Latest / Wellness, Actually with Emily Oster & Perry Wilson, MD / What's the deal with full body scans?

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What's the deal with full body scans? · Wellness, Actually with Emily Oster & Perry Wilson, MD

• 0:01
  Speaker 1: Hi, Perry High Emily. I'm glad to be back. Thank
• 0:04
  Speaker 1: you for holding down the fort without me last week.
• 0:07
  Speaker 2: I'm glad you had such a nice vacation. And I
• 0:09
  Speaker 2: am really excited about today's topic. This is one where
• 0:14
  Speaker 2: to be honest, I am hoping to get to my
• 0:16
  Speaker 2: smasher pass. Like through the course of our discussion, I
• 0:19
  Speaker 2: am not there.
• 0:20
  Speaker 1: You haven't committed, You're not crazy.
• 0:23
  Speaker 2: It's really difficult. We'll get to that. You know, we're
• 0:25
  Speaker 2: talking about full body scans today. And because I know
• 0:29
  Speaker 2: our listeners are dedicated Treki's Like, I know this because
• 0:34
  Speaker 2: I choose to believe it. And you know, I grew
• 0:38
  Speaker 2: up watching Star Trek the Next Generation, and you know,
• 0:41
  Speaker 2: watching the doctors use the tricorder scanner and you just
• 0:44
  Speaker 2: kind of and all of a sudden, you know everything
• 0:47
  Speaker 2: that's wrong with the person. This is basically why I
• 0:52
  Speaker 2: wanted to become a doctor. I assumed that this is
• 0:54
  Speaker 2: how it would work. I frequently walk around telling people
• 1:01
  Speaker 2: God damn it, I'm a doctor, not a blank like
• 1:03
  Speaker 2: that is one of my go to catchphrases.
• 1:06
  Speaker 1: Yeah, I considered becoming a doctor because I wanted to
• 1:09
  Speaker 1: meet Doogie Houser, Because I had the biggest crush on
• 1:13
  Speaker 1: Neil Patrick Harris.
• 1:14
  Speaker 2: I have some bad news for you, Emily.
• 1:16
  Speaker 1: I know, but it's okay, it's okay. And then I
• 1:20
  Speaker 1: didn't become a doctor, and you know he's not for me,
• 1:23
  Speaker 1: but I still love him anyway. My point is we're
• 1:27
  Speaker 1: going to get to your smasher pass. And this is
• 1:29
  Speaker 1: a great topic because it apparently intersects with your love
• 1:33
  Speaker 1: of Star Trek and my love of bays Rule, and
• 1:36
  Speaker 1: we're going to find out about both of those things.
• 1:38
  Speaker 2: Awesome, let's go.
• 1:42
  Speaker 1: I'm Emily Oster, I'm an economist and a data expert.
• 1:45
  Speaker 2: And I'm Perry Wilson, I'm a medical doctor.
• 1:47
  Speaker 1: It's Thursday, June twenty fifth, and this is wellness.
• 1:51
  Speaker 2: Actually, because you're getting a staggering amount of health and
• 1:55
  Speaker 2: wellness information nowadays from every source imaginable, and some of
• 1:59
  Speaker 2: it is awesome and some.
• 2:00
  Speaker 3: Of it is well actually both Fortunately we're both people
• 2:06
  Speaker 3: who know how to read studies, how to parse the data,
• 2:09
  Speaker 3: and can tell you what's worth thinking about and what
• 2:12
  Speaker 3: you can safely ignore.
• 2:13
  Speaker 2: But before we dig in, a note that this podcast
• 2:15
  Speaker 2: is for educational purposes and should not be construed as
• 2:18
  Speaker 2: medical advice. We don't know your unique situation, so talk
• 2:21
  Speaker 2: to your doctor for personal health decisions.
• 2:25
  Speaker 1: This week we're asking what's the deal with full body scans?
• 2:29
  Speaker 1: Perry and I will give the official smasher pass, and
• 2:31
  Speaker 1: then we'll get to your question of the week. But first,
• 2:34
  Speaker 1: let's do the health news roundup after the break. And
• 2:49
  Speaker 1: now for the health news of the week, Perry. First up,
• 2:53
  Speaker 1: the flu. We're having a flu outbreak on a military base.
• 2:57
  Speaker 1: No one could have predicted this except us, and also
• 3:00
  Speaker 1: many other people say more you.
• 3:02
  Speaker 2: Know, no one likes and I told you so. But
• 3:05
  Speaker 2: I would like to play the following clip from a
• 3:09
  Speaker 2: prior episode of Wellness. Actually, Perry, no.
• 3:12
  Speaker 1: More flu vaccine mandates for military troops.
• 3:17
  Speaker 2: Your thoughts, Yeah, this is weird. Combat readiness is in
• 3:23
  Speaker 2: part determined by the health of the troops in terms
• 3:26
  Speaker 2: of infectious diseases. I mean, if you look at like
• 3:28
  Speaker 2: the history of warfare, you would find that infection has
• 3:34
  Speaker 2: killed vastly more soldiers than combat. Is often responsible for
• 3:41
  Speaker 2: losing the war. I mean, one of the reasons the
• 3:44
  Speaker 2: Americans were able to hold out during the Revolutionary War
• 3:47
  Speaker 2: was because Washington made the rather bold and somewhat risky
• 3:51
  Speaker 2: decision to force smallpox vaccination on all the Revolutionary war troops.
• 3:57
  Speaker 2: And like, let's not forget that the worst influenza pandemic
• 4:02
  Speaker 2: in history, this is the Spanish flu Influenza pandemic, occurred
• 4:06
  Speaker 2: after World War One because a bunch of infected troops
• 4:09
  Speaker 2: brought brought the virus home. So a weird decision. It
• 4:13
  Speaker 2: feels completely like brazenly sort of political to me. I
• 4:18
  Speaker 2: see no justification for this in a rational society. All right,
• 4:24
  Speaker 2: we told you so. We are referring, of course, to
• 4:32
  Speaker 2: influenza outbreak on a joint military base in Lackland, Texas.
• 4:37
  Speaker 2: As at the time of this recording, there are two
• 4:39
  Speaker 2: hundred and twenty two positive cases from the thirty seventh
• 4:42
  Speaker 2: Training Wing. This is from what I can tell, a
• 4:45
  Speaker 2: flying training group who live in close quarters, obviously, and
• 4:51
  Speaker 2: this is happening after Secretary of Defense Pete Hegseth eliminated
• 4:55
  Speaker 2: the flu vaccine mandate, after which time for military personnel,
• 4:59
  Speaker 2: and after which time only forty percent of trainees chose
• 5:04
  Speaker 2: to be vaccinated for the flu, which is a yearly vaccine.
• 5:08
  Speaker 2: You know. Once again, although we said it before, military
• 5:12
  Speaker 2: readiness is more inhibited by illness than just about anything else,
• 5:18
  Speaker 2: which is why vaccination has been such a huge part
• 5:21
  Speaker 2: of armies all around the world. And you know, they
• 5:24
  Speaker 2: even joke about how much stuff they're getting vaccinated for,
• 5:27
  Speaker 2: and there's a reason for that, and this flu outbreak
• 5:29
  Speaker 2: is telling us why. It is the case. Two hundred
• 5:33
  Speaker 2: and twenty two people out of training for a while,
• 5:35
  Speaker 2: two of them hospitalized by the way, which is not great,
• 5:38
  Speaker 2: and we're obviously pulling for them. Emily, do you think
• 5:40
  Speaker 2: this is going to change policy?
• 5:42
  Speaker 1: Nope, I don't, but I wish it would, but I'm
• 5:45
  Speaker 1: not optimistic. I think you will hear people say, well,
• 5:48
  Speaker 1: even if they had been vaccinated, blah blah blah blah.
• 5:51
  Speaker 1: So I don't think it will change policy, even though
• 5:53
  Speaker 1: it definitely should.
• 5:54
  Speaker 2: Absolutely, let's stick with vaccines for a second, because we
• 5:59
  Speaker 2: have some really cool vaccine news. A new study appearing
• 6:02
  Speaker 2: in the Lancet about the HPV vaccine in the UK. Emily,
• 6:08
  Speaker 2: what's going on with HPV so.
• 6:09
  Speaker 1: Great, So I think first it's worth sort of stepping back.
• 6:14
  Speaker 1: We give kids to the HPV vaccine, and we give
• 6:15
  Speaker 1: people the HPV vaccine, typically in adolescents, and it's actually
• 6:19
  Speaker 1: one of the vaccines where you see more hesitancy, and
• 6:22
  Speaker 1: I think we're not always doing a great job of
• 6:24
  Speaker 1: explaining to people why we should give kids this vaccine.
• 6:30
  Speaker 1: The vaccine prevents against the human papuloma virus, two different
• 6:33
  Speaker 1: versions of it, and the reason for this is that
• 6:36
  Speaker 1: those are the primary causes of cervical cancer. So this
• 6:40
  Speaker 1: is really a true cancer vaccine. It's a vaccine that
• 6:44
  Speaker 1: prevents you from getting cervical cancer in principle and also
• 6:48
  Speaker 1: now in practice. So this new study is from the Lancet.
• 6:52
  Speaker 1: It's a population based study which looks at cervical cancer
• 6:55
  Speaker 1: mortality from two thousand and one to twenty twenty four.
• 6:59
  Speaker 1: This cover some of the period in which the vaccine
• 7:02
  Speaker 1: was rolled out. You know, it's not a randomized trial
• 7:06
  Speaker 1: because at this point the vaccine was available to everyone.
• 7:08
  Speaker 1: But they've got calendar year and age to try to
• 7:11
  Speaker 1: sort of suss out the causal impact of the vaccine
• 7:15
  Speaker 1: on cervical cancer. And more or less, this eliminated get
• 7:21
  Speaker 1: close to eliminating cervical cancer. So they estimate a vaccine
• 7:25
  Speaker 1: efficacy between eighty five and one hundred percent, which is amazing,
• 7:29
  Speaker 1: and you know, people die of cervical cancer. Cervical cancer
• 7:32
  Speaker 1: is a it's a really bad cancer. I mean all
• 7:35
  Speaker 1: cancers are bad. This is this is a bad one.
• 7:37
  Speaker 1: And to have a vaccine that is so effective is amazing. Actually,
• 7:42
  Speaker 1: I'm so excited that my kids live in a time
• 7:45
  Speaker 1: when they can be vaccinated for this. And I will
• 7:47
  Speaker 1: just say, not only should you vaccinate your daughters for this,
• 7:52
  Speaker 1: you should also vaccinate your sons because they can give
• 7:56
  Speaker 1: people HPV and because there are some other sort of
• 8:00
  Speaker 1: reasons why they should be vaccinated. So kids should get
• 8:03
  Speaker 1: this vaccine.
• 8:04
  Speaker 2: Absolutely, It's not it's not even just cervical cancer. Cancers
• 8:08
  Speaker 2: of the head and neck are now more driven by
• 8:11
  Speaker 2: HPV than smoking as smoking rates have gone down. Those
• 8:14
  Speaker 2: can obviously affect everybody, boys and girls, men and women.
• 8:18
  Speaker 2: So really positive results. No cervical cancer deaths in this
• 8:23
  Speaker 2: vaccinated group.
• 8:24
  Speaker 1: My eleven year old was bemoaning his need for the
• 8:28
  Speaker 1: HPV vaccine at the next well child visit, which is
• 8:31
  Speaker 1: next week, and I was just like, I can't wait. Sorry, dude,
• 8:35
  Speaker 1: I'm so excited.
• 8:37
  Speaker 2: The best. Yeah, joy, your eleven year old might have
• 8:42
  Speaker 2: something else to bemoan with our last piece of health news,
• 8:46
  Speaker 2: and that is that we are saying goodbye to two
• 8:49
  Speaker 2: close friends, the blue and brown colored Eminems.
• 8:54
  Speaker 1: That's so sad.
• 8:56
  Speaker 2: Why are they going away?
• 8:58
  Speaker 1: I don't know. I blame the Health secretary for everything, actually,
• 9:04
  Speaker 1: but this particular thing. So so, there's been a push
• 9:09
  Speaker 1: towards having no artificial dyes in food. We've talked about
• 9:15
  Speaker 1: this perhaps before. I'm sure we'll talk more about it.
• 9:17
  Speaker 1: I think that's not real evidence based, but at any rate,
• 9:20
  Speaker 1: that's the direction we're going. And so Eminem's is trying
• 9:23
  Speaker 1: to replace all of their dyes with natural colors, and
• 9:26
  Speaker 1: it seems like they can't produce blue and brown. Is
• 9:29
  Speaker 1: that your understanding? Like I was a little confused.
• 9:32
  Speaker 2: I definitely get blue, like that blue color, Yeah, that's
• 9:35
  Speaker 2: not in nature. I don't see that anywhere or that
• 9:39
  Speaker 2: flavor Like blue is its own flavor.
• 9:40
  Speaker 4: But it was not its own fault, but not for
• 9:44
  Speaker 4: eminem but for like, Okay, sure there's like blue, raspberry
• 9:47
  Speaker 4: whatever anyway, yes, blue, but like brown, like, I'm pretty
• 9:50
  Speaker 4: sure you can find something that's brown.
• 9:53
  Speaker 1: There's all kinds of brown things, but it must be
• 9:56
  Speaker 1: the yes. I don't understand that much about color dyes,
• 9:58
  Speaker 1: but I will say blue and brown eminem's are off,
• 10:01
  Speaker 1: and I suspect when we get the new M and
• 10:03
  Speaker 1: ms they will also be not so colored. I mean
• 10:07
  Speaker 1: one of the features of natural dyes, for example in
• 10:11
  Speaker 1: European fruit loops, is that they.
• 10:13
  Speaker 5: Are just like they're not as intense, it's not as
• 10:18
  Speaker 5: fun and so yes, our producer has pointed out in
• 10:22
  Speaker 5: the comments here that chocolate is brown and so could
• 10:25
  Speaker 5: you just leave the eminem But I think it's the
• 10:27
  Speaker 5: candy coating on the m M that's sort of crazy.
• 10:30
  Speaker 2: I mean, what is it without the candy, It's coding.
• 10:32
  Speaker 1: It's nothing. Also would melt on itself, which would be
• 10:35
  Speaker 1: a bad experience.
• 10:37
  Speaker 2: All right, So hoarde your blue eminem's. They will no
• 10:39
  Speaker 2: doubt be worth millions of dollars.
• 10:42
  Speaker 1: They're going to be people who are selling choco tacos
• 10:45
  Speaker 1: and in blue eminems on ets for decades.
• 10:48
  Speaker 2: All right. That is it for the health news of
• 10:51
  Speaker 2: the week. After the break, what's the deal with full
• 10:54
  Speaker 2: body scans? And we are back. What's the deal with
• 11:02
  Speaker 2: full body scans? Emily, I'm going to start by playing
• 11:06
  Speaker 2: a representative clip from Instagram to get us going here.
• 11:10
  Speaker 6: So I just did a full body scan that tests
• 11:12
  Speaker 6: for over five hundred different conditions, including cancer. Now you
• 11:15
  Speaker 6: sit in this little tube thing for an hour and
• 11:17
  Speaker 6: you just watch a little Netflix show, and then you'll
• 11:19
  Speaker 6: get all the information. Now there's gonna be a whole
• 11:21
  Speaker 6: report of like everything from your brain to your toenails.
• 11:25
  Speaker 6: They did find a nodule in my lung. So let
• 11:27
  Speaker 6: me show you that. I can see here, there's a
• 11:29
  Speaker 6: lung nodule. You can see it there. It's point five centimeters. Now,
• 11:32
  Speaker 6: apparently what the doctor told means that lung nodule is
• 11:34
  Speaker 6: either from a prior lung infection, which is okay, and
• 11:37
  Speaker 6: that it doesn't look like it's cancerous. But we're gonna
• 11:39
  Speaker 6: get a scan in a year from now and just
• 11:41
  Speaker 6: make sure it doesn't grow, and we'll keep an eye
• 11:42
  Speaker 6: on it. And so this scan is preventative. And I
• 11:45
  Speaker 6: just don't understand why health insurance companies don't offer and
• 11:48
  Speaker 6: pay for this, and or why our entire system doesn't
• 11:52
  Speaker 6: provide us more preventive care like this. Now, this total
• 11:55
  Speaker 6: scan with pernuvo is twenty five hundred dollars. I know
• 11:59
  Speaker 6: that's a lot of money, but for me, thinking about
• 12:02
  Speaker 6: all the findings you're going to get I think it's
• 12:04
  Speaker 6: well worth.
• 12:05
  Speaker 2: It, all right. So so there you have someone and
• 12:09
  Speaker 2: you know, this was not hard to find a clip
• 12:10
  Speaker 2: like this. There are hundreds of them out there, of
• 12:13
  Speaker 2: people who have gone through these direct to consumer scans.
• 12:16
  Speaker 2: These are things that you pay for out of pocket
• 12:18
  Speaker 2: and you know, find something, and broadly speaking, the people
• 12:22
  Speaker 2: seem quite grateful that they've found a thing.
• 12:27
  Speaker 1: Yeah, ah, this is a really okay. So let me
• 12:34
  Speaker 1: just tee up Why I think this space is so
• 12:36
  Speaker 1: complicated because these scans are on a long continuum, some
• 12:41
  Speaker 1: of which we recommend, and so you will often hear people,
• 12:44
  Speaker 1: you know, doctors say like, well, don't you don't need
• 12:46
  Speaker 1: a full body scan? Like you don't you don't need
• 12:48
  Speaker 1: a full body scan? But then in the same breath
• 12:49
  Speaker 1: it'll be like, but definitely get this, mamma rep and
• 12:51
  Speaker 1: definitely get this cooling cancer screening can definitely get. And
• 12:54
  Speaker 1: I think that's where it's hard to navigate. It's, well,
• 12:58
  Speaker 1: you told me these scans I want. Why don't I
• 13:00
  Speaker 1: want this other scan? It just seems like it would
• 13:02
  Speaker 1: be better.
• 13:04
  Speaker 2: Isn't more information?
• 13:05
  Speaker 1: Is it more information better? And there's a sense in
• 13:09
  Speaker 1: which the answer must be yes, and then other senses
• 13:12
  Speaker 1: in which the answer must be no. But before we
• 13:15
  Speaker 1: get into that, you know, there are a lot of
• 13:18
  Speaker 1: these scans. The one I think, my guess is people
• 13:21
  Speaker 1: have heard most frequently is a company called Prinovo, which
• 13:27
  Speaker 1: does a full body MRI, sends it to a radiologist
• 13:31
  Speaker 1: and probably some AI to read it. These cost something
• 13:37
  Speaker 1: in the range of you onenty to twenty five hundred
• 13:40
  Speaker 1: dollars and they come back with some information about what
• 13:44
  Speaker 1: to do, and then you maybe have to follow up
• 13:46
  Speaker 1: in some other way. So that's the most popular one.
• 13:49
  Speaker 2: There are a bunch of popularized by no less than
• 13:53
  Speaker 2: Kim Kardashian, who got some significant flack actually for promoting Pernuvo.
• 13:59
  Speaker 2: We can talk about this in a little bit, but
• 14:01
  Speaker 2: but Kim Kardashian got one of these scans. By the way,
• 14:05
  Speaker 2: they Pernuvo often gives these scans to celebrities and influencers.
• 14:10
  Speaker 2: So if you look at the.
• 14:11
  Speaker 1: No one has offered me any oh, I still haven't
• 14:16
  Speaker 1: gotten my graphics card from episode one or two either.
• 14:19
  Speaker 1: Come on, we're waiting, guys.
• 14:21
  Speaker 3: Guys.
• 14:21
  Speaker 2: So Pernuvo will give these scans to influencers and then
• 14:24
  Speaker 2: you know, they'll put something on Instagram and with a
• 14:26
  Speaker 2: little with a little discount code and stuff like that.
• 14:29
  Speaker 2: This is clearly part of their marketing strategy. Kim Kardashian
• 14:32
  Speaker 2: had a pernevo scan they found aneurysm in her brain
• 14:35
  Speaker 2: that got a lot of attention. She talked about it
• 14:38
  Speaker 2: on her reality show. I'm going to hold off for
• 14:41
  Speaker 2: a second to tell you what the like end of
• 14:43
  Speaker 2: that story is. Uh, but I just want to say that, like,
• 14:47
  Speaker 2: this is something that you will hear a lot about
• 14:51
  Speaker 2: from really famous people.
• 14:53
  Speaker 1: Yeah, so there are a bunch of companies that do this.
• 14:56
  Speaker 1: I think one one thing I wanted to kind of
• 15:00
  Speaker 1: in some ways differentiate a little bit is there is
• 15:02
  Speaker 1: another kind of whole body scan called a dexa scan,
• 15:06
  Speaker 1: which people will hear about, which is basically a way
• 15:10
  Speaker 1: to scan how much body fat and muscle you have.
• 15:13
  Speaker 1: These are much cheaper and they are a totally different thing.
• 15:16
  Speaker 1: So I sort of in the space of influencers, these
• 15:19
  Speaker 1: things will get kind of put on top of each other,
• 15:22
  Speaker 1: but they aren't the same thing.
• 15:24
  Speaker 6: Here.
• 15:24
  Speaker 1: We're really talking about these like full body either CT
• 15:27
  Speaker 1: or MRI scans designed to look for things like tumors
• 15:30
  Speaker 1: or aneurysms or other abnormalities of your body as opposed
• 15:35
  Speaker 1: to looking at your body fat percentage.
• 15:38
  Speaker 2: Right, this is really a build as a broad sweep,
• 15:42
  Speaker 2: and we have companies in addition to Pernuvo. People may
• 15:45
  Speaker 2: have heard of Ezra or True Scan or the Simon
• 15:49
  Speaker 2: one scan, or there's even some ct versions. There is
• 15:53
  Speaker 2: one that I want to address just because it's like
• 15:58
  Speaker 2: exploding on social media just over the last week. So, Emily,
• 16:03
  Speaker 2: what if I were to submerge you in water and
• 16:05
  Speaker 2: shoot ultrasound waves through your body? Does that seem like
• 16:09
  Speaker 2: a good idea?
• 16:10
  Speaker 1: Yes, yes, it sounds amazing, is like a massage.
• 16:14
  Speaker 2: This just so people, this is the new mid Journey scan,
• 16:17
  Speaker 2: which is like the tech bros are are over the
• 16:19
  Speaker 2: moonflo mid Journey is the company that did like AI
• 16:22
  Speaker 2: image generation.
• 16:23
  Speaker 7: Yeah, like that was the big what I'm familiar Now
• 16:27
  Speaker 7: they're a full body scanning company, Pivoting, and they've showed
• 16:30
  Speaker 7: a demo of like you get submerged in water and
• 16:32
  Speaker 7: this thing goes like and you get a whole scan
• 16:36
  Speaker 7: of your body using ultrasound.
• 16:37
  Speaker 1: Waves and then what how does that help?
• 16:39
  Speaker 8: What?
• 16:40
  Speaker 2: Well, it's the similar idea to the full body MRI scans,
• 16:43
  Speaker 2: except they they're arguing it'll be cheaper and we can
• 16:48
  Speaker 2: sort of get to the costs in a minute. Uh
• 16:51
  Speaker 2: and and and the problems with full body ultrasound as well.
• 16:56
  Speaker 2: I just want to say it at the top because
• 16:57
  Speaker 2: I think people will start hearing about this and and
• 17:00
  Speaker 2: we will touch on it. But frankly, the data is
• 17:03
  Speaker 2: all in that full body MRI scan space. This full
• 17:06
  Speaker 2: body ulchstund is completely new, and like there's very little
• 17:09
  Speaker 2: we can say about its diagnostic accuracy or anything because
• 17:12
  Speaker 2: it hasn't been really used on humans yet, but you'll
• 17:14
  Speaker 2: see it in your feeds.
• 17:15
  Speaker 1: How much do you think that the AI, the growth
• 17:17
  Speaker 1: of AI is powering this. I mean a radiology is
• 17:20
  Speaker 1: one of the things that AI is sort of the
• 17:22
  Speaker 1: best at, the best kind of doctoring on. I would
• 17:26
  Speaker 1: have thought this is like we're only able to do
• 17:28
  Speaker 1: this because AI is reading a huge share of these scans.
• 17:30
  Speaker 2: In almost all of these companies, AI is built as
• 17:35
  Speaker 2: augmenting the read from the radiologists. No one is saying
• 17:38
  Speaker 2: like it's only AI.
• 17:40
  Speaker 1: You look skeptical, No, I think that's I mean, that
• 17:42
  Speaker 1: is the way that radiology I think will work for everything,
• 17:47
  Speaker 1: is that the AI does a first read and somebody
• 17:49
  Speaker 1: does so as a follow up read, we have actually
• 17:51
  Speaker 1: quite a significant radiologist shortage and the moment, and so
• 17:55
  Speaker 1: this is a natural place for AI to come in,
• 17:59
  Speaker 1: including for these kind of scans.
• 18:01
  Speaker 2: Yeah, and if you're one of these companies trying to
• 18:02
  Speaker 2: raise money from investors, like, are you not going to
• 18:04
  Speaker 2: say the AI AI?
• 18:07
  Speaker 1: It's like everybody's an AI company a meal delivery service.
• 18:10
  Speaker 1: It's more of an AI meal delivery AI stake. You know,
• 18:16
  Speaker 1: we're optimized AI.
• 18:17
  Speaker 2: It's all that I I Okay, total aside, But my
• 18:22
  Speaker 2: dystopian prediction for the future of AI and consumerism is
• 18:25
  Speaker 2: that soon enough, Amazon is actually going to start sending
• 18:29
  Speaker 2: things to your house that you haven't ordered. That it's
• 18:32
  Speaker 2: going to just like it's going to show up and
• 18:34
  Speaker 2: then they'll be like, look, look, send it back if
• 18:36
  Speaker 2: you don't if you don't want it.
• 18:38
  Speaker 1: That already happens in my house because it's one of
• 18:40
  Speaker 1: my children has ordered it. But it's going to be
• 18:43
  Speaker 1: even worse when Amazon is doing it.
• 18:45
  Speaker 2: Yeah, all right, mark my words.
• 18:46
  Speaker 1: Okay, So before we get into the like what do
• 18:51
  Speaker 1: we know about these things in the data? I actually
• 18:54
  Speaker 1: want to start a little bit bigger picture with how
• 18:58
  Speaker 1: we think about scan and how we think about results
• 19:02
  Speaker 1: that we get in medicine. So I'm going to give
• 19:05
  Speaker 1: you a quiz. It's a quiz for everybody, So everybody
• 19:08
  Speaker 1: put your thinking cap on. Imagine you have a disease
• 19:12
  Speaker 1: that affects one in ten thousand people. Okay, and you
• 19:17
  Speaker 1: have a test for the disease that detects ninety nine
• 19:20
  Speaker 1: percent of cases with a two percent false positive rate.
• 19:23
  Speaker 1: So it's really good test. It finds ninety nine percent
• 19:25
  Speaker 1: of cases. Small false positive rate of two percent.
• 19:28
  Speaker 2: Amazing. Tests sounds great.
• 19:30
  Speaker 1: You give someone the test and they test positive, what
• 19:33
  Speaker 1: is the chance that they have the disease? Short jeopardy pause,
• 19:37
  Speaker 1: do you do?
• 19:37
  Speaker 9: Do you do?
• 19:38
  Speaker 1: Okay, what do you think?
• 19:41
  Speaker 2: I think that all your bays are belonged to us.
• 19:47
  Speaker 2: I know what you're getting at here, But let me
• 19:49
  Speaker 2: tell you what I think your intuition is, and then
• 19:52
  Speaker 2: we can talk about why the intuition is wrong. The
• 19:54
  Speaker 2: intuition is, here's a test that detects ninety nine percent
• 19:57
  Speaker 2: of disease. Great, only has a two percent false positive rate. Great,
• 20:00
  Speaker 2: you got a positive test. Pretty sure you have the disease?
• 20:03
  Speaker 1: Pretty sure you have.
• 20:04
  Speaker 2: That sounds right, yeahad bad news. Right, you have the
• 20:06
  Speaker 2: positive test, but you are you mentioned that this is
• 20:11
  Speaker 2: a pretty rare disease, one in ten thousand, and so
• 20:15
  Speaker 2: maybe you can walk us through the math Emily of
• 20:18
  Speaker 2: like what the actual value of a positive test is here.
• 20:21
  Speaker 1: So the answer to the question is one half of
• 20:24
  Speaker 1: one percent. So with a positive test, the chance that
• 20:27
  Speaker 1: you actually have the disease is one in two hundred.
• 20:32
  Speaker 1: And the reason for that is that if you think
• 20:35
  Speaker 1: about this test, Let's say you have ten thousand people,
• 20:37
  Speaker 1: you test, one of them has it, You're going to
• 20:40
  Speaker 1: find that the very very good chance you find out
• 20:42
  Speaker 1: ninety nine percent chance you ninety nine percent chance. Let's
• 20:44
  Speaker 1: say we find that one person, and then there's a
• 20:48
  Speaker 1: two percent false positive rate, and that means of the
• 20:51
  Speaker 1: ninety nine people who don't have it, about two hundred
• 20:55
  Speaker 1: of them are going to test positive. And so now
• 20:58
  Speaker 1: you've got two hundred people who tested positive who don't
• 21:01
  Speaker 1: have it, and one person who tested positive who does
• 21:05
  Speaker 1: and that means that it's about one in two hundred.
• 21:08
  Speaker 1: That's the chance that you actually are affected. And so
• 21:10
  Speaker 1: if you're sitting there with a positive if you're sitting
• 21:12
  Speaker 1: there with a positive test, so I think this will
• 21:14
  Speaker 1: really like. I have given this test to many people,
• 21:21
  Speaker 1: ranging from middle school students to members of the Ivy
• 21:24
  Speaker 1: League corporation, and almost nobody gets it right. And in fact,
• 21:29
  Speaker 1: when you get this to doctors, they also mostly don't
• 21:31
  Speaker 1: get it right. I guess you're an exception, and a
• 21:33
  Speaker 1: lot of people have the instinct it's like ninety five percent.
• 21:38
  Speaker 1: The reason that I say this is that one of
• 21:41
  Speaker 1: the most significant issues with this kind of full body
• 21:44
  Speaker 1: scan and by the way, with any kind of scanning
• 21:49
  Speaker 1: for conditions, is that many of these conditions are pretty
• 21:54
  Speaker 1: rare and false positives are pretty calm. So when you
• 21:58
  Speaker 1: go to scan people for something like breast cancer, even
• 22:01
  Speaker 1: with the standard mammogram, there's a lot of false positives,
• 22:04
  Speaker 1: a lot of incidental findings, a lot of just we
• 22:07
  Speaker 1: saw something on the mammogram and then when we went
• 22:09
  Speaker 1: more into it, it it wasn't. It wasn't in there.
• 22:12
  Speaker 1: And that's important for two reasons. One is that if
• 22:14
  Speaker 1: you do more of this scanning, you're just going to
• 22:16
  Speaker 1: have more of these false positives. Now you'll have more
• 22:19
  Speaker 1: true positives also, but you will end up with a
• 22:22
  Speaker 1: lot of people either very anxious or just having a
• 22:28
  Speaker 1: lot of additional testing that they didn't necessarily need. And
• 22:31
  Speaker 1: when we think about these tests, we want to weigh
• 22:34
  Speaker 1: those things. And full body scans are an extreme form
• 22:38
  Speaker 1: of a problem that is already there with any kind
• 22:40
  Speaker 1: of scanning. So we already think about this problem with
• 22:43
  Speaker 1: breast cancer screening or colonas could be, or prostive cancer
• 22:45
  Speaker 1: screening or whatever. That's already an issue. If you're now
• 22:49
  Speaker 1: scanning somebody's entire body and you'll picking up every you know,
• 22:53
  Speaker 1: weird rando thing in their elbow, you're gonna have this
• 22:57
  Speaker 1: problem even more extreme.
• 22:59
  Speaker 2: So this is this is so important, but it's also
• 23:03
  Speaker 2: going to play into the central tension that I have
• 23:06
  Speaker 2: with these scans, and we'll get there, But broadly speaking,
• 23:11
  Speaker 2: there's always going to be this thing that like, we
• 23:13
  Speaker 2: can look objectively at the numbers on a population level
• 23:16
  Speaker 2: and be like, okay, yeah, you know, there's a lot
• 23:18
  Speaker 2: of false positives and people are going to be chasing
• 23:19
  Speaker 2: this down and seeing the doctor and stuff. But there
• 23:23
  Speaker 2: is that one guy, what if it was you, There's
• 23:25
  Speaker 2: that one guy you said who actually had that rare
• 23:27
  Speaker 2: disease that we caught, and there is clearly some value
• 23:33
  Speaker 2: in catching that one guy. But the question is sort
• 23:37
  Speaker 2: of how many false positives is worth the true positive?
• 23:41
  Speaker 2: And this is where I like get stuck on full
• 23:44
  Speaker 2: body scans.
• 23:45
  Speaker 1: And I think that's a part of the reason it's
• 23:46
  Speaker 1: a very complicated question is that it's probably different if
• 23:51
  Speaker 1: we think about what the individual incentive is versus the
• 23:55
  Speaker 1: kind of health system incentive. So when we make decisions about,
• 23:59
  Speaker 1: you know, who should we recommend a mammography for, we're
• 24:03
  Speaker 1: making decisions based on trading off false positives and true
• 24:06
  Speaker 1: positives from a kind of like population cost perspective, which
• 24:11
  Speaker 1: may be the right frame for some decisions, but maybe
• 24:14
  Speaker 1: different from you as an individual, And what do you
• 24:16
  Speaker 1: you know, what what is sort of your risk tolerance
• 24:19
  Speaker 1: and what is your demand? And I will tell you
• 24:21
  Speaker 1: from a personal level. When my mom was diagnosed with
• 24:27
  Speaker 1: lung cancer, it was an it was an incidental finding
• 24:30
  Speaker 1: on a CT scan that was being done for some
• 24:34
  Speaker 1: other reason. She had vertigo, They thought she might have
• 24:36
  Speaker 1: a stroke. It turned out they found lung cancer. She
• 24:39
  Speaker 1: was in a risk group because she was a former
• 24:41
  Speaker 1: smoker who like could have been going for yearly CT scans.
• 24:47
  Speaker 1: And there's a lot of debate about exactly who should
• 24:50
  Speaker 1: be doing those, and I think all the time, like
• 24:53
  Speaker 1: boy ex post, I really wish that she had she
• 24:56
  Speaker 1: had been doing that, even if it you know, from
• 24:58
  Speaker 1: a kind of population standpoint, maybe that isn't that isn't
• 25:01
  Speaker 1: the right thing. So for me, that really crystallizes this
• 25:05
  Speaker 1: trade off between yeah, what about the one that you missed?
• 25:08
  Speaker 2: Yeah, one hundred percent. So there are a couple of
• 25:12
  Speaker 2: concepts that I want people to be aware of. You've
• 25:15
  Speaker 2: hit on one, which is the false positive thing. In medicine,
• 25:19
  Speaker 2: we call these incidental omas.
• 25:21
  Speaker 1: So I just give things regular names.
• 25:23
  Speaker 2: I could, you know, because we like to have jargons.
• 25:26
  Speaker 10: So that OSMA, this was originally named after these things
• 25:34
  Speaker 10: you see on adrenal glands when you get a cat
• 25:36
  Speaker 10: scan of the abdomen.
• 25:37
  Speaker 2: So we give people cat skins of the abdomen for
• 25:39
  Speaker 2: you know everything, right, you come in with abdominal pain
• 25:41
  Speaker 2: to the E D whatever, You're getting a cats scan
• 25:43
  Speaker 2: your abdue pelvis, and then you know, not infrequently you
• 25:46
  Speaker 2: see these little spots on an adrenal gland. We typically
• 25:49
  Speaker 2: refer to them as incidental omas. They were found incidentally.
• 25:52
  Speaker 2: You weren't looking for them, but they tend to necessitate
• 25:56
  Speaker 2: at least some further work up and and and down
• 26:00
  Speaker 2: stream stuff, and that can happen anywhere in the body.
• 26:03
  Speaker 2: Incidental omas are things that turn out to be nothing.
• 26:08
  Speaker 2: So you find them and then you've got to do
• 26:11
  Speaker 2: something about it, But then it turns out it didn't matter, right,
• 26:15
  Speaker 2: Like you buy up see that thing on your adrenal
• 26:17
  Speaker 2: land and it was a benign It was a benign growth.
• 26:19
  Speaker 2: It would never have hurt you. It's an incidental oma.
• 26:23
  Speaker 2: There's a related concept which people have a little more
• 26:26
  Speaker 2: trouble with called over diagnosis, which is when you diagnose
• 26:30
  Speaker 2: something that really is bad, like a cancer or something
• 26:34
  Speaker 2: like that, but it turns out that had you not
• 26:37
  Speaker 2: diagnosed it, it probably wouldn't have hurt you at all,
• 26:41
  Speaker 2: because you were going to die of something else before
• 26:44
  Speaker 2: this got to you at all. So overdiagnosis is sort
• 26:47
  Speaker 2: of a different thing from an incidental oma or a
• 26:51
  Speaker 2: false positive. To give you a sense. It's hard to
• 26:54
  Speaker 2: get it like some of this stuff, but there are
• 26:56
  Speaker 2: autopsy studies where we'll look at people who died something
• 27:00
  Speaker 2: else and ask a question, for example of like, okay,
• 27:02
  Speaker 2: you died of not a cancer related problem. We do
• 27:05
  Speaker 2: an autopsy, how often do we find cancer? And the
• 27:08
  Speaker 2: answer is pretty often, Yeah, five percent of the time.
• 27:13
  Speaker 2: There's a nice study of eight hundred thousand non cancer
• 27:17
  Speaker 2: autopsies in Japan where the overall cancer rate was four
• 27:21
  Speaker 2: point two percent. I will say it's a little higher
• 27:22
  Speaker 2: in recent years now it's like up to seven percent overall.
• 27:25
  Speaker 2: And then of course the older the person was when
• 27:27
  Speaker 2: they died, the higher the chance of finding an incidental
• 27:30
  Speaker 2: cancer was. This isn't a false positive, like had you
• 27:33
  Speaker 2: found that while they were alive and biopsied it, it
• 27:36
  Speaker 2: would have come back cancer. They would have gotten cancer treatment,
• 27:39
  Speaker 2: but they didn't die of that, so all of that
• 27:42
  Speaker 2: treatment was theoretically over diagnosis. So that's the second major concept.
• 27:47
  Speaker 1: Yeah, and I think this is I mean, this is
• 27:49
  Speaker 1: where you know, for men in particular, a lot of
• 27:51
  Speaker 1: men get prostate cancer before they're dead, and at some
• 27:54
  Speaker 1: point we almost everyone, almost everybody agains, and at some
• 27:58
  Speaker 1: point it makes sense to just stop greening for prostate cancer,
• 28:01
  Speaker 1: because if you're ninety three years old and we find
• 28:03
  Speaker 1: out you have prosta cancer, it's fine, like something else
• 28:07
  Speaker 1: is going to take you before the prostate cancer. For
• 28:09
  Speaker 1: almost everybody, and so that is that is in a
• 28:12
  Speaker 1: space of overdiagnosis. Again, it's not that it's it's not
• 28:15
  Speaker 1: that it's not cancer. It's just not we care about
• 28:18
  Speaker 1: the death, not the specific cause of death.
• 28:21
  Speaker 2: Yeah, so this brings me back to Kim.
• 28:23
  Speaker 1: Ki, Kim k Kim k what's to stay up to?
• 28:27
  Speaker 2: So, so what Kim Kardashian told the world, I mean,
• 28:31
  Speaker 2: we don't have her report, her Pernuva report, but what
• 28:33
  Speaker 2: she what she said publicly is that they found a
• 28:36
  Speaker 2: little or small aneurism in her brain, as well as
• 28:39
  Speaker 2: some uterine fibroids. She said that, you know, after that
• 28:44
  Speaker 2: Pernuva found the little aneurism in her brain, she went
• 28:46
  Speaker 2: to see her SINAI. She got quote tons of brain scans,
• 28:49
  Speaker 2: met with a bunch of neurosurgeons, et cetera, et cetera,
• 28:53
  Speaker 2: and decided to do nothing. It was small enough that
• 28:57
  Speaker 2: they decided to do this thing called watchful waiting. That's
• 29:00
  Speaker 2: probably the right choice talking about overdiagnosis of aneurysms. If
• 29:05
  Speaker 2: you look at the rate of brain incidental brain aneurysms
• 29:07
  Speaker 2: at autopsy. Okay, so you take people who did not
• 29:09
  Speaker 2: die of a brain aneurism, but you look at their
• 29:12
  Speaker 2: brain after they died. Two to six percent have an
• 29:16
  Speaker 2: aneurysm in there, so they are there and a lot
• 29:19
  Speaker 2: of them don't rupture. And Kim Kardashian's surgeons looked at
• 29:24
  Speaker 2: the size and said, well, this is something we can
• 29:26
  Speaker 2: keep an eye on. Now. She build this as like
• 29:30
  Speaker 2: a life saving thing, like she has talked about this
• 29:34
  Speaker 2: as she is so thankful to know about this. She's
• 29:37
  Speaker 2: reducing the stress in her life to know potentially reduce
• 29:40
  Speaker 2: the risk of this aneurysm bursting.
• 29:42
  Speaker 1: I would find this so awful, Like I mean, I
• 29:46
  Speaker 1: feel like, at least for some people, and I would
• 29:49
  Speaker 1: put myself in this camp. The idea that I have
• 29:53
  Speaker 1: this aneurism but I'm doing nothing about it is so
• 29:57
  Speaker 1: much worse than not knowing, because in every time you
• 30:00
  Speaker 1: have a headache, you're like, oh my God, is in miamirism?
• 30:02
  Speaker 3: Right?
• 30:03
  Speaker 1: And this is a big part of this is people
• 30:05
  Speaker 1: just being anxious about what might happen because the information
• 30:11
  Speaker 1: is because we're not robots and we can't like just
• 30:14
  Speaker 1: pretending information is not there.
• 30:15
  Speaker 2: And I don't know, yeah, and so much of what
• 30:19
  Speaker 2: I see when and it's mostly doctors online who are
• 30:22
  Speaker 2: pushing back against full body skins. It's mostly like people
• 30:25
  Speaker 2: my profession that's like, guy's careful, false positive and all
• 30:28
  Speaker 2: this kind of thing. And then there's a lot of
• 30:30
  Speaker 2: sort of wellness tech people who are like, no, no, no,
• 30:34
  Speaker 2: you know, more information is better. I want to find
• 30:37
  Speaker 2: the thing before it becomes a problem. And hey, I
• 30:40
  Speaker 2: know there's you know, I know there's false positive. I
• 30:42
  Speaker 2: know there's over diagnosis. We'll figure that out over time,
• 30:45
  Speaker 2: we'll like learn how better to manage these things. And
• 30:49
  Speaker 2: that's the step where I'm like, you know, this is
• 30:51
  Speaker 2: going to require if you really want to deal with
• 30:53
  Speaker 2: a false positive issue, a lot of people to have
• 30:56
  Speaker 2: a spot on their liver, yeah, and to be like, well,
• 31:00
  Speaker 2: there's a one percent chance it's cancer or maybe a
• 31:03
  Speaker 2: three per Let's say there's a five percent chance it's cancer.
• 31:05
  Speaker 2: There's a ninety five percent chance it's not. I'm not
• 31:07
  Speaker 2: going to do anything because like, chances are it's fine.
• 31:10
  Speaker 2: There's some people who can handle that. There are a
• 31:12
  Speaker 2: lot of people who can't. Right, Like, the whole reason
• 31:14
  Speaker 2: they did the scan was to find the spot on
• 31:16
  Speaker 2: the liver. Now it needs a biopsy.
• 31:18
  Speaker 1: Yeah, And I think we see this in you know,
• 31:21
  Speaker 1: in outside of the full body scan space in you know,
• 31:25
  Speaker 1: in in mimography. So our mamogram approtion mamorrams gotten better
• 31:29
  Speaker 1: over time. We're doing more mammograms broadly, that's very good.
• 31:32
  Speaker 1: It means we're catching cancers earlier. But there's actually a
• 31:35
  Speaker 1: fairly large or at least some set of kind of
• 31:37
  Speaker 1: stage zero cancers for which it may be based on
• 31:40
  Speaker 1: the age of the person or what it looks like,
• 31:42
  Speaker 1: you just shouldn't do anything. And we are almost always
• 31:46
  Speaker 1: doing things. So typically people will be given the choice,
• 31:48
  Speaker 1: you know, we could do watchful waiting or we could
• 31:51
  Speaker 1: do stuff. And people want to do stuff once they
• 31:53
  Speaker 1: say you have you know, ductal blah blah blah with
• 31:57
  Speaker 1: the word car sonoma on it, you're doing stuff, And
• 32:00
  Speaker 1: that is maybe a good idea, but it does it
• 32:05
  Speaker 1: does have trade offs. I think it's just not it's
• 32:07
  Speaker 1: not free for you or for money. I mean, it's
• 32:10
  Speaker 1: not free in terms of money, but it's not free
• 32:12
  Speaker 1: in terms of your emotional state either.
• 32:14
  Speaker 2: Yeah. I want to walk through the sort of third
• 32:18
  Speaker 2: large concept which we've we've tested on here, which is
• 32:22
  Speaker 2: called care cascades.
• 32:24
  Speaker 1: Can I say before we get to that, can I
• 32:26
  Speaker 1: can I say, sort of something else that happens in here.
• 32:29
  Speaker 1: That where I think this intersects with some of the
• 32:32
  Speaker 1: way we're doing medicine these days, which is it is
• 32:36
  Speaker 1: much more common for people to do like a share
• 32:39
  Speaker 1: what do we call shared decision making, and shared decision
• 32:42
  Speaker 1: making is great because it puts the patient in the
• 32:44
  Speaker 1: driver's seat at some of the time, and we generally
• 32:47
  Speaker 1: don't want the kind of nineteen fifties doctor where it
• 32:50
  Speaker 1: was like he says there and smokes a cigarette and
• 32:52
  Speaker 1: tells you you know what to do, like we've moved away,
• 32:55
  Speaker 1: and that's yeah, that's probably for the best, especially with
• 32:57
  Speaker 1: we're not.
• 32:58
  Speaker 2: Going to tell your wife she has cancer just well.
• 33:01
  Speaker 1: It'll just make her sad. But the idea that the
• 33:05
  Speaker 1: patient should be in the driver's seat around some of
• 33:08
  Speaker 1: these decisions is very stressful for people, and I somehow
• 33:13
  Speaker 1: it comes up more in these cases where we're just
• 33:15
  Speaker 1: not sure what to do, and that piece of it
• 33:19
  Speaker 1: feels like, I'm not I'm not sure there's a good
• 33:23
  Speaker 1: solution to it, but I think it's yet another piece
• 33:25
  Speaker 1: adding to this anxiety.
• 33:26
  Speaker 2: Yeah, it varies obviously based on the patient. Some patients
• 33:29
  Speaker 2: very much want to be told what to do. It's
• 33:31
  Speaker 2: my experience, and they'll phrase that in different ways, but
• 33:33
  Speaker 2: often it comes to me as like, Okay, if I
• 33:35
  Speaker 2: were your brother or if I were your father, what
• 33:37
  Speaker 2: would you tell me to do here? Which is always
• 33:39
  Speaker 2: a hard question for me. I'm like, no, I would
• 33:41
  Speaker 2: never tell my own family because I'm completely completely biased.
• 33:46
  Speaker 2: And then some yeah, some have very strong opinions. And
• 33:49
  Speaker 2: then I mean, just to say it as doctor like,
• 33:52
  Speaker 2: there are medical legal implications of this stuff, right, someone
• 33:56
  Speaker 2: comes to me after a full body scan and says,
• 33:59
  Speaker 2: you know, hey, they found this thing on my you know,
• 34:04
  Speaker 2: on my kidney. It's ambiguous what it is. Could be cancer,
• 34:08
  Speaker 2: might not be. What do you think I should do?
• 34:10
  Speaker 2: There's definitely a part of my brain that's like, well,
• 34:12
  Speaker 2: you know, if I don't work this up, if I'm
• 34:16
  Speaker 2: like it is cancer, what if it is cancer five
• 34:18
  Speaker 2: years from now? And and you know, so that's just
• 34:22
  Speaker 2: sort of the way we're structured. It's much safer for me,
• 34:25
  Speaker 2: in a cover your ass kind of sense, to be like,
• 34:27
  Speaker 2: all right, well, let's get you a dedicated scan of that,
• 34:30
  Speaker 2: let's get a biopsy of that, and so on and
• 34:32
  Speaker 2: so forth, And that is what happens. So a lot
• 34:35
  Speaker 2: of these arguments that's like, oh, guys, we just it's
• 34:37
  Speaker 2: not the scans that are the problem, it's the psychology
• 34:39
  Speaker 2: around them, and we have to get better at dealing
• 34:41
  Speaker 2: with ambiguity. Is a nice theory, but we're just not
• 34:45
  Speaker 2: very good at it.
• 34:45
  Speaker 1: No, we're just not. It's a nice theory, but not
• 34:47
  Speaker 1: very realistic.
• 34:49
  Speaker 2: Yeah, all right. A guy walked into a routine physical
• 34:53
  Speaker 2: feeling completely fine. He walked out ten units of blood
• 34:57
  Speaker 2: and fifty thousand dollars later, and he never acts had
• 35:00
  Speaker 2: anything wrong with him.
• 35:03
  Speaker 1: This is great, not great.
• 35:06
  Speaker 2: This is such a great piece of writing from Michael Rothberg,
• 35:11
  Speaker 2: who is writing in jama about the true experience of
• 35:14
  Speaker 2: his father and how medicine obligates subsequent testing. So let
• 35:22
  Speaker 2: me tell you what happened to this person and get
• 35:23
  Speaker 2: your opinion. Okay, this older guy comes in, gets his
• 35:26
  Speaker 2: routine physical. His doctor does a physical exam, listens to
• 35:30
  Speaker 2: his heart, pushes on his belly, feels his a orda
• 35:33
  Speaker 2: an aortic exam. You've kind of pushed down the belly,
• 35:36
  Speaker 2: feel the pulse. The doctor thinks the order is a
• 35:39
  Speaker 2: little bit big. Maybe there's an aneurysm there, but there's
• 35:42
  Speaker 2: an appropriate test for that, that's an abdominal ultrasound. So
• 35:44
  Speaker 2: he sends him for an abdominal ultrasound. Turns out the
• 35:47
  Speaker 2: A order is normal, but during that ultrasound they see
• 35:50
  Speaker 2: something in the head of the pancreas. That's an incidental finding.
• 35:53
  Speaker 2: All right, Well, now there's something in the head of
• 35:54
  Speaker 2: the pancreas. So the next step is, of course to
• 35:57
  Speaker 2: get a CT scan. Well, good news. The T scans
• 36:00
  Speaker 2: showed the pancreas was normal, but there was a solitary
• 36:03
  Speaker 2: lesion on his liver. Okay, that needs to be biopsied,
• 36:07
  Speaker 2: so he gets a liver biopsy. It's not liver cancer,
• 36:11
  Speaker 2: that's good news, but it was a hamangioma, which led
• 36:13
  Speaker 2: to a huge bleed requiring a ten unit's blood transfusion
• 36:18
  Speaker 2: and an inpatient stay that cost fifty thousand dollars. Every
• 36:24
  Speaker 2: step of this care was appropriate. There was no malpractice here.
• 36:29
  Speaker 2: This is all exactly what you do. The only exception
• 36:33
  Speaker 2: actually is that initial physical exam palpating the A order.
• 36:37
  Speaker 2: There's no evidence that we're good enough at our physical
• 36:40
  Speaker 2: exam to tell if someone's order is dilated or not.
• 36:43
  Speaker 2: But like if your doctor does that, right, you're sort like, oh,
• 36:46
  Speaker 2: this is a good I mean, this is their job
• 36:48
  Speaker 2: they do, They're doing stuff. Listen. This is a care cascade,
• 36:52
  Speaker 2: albeit obviously one that's very dramatic. But I love this
• 36:56
  Speaker 2: story because it illustrates how like these aren't bad decisions.
• 37:00
  Speaker 2: Every step of this way was the answer to the
• 37:02
  Speaker 2: board question, like what do you do if you see
• 37:05
  Speaker 2: a mass in the head of the pancreas you get
• 37:06
  Speaker 2: a dedicated CT scan, Like that is all correct, but
• 37:10
  Speaker 2: it all started from a screening test. In this case,
• 37:14
  Speaker 2: it was a physical exam, not a full body scan.
• 37:17
  Speaker 1: Yeah, I mean, ah, that's obviously a very extreme story,
• 37:22
  Speaker 1: but I do think it is even in the Instagram
• 37:27
  Speaker 1: versions of this, it is what we're seeing from a
• 37:29
  Speaker 1: lot of people who have these sands. Do you see this?
• 37:31
  Speaker 1: You see this? You see you know this? Your liver
• 37:35
  Speaker 1: is too big? At least one person I know has
• 37:37
  Speaker 1: had these, Like they were like just like your liver
• 37:39
  Speaker 1: is enormous, Like you have an enormous liver, And it
• 37:42
  Speaker 1: led to all this stuff and it's turned out like
• 37:43
  Speaker 1: this person just had kind of a big liver, like
• 37:45
  Speaker 1: sometimes sometimes you have that, and so we're over diagnosing,
• 37:51
  Speaker 1: we're care caskating, we're just But again, it's not that
• 37:55
  Speaker 1: the decisions were wrong, And I think that's that's the
• 37:58
  Speaker 1: question is where do you stop the decisions? I think
• 38:00
  Speaker 1: that's what's such a hard piece of this is which
• 38:02
  Speaker 1: of these things do you not want to do? Which
• 38:04
  Speaker 1: piece of information do you want to just stop? And
• 38:07
  Speaker 1: then we're attempted to say, well, you know what, I
• 38:09
  Speaker 1: just shouldn't have gotten the information in the first place,
• 38:11
  Speaker 1: and then we wouldn't have been wouldn't have had all
• 38:13
  Speaker 1: these other problems. But then what have you missed the
• 38:15
  Speaker 1: one guy? That's why this is hard.
• 38:17
  Speaker 2: That's all right. So we've got the big concepts people,
• 38:20
  Speaker 2: all right, everyone understands now we have a visceral feeling
• 38:23
  Speaker 2: about about what the conceptually, what the issues are. I
• 38:27
  Speaker 2: think we need to talk about the data.
• 38:29
  Speaker 1: Yes, what happens when this actually occurs? I don't know. Okay,
• 38:38
  Speaker 1: So yeah, So let's say a thousand people get a
• 38:43
  Speaker 1: full body scan. Seventy of them, just seventy are going
• 38:47
  Speaker 1: to get totally normal results, nine hundred and thirty will
• 38:50
  Speaker 1: have something abnormal. Three hundred of them we'll need some
• 38:54
  Speaker 1: specific follow up twenty two will have cancer. Five will
• 38:57
  Speaker 1: have cancer that the scan missed. Anyway, that is a
• 39:01
  Speaker 1: broad summary of the data from these full body scans.
• 39:05
  Speaker 1: How do we feel about that? Doesn't seem amazing?
• 39:09
  Speaker 2: This crystallizes everything we've been saying to me. All right,
• 39:12
  Speaker 2: first of all, if you're going to get one of
• 39:13
  Speaker 2: these scans. This, by the way, this data comes from
• 39:16
  Speaker 2: the Polaris study, which is a Perneuvo funded study. This
• 39:21
  Speaker 2: it's still recruiting, but this was their initial read. So, yeah,
• 39:25
  Speaker 2: you get one of these scans, there's a ninety three
• 39:26
  Speaker 2: percent chance they'll find something abnormal. Like if you think
• 39:28
  Speaker 2: you're going to go and get a clean bill of health,
• 39:30
  Speaker 2: you're not.
• 39:30
  Speaker 1: You're not. No, But and I think that's good. That's
• 39:33
  Speaker 1: good for people to know coming into this, right, you know,
• 39:35
  Speaker 1: like if you go for one of these, like they're
• 39:37
  Speaker 1: finding something, right, This is like this is actually what
• 39:40
  Speaker 1: my doctor told me the first time I had an mammorgram.
• 39:42
  Speaker 1: She was like, they always find something. It's probably fun.
• 39:45
  Speaker 2: Yeah. The next question, of course, is is it actionable?
• 39:49
  Speaker 8: Right?
• 39:49
  Speaker 2: Like, Like you know, people have found for example, modest
• 39:53
  Speaker 2: slip discs or something like that, and for some people
• 39:56
  Speaker 2: that's useful, like, oh that's why I have backpain. Okay, great,
• 39:59
  Speaker 2: there's nothing to be on about it, or maybe get
• 40:01
  Speaker 2: some PT. But three hundred of so thirty percent of people,
• 40:05
  Speaker 2: we'll have a finding that requires specific follow up, like
• 40:09
  Speaker 2: you now have to see another doctor or get another scan,
• 40:11
  Speaker 2: or get another test or something to tie this together.
• 40:15
  Speaker 2: And that's where we start running into this. There's sort
• 40:18
  Speaker 2: of an ethical issue here, which is that the ethical
• 40:22
  Speaker 2: issue with full body scans is that they privatize profits
• 40:27
  Speaker 2: but socialize the risks. This is one of the problems
• 40:31
  Speaker 2: I have with these companies is that, like, they make
• 40:33
  Speaker 2: money from us, right, like you pay them, but if
• 40:35
  Speaker 2: they if they find something like your insurance company pays
• 40:39
  Speaker 2: for all that subsequent workup and stuff. And the more
• 40:43
  Speaker 2: people that do this, the companies keep that money, right,
• 40:46
  Speaker 2: they keep the profits that they've made. But theoretically, you're
• 40:50
  Speaker 2: the economist then only theoretically, if we're chasing down all
• 40:53
  Speaker 2: these incidental omas, it's going to drive up insurance costs
• 40:56
  Speaker 2: for everyone, right, because the insurance just has to be like, well, part,
• 40:59
  Speaker 2: you know, we got to allocate X number of dollars
• 41:01
  Speaker 2: per person for the weird stuff that it's going to
• 41:04
  Speaker 2: get fined in full body st sure.
• 41:05
  Speaker 1: And also, like there's a much more direct version of this,
• 41:07
  Speaker 1: which is if anybody is over sixty five, were already
• 41:10
  Speaker 1: you know, your tax dollars are paying for their healthcare,
• 41:12
  Speaker 1: and so if they get this thing, then Medicare is
• 41:15
  Speaker 1: paying and you're paying for medical rights.
• 41:17
  Speaker 2: So you're not the thirty percent of people who get
• 41:19
  Speaker 2: follow up, like generally they're not paying for well, they're
• 41:22
  Speaker 2: paying their deductibles or whatever. And so people should be aware,
• 41:24
  Speaker 2: especially if you buy a deductible plan, that you might
• 41:26
  Speaker 2: be digging into that, but you know that's still sort
• 41:29
  Speaker 2: of a socialized form of medicine. Twenty two have cancer
• 41:34
  Speaker 2: and here's and this is this is a study where
• 41:37
  Speaker 2: they they proved it. These are biopsy proven cancer. So
• 41:41
  Speaker 2: two point two percent out of the thousand people who
• 41:43
  Speaker 2: got a pernuvo scan. And this is where I keep
• 41:46
  Speaker 2: just like hitting the wall in terms of what I
• 41:49
  Speaker 2: think about this, because from a public health standpoint, I'm like, well,
• 41:53
  Speaker 2: clearly this is a bad idea. It costs way too
• 41:55
  Speaker 2: much to the public. It's like no one, no no
• 41:57
  Speaker 2: agency would ever recommend this. It's it's clearly not cost effective,
• 42:01
  Speaker 2: you're spending so much money chasing down nonsense. But for
• 42:05
  Speaker 2: an individual one of those twenty two people, Emily like,
• 42:10
  Speaker 2: what if you're one of those twenty two people?
• 42:13
  Speaker 1: Yeah, And I think it's once you put it in
• 42:15
  Speaker 1: that frame again, our psychology makes it very difficult because
• 42:19
  Speaker 1: then you're in a I don't know, like a loss
• 42:21
  Speaker 1: frame of Basically, if you don't do this, what if
• 42:26
  Speaker 1: you're one of the twenty two people, and then that's
• 42:28
  Speaker 1: the salient that's the salient fact that feels terrible. And
• 42:33
  Speaker 1: of course I would do anything to not be you know,
• 42:36
  Speaker 1: to have this found as part of those those twenty
• 42:38
  Speaker 1: two people.
• 42:39
  Speaker 2: Yeah, Now we don't know if those twenty two what
• 42:41
  Speaker 2: number of them are overdiagnosis? Right, some in theory, those
• 42:46
  Speaker 2: cancers that really were found might have never amounted to anything.
• 42:50
  Speaker 2: I think people might not appreciate this is like we
• 42:53
  Speaker 2: as doctors don't really understand disease before it becomes symptomatic
• 42:58
  Speaker 2: in a lot of cases, like the way we diagnose
• 43:02
  Speaker 2: most cancers, not the screening ones, not breast cancer and
• 43:06
  Speaker 2: colon cancer, but cancers that come up in other ways
• 43:09
  Speaker 2: is because someone has symptoms and general you know, yes,
• 43:12
  Speaker 2: sometimes they get found. Incidentally, we know that it seems
• 43:17
  Speaker 2: that cancers start off small and get bigger over time.
• 43:22
  Speaker 2: We tend to find them when they are not small,
• 43:26
  Speaker 2: unless it's a screening detected cancer. We don't really know
• 43:30
  Speaker 2: if the small ones always become the big one. Like,
• 43:34
  Speaker 2: we don't because we've never done a study where we
• 43:37
  Speaker 2: do a full body scan and just sit on our
• 43:38
  Speaker 2: hands and watch. Maybe maybe that'll happen in the future.
• 43:42
  Speaker 2: I'm not sure, but it's you're sort of obligated because
• 43:46
  Speaker 2: of your understanding of cancer biology to like you got
• 43:49
  Speaker 2: to do something about these twenty two cancers. But I
• 43:52
  Speaker 2: can't tell you for sure that they all would have
• 43:54
  Speaker 2: killed these people.
• 43:55
  Speaker 1: Yeah, I mean, I think what's missing from this boat,
• 43:58
  Speaker 1: from this discussion and from the data is probably two things.
• 44:02
  Speaker 1: So one is just a lot of these being done right.
• 44:05
  Speaker 1: So if we had a bigger database and we understood
• 44:08
  Speaker 1: more about what are the things that will turn into
• 44:11
  Speaker 1: something and what are the things that are not, then
• 44:13
  Speaker 1: this information would be more valuable because you would have
• 44:15
  Speaker 1: more of a sense of what to action on. Even
• 44:17
  Speaker 1: within those people with the abnormal findings, you would have
• 44:20
  Speaker 1: a better sense of like you know, yeah, like seventy
• 44:23
  Speaker 1: three percent of people have an allsion on their pancreas.
• 44:27
  Speaker 1: Is no big deal, Like we see that, we see.
• 44:29
  Speaker 2: That all the time.
• 44:30
  Speaker 1: Since we haven't done this, it's hard to say that.
• 44:32
  Speaker 1: I think the second piece here is most of the
• 44:36
  Speaker 1: time people are doing this once, or at least most
• 44:39
  Speaker 1: of the data is on the first time you do
• 44:40
  Speaker 1: a scan, and a lot of what we are looking
• 44:44
  Speaker 1: for in medicine to diagnose whether something's a problem, is
• 44:47
  Speaker 1: it is a change. Think about dermatology, Think about skin
• 44:51
  Speaker 1: cancer screening. You know, why do you go back to
• 44:54
  Speaker 1: the dermatologists every six months if you're at high risk
• 44:56
  Speaker 1: for skin cancer. It's because they're looking for did that change?
• 45:00
  Speaker 1: You know, there's no problem of just being a person
• 45:02
  Speaker 1: full of moles. The problem is when your moles start
• 45:04
  Speaker 1: looking weird and being a different weird color. Yeah, and
• 45:07
  Speaker 1: this is a case where if you have one scan
• 45:10
  Speaker 1: and then you can compare them over time those second
• 45:14
  Speaker 1: that second scan is going to be a lot more
• 45:16
  Speaker 1: cost effective than the first scan because the second time
• 45:19
  Speaker 1: you do the scan, all of those things that like
• 45:21
  Speaker 1: we saw it before and it looks the same now
• 45:23
  Speaker 1: we're just ignoring. We're into the things that are that
• 45:26
  Speaker 1: are changing, and I think that's the kind of promise here.
• 45:28
  Speaker 1: I assume Pernevo who tells you should do this every
• 45:30
  Speaker 1: you know, twenty three days or whatever, because that's what
• 45:33
  Speaker 1: money is for. But it does feel like that's a
• 45:37
  Speaker 1: that's a piece of something.
• 45:38
  Speaker 2: I think there's something there. I will say the mid Journey,
• 45:41
  Speaker 2: that whole body ultrasound submerging water like sci fi thing,
• 45:45
  Speaker 2: is specifically marketing it for that. They're like, we're going
• 45:47
  Speaker 2: to be cheaper. They're saying it might only be one
• 45:50
  Speaker 2: hundred dollars a scan, which, like, you know, I've got
• 45:52
  Speaker 2: a bridge to sell you if it turns out to
• 45:54
  Speaker 2: one hundred dollars, but that's fine. Maybe VC funds it
• 45:56
  Speaker 2: like Uber. But but they're like, oh yeah, then you
• 45:59
  Speaker 2: can do this heatedly. So we're going to solve the
• 46:01
  Speaker 2: false positive and the incidental oma stuff by just you'll
• 46:04
  Speaker 2: do this again and again and we'll watch things over time.
• 46:06
  Speaker 2: And the answer is like, okay, maybe, but we have
• 46:09
  Speaker 2: no data to suggest that that's the case yet.
• 46:12
  Speaker 1: Yeah.
• 46:12
  Speaker 2: So there's those five people in the in the Pernuvo
• 46:16
  Speaker 2: study that ended up having a cancer that Pernuvo missed.
• 46:19
  Speaker 2: I'll point out there's just some things that MRIs don't
• 46:23
  Speaker 2: see very well. So so breast, colon and thyroid are
• 46:26
  Speaker 2: like kind of classic hard to see on MRI. A
• 46:29
  Speaker 2: whole body MR you can get dedicated breast MRI, for example,
• 46:32
  Speaker 2: but that's not how this works. Breast and colon obviously
• 46:36
  Speaker 2: are ones that we screen for. So you know, even
• 46:39
  Speaker 2: if you're doing a whole body scan, you still want
• 46:41
  Speaker 2: to do your age recommended cancer screening too.
• 46:45
  Speaker 1: Yes, you just want to be constantly getting screened.
• 46:52
  Speaker 2: Got to generate those generate medical expenses.
• 46:57
  Speaker 1: So I think it's worth we're sort of saying how
• 47:03
  Speaker 1: common it is to find some kind of as you
• 47:06
  Speaker 1: call it, an incidental loma when we do these. When
• 47:08
  Speaker 1: we do these just in case people go to do it,
• 47:11
  Speaker 1: like what it's going to happen is not that they're
• 47:14
  Speaker 1: going to tell you everything's fine. Something is going to happen.
• 47:16
  Speaker 1: So to put some datea on this, there's a twenty
• 47:19
  Speaker 1: fourteen study that looked at six sixty six MRIs performed
• 47:25
  Speaker 1: on people, and they looked at what were the incidental findings,
• 47:28
  Speaker 1: And I think an important point to note is that
• 47:32
  Speaker 1: they found some incidental finding in six hundred and fifty
• 47:36
  Speaker 1: nine of the six hundred and sixty six people that
• 47:39
  Speaker 1: they scanned, so that is almost everyone. I don't know
• 47:42
  Speaker 1: what happened to those seven people, maybe there was an
• 47:45
  Speaker 1: error in their scan or something, but basically everyone found
• 47:50
  Speaker 1: something that was wrong. And you know, some of this
• 47:55
  Speaker 1: is in your brain, some of it is in your
• 47:58
  Speaker 1: your spine, some of that are renal cysts. There were
• 48:01
  Speaker 1: many different things that they found, but for me, the
• 48:03
  Speaker 1: headline here was like you always get something. Yeah, was
• 48:06
  Speaker 1: that your headline?
• 48:07
  Speaker 2: Yeah? And I mean, I'll put some numbers on it
• 48:10
  Speaker 2: for you. So like between twenty two in the younger
• 48:13
  Speaker 2: age group, twenty two percent had some evidence of brain infarct,
• 48:18
  Speaker 2: forty five percent in the older group. Things you know,
• 48:21
  Speaker 2: just like little areas of the brain that look like
• 48:22
  Speaker 2: they've had a problem in the past. Five percent of
• 48:25
  Speaker 2: the younger cohort had pulmonary nodules sixteen percent and the
• 48:28
  Speaker 2: older cohort renal cysts seventeen percent and forty one percent,
• 48:32
  Speaker 2: spinal degeneration twenty three percent and forty five percent. So
• 48:35
  Speaker 2: these are like you're gonna you're gonna see this stuff,
• 48:38
  Speaker 2: so be prepared, like you there's a very good chance
• 48:41
  Speaker 2: that someone's going to tell you after a full body
• 48:43
  Speaker 2: scan that you've got a nodule in your lung, you've
• 48:46
  Speaker 2: got a spot in your kidney, you have disgeneration, or
• 48:48
  Speaker 2: even that you may have at one point in the
• 48:50
  Speaker 2: past had a micro's stroke that you've never noticed.
• 48:54
  Speaker 1: Yeah, So can we talk about whether there are medical
• 49:00
  Speaker 1: risks to doing this? So, I mean we've talked a
• 49:02
  Speaker 1: tremendous amount about what I think of as sort of
• 49:05
  Speaker 1: cost risks, but also psychology risks. You know, you're going
• 49:08
  Speaker 1: to somebody's going to tell you have a you had
• 49:10
  Speaker 1: a mini stroke, Like maybe that's going to freak you out.
• 49:13
  Speaker 1: But we are also, interestingly, many of the same people
• 49:16
  Speaker 1: who are into these things are also very worried about
• 49:18
  Speaker 1: radiation from like their microwave, And so I always find
• 49:21
  Speaker 1: it interesting to I'd be like, people don't want to
• 49:23
  Speaker 1: stand in front of their microwave because of microwaves, but
• 49:26
  Speaker 1: then they want to go into an MRI machine and
• 49:29
  Speaker 1: get you know, zappered.
• 49:31
  Speaker 2: Yeah, is that a problem? I don't, I mean not really.
• 49:34
  Speaker 2: You know, the medical risk is mostly from the downstream stuff.
• 49:37
  Speaker 2: So MRIs don't use ionizing radiation, and contrast to CT scans,
• 49:41
  Speaker 2: So there theoretically is no increased risk of cancer from
• 49:45
  Speaker 2: repeated MRI scanning. There are companies that offer whole body
• 49:48
  Speaker 2: CEET scans, and that certainly is radiation and so like
• 49:51
  Speaker 2: that in theory would increase your risk of cancer over time,
• 49:54
  Speaker 2: But for a whole body MRI probably not. I guess
• 49:58
  Speaker 2: if you're claustrophobic, there's a risk you could break out.
• 50:00
  Speaker 6: You know.
• 50:00
  Speaker 2: Those tubes are a little bit Yeah, we should.
• 50:02
  Speaker 1: Say the MRI they put you on a tube and
• 50:04
  Speaker 1: they get you in this like great loud tube and
• 50:05
  Speaker 1: they go, yeah.
• 50:07
  Speaker 2: So it's it's not it's not super comfortable, but but yeah,
• 50:11
  Speaker 2: I don't think it's a cancer issue.
• 50:14
  Speaker 1: Okay, no cancer should is it? Okay to stand in
• 50:16
  Speaker 1: fron of the microwave? How is that? We'll do that later.
• 50:22
  Speaker 2: I have to watch my food carefully because I'm so hungry.
• 50:28
  Speaker 1: Okay. Does anyone think anyone in the official doctor space
• 50:34
  Speaker 1: think these are a good idea?
• 50:37
  Speaker 2: Uh? No?
• 50:39
  Speaker 1: Yeah.
• 50:39
  Speaker 2: The the formal like recommendations from the medical societies are like,
• 50:48
  Speaker 2: are are that no, that screening whole body MRI is
• 50:51
  Speaker 2: not cost effective and will not save lives?
• 50:54
  Speaker 1: How do they come? Like? I will say, though, twenty
• 50:58
  Speaker 1: two people, like, how do they confront that. I know,
• 51:02
  Speaker 1: some of those people maybe were saved by this.
• 51:06
  Speaker 2: Yeah, so you're saying there's a chance.
• 51:08
  Speaker 1: Yeah, you're saying there's a chance.
• 51:10
  Speaker 2: I mean, in the end, I think the problem is
• 51:13
  Speaker 2: that we don't have the real high quality study that
• 51:18
  Speaker 2: you would do here, which is a full on randomized
• 51:21
  Speaker 2: trial where you take ten thousand people and you do
• 51:23
  Speaker 2: a whole body MRI and you do take ten thousand
• 51:26
  Speaker 2: people that don't you follow them for ten years and
• 51:28
  Speaker 2: you see what happens. You know, the thing about those
• 51:31
  Speaker 2: twenty two people with cancer, we already like some of
• 51:34
  Speaker 2: them maybe the cancer never matters, never would have been detected,
• 51:38
  Speaker 2: they die of something else. Some of them the cancer
• 51:40
  Speaker 2: would be detected anyway, they develop a symptom. And although
• 51:47
  Speaker 2: it's often true that detecting a cancer earlier is better
• 51:52
  Speaker 2: than detecting it later, that's not always the case. And
• 51:55
  Speaker 2: you know, something comes up in some other way and
• 51:57
  Speaker 2: you pick up that cancer and you get to treat
• 51:59
  Speaker 2: it and there's no difference and outcomes and so there's
• 52:01
  Speaker 2: a lot of ways that even in those twenty two people,
• 52:04
  Speaker 2: like if you would do the sliding doors thing of
• 52:07
  Speaker 2: you know, their life where they went through the whole
• 52:09
  Speaker 2: body MRI and their life where they didn't go through
• 52:11
  Speaker 2: the whole body MRI. The outcomes end up being the same,
• 52:15
  Speaker 2: at least on sort of the broad population level.
• 52:18
  Speaker 1: Yeah. I like that study. That study is probably too expensive.
• 52:22
  Speaker 2: It's an expensive study. There's one study I really kind
• 52:26
  Speaker 2: of liked that. I thought it was clever in this space.
• 52:28
  Speaker 2: This is from the European Journal of epidem Aology, and
• 52:31
  Speaker 2: they actually they did a whole body MRI on about
• 52:35
  Speaker 2: thirty three hundred people, so everyone got it, but they
• 52:38
  Speaker 2: actually only disclosed the findings to half of them. That's
• 52:43
  Speaker 2: what they sort of randomized, which I think is really interesting.
• 52:47
  Speaker 8: Yeah.
• 52:48
  Speaker 2: I think this is sort of something that maybe you
• 52:49
  Speaker 2: could only do in Europe. And what they found is
• 52:54
  Speaker 2: that if you disclosed to people, the rate of biopsy
• 52:58
  Speaker 2: of something that turns out not to be care answer
• 53:00
  Speaker 2: was thirty nine percent higher. Okay, so basically, you see something,
• 53:05
  Speaker 2: they get biopsy and it's not cancer. So you've got
• 53:07
  Speaker 2: about a forty percent increased risk of getting a needle
• 53:10
  Speaker 2: stuck in you and it turns out to be nothing.
• 53:12
  Speaker 2: But the rate of biopsies that did turn out to
• 53:16
  Speaker 2: be cancer was seventy four percent higher. Now, there weren't
• 53:21
  Speaker 2: numerically there were very few of these, but sure enough,
• 53:24
  Speaker 2: some of those spots do turn out to be cancer,
• 53:26
  Speaker 2: as we've seen before. The authors concluded that there was
• 53:30
  Speaker 2: good evidence of overtesting an overdiagnosis and called for further research.
• 53:37
  Speaker 2: But I think this is a potential study design that,
• 53:39
  Speaker 2: like if people were willing to not hear their results
• 53:42
  Speaker 2: for two years, but then you can even imagine like
• 53:44
  Speaker 2: two years later when the study's over, they're like, oh,
• 53:47
  Speaker 2: by the way, here are your results. Like there's there's
• 53:49
  Speaker 2: a big spot on your liver.
• 53:50
  Speaker 1: Like check, get it checked out.
• 53:53
  Speaker 2: Don't be mad. I mean you have to do a
• 53:55
  Speaker 2: really good job of informed consent.
• 53:57
  Speaker 1: Yeah, yeah, I mean I think there's all kinds of
• 53:59
  Speaker 1: interesting sort of information procedures you could think about here,
• 54:04
  Speaker 1: Which is, you know, can you have your AI after
• 54:06
  Speaker 1: a reads the radiology report? Can you have it like
• 54:09
  Speaker 1: decide how to like which pieces of information are potentially
• 54:14
  Speaker 1: actionable and which are and which are not. Again, something
• 54:18
  Speaker 1: for which having more data would be more helpful.
• 54:21
  Speaker 2: I've got one other hypothetical for you. Yeah, Okay, Emily
• 54:24
  Speaker 2: as we're coming down to smasher past this. So I
• 54:26
  Speaker 2: was thinking that one of the issues on a population
• 54:30
  Speaker 2: level is the costs born by downstream care, which, as
• 54:33
  Speaker 2: we said, are sort of born by all of us,
• 54:35
  Speaker 2: and the profits are absorbed by these few companies. Okay,
• 54:39
  Speaker 2: imagine a world where the insurance companies start to say, like, look, listen,
• 54:44
  Speaker 2: we're not gonna pay for anything that happens downstream of
• 54:48
  Speaker 2: these scans, which I don't know if that's possible, or
• 54:52
  Speaker 2: give you an alternative view where they're like, Okay, anything
• 54:56
  Speaker 2: that you chase down after these scans, if it turns
• 54:58
  Speaker 2: out to be like a cancer or something that would
• 55:00
  Speaker 2: I killed you, we'll pay for all that care. But
• 55:02
  Speaker 2: if it turns out to be an incidental oma and
• 55:04
  Speaker 2: you get a biopsy and it's benign, we're not paying
• 55:06
  Speaker 2: for any of that. Do you think that changes the
• 55:11
  Speaker 2: individual calculus here if more of the risk of the
• 55:15
  Speaker 2: results is borne by the individual instead of like the
• 55:17
  Speaker 2: insurance company or society, does that change the outlook for
• 55:20
  Speaker 2: these companies?
• 55:22
  Speaker 1: I think it would change the outlook for the companies
• 55:24
  Speaker 1: quite a lot in the long term, because I think
• 55:27
  Speaker 1: it would limit their growth. I mean, right now, this
• 55:30
  Speaker 1: is broadly consumed by a set of people with quite
• 55:33
  Speaker 1: a lot of resources, for whom I suspect that incentive
• 55:38
  Speaker 1: would be pretty small on the margin.
• 55:41
  Speaker 2: They're like, Okay, I'll pay for it. That's fine.
• 55:43
  Speaker 1: Yeah, Kim Gardassian can pay for her extra stuff. But
• 55:47
  Speaker 1: if you think about trying to expand this into like
• 55:50
  Speaker 1: everybody has this, yeah, then yes, absolutely, it's going to
• 55:53
  Speaker 1: you know, the like downstream costs of this are going
• 55:56
  Speaker 1: to matter. On the other hand, again getting back to
• 55:59
  Speaker 1: the psychology, if you put it in a loss frame
• 56:01
  Speaker 1: like you are, we're going to find what if you're
• 56:04
  Speaker 1: one of the twenty two people like so, maybe it'll
• 56:07
  Speaker 1: cost you a little bit of money, but you might
• 56:09
  Speaker 1: find out that you have cancer and then not die
• 56:11
  Speaker 1: from it so soon. That's a very very very powerful pull.
• 56:18
  Speaker 2: All right, Emily, I need you to go first here.
• 56:20
  Speaker 2: You've got to tell me, please convince me, smash your pass.
• 56:23
  Speaker 2: This is really hard.
• 56:25
  Speaker 1: I also find this one very hard. But right now
• 56:29
  Speaker 1: I am a pass. I think that the the incidental
• 56:33
  Speaker 1: findings feel so much more central to me than the
• 56:37
  Speaker 1: other findings. And I think if people are doing a
• 56:41
  Speaker 1: good job of the regular cancer screenings that they are
• 56:45
  Speaker 1: supposed to be doing mimography, callon cancer screening, et cetera.
• 56:50
  Speaker 1: That is sufficient, So I'm a pass.
• 56:57
  Speaker 2: Yeah, those screenings had random LID trial data to show
• 57:02
  Speaker 2: that they decrease breast cancer specific or colon cancer specific mortality,
• 57:05
  Speaker 2: like they did that work. These companies have not done
• 57:08
  Speaker 2: that work yet. So by that standard, I'm going to
• 57:12
  Speaker 2: say I'm definitely a pass on the sort of population
• 57:15
  Speaker 2: wide level. But for an individual, I'm actually let me
• 57:19
  Speaker 2: just personally like, no, I'm a pass, Like, I don't
• 57:21
  Speaker 2: want to do this. I think I'll find it'll find
• 57:25
  Speaker 2: something that I have to deal with. I don't want
• 57:26
  Speaker 2: to deal with more. Sh I'm going to pass.
• 57:29
  Speaker 1: Okay, we're passing. You seem sad, but you know this
• 57:34
  Speaker 1: is so this I will say, this is the hardest
• 57:38
  Speaker 1: these that we have done for me in terms of
• 57:40
  Speaker 1: like the smash of pass decision. It's something I do
• 57:43
  Speaker 1: think about, like cause and I do all kinds of
• 57:45
  Speaker 1: other weird you know, like all these like blood tests
• 57:47
  Speaker 1: and all this kind of stuff, but this one is
• 57:49
  Speaker 1: just like one step too far from me.
• 57:51
  Speaker 2: Yeah, we're not going to blame anyone for doing it.
• 57:53
  Speaker 1: How about that No, that's for sure. We don't blame people.
• 57:56
  Speaker 1: All right, that's it for full body Scans. Your mail
• 57:58
  Speaker 1: back Question of the Week after the Break.
• 58:06
  Speaker 8: Hey, Emiliam Perry, this is Margaret from Charleston and my
• 58:09
  Speaker 8: question is about the shingles vaccine or I guess it's
• 58:11
  Speaker 8: called the Shingri vaccine, you know, the one for shingles.
• 58:16
  Speaker 8: I've been trying to convince my mother to get it
• 58:17
  Speaker 8: as a way of preventing dementia? Am I right about this?
• 58:20
  Speaker 8: Should I keep harassing her? Love the show?
• 58:23
  Speaker 1: Thanks so much so. There's a lot of new data
• 58:26
  Speaker 1: on this which I find very compelling, So I have
• 58:31
  Speaker 1: been trying. I will just say, full disclosure. I've been
• 58:33
  Speaker 1: trying to get my mother in law to get the
• 58:35
  Speaker 1: Shingrix vaccine for like a decade, and every time there's
• 58:38
  Speaker 1: new information about it, I send it to her. And
• 58:42
  Speaker 1: my read is that the evidence on dementia, while not
• 58:46
  Speaker 1: perfect randomized trial evidence, is increasingly quite strong. It's now
• 58:51
  Speaker 1: coming out of a number of studies stronger for women
• 58:54
  Speaker 1: than for men, and reasonably large effect sizes, you know,
• 58:59
  Speaker 1: five to ten percent reduction in dementia risk, which is
• 59:02
  Speaker 1: like pretty solid, pretty solid for something that also prevents
• 59:06
  Speaker 1: you from getting shingles, which I hear is a terrible experience, horrible,
• 59:11
  Speaker 1: so painful.
• 59:12
  Speaker 2: Yeah, I mean, the data on dementia is observational, right.
• 59:18
  Speaker 2: You look at large data sets of people, some of
• 59:21
  Speaker 2: whom got the vaccine, some who didn't, and then you
• 59:22
  Speaker 2: look and see if they end up with dementia. And
• 59:24
  Speaker 2: of course there are other factors that predispose both to
• 59:27
  Speaker 2: vaccination and maybe to your dementius. The sort of healthy
• 59:30
  Speaker 2: user effect you can adjust for a lot of things,
• 59:32
  Speaker 2: you know. That said, we interpret this in the context
• 59:34
  Speaker 2: of the risk of the vaccine, which is extraordinarily low,
• 59:37
  Speaker 2: the other benefits like preventing shingles, which is clearly documented
• 59:41
  Speaker 2: in randomized trials, and like, that's great. So this feels
• 59:44
  Speaker 2: like an icing on the cake thing. I will say.
• 59:46
  Speaker 2: Vercella zoster virus, which is the virus that causes both
• 59:49
  Speaker 2: chicken pox and shingles, is a weird one. It's a
• 59:53
  Speaker 2: DNA virus, so it can integrate into the DNA of
• 59:56
  Speaker 2: your cells. That's actually how it lays dormant for so
• 59:59
  Speaker 2: long and goes and it's sitting in your DNA and
• 1:00:03
  Speaker 2: just waiting to be reactivated and then for reasons that
• 1:00:06
  Speaker 2: we don't fully understand, stress sometimes like UV light or
• 1:00:09
  Speaker 2: whatever will reactivate this. That's actually why shingles appears in
• 1:00:14
  Speaker 2: a patch in your body, because it's traveling out from
• 1:00:17
  Speaker 2: a nerve, like it's coming from the nerve that innervates
• 1:00:19
  Speaker 2: that patch of skin. It's also why it's so incredibly painful.
• 1:00:22
  Speaker 2: So it integrates into DNA, and it's neurotropic, so it's
• 1:00:25
  Speaker 2: a virus that likes to infect nerve cells. So you know,
• 1:00:29
  Speaker 2: dementia nerve cells integrates into DNA lasts a really long time.
• 1:00:34
  Speaker 2: Like I'm there's a lot of convincing push here, so
• 1:00:38
  Speaker 2: I see no reason not to get this vaccine.
• 1:00:40
  Speaker 1: Yeah, I mean I think that in some sense, there's
• 1:00:42
  Speaker 1: no reason not to get this vaccine. There are other
• 1:00:44
  Speaker 1: reasons to get this vaccine other than the dementia risk.
• 1:00:47
  Speaker 1: And so in many ways this feels to me like, yes,
• 1:00:50
  Speaker 1: it's one more thing, but also it's just interesting and
• 1:00:53
  Speaker 1: it's an interesting thing to think about as we contemplate
• 1:00:55
  Speaker 1: what causes some people to have dementia versus first is
• 1:01:00
  Speaker 1: not having dementia. So yes, if my mother in law
• 1:01:04
  Speaker 1: is listening, you should get the shingles vaccine, like I've
• 1:01:08
  Speaker 1: been telling you.
• 1:01:11
  Speaker 2: All Right, that's it for us today. Stick with us
• 1:01:14
  Speaker 2: next week when we'll ask what's the deal with mRNA.
• 1:01:19
  Speaker 1: Wellness Actually is produced in association with iHeartMedia. Our senior
• 1:01:24
  Speaker 1: producer is Tamar Avishai. Our executive producer at iHeart is
• 1:01:27
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• 1:01:31
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• 1:01:55
  Speaker 1: We'll let the influencers have the last word.
• 1:01:58
  Speaker 9: I got my results from my pronuvosk and if you
• 1:02:00
  Speaker 9: don't know who that is, it's a full body MRI.
• 1:02:02
  Speaker 9: So we're gonna go over what they found. And they
• 1:02:05
  Speaker 9: found twenty six findings. So when I saw this, I
• 1:02:07
  Speaker 9: was like, oh my gosh, there's twenty six things that's
• 1:02:09
  Speaker 9: wrong with me. But really yes, but no. But with
• 1:02:13
  Speaker 9: the minor findings that they did find is that this
• 1:02:16
  Speaker 9: right here is my lip filler. It says right here,
• 1:02:18
  Speaker 9: just like filler or botox injections. So this is just
• 1:02:21
  Speaker 9: showing my lip filler, which is like okay,