6 ms·

Very sad, very scary. What is the cost-benefit ratio for a routine MRI scan every six months?

by VMG 14y ago

niels_olson 14y ago
Whole-body MRI? Several thousand dollars just for the scan. The radiologist's interpretation typically costs as much. We haven't even begun to talk about resultant interventions. Eat less and exercise more is a lot cheaper and more effective.
- lostlogin 14y ago
  Where I work, about $700 US. It's not a great test, despite excellent radiologists and brand new equipment as whole body imaging is far lower resolution than localized imaging (its about 1500 pixels by 250 in resolution versus 512x512 when just your knee is done using an educated guess).
mdonahoe 14y ago
This. This is the cure for cancer we need: affordable routine scans. Though more scans means more results for doctors to analyze. Hopefully algorithms can make that part cheaper too.
- tisme 14y ago
  No. Affordable routine scans will result in massive overloading of the health system with unnecessary procedures, and the complications arising from those procedures will kill more people than would have died otherwise from whatever shows up on those scans. There is no such thing as an intervention without risk, and that starts with the risks associated with general anaesthesia. Scanning is one thing, interpreting a scan and deciding when and where to intervene is something that does not scale well at our current level of technology. Basically it needs a human to sit down and spend time analysing the scan to make sure that what is there warrants intervention. So even if the scan costs would drop to 0 you'd still have the component of the interpretation to deal with. The end result of overloading the system like this is that those with symptoms that need care are less likely to receive it or receive it timely, and that those that didn't need the care will suffer from complications. Knowing when to scan and when not to scan is a crucial ingredient in giving good care.
  - lostlogin 14y ago
    Better than what I said. And your last point flows into socializes versus privatized care quite quickly, where fear of litigation drives further testing, which creates a positive feedback loop. The more you test for the more you need to test for. In an exceptionally cynical view of private healthcare by S. Sheem, House of God, he says Rule 10: If you you don't take a temperature you can't find a fever. There are quite a few gems in there for those with a dark sense of humour.
  - mdonahoe 14y ago
    Ok. What if no one looks at the scans? What if I get scanned every month and no one looks at them until I start showing symptoms? My aunt got breast cancer recently. She got mammograms every year but the doctors never saw anything. Finally there was a mass discovered, and a when they went back to look at the old images, they could see it growing.
- lostlogin 14y ago
  No, not now, maybe in the future (with regards to MRI). Even with breast imaging where MRI provides great results, routine screening is only shown to be helpful in those genetically predisposed to disease. Generating masses of biopsy procedures, untold stress, misdiagnoses, botched procedures etc. The false positive rate for MRI is currently too high in breast imaging for it to be a routine tool, let alone whole body imaging with the pitfalls in the technique.
- pja 14y ago
  No. Many, many people have small, non-malignant cancers growing within us right now. Some people carrying such growths will develop life-threatening cancers, whilst the rest (probably the vast majority) of the population will die of something else at a ripe old age before the growths in question ever become malignant. Once you start screening everyone, suddenly you have this huge population of growths that you have to biopsy in order to determine whether or not they're malignant or not. Your false-positive rate means that you start giving extremely harmful treatments (chemotherapy is itself mutagenic & can cause cancer!) to individuals who if they'd never have been scanned would have remained blissfully unaware of the harmless growth within them & would have had productive, happy lives. Routine scans are not cost free: They put a huge diagnostic burden on the system & they inevitably mean that you deliver invasive, potentially harmful treatments to people that don't need them.
- sskates 14y ago
  I'm surprised there are three responses to this comment, all starting with the word "no". I'm not arguing for scanning irrespective of the cost. I'm saying that if the cost were 0 then you should always scan. More information should always lead to better decisions and better outcomes. If it's the case that more information leads to worse decisions then it's indicative of a problem in your rule set, not a problem with your information. Imagine if taking someone's blood pressure was a multi-thousand dollar test that required specialized expertise to interpret, and could easily lead to misdiagnoses of heart problems. Now imagine that we just got the technology to do it cheaply and easily. It wouldn't make anyway sense to be afraid of testing blood pressure- it's just more information that can lead to a more complete picture of a patient's condition. But that's exactly what my sibling comments are arguing for now with MRI scans. Also see number 7 in a list of ambitious startup ideas: http://paulgraham.com/ambitious.html http://paulgraham.com/ambitious.html
  - aidenn0 14y ago
    The parent post wasn't some theoretical awesome scan with no false-positives; it was specifically whole-body MRI. Even if you could do a whole-body MRI scan for say a nickel, and have automated software mark all new tumors, more people would die sooner than if you hadn't done this. Once you find a tumor you need to biopsy it before you can treat it. There is a small, but non-zero, chance of death from a biopsy. The number of tumors that won't kill you right away is so much greater than the number of tumors that will kill you right away, that this small chance of death multiplied by the large number of people with non-threatening tumors is a larger number than the small number of people with highly malignant tumors.
    - sskates 14y ago
      So then it's a problem with the rule set- you shouldn't automatically biopsy every tumor. It's doesn't make sense that there's a rule in place (you must biopsy every tumor) such that people are afraid of getting more information because it will lead them to make worse decisions. More information should always lead to better decisions and better outcomes. Why are we forced to biopsy every tumor, even in the case where you agree it's suboptimal? Imagine if every time someone had really high blood pressure, we had a rule to perform bypass surgery. People would then avoid taking blood pressure because it might lead to surgery. That doesn't make sense- knowing someone's blood pressure isn't the problem, the problem is our suboptimal rule.
Alex3917 14y ago
"What is the cost-benefit ratio for a routine MRI scan every six months?" Should I Be Tested for Cancer?: Maybe Not and Here's Why: http://www.amazon.com/Should-Be-Tested-Cancer-Maybe/dp/0520248368/ref=wl_it_dp_o_pC_nS_nC?ie=UTF8&colid=L9VX8S7A67UO&coliid=I39VMKFXGP70DF http://www.amazon.com/Should-Be-Tested-Cancer-Maybe/dp/05202... (I haven't personally read this yet, but it's an entire book about exactly this question, and it's very highly reviewed.)
lostlogin 14y ago
Not a good idea. Unproven as a technique, very expensive, very low resolution when whole body imaging is performed, will miss important stuff, and generate unnecessary biopsy procedures. Population screening is a vastly complicated area - for example, what would a whole body MRI be looking for. Name the process(s) and there will be a better way, even if its a scan of a smaller body site, the results will be vastly superior. Dedicated coils, established imaging protocols etc.
- jpiasetz 14y ago
  I've also considered what the parent asked. What if you diff the image with a previous MRI and just examine area's that differ.
  - deleted 14y ago
    [deleted]
  - lostlogin 14y ago
    Image fusion software exists that does this, allowing you to mere images and emphasis areas of difference (usually used for allowing comparison of different imaging modalities such as CT and PET, rather than same modality over time. The trouble is, people are never, ever in the same position (different breath hold, mobile organs move, people lie in different positions, get taller, shorter, more bent etc) , and, more importantly, are the changes seen problematic or normal? In the case were a big mass has appeared, its easy. But that is easy to spot without software help. If a software technique is to emphasis small malignant changes early on, it's going to have to be very clever and be better than (or help improve the abilities of) some very clever people. Edit: sorry, I do realize that this doesn't quite address what you said. Your suggestion would be very hard to implement I suspect, but is better than what I discussed.
  - tsotha 14y ago
    This is one of those things that seems like it would be a good idea but doesn't really work in practice. There are outfits where I live that will do a full body MRI for you for a few thousand bucks. So people think "Hey, what's more valuable than my health? Maybe I'll catch a tumor before it metastasizes and live an extra 20 years." The problem is people have benign tumors and cists and other oddities that show up on the MRI, most of which will never cause a problem. And every time you have something done at the hospital, even something generally thought to be totally safe like a biopsy or a minor excision, there's some (hopefully very small) risk the doctor will make a mistake, or you'll react badly to anesthesia, or you'll pick up MRSA, or something else bad will happen unrelated to the reason you're there. People have cranked the numbers on this, and what they found is you're more likely to die from an unnecessary medical procedure as a result of one of these scans than you are to be saved by early detection of a problem.
gilgoomesh 14y ago
Based on the aggressiveness of the cancer in this story, my (non-medical) guess is that you wouldn't have seen the cancer any earlier unless you scanned every two months. This thing came out of nowhere and came fast. Even if you did see it... what would you do? Surgery, chemotherapy, radiotherapy... these things don't stop a metastatic cancer this aggressive. Without a cancer treatment that can stop the progression of an aggressive metastatic cancer within a week or two we are powerless to stop this type of death.

Very sad, very scary. What is the cost-benefit ratio for a routine MRI scan every six months?

by VMG 14y ago

Very sad, very scary. What is the cost-benefit ratio for a routine MRI scan every six months?

Whole-body MRI? Several thousand dollars just for the scan. The radiologist's interpretation typically costs as much. We haven't even begun to talk about resultant interventions. Eat less and exercise more is a lot cheaper and more effective.

lostlogin 14y ago
Where I work, about $700 US. It's not a great test, despite excellent radiologists and brand new equipment as whole body imaging is far lower resolution than localized imaging (its about 1500 pixels by 250 in resolution versus 512x512 when just your knee is done using an educated guess).

mdonahoe 14y ago

This. This is the cure for cancer we need: affordable routine scans. Though more scans means more results for doctors to analyze. Hopefully algorithms can make that part cheaper too.

tisme 14y ago
No. Affordable routine scans will result in massive overloading of the health system with unnecessary procedures, and the complications arising from those procedures will kill more people than would have died otherwise from whatever shows up on those scans. There is no such thing as an intervention without risk, and that starts with the risks associated with general anaesthesia. Scanning is one thing, interpreting a scan and deciding when and where to intervene is something that does not scale well at our current level of technology. Basically it needs a human to sit down and spend time analysing the scan to make sure that what is there warrants intervention. So even if the scan costs would drop to 0 you'd still have the component of the interpretation to deal with. The end result of overloading the system like this is that those with symptoms that need care are less likely to receive it or receive it timely, and that those that didn't need the care will suffer from complications. Knowing when to scan and when not to scan is a crucial ingredient in giving good care.
- lostlogin 14y ago
  Better than what I said. And your last point flows into socializes versus privatized care quite quickly, where fear of litigation drives further testing, which creates a positive feedback loop. The more you test for the more you need to test for. In an exceptionally cynical view of private healthcare by S. Sheem, House of God, he says Rule 10: If you you don't take a temperature you can't find a fever. There are quite a few gems in there for those with a dark sense of humour.
- mdonahoe 14y ago
  Ok. What if no one looks at the scans? What if I get scanned every month and no one looks at them until I start showing symptoms? My aunt got breast cancer recently. She got mammograms every year but the doctors never saw anything. Finally there was a mass discovered, and a when they went back to look at the old images, they could see it growing.
lostlogin 14y ago
No, not now, maybe in the future (with regards to MRI). Even with breast imaging where MRI provides great results, routine screening is only shown to be helpful in those genetically predisposed to disease. Generating masses of biopsy procedures, untold stress, misdiagnoses, botched procedures etc. The false positive rate for MRI is currently too high in breast imaging for it to be a routine tool, let alone whole body imaging with the pitfalls in the technique.
pja 14y ago
No. Many, many people have small, non-malignant cancers growing within us right now. Some people carrying such growths will develop life-threatening cancers, whilst the rest (probably the vast majority) of the population will die of something else at a ripe old age before the growths in question ever become malignant. Once you start screening everyone, suddenly you have this huge population of growths that you have to biopsy in order to determine whether or not they're malignant or not. Your false-positive rate means that you start giving extremely harmful treatments (chemotherapy is itself mutagenic & can cause cancer!) to individuals who if they'd never have been scanned would have remained blissfully unaware of the harmless growth within them & would have had productive, happy lives. Routine scans are not cost free: They put a huge diagnostic burden on the system & they inevitably mean that you deliver invasive, potentially harmful treatments to people that don't need them.
sskates 14y ago
I'm surprised there are three responses to this comment, all starting with the word "no". I'm not arguing for scanning irrespective of the cost. I'm saying that if the cost were 0 then you should always scan. More information should always lead to better decisions and better outcomes. If it's the case that more information leads to worse decisions then it's indicative of a problem in your rule set, not a problem with your information. Imagine if taking someone's blood pressure was a multi-thousand dollar test that required specialized expertise to interpret, and could easily lead to misdiagnoses of heart problems. Now imagine that we just got the technology to do it cheaply and easily. It wouldn't make anyway sense to be afraid of testing blood pressure- it's just more information that can lead to a more complete picture of a patient's condition. But that's exactly what my sibling comments are arguing for now with MRI scans. Also see number 7 in a list of ambitious startup ideas: http://paulgraham.com/ambitious.html http://paulgraham.com/ambitious.html
- aidenn0 14y ago
  The parent post wasn't some theoretical awesome scan with no false-positives; it was specifically whole-body MRI. Even if you could do a whole-body MRI scan for say a nickel, and have automated software mark all new tumors, more people would die sooner than if you hadn't done this. Once you find a tumor you need to biopsy it before you can treat it. There is a small, but non-zero, chance of death from a biopsy. The number of tumors that won't kill you right away is so much greater than the number of tumors that will kill you right away, that this small chance of death multiplied by the large number of people with non-threatening tumors is a larger number than the small number of people with highly malignant tumors.
  - sskates 14y ago
    So then it's a problem with the rule set- you shouldn't automatically biopsy every tumor. It's doesn't make sense that there's a rule in place (you must biopsy every tumor) such that people are afraid of getting more information because it will lead them to make worse decisions. More information should always lead to better decisions and better outcomes. Why are we forced to biopsy every tumor, even in the case where you agree it's suboptimal? Imagine if every time someone had really high blood pressure, we had a rule to perform bypass surgery. People would then avoid taking blood pressure because it might lead to surgery. That doesn't make sense- knowing someone's blood pressure isn't the problem, the problem is our suboptimal rule.

Alex3917 14y ago

"What is the cost-benefit ratio for a routine MRI scan every six months?" Should I Be Tested for Cancer?: Maybe Not and Here's Why: http://www.amazon.com/Should-Be-Tested-Cancer-Maybe/dp/0520248368/ref=wl_it_dp_o_pC_nS_nC?ie=UTF8&colid=L9VX8S7A67UO&coliid=I39VMKFXGP70DF http://www.amazon.com/Should-Be-Tested-Cancer-Maybe/dp/05202... (I haven't personally read this yet, but it's an entire book about exactly this question, and it's very highly reviewed.)

lostlogin 14y ago

Not a good idea. Unproven as a technique, very expensive, very low resolution when whole body imaging is performed, will miss important stuff, and generate unnecessary biopsy procedures. Population screening is a vastly complicated area - for example, what would a whole body MRI be looking for. Name the process(s) and there will be a better way, even if its a scan of a smaller body site, the results will be vastly superior. Dedicated coils, established imaging protocols etc.

jpiasetz 14y ago
I've also considered what the parent asked. What if you diff the image with a previous MRI and just examine area's that differ.
- deleted 14y ago
  [deleted]
- lostlogin 14y ago
  Image fusion software exists that does this, allowing you to mere images and emphasis areas of difference (usually used for allowing comparison of different imaging modalities such as CT and PET, rather than same modality over time. The trouble is, people are never, ever in the same position (different breath hold, mobile organs move, people lie in different positions, get taller, shorter, more bent etc) , and, more importantly, are the changes seen problematic or normal? In the case were a big mass has appeared, its easy. But that is easy to spot without software help. If a software technique is to emphasis small malignant changes early on, it's going to have to be very clever and be better than (or help improve the abilities of) some very clever people. Edit: sorry, I do realize that this doesn't quite address what you said. Your suggestion would be very hard to implement I suspect, but is better than what I discussed.
- tsotha 14y ago
  This is one of those things that seems like it would be a good idea but doesn't really work in practice. There are outfits where I live that will do a full body MRI for you for a few thousand bucks. So people think "Hey, what's more valuable than my health? Maybe I'll catch a tumor before it metastasizes and live an extra 20 years." The problem is people have benign tumors and cists and other oddities that show up on the MRI, most of which will never cause a problem. And every time you have something done at the hospital, even something generally thought to be totally safe like a biopsy or a minor excision, there's some (hopefully very small) risk the doctor will make a mistake, or you'll react badly to anesthesia, or you'll pick up MRSA, or something else bad will happen unrelated to the reason you're there. People have cranked the numbers on this, and what they found is you're more likely to die from an unnecessary medical procedure as a result of one of these scans than you are to be saved by early detection of a problem.

gilgoomesh 14y ago

Based on the aggressiveness of the cancer in this story, my (non-medical) guess is that you wouldn't have seen the cancer any earlier unless you scanned every two months. This thing came out of nowhere and came fast. Even if you did see it... what would you do? Surgery, chemotherapy, radiotherapy... these things don't stop a metastatic cancer this aggressive. Without a cancer treatment that can stop the progression of an aggressive metastatic cancer within a week or two we are powerless to stop this type of death.