Comment by jmward01
6 days ago
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).
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.
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.
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.
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.
How would this work?
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.
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.
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?
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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 very high, and the missing evidence this story is about is whether you can get to that threshold with an MRI.
Treating MRIs the way we treat blood tests would almost certainly result in huge numbers of needless invasive procedures.
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> Maybe the right answer isn't to do a biopsy, but to monitor the area with follow-up scans?
Doctors have already thought of this. Several issues with it:
* Monitoring still causes anxiety and mental health issues which come with real effects on patient's quality of life. It's not "harmless".
* 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.
* Monitoring via MRI might be just as useful as monitoring via symptoms or any other "passive" methods that do not require a previous scan.