8 doctors duke it out on whole body MRI scans
Companies like Prenuvo and Ezra are provoking some big debates within the medical community
One of the most contentious topics out there right now in health-tech is whole body MRI scanning. There’s now a group of venture-backed companies, including Prenuvo and Ezra, that offer to scan for an array of medical issues, including cancer and brain aneurysms.
For the most part, the early adopters have been those that can afford it. Prenuvo’s scan will cost set you back $2,499. Ezra’s also costs about $2000.
All of this provokes the question: As a health-tech industry, how should we be thinking about this new technology?
Personally, I’ll share with you all that I’m conflicted. One the one hand, I have friends who have genuinely benefited from these scans. If people are willing to pay for it out-of-pocket, who are we to deny them? And there are aspects of medicine that feel paternalistic to me. I believe it takes more work to educate and inform, but patients can absolutely understand nuances. On the other hand, many physicians in my network have pointed to the problem of “incidentalomas” and the concern related to over-utilization in an already overburdened system.
With all that said, I am in the neutral camp. If a family-member of mine caught something early, I would be hard-pressed to make an argument against this technology. But there’s deeper philosophical issues here that we should be asking as we design a health “system” that serves us all. Not everyone can afford a multi-thousand dollar scan. It only begins to become more palatable, if insurers agree to foot the bill. But that would take longitudinal, randomized-controlled trials.
One of my favorite formats of all time is a ‘Town Hall’ style debate. So I invited a group of physicians across a variety of specialty areas to duke it out with this question: “Whole body scans, good, bad or somewhere in the middle?”
The Pro Camp
Dr. Danish Nagda, founder of Rezilient: “Disease goes undetected all the time.”
“The general premise that patients shouldn’t know because it will lead to more costs to the healthcare system is a ridiculous argument coming from a health system that regularly misses disease and misdiagnoses patients. My own father had undiagnosed sleep apnea for decades and the health system let him down. Countless examples of black and brown patients or immigrants for whom English is a second language being told that they’re fine when they’re not. So, these academics need to spare us all of their beliefs that the system is working well. when we know it isn’t. Disease goes undetected all the time.”
Dr. Rohan Ramakrishna, Weill Cornell and the cofounder of Roon: “Whole body scans are the future.”
“The field of preventative health is poised to explode in the coming years, supported by real science and therapies. So I believe Whole Body scans will be an important tool in the preventative medicine toolkit. There are many questions to be worked out, like how often you need them and cost/coverage, but eventually we’ll have these answers. If you believe in screening for certain cancers, for example, this is a logical next step. The apprehension around ‘incidentalomas; and the unease/anxiety around their discovery is real as is the potential burden on health care cost and utilization. However, an incidental finding can still be clinically significant, and early intervention may be either life-saving or life-enhancing ; I’ve certainly seen examples of this with cancer screening tests in healthy patients. Moreover, we need to get the data around what early stage disease looks like in healthy individuals and current early adopters will pave the way forward. These scans may not just offer observations on your current state, but predictions on your health future. And these predictions, ideally enhanced/personalized with your other health data, may give you enhanced agency in your health care. Whole Body scans are the future.”
Dr. Chris Doyle: “I support the rise of the whole body MRI as a change leader in the medical imaging market.”
“Yes, whole body MRI scans offer uncertain clinical value through the discovery of incidental findings. Contrary to what is portrayed, these scans do not represent preventive care, which should reliably demonstrate a health benefit in order to be labeled as such. (But) with time and longitudinal data, this view could easily shift. Almost ironically, whole body MRI can have a significant, positive impact on the future of value based care (VBC). For many pathologies, MRI has clear advantages over legacy imaging platforms as a diagnostic. In many cases I would also argue that radiology reads and scanner types have less variability than different providers performing the same clinical assessment. Whole body MRI scans move the needle on cost in a direction that favors value, and provide personalized information to inform quality. Brief comparisons on published hospital and whole body MRI practice prices suggest up to 50% differences between payor/provider negotiated costs and single body part scans. For value-based organizations with a clear incentive to avoid low-value imaging practices, growing access to the whole body MRI business model disrupts local monopolies on MRI pricing. It is my hope that these two forces align in the interests of patients with cost effective, timely, and accurate diagnostic information. For this reason I support the rise of the whole body MRI as a change leader in the medical imaging market.”
Team Neutral
Dr. Anjali Thakkar, cardiology fellow at UCSF: “What if we reframed the “job to be done” by whole body MRI?”
“It doesn’t seem like screening whole body MRI in healthy individuals is ready for prime time yet. It is unlikely that any company or academic medical center will be able to run a study of the magnitude large and long enough to detect meaningful clinical differences between individuals who do and do not receive whole body MRI screening exams. And without these data, it is unlikely that regulatory and payor bodies will approve and cover these technologies for population level use.
But what if we reframed the “job to be done” by whole body MRI? What if we shifted from thinking about whole body MRI as a screening tool to just one piece of a quantitative triage tool that would allow us to precisely match our scarce resources (physicians, diagnostic testing, etc) with the individuals who need these resources most? While whole body MRI offers an anatomic visualization of the human body, other data sources like laboratory and physiologic testing provide equally valuable insight, and the combination of these modalities–which could be the physical exam of the future–is likely to be far more powerful than each individual test alone.” We’ve seen developments in other technologies that aim to enhance physicians’ ability to evaluate their patients like the digital otoscope, the digital stethoscope, and POCUS. Could the whole body MRI serve as another (operator-independent) tool in this armamentarium? A key barrier today for this technology remains the high price point, but we are optimistic that as whole body MRI companies achieve economies of scale, better, data-driven prevention technologies may ultimately reach the masses.”
Dr. Nihir Patel: Director of Regional Anesthesiology and Acute Pain Medicine at Metropolitan Hospital in NYC: “Large, prospective, and ideally randomized studies in diverse populations would be needed”
“Screening tests should either detect asymptomatic disease at a stage when treatment would be more effective, or identify risk factors of a disease where modification of risk factors could lessen the risk of developing the disease. There is currently no compelling evidence that screening whole body MRI exams compared to the standard of care. This doesn’t mean that whole body MRI does not improve outcomes–it very well could, but large, prospective, and ideally randomized studies in diverse populations would be needed to demonstrate this. Studies like this are highly capital-intensive, however, since large sample sizes of participants would be required for the study to be powered to detect meaningful differences in hard clinical outcomes in healthy populations. Moreover, prolonged follow up (i.e. multiple decades) would be needed since the development and progression of chronic diseases like cancer are, well, chronic. Once clinical utility is proven out, cost-effectiveness studies would be needed to demonstrate that whole body MRI exams reduce downstream healthcare utilization. The paucity of supportive data on either front makes it challenging to recommend this technology to asymptomatic, healthy patients.
Marketing whole body MRI as a catch-all screening may also provide a false sense of security to patients. To dig into this argument, a basic technical understanding of MRI is necessary. The information obtained from any MRI is heavily dependent upon the protocol used. Screening whole body MRI uses a large field of view, limited acquisition planes, and no intravenous contrast. This allows for efficient, safe and broad anatomical imaging at the expense of detailed characterization of structures and lesions. On the other hand, targeted diagnostic MRI protocols are specifically designed to acquire the MRI sequences necessary to best characterize the region(s) of interest (i.e. contrast or focused angulations used when appropriate), yielding more comprehensive diagnostic information. Think of it like looking at panoramic photos of the crowds at a football game versus the zoomed in photos of Taylor Swift’s reactions when the Chiefs won the Superbowl. With screening whole body MRI, some pathologies may be missed or under-characterized.”
The Naysayers
Dr. Jared Dashevsky, a resident physician in NYC and the founder of Healthcare Huddle: “From a medical POV, there is rarely an indication.”
“From a medical point of view, there is rarely an indication for a whole-body imaging scan in asymptomatic, healthy individuals. A systematic review of whole-body MRI for preventive health screening showed significant incidental findings and high false positive rates in 5,400 asymptomatic adults. With both critical and indeterminate incidental findings at 13% and false positives at 16%, the study advised against using whole-body MRI for screening asymptomatic individuals. Another review found that abnormal whole-body scan findings are expected in about 95% of individuals. Thirty percent of these individuals would require further investigations, but less than 2% of these findings would actually be reported as suspicious for malignant cancers. If you run the math, 0.57% of abnormal scans would raise concerns for malignancy. For this reason, The American College of Preventive Medicine recommends against using whole-body scans for early tumor detection in asymptomatic individuals.
The high rates of incidental findings and false positives from whole-body scans adversely affect patients' mental, physical, and financial well-being. These findings often lead to increased anxiety, necessitate further invasive tests that may result in negative outcomes, and incur substantial costs, particularly as insurance does not cover the whole-body scan. Personally, I would not recommend whole-body imaging scans to my patients based on the limited evidence for its efficacy. While we’ve heard stories of the scans catching something, just realize you’re not hearing about the vast majority of scans which have either caught nothing or a benign. I hate medical paternalism, though, and will end by saying that if you have the money and understand the risks, sure… go get scanned.”
Dr. Nisha Patel, a practical board-certified internal medicine and obesity medicine physician in San Francisco: “Knowledge in inexperienced hands can be dangerous”
“As a physician, I fully appreciate that our healthcare system is FAR from perfect. Wait times to see a doctor are very long and sometimes patients feel their concerns are dismissed by healthcare providers. Superficially, one may think that a whole body magnetic resonance imaging (MRI) scan has potential to improve health outcomes. MRI scans are commonly used to work up a variety of ailments whether it be neurological concerns, joint problems or for further evaluation of cancer. These scans are interpreted by highly skilled radiologists who further subspecialize or receive training to be the experts for that particular body system. For example, brain MRI's are best interpreted by trained neuroradiologists and musculoskeletal MRI's are best interpreted by a radiologist who is comfortable reading orthopedic studies.
My concern with allowing the general public to undergo full body MRI scans is that the clinical expertise to appropriately interpret any potential findings is just not there. Oftentimes, a scan is ordered in response to a concern or symptom. The radiologist uses this clinical history to provide their best interpretation of the MRI results to help aid in the diagnosis of a condition. The clinical question precedes the scan, not the other way around. Incidental findings, also known as incidentaloma, can be picked up on MRI scans. To a lay person, these incidental findings can cause significant anxiety and lead to unnecessary work up. Simply sending someone home with a written report of their scan without any context or guidance on what to make of the results is irresponsible and can be dangerous. A "normal scan" may falsey reassure individuals into thinking they don't need the age appropriate screening for cancer for instance, for example colon cancer where colonoscopy would pick up small cancerous polyps not seen on MRI. It is unclear to me if these companies would provide guidance to their consumers on the next best steps should they have an "abnormal finding." Chances are these individuals will seek care with their own doctor or medical provider for the abnormal finding. Consumers need to know what they are potentially getting themselves into and make an appropriately informed decision if they do decide to pursue a whole body MRI. Who will be held liable if there is a bad outcome from an MRI scan? Are the companies responsible for following up on abnormal findings and arranging the appropriate work up? That is what would happen in the medical system if an abnormal finding is found, it would need to be appropriately worked up but my concern is that this won't happen.”
Dr. Disha Narang, a board-certified endocrinologist and obesity medicine specialist: “Unnecessary biopsies are not benign”
“Whole-body scanning appears to be trendy, fancy, easily accessible, and marketed as a window into your health. But in truth, only a small fraction of the public may find this [option] affordable, as insurance does not cover these scans. They are expensive, with wait times, just like regular imaging modalities ordered by your doctor. Putting AI in charge of this interpretation, or an inexperienced medical provider, certainly opens the door to error, and over-diagnosis of insignificant findings, often called “incidentalomas”. This then leads us down the rabbit hole of further imaging, testing, doctor’s appointments, and the wait times that go along with those appointments, only to understand that those “incidentalomas” are most often normal variants. Not to mention, the psychological toll and anxiety behind a lesion that may very well be a “nothing” can be crumbling; I say this, because I see this all the time in my practice. Unnecessary biopsies are not benign; any ‘procedure’ increases the risk of infection, which then may require antibiotics, which then could cause side effects, or the infection could become systemic and lead to something like sepsis which is a guaranteed ICU stay. Not a single research study has shown overall long-term benefit in whole-body scanning.
After medical school, radiologists undergo at least 4 years of residency training, with most going on to complete fellowship training in their specific area of anatomical interest. Meaning, your musculoskeletal radiologist has at least 5-6 years of post- graduate training to be able to interpret your spinal or knee MRI. Additionally, understanding clinical context is everything. A patient’s clinical picture, their history, presenting complaints, and symptoms are all put together to then start to make correlations on imaging. Do we really want AI or an untrained eye to be interpreting this? I certainly would not recommend it for myself, or any of my family or friends.”
This is certainly a hot topic as you can tell. I’d love to know where you land on it! Shoot me a note about whether you’re pro, neutral or against, and if you’re open, I’d love to hear if you’ve had any experiences with whole-body scanning personally.
Being actively involved in your own care leads to better outcomes. No test is a panacea but information contributes to agency. There is a lot of undiagnosed disease that benefits from early detection - I believe in giving people more ways to access the care system when it can do the most good.
I think Vinay Prasad's response to this was pretty compelling: https://www.drvinayprasad.com/p/why-you-should-not-get-a-whole-body