However, MRI is completely benign. It doesn't expose patients to any dangerous radiation and is minimally intrusive (you just need an IV for contrast).
The justification "but then we'll have to check the findings!" is super-weak.
The problem here is our old friend the Bayesian Base Rate fallacy. The diseases you're looking to intercept and intervene against are, in the general population, pretty rare. That means that even if the indications you'd get from diagnostic imaging are extraordinarily accurate (they aren't), the overwhelming majority of the flags they raise are going to be false positives.
The cost of a false positive imaging flag is far worse than having to have an unpleasant chat with your doctor, or worrying for several weeks (do not discount the cost of worrying for several weeks, though; these scares can absolutely fuck up a month of your life). Rather: you'll pay the price in follow-up imaging, which won't be as benign as the MRI, or worse, in unnecessary intrusive diagnostics.
Yes, the medical system in the US is for-profit and fee-based. Medical providers make money by building small businesses which do a lot of procedures. Here is another very expensive, uncovered procedure for them to bill.
I am curious but not willing to spend $5-20k in scans and tests. Especially since they can be done annually. Why not? There’s no medical guidelines for what period has higher positive impact.
My doctor has mentioned tests that cost thousands and have a low probability of useful information. I say no. If I was rich, I’d probably do any test if the only downside was cost.
The question about "VIP healthcare" pops up all the time on certain subreddits and the physicians who comment usually say "it's not worth it at all".
What next—trolling assisted living communities?
It is a fallacy to account the cost of follow-up procedure to the initial scan, when the follow-up procedures are not necessary regardless of the result from the scan.
Then a more reasonable step is not to get the scan. Why do the scan if you don’t follow up.
This is why not all screenings are recommended. People think that insurance won’t pay for scans because insurance is a jerk. They don’t pay because the scans aren’t medically effective at protecting populations.
The fact that we treat diagnostic results the same regardless of priors just means our medical system is still stuck in the stone age
Saying the screenings aren't recommended is just saying "we're too dumb to use the results of this screening the correct way, so you shouldn't get the screening"
We can only hope that the new developments in AI will mean that modern statistical procedures will finally be applied to medicine as a side effect (though I wouldn't hold my breath)
I agree with this. One day we might be smart enough. But they say is not today. It’s ok to be dumb.
It’s also dumb to spend thousands of dollars on these diagnostic scans that we’re too dumb to use.
We can plan around our stupidity. We can also research new ways to use these data and, hopefully, one day be less dumb.
1. Bad 2. Indeterminate 3. Benign 4. Nondiagnostic
One and two are simple enough. Three and four are really problematic. And they are more common that people assume. Worse people confuse the two.
Indeterminate says they have a sample that is sufficient but can't be assigned to Bad or Benign. What do you do then? If you treat some large percentage will be treated for nothing. If you don't some percentage will see progression.
Nondiagnostic says there are issues with the sample that make a determination impossible at all. What do you do then? Repeat the biopsy? What if you get another Nondiagnostic? Forget about it?
"Bob Nelsen says that he has a family history of cancer, so began getting annual Prenuvo scans around 10 years ago.
- The early scans showed a nodule in his thyroid, but doctors didn't believe it was problematic. Then a scan in 2018 showed that the nodule had changed, which isn't supposed to happen in healthy people.
- "When I went into Stanford for surgery, I asked how many patients they'd had with five years of longitudinal data on their thyroid, and they said I was the first," Nelsen tells Axios. "The medical profession is trained to be reactive, not proactive."
- He adds that the scans also discovered a small scar on his brain, which he assumes came from falling off his bike and getting knocked out when he was 11 years-old."Imagine you have a test with a 1% false positive rate when screening for a disease that has a prevalence of 1 in 1,000 and the invasive operation to confirm the diagnosis has a 10% chance of serious (potentially life altering) complications like internal infection or an embolism.
If you test 10,000 people, you'll identify 10 true cases (assuming 0% false negative rate) and 100 false cases. Meanwhile testing those 110 people will result in 11 patients suffering serious complications. Once you include the complicated math of quality-adjusted life years, it's almost never worth it.
In reality the numbers are a lot worse - there is a long tail of diseases with 2-10% false positive rate tests and 1 in 10,000 incidence or worse, with 20% of patients experience QALY effecting complications from false positives. On top of that there are a lot of interventions that require invasive procedures with low rates of success.
This is an actuarial argument, that applies is you want to have the most efficient overall healthcare system. In other words, if you have to ration the access to MRIs and to followup tests.
Now suppose that you are not limited by scarcity. It would absolutely make sense to use the minimally invasive procedures, but perhaps weigh the results a bit less heavily for followup tests.
>The disease [...] are, in the general population, pretty rare.
Cancer is not rare, particularly from a certain age. Early detection heavily skews the odds on one's side. This is such common knowledge that it feels weird having to justify it here.
I know I'm not a "survey performed under the most strict standards of quality" but among my close groups of friends and family there have been a few cases where they got lucky enough to detect this disease very early on, and their treatment and outcome was significantly better (and cheaper, while we are at it, bc you mention cost as well) than if they've just waited even a couple more months.
OTOH, I have yet to hear a story from someone who had some sort of scan done, found something worth to take a look at, that then turned out to be nothing and, for some strange reason, had its life significantly affected by that.
Doctors are not stupid, they know (or intuitively correct for) this Bayesian Base Rate you mention, plus they have other things like years of experience in their particular field. It's not like someone's going to cut your arm the moment you find a weird looking lump growing inside.
>these scares can absolutely fuck up a month of your life
That sounds quite immature, tbh. It's definitely a small price to pay compared to all the trouble you save by potentially detecting issues early on. "Oh, but needles hurt :'(", sure, but their benefit far outweigh such small nuisance. This is also an argument I would've thought anyone would just get naturally, and yet I have to explicitly bring it up here, weird.
Also, if it came to be the case that everyone got scanned regularly, that massive trove of new data would definitely help improve the accuracy of said tests. It definitely won't make matters worse, but better.
Depends on the cancer and even the doctors are torn. Most breast tumors and prostate tumors will not kill you or affect your life much. Treating them likely will (especially for prostate). Depending on the model, the overall health of the population is actually reduced by early detection because in most of these tumors treatment is worse than the disease.
One of my doctors is a strong believer in periodic prostate exams after 40. The other recommends only if there are other symptoms. You can guess which is the older one and which is the younger one.
Years ago there was the whole Gardasil controversy. What was often excluded in the noise was that if it were mandated for all girls as some states were recommending, it would be so expensive that funding for other health programs would need to be reduced. The studies were showing that this kind of preventative approach would again reduce the health of the state's population.
Preventive medicine is good - to an extent. Beyond that it is bad.
It mentions Angelina Jolie as a good example of how fear can lead to drastic actions.
Probably better to find an article talking about the general problem to find more references.
The Cochrane collaboration (2013) states that the best quality evidence neither demonstrates a reduction in cancer specific, nor a reduction in all cause mortality from screening mammography. When less rigorous trials are added to the analysis there is a reduction in mortality due to breast cancer of 0.05% (a decrease of 1 in 2000 deaths from breast cancer over 10 years or a relative decrease of 15% from breast cancer). Screening over 10 years results in a 30% increase in rates of over-diagnosis and over-treatment (3 to 14 per 1000) and more than half will have at least one falsely positive test. This has resulted in the view that it is not clear whether mammography screening does more good or harm. Cochrane states that, due to recent improvements in breast cancer treatment, and the risks of false positives from breast cancer screening leading to unnecessary treatment, "it therefore no longer seems beneficial to attend for breast cancer screening" at any age. Whether MRI as a screening method has greater harms or benefits when compared to standard mammography is not known.
You forgot your lines, man!
But that's a different thing. I'm sorry, I will not talk about that.
For people setting policies (and that includes doctors) cost is absolutely not a different thing.
If you can afford to pay for everything without involving insurance, by all means do whatever tests you want. If you're a doctor you don't want to maybe help Betty while definitely hiring Veronica.
They pushback against too much screening is relatively recent, and thus younger doctors are more likely to adopt it.
For perspective even with all the advances in modern medicine in 2020 and thus a pandemic, cancer was still the #2 killer in the US after heart disease. It killed over 600,000 Americans in 2020 and that’s a 27% improvement over what it was doing as recently as 2001.
That said, there’s currently believed to be a long undetectable period where the body fights off most pre cancers. We’re approaching the ability to detect cancers below 0.5mm which we don’t have much clinical data on.
This is yet another fallacy.
A prostate cancer takes about 10 years to kill you. If you're 80, then it's probably not worth pursuing aggressive treatment. You're likely to die of something else.
However, if you're 40 then it's another story entirely.
This is an argument from scarcity. If you have a severely limited amount of a resource, it makes sense to sacrifice some people, so that more people can receive life-saving care.
If the resource is not scarce, then this simply doesn't apply. These days HPV vaccine (in Europe) is around $30, so it makes sense to just vaccinate everybody.
> Preventive medicine is good - to an extent. Beyond that it is bad.
Nope. It's always good, but sometimes it's too expensive.
These days it's likely a very different from 2007 when it was being debated.
There argument wasn't that no one should get Gardasil. Just that it would hurt the health of the society if it was mandated for all. Obviously if you had the money it's good to get it
On the other hand, the quantity of MRI units is not fixed. We can always build more, they are just inherently very expensive. And if you can afford an MRI scan from your personal disposable income, then what's the problem?
The go-to for a lot of the "take a look at that" procedures is a biopsy, and a biopsy is not a risk free procedure. I'm surprised that you know more than one person that's had a full-body scan, but don't know anyone that's had a biopsy complication, I know one person who spent several days in the hospital on IV antibiotics after an infection after a Prostate biopsy (which was negative)
>>these scares can absolutely fuck up a month of your life
>That sounds quite immature, tbh. It's definitely a small price to pay compared to all the trouble you save by potentially detecting issues early on.
Have you ever had a cancer or other serious disease diagnosis? It can be surprisingly stressful and detrimental to your health even if it is something that can be effectively treated.
It's not, sounds like you're not familiar at all with any of this.
There's some road to cover from imaging -> biopsy. Blood tests, more detailed imaging, even keeping an eye on it for some time, etc...
Have you heard of Pap tests? A lot of them come out find signs which could be indicative of a developing cervical cancer. Do all these women get their cervix removed the next week? No, not at all. Most of the time the symptoms go away in a few weeks, after some care and treatment.
Pap tests are done for a reason. Pap tests are the single thing that completely obliterate the "screening everyone is bad" argument.
"Tissue is the issue"
I have yet to see any of my radiologists differentiate a lung nodule that was actually a metastasis from the colon (which can easily miss on PET ) from primary adenocarcinoma/small cell/etc. Neither a pancreatic neuroendocrine tumor from an adenocarcinoma based on a CT or PET.
I have (and often) see my patients incidentally discover masses on imaging. Perfect example- a pancreatic mass on imaging. Next stop is an anxiety filled few weeks while they wait for their biopsy to be scheduled. You then have an additional radiation exposure as these are CT guided. You hope the radiologist doesn't poke a hole in a nearby vessel, induce pancreatitis just by doing the biopsy itself, nor develop a subsequent infection related to the procedure. They then wait an additional week for pathology to result, often only to see normal pancreatic cells indicating this is a cyst.
All of this is often the result of looking for a seemingly innocent diagnosis. Eg an ultrasound to reassure your patient that their abdominal pain is not their gallbladder.
I had a similar event earlier today with a cervical lymph node seen on an ultrasound. Thyroid nodules, renal masses, lung nodules. How long do you have?
If I do the biopsy and they don't find cancer or something, they'll just tell me to drink less and eat better. Seems like mostly downside to doing the biopsy.
Silly comment. They tell you there's a 16% false positive rate. Maybe you don't know any of these people, but I'd certainly be willing to bet money that some of them got worried sick about it.
In addition, an older case is prostate cancer. At least in the older days, they would do painful procedures that left the patient with significantly lower quality of life, when in fact, many men with prostate cancer die of something else. Nowadays they're a little smarter about it.
So, what's your point? I live in 2023.
It’s hard to dial it in just right, but study after study have borne out that more diagnostics can often lead to worse outcomes.
This is an important distinction, because you can delude yourself and your medical team into believing you are healthy because you had a clean scan x months ago, as part of your annual deep checkup or whatever you want to call it. Leading into that part of if your friends had waited a couple more months it would have been a very different outcome!
You're arguing against something your mind made up.
My friend's wife had a scan done when she was 55 and they found "something they wanted to look at" in her breasts and needed to do a biopsy.
She has anxiety. Her blood pressure spiked to a dangerous zone. It stayed elevated even as they tried to control it with medication. It didn't go back to normal until the biopsy came back negative.
During that time, she was at significant risk of having a stroke or heart attack. All for eventually nothing.
Things like women who have a small cancer that is treated with suregry and quick radiation but insist on getting a mastectomy are not rare, either.
Humans are not rational.
> Her blood pressure spiked to a dangerous zone.
> Humans are not rational.
if i take it myself, for some reason im not nervous, comes out ok...
"Suppose that at your regular physical exam you test positive for Disease X. Although Disease X has only mild symptoms, you are concerned and ask your doctor about the accuracy of the test. It turns out that the test is 95% accurate. It would appear that the probability that you have Disease X is therefore 0.95. However, the situation is not that simple."
For the exciting conclusion to this story, please see https://stats.libretexts.org/Bookshelves/Introductory_Statis...
"Wealthy People Are Getting Full-Body Scans. Early Detection or Unnecessary?"
"Wealthy" appears 3 times. Multiple allusions to income, "summer in the Hamptons" and such.
I'd need to reflect a bit, but I think I'm pretty comfortable with applying FDA requirements and prohibiting any health claims, but feel free to let the snake-oil salesmen fleece away.
As an aside, I wanted to say snake-oil alone, but I learned recently snake-oil itself got a bad rap - https://www.collectorsweekly.com/articles/how-snake-oil-got-...
In this case we ABSOLUTELY KNOW the base rate is lower, since it was a preventative scan. The fallacy only happens if you then subsequently fail to adjust for the differing base rate.
If doctors later in the diagnostic process fail to take the differing base rate into account, that is not the fault of the preventative test, that is an error in determining what the correct follow up care is.
In today's medical malpractice climate, many physicians intentionally ignore the differing base rate.
But now we're no longer having a conversation about medicine
we're having a conversation about our broken legal system and our broken regulatory frameworks
I think pretending that medicine is equipped to deal with this in a healthy way is stretching the limits of well established medical science, and beyond what I would expect even a well intentioned and astute physician to know how to approach (or at least have been trained to do so expertly).
Not that you're wrong, you're not, strictly speaking.
Relevant piece: https://dynomight.net/diagnostics/
Yes, it is weak. The so-called downside is that you might need to do intrusive procedures as a followup.
But guess what? You don't HAVE to do that.
> The cost of a false positive imaging flag is far worse
Now think about the costs of not detecting a true reading. Most cancers start having visible symptoms only when they are far too advanced to be cured.
So the status quo is: you wait until you get an incurable disease, and then use MRI to solemnly confirm that. And then use it to give you estimates on how soon you'll die.
> Rather: you'll pay the price in follow-up imaging, which won't be as benign as the MRI, or worse, in unnecessary intrusive diagnostics.
Or you can just wait for a bit and do another MRI to check if there's any worsening. If you can afford an MRI, you likely can afford a second one.
That's also exactly the case with most safety systems.
If you have an abnormal result on the MRI, just wait for some time to check if it's really abnormal.
This is pseudoscience at best and quakery at worst.
Body is not a Kubernetes cluster that can be restarted or reprovisioned from scratch when it has become too late to fix an aling pod or a service on the spot.
Physiological processes taking place in the body are more akin to stochastic processes whose behaviour can be accurately projected only to a certain extent (the extent varies depending on what the actual process is) based on levels of our current (but evolving) understanding of the biochemistry and phsysiology. Therefore, our bodies require a set of anomaly detection monitoring alarms, of which preventive health scans (whatever that means, not just CT/MRT/etc) are one example. If one such stochastic process goes awry, it can trigger an irreversible cascading failure in the body with the only outcome: premature death.
Take inflammation as an example. Inflammation is a root cause of multiple severe as well as degenerative health problems that impair the healthy aging of the body. Inflammation is notoriously difficult to detect via conventional testing means such as blood tests, unless somebody is looking for a specific inflammation biomarker. Routine blood tests do not do that (other than checking the monocyte and eosinophils counts), and when the inflammation reveals itself, it is already loud (pain or impaired wellbeing) and severe (a heart attack) or it is already too late (late stage cancers).
Inflammation starts out small and incospicous, and it takes a long time to progress and develop into something more unpleasant. Alzeheimer's, Parkinson, cancers, heart disease, IBS and many, many other health conditions have all been implicated to be caused by chronic inflammation processes that went undetected and were allowed to unfold, with plenty of sufficient (although not always fully conclusive yet) evidence. The vast majority of people of this planet are thought to have inflammatory processes going on of varying degrees of severity – from benign (that the body eventually suppresses) to malignant.
If a routine preventive health scan can unravel an inflammatory process early on, it is a win – for the patient (improves the long term prognosis and the quality of life) and for the health care system (early treatments are usually simpler and are more cost efficient, therefore less or no expenditure later).
Even if a preventive health scan is a false positive, it is still a net positive, is a net win as it indicates the lack of a health problem, and it is long term investment that time, effort and money for everyone.
https://en.wikipedia.org/wiki/Base_rate_fallacy#:~:text=The%...).
[0] https://www.fda.gov/drugs/fda-drug-safety-podcasts/fda-drug-...
Unless you use a contrast dye--which is basically needed to be useful at spotting anything.
And an MRI will find something. So, the real problem is that you now need 3 or 4 followup MRIs over a period of 2 years to classify them as benign or not.
Not my/my family's experience - in fact MRI were used to clarify CAT scan false alarms / rule out real issues.