What's the deal with full body scans?

22:30Emily Oster:Yeah. That was their thing. That's what I'm familiar with. Now they're a full body scanning company. They're pivoting. And they've showed a demo of like, you get submerged in water and this thing goes like bloop and you get a whole scan of your body using ultrasound waves. And then what? How does that help? What? Well, it's the similar idea to the full body MRI scans, except they're arguing it'll be cheaper and we can sort of get to the costs in a minute and the problems with full body ultrasound as well. I just want to say it at the top because I think people will start hearing about this and we will touch on it, but frankly, the data is all in that full body MRI scan space.

23:12Emily Oster:This full body ultrasound is completely new and there's very little we can say about its diagnostic accuracy or anything because it hasn't been really used on humans yet, but you'll see it in your feeds. How much do you think that the AI, the growth of AI is powering this? I mean, radiology is one of the things that AI is sort of the best at, the best kind of doctoring on. I would have thought this is like, we're only able to do this because AI is reading a huge share of these scans. In almost all of these companies, AI is billed as augmenting the read from the radiologist. No one is saying like, it's only AI.

23:46Emily Oster:You look skeptical. No, I think that's, I mean, that is the way that radiology, I think, will work for everything is that the AI does a first read and somebody does a follow-up read. We have actually quite a significant radiologist shortage at the moment. And so this is a natural place for AI to come in, including for these kinds of scans. Yeah. And if you're one of these companies trying to raise money from investors? Like, are you not going to say that AI is part of it? You're going to say you're an AI. It's like everybody's an AI company. I'm a meal delivery service. It's more of an AI meal delivery, AI steak.

24:22We're optimized. AI, it's all about it.

24:25Emily Oster:Okay. Total aside, but my dystopian prediction for the future of AI and consumerism is that soon enough, Amazon is actually going to start sending things to your house that you haven't ordered. It's going to show up and then they'll be like, look, look, send it back if you don't want it. That already happens in my house because one of my children has ordered it, but it's going to be even worse when Amazon is doing it. All right. Mark my words. Okay. So before we get into what do we know about these things in the data, I actually want to start a little bit bigger picture with how we think about scanning and how we think about results that we get in medicine.

25:09So I'm going to give you a quiz. It's a quiz for everybody. So everybody put your thinking cap on. Imagine you have a disease that affects one in 10 ,000 people. Okay. And you have a test for the disease that detects 99 % of cases with a 2 % false positive rate. So it's a really good test. It finds 99 % of cases, small false positive rate of 2%. Amazing test. Sounds great. You give someone the test and they test positive. What is the chance that they have the disease? Short Jeopardy pause. Okay. What do you think?

25:46Emily Oster:I think that all your bays are belong to us. I know what you're getting at here, But let me tell you what I think your intuition is, and then we can talk about why the intuition is wrong. The intuition is here's a test that detects 99 % of disease. Great. Only has a 2 % false positive rate. Great. You got a positive test. Pretty sure you have the disease. Pretty sure you have. That sounds right. Yeah. Bad, bad news, right? You have the positive test. But you mentioned that this is a pretty rare disease, one in 10 ,000. And so maybe you can walk us through the math, Emily, of like what the actual value of a positive test is here.

26:27So the answer to the question is one half of 1%. So with a positive test, the chance that you actually have the disease is 1 in 200. And the reason for that is that if you think about this test, let's say you have 10 ,000 people you test. One of them has it. You're going to find that. Very, very good chance you find that 1%.

26:49Emily Oster:99 % chance you find a guy. 99 % chance. Let's say we find that one person, and then there's a 2 % false positive rate. And that means of the 9 ,999 people who don't have it, about 200 of them are going to test positive. And so now you've got 200 people who tested positive who don't have it, and one person who tested positive who does. And that means that it's about one in 200, that's the chance that you actually are affected. And so - If you're sitting there with a positive test. So I think this is a really, like, I have given this test to many people, ranging from middle school students to members of an Ivy League corporation.

27:31And almost nobody gets it, right? And in fact, when you give this to doctors, they also mostly don't get it right. I guess you're an exception. And a lot of people have the instinct it's like 95%. percent. The reason that I say this is that one of the most significant issues with this kind of full body scan, and by the way, with any kind of scanning for conditions, is that many of these conditions are pretty rare and false positives are pretty common. So when you go to scan people for something like breast cancer, even with a standard mammogram, there's a lot of false positives, a lot of incidental findings, a lot of just we saw something on the mammogram, and then when we went more into it, it wasn't in there.

28:18And that's important for two reasons. One is that if you do more of this scanning, you're just going to have more of these false positives. Now you'll have more true positives also, but you will end up with a lot of people either very anxious or just having a lot of additional testing that they didn't necessarily need. And when we think about these tests, we want to weigh those things. And full body scans are an extreme form of a problem that is already there with any kind of scanning. So we already think about this problem with breast cancer screening or colonoscopy or prostate cancer screening or whatever.

28:52That's already an issue. If you're now scanning somebody's entire body and picking up every weird rando thing in their elbow, So you're going to have this problem even more extreme.

29:06Emily Oster:This is so important. But it's also going to play into the central tension that I have with these scans. And we'll get there. But broadly speaking, there's always going to be this thing that we can look objectively at the numbers on a population level and be like, okay, yeah, there's a lot of false positives and people are going to be chasing this down and seeing the doctor and stuff. But there is that one guy. What if it was you? There's that one guy you said who actually had that rare disease that we caught. And there's clearly some value in catching that one guy. But the question is sort of how many false positives is worth the true positive.

29:47Emily Oster:And this is where I like get stuck on full body scans. And I think that's a part of the reason it's a very complicated question is that it's probably different if we think about what the individual incentive is versus the health system incentive. So when we make decisions about who should we recommend a mammography for, we're making decisions based on trading off false positives and true positives from a kind of like population cost perspective, which may be the right frame for some decisions, but may be different from you as an individual and what is sort of your risk tolerance and what is your demand?

30:26And I will tell you from a personal level, when my mom was diagnosed with lung cancer, it was an incidental finding on a CT scan that was being done for some other reason. She had vertigo. They thought she might have a stroke. It turned out they found lung cancer. She was in a risk group because she was a former smoker who like could have been going for yearly CT scans. And there's a lot of debate about exactly who should be doing those. And I think all the time, like, boy, ex post, I really wish that she had, she had been doing that, even if it, you know, from a kind of population standpoint, maybe that isn't, that isn't the right thing.

31:08So for me, that really crystallizes this trade-off between what about the one that you missed?

31:14Emily Oster:Yeah, a hundred percent. So there are a couple of concepts that I want people to be aware of. You've hit on one, which is the false positive thing. In medicine, we call these incidentalomas. I know you should just give things regular names. What's wrong with you? You know, because we like to have jargon. It's an oma. Oh, it's an incidentaloma. It's an incidentaloma. This was originally named after these things you see on adrenal glands when you get a CAT scan of the abdomen. So we give people CAT scans of the abdomen for, you know, everything, right? You come in with abdominal pain to the ED, whatever.

31:48Emily Oster:You're getting a CAT scan, you're having a pelvis. And then, you know, not infrequently, you see these little spots on an adrenal gland. We typically refer to them as incidentalomas. They were found incidentally. You weren't looking for them, but they tend to necessitate at least some further workup and downstream stuff. And that can happen anywhere in the body. Incidentalomas are things that turn out to be nothing. So you find them and then you've got to do something about it. But then it turns out it didn't matter, right? Like you biopsy that thing on your adrenal gland and it was a benign, it was a benign growth.

32:26Emily Oster:It would never have hurt you. It's an incidentaloma. There's a related concept which people have a little more trouble with called overdiagnosis, which is when you diagnose something that really is bad, like a cancer or something like that. But it turns out that had you not diagnosed it, it probably wouldn't have hurt you at all because you were going to die of something else before this got to you at all. So overdiagnosis is sort of a different thing from an incidental limb or a false positive. To give you a sense, it's hard to get it like some of this stuff, but there are autopsy studies where we'll look at people who died of something else and ask a question, for example, of like, okay, you died of not a cancer-related problem.

33:11Emily Oster:We do an autopsy. How often do we find cancer? And the answer is pretty often. Yeah. 5 % of the time, there's a nice study of 800 ,000 non-cancer autopsies in Japan, where the overall cancer rate was 4.2%. I will say it's a little higher in recent years. Now, it's like up to 7 % overall. And then of course, the older the person was when they died, the higher the chance of finding an incidental cancer was. This isn't a false positive. Had you found that while they were alive and biopsied it, it would have come back cancer. They would have gotten cancer treatment, but they didn't die of that. So all of that treatment was theoretically overdiagnosis.

33:51Emily Oster:So that's the second major concept. Yeah. And I think this is, I mean, this is where, you know, for men in particular, a lot of men get prostate cancer before they're dead. And at some point we - Almost everyone. Almost everybody gets it. And at some point, it makes sense to just stop screening for prostate cancer because if you're 93 years old and we find out you have prostate cancer, it's fine. Something else is going to take you before the prostate cancer for almost everybody. And so that is in this space of overdiagnosis. Again, it's not that it's not cancer. We care about the death, not the specific cause of death.

34:27Emily Oster:Yeah. So this brings me back to Kim K, Kim Kardashian. Of course, Kim K, Kim K. What's Kim K up to? So what Kim Kardashian told the world, I mean, we don't have her report, her Pernuva report, but what she said publicly is that they found a little or small aneurysm in her brain as well as some uterine fibroids. She said that after Pernuva found a little aneurysm in her brain, she went to Cedars-Sinai. She got, quote, tons of brain scans, met with a bunch of neurosurgeons, et cetera, et cetera, and decided to do nothing. It was small enough that they decided to do this thing called watchful waiting.

35:06Emily Oster:That's probably the right choice. Talking about overdiagnosis of aneurysms, if you look at the rate of incidental brain aneurysms at autopsy, okay, so you take people who did not die of a brain aneurysm, but you look at their brain after they died, 2 % to 6 % have an aneurysm in there. So they are there, and a lot of them don't rupture. and Kim Kardashian's surgeons looked at the size and said, well, this is something we can keep an eye on. Now she billed this as like a life-saving thing. Like she has talked about this as she's so thankful to know about this. She's reducing the stress in her life to potentially reduce the risk of this aneurysm bursting.

35:48I would find this so awful. Like, I mean, I feel like at least for some people, and I would put myself in this camp, the idea that I have this aneurysm, but I'm doing nothing about it, is so much worse than not knowing, because then every time you have a headache, you're like, oh my God, is it my aneurysm? Right? And I, this is a big part of this, is people just being anxious about what might happen because the information is, because we're not robots and we can't like just pretend the information is not there. And I don't know. Yeah.

36:23Emily Oster:And so much of what I see when, and it's mostly doctors online who are pushing back against full body scans. It's mostly like people, my, my profession that's like, guys, careful, false positives, you know, all this kind of thing. And then there's a lot of sort of wellness tech people who are like, no, no, no, you know, more information is better. I want to find the thing before it becomes a problem. And Hey, I know there's, you know, I know there's false positive. I know there's over diagnosis. We'll figure that out over time. We'll like learn how better to manage these things. And that's the step where I'm like, you know, this is going to require, if you really want to deal with a false positive issue, a lot of people to have a spot on their liver and to be like, well, there's a 1 % chance it's cancer or maybe a three, let's say there's a 5 % chance it's cancer.

37:11Emily Oster:There's a 95 % chance it's not. I'm not going to do anything because like chances are it's fine. There are some people who can handle that. There are a lot of people who can't, right? Like the whole reason they did the scan was to find the spot on the liver. Now it needs a biopsy. Yeah. And I think we see this in, you know, in outside of the full body scan space in, you know, in mammography. So our mammogram, proportion mammograms have gotten better over time. We're doing more mammograms broadly. That's very good. It means we're catching cancers earlier, but there's actually a fairly large, or at least some set of kind of stage zero cancers for which it may be based on the age of the person or what it looks like.

37:48You just shouldn't do anything. And we are almost always doing things. So typically people will be given the choice. We could do watchful waiting or we could do stuff and people want to do stuff. Once they say you have ductal blah, blah, blah with the word carcinoma on it, you're doing stuff. And that is maybe a good idea, but it does have trade-offs. I think it's just not free for you or for money. I mean, it's not free in terms of money, but it's not free in terms of your emotional state either. Yeah.

38:21Emily Oster:I want to walk through the sort of third large concept, which we've tested on here, which is called care cascades. Can I say before we get to that, can I say sort of something else that happens in here where I think this intersects with some of the way we're doing medicine these days, which is it is much more common for people to do like a share, what do we call it? Share decision making. And share decision making is great because it puts the patient in the driver's seat some of the time. And we generally don't want the kind of 1950s doctor where it was like, he sits there and smokes a cigarette and tells you what to do.

39:00Like we've moved away and that's probably for the best, especially with cigarettes.

39:03Emily Oster:We're not going to tell your wife she has cancer. It will just disturb her. It'll just make her sad. But the idea that the patient should be in the driver's seat around some of these decisions is very stressful for people. And somehow it comes up more in these cases where we're just not sure what to do. And that piece of it feels like, I'm not sure there's a good solution to it, but I think it's yet another piece to adding to this anxiety. Yeah. It varies, obviously, based on the patient. Some patients very much want to be told what to do. It's my experience. And they'll phrase that in different ways, but often it comes to me as like, okay, if I were your brother or if I were your father, what would you tell me to do here?

39:44Emily Oster:Which is always a hard question for me. I'm like, no, I would never tell my own family because I'm completely biased. And then some, yeah, some have very strong opinions. And then, I mean, just to say it, as a doctor, there are medical legal implications of this stuff, right? Someone comes to me after a full body scan and says, hey, they found this thing on my kidney. It's ambiguous what it is. Could be cancer. Might not be. What do you think I should do? There's definitely a part of my brain that's like, well, if I don't work this up, if I'm like, well - What if it is cancer? What if it is cancer five years from now?

40:26Emily Oster:And so that's just sort of the way we're structured, it's much safer for me in a cover your ass kind of sense to be like, all right, well, let's get you a dedicated scan of that. Let's get a biopsy of that and so on and so forth. And that is what happens. So a lot of these arguments that's like, oh, guys, we just, it's not the scans that are the problem. It's the psychology around them. And we have to get better at dealing with ambiguity is a nice theory, but we're just not very good at it. No, we're just not. It's a nice theory, but not very realistic. Yeah. All right. A guy walked into a routine physical feeling completely fine.

41:01Emily Oster:He walked out 10 units of blood and$50 ,000 later, and he never actually had anything wrong with him. This is Care of Pascades. Not great. This is such a great piece of writing from Michael Rothberg, who was writing in JAMA about the true experience of his father and how medicine obligates subsequent testing. So let me tell you what happened to this person and get your opinion. Okay. This older guy comes in, gets his routine physical. His doctor does a physical exam, listens to his heart, pushes on his belly, feels his aorta, an aortic exam. You kind of push down the belly, feel the pulse. The doctor thinks the aorta is a little bit big.

41:46Emily Oster:Maybe there's an aneurysm there, but there's an appropriate test for that. That's an abdominal ultrasound. So he sends them for an abdominal ultrasound. Turns out the aorta is normal. But during that ultrasound, they see something in the head of the pancreas. That's an incidental finding. All right. Well, now there's something in the head of the pancreas. So the next step is, of course, to get a CT scan. Well, good news. The CT scans showed the pancreas was normal, but there was a solitary lesion on his liver. Okay, that needs to be biopsied. So he gets a liver biopsy. It's not liver cancer. That's good news.

42:17Emily Oster:But it was a hemangioma, which led to a huge bleed requiring a 10 units blood transfusion and an inpatient stay that cost$50 ,000. Every step of this care was appropriate. There was no malpractice here. This is all exactly what you do. The only exception actually is that initial physical exam palpating the aorta. There's no evidence that we're good enough at our physical exam to tell if someone's aorta is dilated or not. But like if your doctor does that, right, you're still like, oh, this is a good, I mean, this is their job. They're doing stuff. They're doing stuff. They listen. This is a care cascade, albeit obviously one that's very dramatic.

43:00Emily Oster:But I love this story because it illustrates how like these aren't bad decisions. Every step of this way was the answer to the board question. Like, what do you do if you see a mass in the head of the pancreas? Oh, you get a dedicated CT scan. Like that is all correct. But it all started from a screening test. In this case, it was a physical exam, not a full body scan. Yeah, I mean, that's obviously a very extreme story. but I do think it is, even in the Instagram versions of this, it is what we're seeing from a lot of people who have these scans. You see this, you see this, you see, you know, this, your liver is too big.

43:42You know, like at least one person I know has had these, like they were like, just like your liver is enormous. Like you have an enormous liver and it led to all this stuff. And it just turned out like this person just had kind of a big liver. Like sometimes sometimes you have that. And so we're over diagnosing, we're care cascading, we're just, but again, it's not that the decisions were wrong. And I think that's, that's the question is where do you stop the decisions? I think that's what's such a hard piece of this is, which of these things do you not want to do? Which piece of information do you want to just stop?

44:13And then we're tempted to say, well, you know what, I just shouldn't have gotten the, the information in the first place. And then we wouldn't have been, wouldn't have had all these other problems, but then what if you miss the one guy? That's why this is hard.

44:23Emily Oster:That's all right. So we've got the big concepts. People, all right, everyone understands now we have a visceral feeling about what the, conceptually what the issues are. I think we need to talk about the data. Yes. What happens when this actually occurs? I don't know. Okay. So let's say a thousand people get a full body scan. 70 of them, just 70 are going to get totally normal results. 930 will have something abnormal. 300 of them will need some specific follow-up. 22 will have cancer. Five will have cancer that the scan missed. Anyway, that is a broad summary of the data from these full body scans.

45:11How do we feel about that? It doesn't seem amazing.

45:15Emily Oster:This crystallizes everything we've been saying to me. All right. First of all, if you're going to get one of these scans, this, by the way, this data comes from the Polaris study, which is a Prunuvo funded study. It's still recruiting, but this was their initial read. So yeah, you get one of these scans, there's a 93 % chance they'll find something abnormal. Like if you think you're going to go and get a clean bill of health, you're not. You're not. No. And I think that's good. That's good for people to know coming into this. Right. You know, like, like if you go for one of these, like they're finding something, right?

45:45This is like, this actually what my doctor told me the first time I had a mammogram. She was like, they always find something. It's probably fine.

45:51Emily Oster:Yeah. The next question, of course, is, is it actionable, right? Like, like, you know, People have found, for example, modest slip discs or something like that. And for some people, that's useful. Like, oh, that's why I have back pain. Okay, great. There's nothing to be done about it or maybe get some PT. But 300 of – so 30 % of people will have a finding that requires specific follow-up. Like you now have to see another doctor or get another scan or get another test or something to tie this together. And that's where we start running into this – there's sort of an ethical issue here which is that the ethical issue with full body scans is that they privatize profits, but socialize the risks.

46:35Emily Oster:This is one of the problems I have with these companies is that like they make money from us, right? Like you pay them. But if they find something, like your insurance company pays for all that subsequent workup and stuff. And the more people that do this, the companies keep that money, right? They keep the profits that they've made. but theoretically you're the economist Emily theoretically if we're chasing down all these incidental Lomas it's going to drive up insurance costs for everyone right because the insurance just has to be like well part you know we got to allocate x number of dollars per person for the weird stuff that it's going to get fined in full body sure and also like there's a much more direct version of this which is if anybody is over 65 we're already you know your tax dollars are paying for their health care and so if they get this thing then medicare is paying and you're paying for medicine.

47:23Emily Oster:So you're not, the 30 % of people who get follow-up, like generally, they're not paying for, well, they're paying their deductibles or whatever. And so people should be aware, especially if you have a high deductible plan that you might be digging into that. But, you know, that's still sort of a socialized form of medicine. 22 have cancer and here's, and this is a study where they proved it. These are biopsy proven cancers. So 2.2 % out of the thousand people who got a Pernuvo scan. And this is where I keep just like hitting the wall in terms of what I think about this. Because from a public health standpoint, I'm like, clearly this is a bad idea.

48:00Emily Oster:It costs way too much to the public. No agency would ever recommend this. It's clearly not cost effective. You're spending so much money chasing down nonsense. But for an individual who, one of those 22 people, Emily, what if you're one of those 22 people? Yeah. And I think it's once you put it in that frame, again, our psychology makes it very difficult because then you're in a, I don't know, like a loss frame of basically if you don't do this, what if you're one of the 22 people? And then that's the salient. That's the salient fact that feels terrible. And of course, I would do anything to not be, you know, to have this found as part of those 22 people.

48:45Yeah.

48:46Emily Oster:Now, we don't know if those 22, what number of them are over diagnosis, right? So some, in theory, those cancers that really were found might have never amounted to anything. I think people might not appreciate this is like we as doctors don't really understand disease before it becomes symptomatic in a lot of cases. Because the way we diagnose most cancers, not the screening ones, not breast cancer and colon cancer, but cancers that come up in other ways is because someone has symptoms. Yes, sometimes they get found incidentally. We know that it seems that cancers start off small and get bigger over time.

49:28Emily Oster:We tend to find them when they are not small, unless it's a screening-detected cancer. we don't really know if the small ones always become the big ones. Like we don't, because we've never done a study where we do a full body scan and just sit on our hands and watch. Maybe, maybe that'll happen in the future. I'm not sure, but it's, it, you're sort of obligated because of your understanding of cancer biology to like, you got to do something about these 22 cancers, but I can't tell you for sure that they all would have killed these people. Yeah. I mean, I think what's missing from this discussion and from the data is probably two things.

50:08So one is just a lot of these being done, right? So if we had a bigger database and we understood more about what are the things that will turn into something and what are the things that are not, then this information would be more valuable because you would have more of a sense of what to action on. Even within those people with the abnormal findings, you would have a better sense of like, you know, yeah, like 73 % of people have a lesion on their pancreas is no big deal. Like we see that all, we see that all the time. Since we haven't done this, it's hard to say that. I think the second piece here is most of the time people are doing this once, or at least most of the data is on the first time you do a scan.

50:47And a lot of what we are looking for in medicine to diagnose whether something's a problem is it, is a change, right? Think about dermatology, Think about skin cancer screening. Why do you go back to the dermatologist every six months if you're at high risk for skin cancer? It's because they're looking for, did that change? There's no problem with just being a person full of moles. The problem is when your moles start looking weird and being a different weird color. And this is a case where if you had one scan and then you can compare them over time, that second scan is going to be a lot more cost effective than the first scan.

51:24because the second time you do the scan, all of those things that like we saw it before, and it looks the same now, we're just ignoring, we're into the things that are changing. And I think that's the kind of promise here. I assume Pernuvo tells you you should do this every 23 days or whatever, because that's what money is for. But it does feel like that's a piece of something.

51:44Emily Oster:I think there's something there. I will say the mid journey, that whole body ultrasound, submerging water, like sci-fi thing is specifically marketing it for that. They're like, we're going to be cheaper. They're saying it might only be$100 a scan, which I've got a bridge to sell you if it turns out to be$100, but that's fine. Maybe VC funds it like Uber. But they're like, oh yeah, then you can do this repeatedly. So we're going to solve the false positive and the incidentaloma stuff by just, you'll do this again and again, and we'll watch things over time. And the answer is like, okay, maybe, but we have no data to suggest that that's the case yet.

52:18Emily Oster:So there's those five people in the Prunuvo study that ended up having a cancer that Prunuvo missed. I'll point out there's just some things that MRIs don't see very well. So breast, colon, and thyroid are kind of classic, hard to see on MRI, a whole body MRI. You can get dedicated breast MRI, for example, but that's not how this works. Breast and colon obviously are ones that we screen for. So even if you're doing a whole body scan, you still want to do your age-recommended cancer screening too. Yes. You just want to be constantly getting screened. Got to generate those medical expenses. Um, so I think it's worth, uh, worth sort of saying how common it is to find some kind of, as you call it, an incidentaloma when we do these, when we do these, just in case people go to do it, like what, what is going to happen is not that they're going to tell you everything's fine.

53:21Something is going to happen. So to, to put some data on this, there's a 2014 study that looked at 666 MRIs performed on people, and they looked at what were the incidental findings. And I think an important point to note is that they found some incidental finding in 659 of the 666 people that they scanned. So that is almost everyone. I don't know what happened to those seven people. Maybe there was an error in their scan or something. But basically everyone found something that was wrong. And some of this is in your brain. Some of it is in your spine. Some of them are renal cysts. There were many different things that they found.

54:09But for me, the headline here was like, you always get something. Was that your headline?

54:13Emily Oster:Yeah. And I mean, I'll put some numbers on it for you. So like between 22 in the younger age group, 22 % had some evidence of brain infarct, 45 % in the older group, things, you know, just like little areas of the brain that look like they've had a problem in the past. 5 % of the younger cohort had pulmonary nodules, 16 % in the older cohort, renal cysts, 17 % and 41%, spinal degeneration, 23 % and 45%. So these are like, you're going to see this stuff. So be prepared. There's a very good chance that someone's going to tell you after a full body scan that you've got a nodule in your lung, you've got a spot in your kidney, you have disgeneration, or even that you may have at one point in the past had a micro stroke that you never noticed.

55:00Yeah. So can we talk about whether there are medical risks to doing this? So, I mean, we've talked a tremendous amount about what I think of as sort of cost risks, but also psychology risks. You know, you're going to, somebody is going to tell you have a, you had a mini stroke, like maybe that's going to freak you out. But we are also, interestingly, many of the same people who are into these things are also very worried about radiation from like their microwave. And so I always find it interesting to be like, people don't want to stand in front of their microwave because of microwaves, but then they want to go into an MRI machine and get, you know, zappered.

55:37Emily Oster:Yeah. Is that a problem? I don't, I mean, not really. You know, the medical risk is mostly from the downstream stuff. So MRIs don't use ionizing radiation in contrast to CT scans. So there theoretically is no increased risk of cancer from repeated MRI scanning. There are companies that offer whole body CT scans, and that certainly is radiation. And so like that, in theory, would increase your risk of cancer over time. But for a whole body MRI, probably not. I guess if you're claustrophobic, there's a risk you could freak out. You know, those tubes are a little bit tight. Yeah, we should say the MRI, they put you on a tube and they get you in this like quite loud tube and they go.

56:13Emily Oster:Yeah. So it's not super comfortable. But yeah, I don't think it's a cancer issue. Okay. No cancer. Is it okay to stand in front of the microwave? How else are you going to do it? We'll do that later. We'll do that later. I have to watch my food carefully because I'm so hungry. Okay. Does anyone think anyone in the official doctor space think these are a good idea? No. The formal recommendations from the medical societies are that no, that screening whole body MRI is not cost effective and will not save lives. How do they come – like I will say though 22 people. Like how do they confront that some of those people maybe were saved by this?

57:12Yeah.

57:12Emily Oster:So you're saying there's a chance. Yeah. You're saying there's a chance. I mean, in the end, I think the problem is that we don't have the real high quality study that you would do here, which is a full on randomized trial where you take 10 ,000 people and you do a whole body MRI and you take 10 ,000 people that don't. You follow them for 10 years and you see what happens. You know, the thing about those 22 people with cancer, we already like some of them, maybe the cancer never matters, never would have been detected. They die of something else. some of them, the cancer would be detected anyway.

57:49Emily Oster:Like they develop a symptom. And although it's often true that detecting a cancer earlier is better than detecting it later, that's not always the case. And something comes up in some other way and you pick up that cancer and you get it treated and there's no difference in outcomes. And so there's a lot of ways that even in those 22 people, like if you would do the sliding doors thing of their life where they went through the whole body MRI and their life where they didn't go through the whole body MRI, the outcomes end up being the same, at least on sort of the broad population level. Yeah. I like that study.

58:27That study is probably too expensive.

58:28Emily Oster:It's an expensive study. There's one study I really kind of liked that I thought was clever in this space. This is from the European Journal of Epidemiology. And they actually, they did a whole body MRI on about 3 ,300 people. So everyone got it, but they actually only disclosed the findings to half of them. That's what they sort of randomized, which I think is really interesting. Yeah. I think this is sort of something that maybe you could only do in Europe. And what they found is that if you disclosed to people, the rate of biopsy of something that turns out not to be cancer was 39 % higher.

59:08Okay.

59:09Emily Oster:So, so basically you see something, they get biopsied, it's not cancer. So you've got about a 40 % increased risk of getting a needle stuck in you and it turns out to be nothing. But the rate of biopsies that did turn out to be cancer was 74 % higher. Now there, there weren't numerically, there were very few of these, but sure enough, some of those spots do turn out to be cancer, as we've seen before, the authors concluded that there was good evidence of over-testing and over-diagnosis and called for further research. But I think this is a potential study design that if people were willing to not hear their results for two years, but then you can even imagine two years later when the study's over, they're like, oh, by the way, here are your results.

59:54Emily Oster:There's a big spot on your liver. Don't be mad. I mean, you have to do a really good job of informed consent. Yeah. Yeah. I mean, I think there's all kinds of interesting sort of information procedures you could think about here, which is, you know, can you have your AI after it reads the radiology report, can you have it like decide how to, like which pieces of information are potentially actionable and which are not? Yeah. Again, something for which having more data would be more helpful. I've got one other hypothetical for you. Yeah. Okay. Emily, as we're coming down to smash or pass this. So I was thinking that one of the issues on a population level is the costs borne by downstream care, which as we said, are sort of borne by all of us and the profits are absorbed by these few companies.

1:00:44Emily Oster:Okay. Imagine a world where the insurance companies start to say, like, look, listen, we're not going to pay for anything that happens downstream of these scans, which I don't know if that's possible. Or I'll give you an alternative view where they're like, okay, anything that you chase down after these scans, if it turns out to be like a cancer or something that would have killed you, we'll pay for all that care. But if it turns out to be an incidentaloma and you get a biopsy and it's benign, we're not paying for any of that. Do you think that changes the individual calculus here? If more of the risk of the results is borne by the individual instead of like the insurance company your society, does that change the outlook for these companies?

1:01:28I think it would change the outlook for the companies quite a lot in the long term because I think it would limit their growth. I mean, right now, this is broadly consumed by a set of people with quite a lot of resources for whom I suspect that incentive would be pretty small on the margin. They're like, okay, I'll pay for it.

1:01:49Emily Oster:That's fine. Yeah. Kim Kardashian can pay for her extra stuff. But if you think about trying to expand this into like everybody has this, yeah, then yes, absolutely. It's going to, you know, the like downstream costs of this are going to matter. On the other hand, again, getting back to the psychology, if you put it in a loss frame, like you are, we're going to find what if you're one of the 22 people, like, so maybe it'll cost you a little bit of money, but you might find out that you have cancer and then not die from it so soon. That's a very, very, very powerful pull. All right, Emily, I need you to go first here.

1:02:26Emily Oster:You've got to tell me, please convince me, smash your pass. This is really hard. I also find this one very hard, but right now I am a pass. I think that the incidental findings feel so much more central to me than the other findings. And I think if people are doing a good job of the regular cancer screenings that they are supposed to be doing, mammography, colon cancer screening, et cetera, that is sufficient. So I'm a pass. Yeah. Those screenings had randomized trial data to show that they decreased breast cancer specific or colon cancer specific mortality. They did that work. These companies have not done that work yet.

1:03:15So by that standard, I'm going to say I'm definitely a pass on the sort

1:03:20Emily Oster:of population-wide level. But for an individual, I'm actually, let me just personally, like, no, I'm a pass. Like, I don't want to do this. I think I'll find, it'll find something that I have to deal with. I don't want to deal with more shit. I'm going to pass. Okay. We're passing. You seem sad, but you know, this is, so this, I will say this is the hardest one. of these that we have done for me in terms of like the smash or pass decision. It's something I do think about. Like, cause, and I do all kinds of other weird, you know, like all these like blood tests and all this kind of stuff. But this one is just like one step too far for me.

1:03:57Emily Oster:Yeah, we're not going to blame anyone for doing it. How about that? No, that's for sure. We don't blame people. All right, that's it for Full Body Scans. Your mailbag question of the week after the break.

1:04:10Apple Vacations,

1:04:11Emily Oster:where your story starts. The Splash Into Savings event from Apple Vacations is here. Now through June 25th, save up to$150 on vacation packages, plus instant savings at select resorts in Mexico, the Caribbean, Central America, and top U.S. destinations. Use promo code JUNE26 for these limited-time offers. Start planning today at AppleVacations.com or contact your travel advisor. Apple Vacations, where your story starts. This is Tony A.O. from The Real Report with Tony A.O. and Uncle Murda. You ever notice how everything keeps going up? Rent's going up. Streaming services are going up. Even your favorite burrito spot suddenly thinks salsa should cost extra.

1:04:51But with Boost Mobile, you and your phone bill don't have to play the will it go up soon game. Because Boost Mobile has an unlimited talk, text, and data plan at a price that'll never go up. It's the same price you'll pay for life. Meaning you're set to never worry about your bill increasing again for as long as you're on the plan. While the world keeps finding new ways to nickel and dime you, Boost Mobile gives you unlimited wireless at one set price for life. Imagine something in your budget actually staying the same. You'll pay the same for unlimited wireless when you're posting mirror selfies in your 20s and when you're posting mirror selfies in retirement.

1:05:24Some things never change. Switch now for unlimited wireless at a price that'll never go up, only at Boost Mobile. After 30 gigabytes, customers may experience slower speeds. Customers will pay$25 a month as long as they remain active on a boost unlimited plan. Who doesn't love warm carby comfort? Satisfying sandwiches, loaded bagels, rich mac and cheese, crave worthy and smart. Hero Bread's loaves, bagels and noodles have just zero to five grams net carbs, zero grams sugar and up to 19 grams of protein and 32 grams of fiber per serving. Hero Bread bakes with heart healthy olive oil and delivers a soft, fluffy, flavorful experience you love.

1:06:00Shop now on Hero.co. Use code IHEART for 10 % off. That's Hero.co. Per serving, not a low-calorie food. Some products contain allulose. See nutrition info on Hero.co for sodium and sugar content.

1:06:13Hey, Emily and Perry. This is Margaret from Charleston, and my question is about the shingles vaccine, or I guess it's called the shingri vaccine, you know, the one for shingles. I've been trying to convince my mother to get it as a way of preventing dementia. Am I right about this? Should I keep harassing her? Love the show. Thanks so much. So there's a lot of new data on this, which I find very compelling. So I have been trying, I will just say full disclosure, I've been trying to get my mother-in-law to get the Shingrix vaccine for like a decade. And every time there's new information about it, I send it to her.

1:06:48And my read is that the evidence on dementia, while not perfect, randomized trial evidence is increasingly quite strong. It's now coming out of a number of studies, stronger for women than for men, and reasonably large effect sizes, 5 % to 10 % reduction in dementia risk, which is pretty solid for something that also prevents you from getting shingles, which I hear is a terrible experience.

1:07:16Emily Oster:Horrible. So painful. Yeah. I mean, And the data on dementia is observational, right? You look at large data sets of people, some of whom got the vaccine, some who didn't. And then you look and see if they end up with dementia. And of course, there are other factors that predispose both to vaccination and maybe to your dementia risk, the sort of healthy user effect you can adjust for a lot of things. That said, we interpret this in the context of the risk of the vaccine, which is extraordinarily low. The other benefits, like preventing shingles, which is clearly documented in randomized trials.

1:07:49Emily Oster:And that's great. So this feels like an icing on the cake thing. I will say varicella zoster virus, which is the virus that causes both chicken pox and shingles, is a weird one. It's a DNA virus. So it can integrate into the DNA of your cells. That's actually how it lays dormant for so long. And it goes and it's sitting in your DNA and just waiting to be reactivated. And then for reasons that we don't fully understand, stress, sometimes like UV light or whatever, will reactivate this. That's actually why shingles appears in a patch in your body because it's traveling out from a nerve. Like it's coming from the nerve that innervates that patch of skin.

1:08:27Emily Oster:It's also why it's so incredibly painful. So it integrates into DNA and it's neurotropic. So it's a virus that likes to infect nerve cells. So, you know, dementia, nerve cells integrates into DNA, lasts a really long time. Like there's a lot of convincing push here. So I see no reason not to get this vaccine. Yeah. I mean, I think that in some sense, there's no reason not to get this vaccine. There are other reasons to get this vaccine other than the dementia risk. And so in many ways, this feels to me like, yes, it's one more thing, but also it's just interesting. And it's an interesting thing to think about as we contemplate what causes some people to have dementia versus not having dementia.

1:09:08So yes, if my mother-in-law is listening, you should get the shingles vaccine like I've been telling you.

1:09:18Emily Oster:All right, that's it for us today. Stick with us next week when we'll ask, what's the deal with mRNA? Wellness Actually is produced in association with iHeart Media. Our senior producer is Tamar Avishai. Our executive producer at iHeart is Jennifer Bassett. Our theme music is by Eric Deutsch. And our content is for educational purposes only. If you like the show, help other people find us. Leave a rating and review on Apple Podcasts or your podcatcher of choice. And help us spread the word about the show. You can follow us on Instagram at wellnessactuallypod. And don't forget, we want to hear from you.

1:09:55Emily Oster:Head over to wellnessactually.fm and leave us a question for our mailbag. Or suggest a topic for a future show. We'll let the influencers have the last word. I got my results from my Pronuvo scan. And if you don't know what that is, it's a full body MRI. So we're going to go over what they found. and they found 26 findings. And when I saw this, I was like, oh my gosh, there's 26 things that's wrong with me. But really, yes, but no. But with the minor findings that they did find is this right here is my lip filler. It says right here, just like filler or Botox injections. So this is just showing my lip filler, which is like, okay.

1:10:42Emily Oster:Apple Vacations, where your story starts. The Splash Into Savings event from Apple Vacations is here. Now through June 25th, save up to$150 on vacation packages, plus instant savings at select resorts in Mexico, the Caribbean, Central America, and top U.S. destinations. Use promo code JUNE26 for these limited-time offers. Start planning today at AppleVacations.com or contact your travel advisor. Apple Vacations, where your story starts. Running a business shouldn't feel like surviving a software group project. One app for accounting, another for inventory, another for sales. And somehow, none of them talk to each other.

1:11:23Emily Oster:That's where Odoo comes in. An all-in-one business management software that brings every part of your business together. From sales and accounting to inventory and marketing. All in one powerful platform. No messy integrations, no bouncing between tabs. And best of all, no spreadsheets. Stop managing software and start managing your business with one unified system. Try for free today at odoo.com slash iHeartRadio. That's O-D-O-O-O dot com slash iHeartRadio. We learned how to love dogs from the dogs that loved us and waited for us to get home from school. They were the dogs that raised us. We returned the love with Pedigree Dog Food.

1:12:05Emily Oster:It was good then. It's better now. For 40 years, Pedigree has been bringing out the goodness in dogs. Every bowl serves up 100 % of the nutrition your dog needs, supporting six health essentials. That's the Pedigree goodness promise. Pedigree. Good then. Better now. This is an iHeart Podcast. Guaranteed human.