this is not fair.
It seems like the key missing piece is long-term randomized data showing mortality benefit and cost-effectiveness in average-risk populations
Maybe the right answer isn't to do a biopsy, but to monitor the area with follow-up scans? It seems like that addresses much of the harm that a false positive can cause (invasive biopsy leading to complications) while maintaining most of the gains (still very early detection).
> Maybe the right answer isn't to do a biopsy, but to monitor the area with follow-up scans?<p>Doctors have already thought of this. Several issues with it:<p>* Monitoring still causes anxiety and mental health issues which come with real effects on patient's quality of life. It's not "harmless".<p>* Unclear when to monitor and when to treat. It's also really hard to get enough data to characterize these early unspecific findings enough to get confidence on what to do.<p>* Monitoring via MRI might be just as useful as monitoring via symptoms or any other "passive" methods that do not require a previous scan.
The problem is that just because you‘re detecting something, it does not mean it is worth watching. Bodies are not standardized and most people habe something off. But you can‘t really reschedule everybody constantly, as that would entirely break the concept.
"Worth watching" implies that watching is expensive. It's really not. A full-body MRI scan is about $1k, and it can be even cheaper.<p>So if you have abnormal findings in 10% of patients that merit follow-up scans, you can trivially do a series of 3-4 scans without affecting the overall cost too much.<p>Doctors simply need to get out of the headspace where MRIs are extremely scarce tools of last resort and treat them like we treat blood tests.
I totally agree. US healthcare is broken and costs aren't tied to the reality of how expensive something actually is. I have very high hopes that modern medicine is in for a massive disruptive change where things like full body MRI, along with analysis, could be done very cheap and with no admin overhead. In that model 'we see something we aren't sure of. It is probably nothing but to be sure we want to do follow-ups' is far less of a problem.<p>A lot of this however is how it is discussed with the patient. Discussions about the likelihood of there being a real issue when something is seen need to be clear and informative without being alarming. 'We did a routine scan and these often show transient artifacts that turn out to be nothing, but in an abundance of caution we want to do a followup' is totally different than 'we saw something we are concerned about and need to do a followup'. How things are messaged really matters.
> MRIs are extremely scarce tools of last resort and treat them like we treat blood tests.<p>How would this work?<p>I can do a blood test and send it to the lab to be processed in ~5 minutes from the moment I meet the patient. Consumable costs are about $2.<p>I can also do an MR scan. It took a fair bit of training and the scanner and scan room cost about US$2 million. Service contracts on the scanner, scan room, chillers and required staffing utterly dwarf the cost of the scanner over its lifetime.<p>The scan takes 20-75 minutes. Then the images get sent for reporting. Unlike a blood test, reporting isn’t automated. Even if it was, how could availability of MR ever be similar to a blood test?
I think you're missing the point. The psychological cost of a conditional-positive result is nonzero, and can be very significant (I speak from a little bit of experience here). But far more importantly: the physiological cost of invasive followups when you eventually trip the threshold of "time to go explore with a scalpel" is <i>very</i> high, and the missing evidence this story is about is whether you can get to that threshold with an MRI.<p>Treating MRIs the way we treat blood tests would almost certainly result in huge numbers of needless invasive procedures.
This is pretty much what the experts say:<p><a href="https://www.ranzcr.com/college/document-library/2024-position-statement-on-whole-body-mri" rel="nofollow">https://www.ranzcr.com/college/document-library/2024-positio...</a>
> Treating MRIs the way we treat blood tests would almost certainly result in huge numbers of needless invasive procedures.<p>Again, _all_ you need to do is to make a follow-up scan in 1-3 months to see if there are any changes. It's a preventative tool, so unless you have other indications, it's almost always safe to wait for a bit.<p>And yes, it requires educating patients that sometimes just waiting and doing a follow-up scan is right. And yes, I also have a personal experience with that (I had an "idiopathic lymphadenopathy", aka "we don't know WTF is going on").
Link for users outside of US: <a href="https://archive.ph/7qWCf" rel="nofollow">https://archive.ph/7qWCf</a>
Just to point out, cancer isn't the only reason to get these. Aneurisms, hemachromatosis, etc can all be serious. I know someone who got scanned for $500 and they caught hemachromatosis via iron deposits in the liver. Much better than eventual chirrosis and liver failure.
Frankly, this sounds like some people aren't so comfortable with the sheer cost of the machine than their absolute utility. CT and MRI scan machines are something that said to cost like $1m/yr/unit that's ~$500 uninsured/$100 insured per run in Japan that China don't publish data on numbers or distributions of. That says "military grade expensive" written all over.
Any numbers on practical pricing per country for these scans?
There’s a major difference between having insurance cover something (socialized cost, immediately drives up provider fees for bizarre reasons) and letting the market allow people to buy it themselves (individual cost, the market drives the cost down fast and hard). Notice the pattern with LASIK and GLP1 where lack of insurance coverage has counterintuitively made it cheaper and more accessible.<p>Let everyone who wants to pay get their scans! But don’t make me pay for you
1. collecting baseline info for later comparison is good<p>2. i can afford the money for the chance of early detection. Many cancers are symptomatic only in the latter stages. It does not hurt to check.
I don't see the point of testing constantly. It's just creating stress and probably most of the time, the tumor might be benign or it might be small and go away on its own.<p>And anyway, you have to die of something so for me cancer would just be a sign that time's up.
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Doctors absolutely hate the idea of people being checked for diseases. Every time someone comes out with a plan to detect cancer or prevent HIV, they start screeching.<p>“But what if the person would have died anyway without noticing they had cancer? Think of the shareholders. They would have paid for treatment for nothing”