Physicians debate the ‘perils and promise’ of whole-body MRI screening

Two imaging experts are debating the potential “perils and promise” of using whole-body MRI exams to assess healthy patients. 

This care model has grown in popularity in recent years, with startups such as Prenuvo and Ezra charging $2,500 out of pocket to screen asymptomatic patients for cancer and other diseases. Radiology providers such as SimonMed and Rayus also have started offering such exams, which the American College of Radiology does not support. 

Two members of the specialty recently weighed in on the debate, publishing dueling opinion pieces in JACR. Saurabh Jha, MBBS, took the contrarian side, noting the risk of overdiagnosis stemming from whole-body MRI. Echoing the ACR’s concerns, he also highlighted the use of cascading services after a scan, including unnecessary biopsies and procedures. 

“Screening converts the healthy to patients who become cancer survivors, celebrating their lives like the World War II soldiers evacuated in Dunkirk,” Jha, an associate professor of radiology with Penn Medicine in Philadelphia, wrote Sept. 6 [1]. “Rather than being angry with imaging for putting them through anxiety and frivolous therapeutic rabbit holes, they are grateful. Instead of recognizing that they are victims of medical imaging technology (VOMIT) they record testimonials for the companies offering screening, lauding their clairvoyance for being screened.”

Jha noted that whole body screening is “hardly revolutionary,” with similar CT programs previously becoming a fad before they were “summarily dismissed by organized radiology.” MRI offers benefits over CT, including a lack of radiation exposure and better soft-tissue contrast resolution. However, these benefits often are “exaggerated,” as “MRI’s cleverness cannot solve overdiagnosis.” 

Whole-body scans can give useful information, such as the amount of fat in the liver, which is associated with adverse cardiovascular events. But the value of learning this is suspect, Jha noted, if all it results in is generic advice (i.e., eat well, sleep well, exercise and practice mindfulness). He also noted the lack of scientific proof of these exams’ effectiveness.  

“As whole-body MRI vendors have discovered, they do not need evidence that whole body MRI creates net health benefits, to achieve commercial success. A tweet from a celebrity is far more financially significant than the chasing of statistical significance of those pesky P values,” Jha concluded. “When a new technology enters the healthcare space, the burden of proof is on the advocates of the technology to prove that the technology works, not on the skeptics to prove that the technology does not work. The advocates have dodged the evidence burden as whole-body MRI is not covered by insurance. People are free to manage their health as they wish and are entitled to pay large premiums to be overdiagnosed and overtreated. To the extent possible, they should also own the costs of the therapeutic cascade whole-body MRI unleashes.” 

Daniel K. Sodickson, MD, PhD, meanwhile took the opposite argument, noting that he believes “there is more to this debate than meets the eye.” Two years ago, the physicist and chief of innovation in NYU’s Department of Radiology signed on as a scientific advisor for whole-body MRI company Ezra. During his career, Sodickson said he has learned to be “legitimately suspicious of indiscriminate screening.” However, over time, “imaging technology changes, as does clinical practice.” 

“It might be tempting to view the emergence of imaging-based screening in the marketplace right now as just another tech industry fad, to be dismissed or actively opposed,” he wrote Sept. 7 [2]. “This trend, though, might also be seen as a sign of tectonic shifts in the healthcare landscape. Many segments of modern society share an interest in moving from our current reactive model of care to a proactive and personalized model. Smart watches and Oura rings aside, there is ample evidence of such ambitions in our own field of radiology.”

Sodickson believes the goal of these programs “would not be comprehensive radiologic evaluation or guidance of potential therapies.” Rather, it’s simply to serve as a “warning flag” when further imaging or follow-up is called for. 

“Any follow-up imaging, meanwhile, would be precisely the sort of imaging favored by radiologists and radiology departments; namely, high-yield examinations in subjects with a high prior probability of disease,” he wrote. 

Current interest in WBMRI is being driven by for-profit companies, raising “understandable concerns about conflict of interest.” And he acknowledged the absence of clinical trials documenting the benefits of regular monitoring in a health population. But other technologies have previously emerged in the field before their value proposition was established via clinical trials. Sodickson believes, in a time where healthcare is moving toward prevention, it would be wise for imaging professionals to “join in the debate, not just about principles but also about practices.” 

“In conversations with numerous colleagues, I have tried to understand the vigor of reactions which the whole-body MRI debate engenders. In the absence of clear data on benefits, practicing clinicians clearly feel a strong moral obligation to protect patients from as of yet unquantified harm,” he closed. “This is a principled stance to take as an individual. If we take this approach too uniformly as a field, however, we risk being merely protective rather than proactive. There is a fundamental tension between innovation and regulation and settling too simply for one or the other risks throwing the baby out with the bathwater.” 

The two pieces did not directly name Prenuvo, but did make references to the startup’s healthcare model. Dan Durand MD, Prenuvo’s chief medical officer, shared a statement with Radiology Business in response to the two editorials. 

“Dr. Jha’s concerns regarding the potential tradeoffs between medical imaging intensity and so-called overdiagnosis are neither new nor are they specific to whole body MRI,” Durand noted. “While we respect and acknowledge his concerns, we subscribe to the countervailing majority viewpoint: that the larger problem to be solved is the underdiagnosis of cancer and other diseases in their earliest stages when treatment is safest, most effective, and least expensive.” 

“With regard to Dr. Sodickson's piece, we are of course largely aligned with his viewpoint that it would be reckless for the field of radiology to abandon the promise of whole-body MRI over unproven fears that can likely be mitigated through developing and adhering to the appropriate clinical protocols and pathways,” Durand added later. “Great minds think alike, and it would seem that in his two years advising Ezra, Dr. Sodickson has come to many of the same conclusions that our medical group has reached collectively over its six-year history and the antecedent 15-year history of our predecessor clinic in Vancouver. We deeply agree with Dr. Sodickson's assertion that how one goes about screening matters.”