Abstract
Objective:
To evaluate the satisfaction of asymptomatic subjects who self-referring Whole-Body Magnetic Resonance Imaging (WB-MRI) for early cancer diagnosis.
Methods:
Subjects completed a pre-examination questionnaire, while waiting for WB-MRI examination, recording demographics, expected discomfort, perceived knowledge and usefulness of the procedure and health risk perceptions, as well as a post-examination questionnaire, measuring discomfort experienced, acceptability and satisfaction with WB-MRI. We examined which factors influenced discomfort and satisfaction associated with WB-MRI.
Results:
65 asymptomatic subjects (median age 51; 29 females) completed the questionnaire. Before WB-MRI, 29% of subjects expected discomfort of some form with claustrophobia (27.7%) and exam duration (24.6%) being the most common concerns. Experienced discomfort due to shortness of breath was significantly lower than expected. This difference was significantly associated with the personal risk perception to get a disease (p = 0.01) and educational level (p = 0.002). More specifically, higher level of perceived personal risk of getting a disease and lower level of education were associated with higher expected than experienced discomfort. Similarly, experiencing less claustrophobia than expected was significantly associated with gender (p = 0.005) and more pronounced among females. A majority (83%) of subjects expressed high levels of satisfaction with WB-MRI for early cancer diagnosis and judged it more acceptable than other diagnostic exams.
Conclusions:
Asymptomatic subjects self-referring to WB-MRI for early cancer diagnosis showed high levels of satisfaction and acceptability with the examination. Nevertheless, a relevant proportion of participants reported some form of discomfort. Interestingly, participants with higher perceived personal risk to get a disease, lower education and females showed to expect higher discomfort than experienced.
Advances in knowledge:
Scope exists for measures to assess expected feelings and develop personalized interventions to reduce the stress anticipated by individuals deciding to undergo WB-MRI for early cancer diagnosis.
Introduction
The past decade has witnessed expansion of the use of whole-body magnetic resonance imaging (WB-MRI) in oncology, to the point of being recommended in international guidelines for the assessment of Multiple Myeloma, 1 Melanoma, 2 Prostate cancer 3 and several cancer-prone syndromes. 4,5
Some early studies have shown consistent performance of WB-MRI in early cancer diagnosis amongst asymptomatic subjects. 6,7 The ability to study multiple organs, together with the lack of radiation exposure and absence of contrast-agent administration, in a typical WB-MRI examination, contribute to its potential attractiveness as an adjunct to traditional screening for early cancer diagnosis. 8–10 As noted in a recent review, 11 however, most of the literature is composed of small single centre studies with a substantial rate of indeterminate incidental findings. Moreover, while false-positive findings have been reported to occur in roughly 16% of cases, there has been very limited verification of negative findings leading to uncertainty in their incidence. Nonetheless, in light of the continuing evolution and potential of the technique for early cancer diagnosis, further investigation into its clinical impact continues.
At present, WB-MRI does not feature in national cancer screening programmes. Its use for early cancer diagnosis is therefore primarily performed at the request of the subject and they pay out of pocket for it. While the number of WB-MRI examinations performed in asymptomatic subjects for early cancer diagnosis in other regions is not known, based on the activity in centres with whom we collaborate we estimate that in the North of Italy over 2000 such examinations were performed in 2019 (personal communications with centres). In this phase of personal choice driving use of WB-MRI for early cancer diagnosis, expanded adoption depends heavily on user experience.
The role of personal variables, such as gender, 12,13 education 14 and risk perception to get a disease, 15 have been demonstrated to affect health and preventive behaviours as reflected in attitudes and decisions toward a screening examination.
More specifically, females are more likely to have positive attitudes towards cancer screening than males. Moreover, people with higher educational levels and higher risk perception are more motivated to engage in healthier behaviours. 16
Despite the attraction of the technique, some 30% of patients who undergo a WB-MRI 17 examination report negative emotional reactions. This is somewhat higher than the sensation of claustrophobia reported by at least 15% of patients for routine MRI procedures. 18 Amongst the factors that may contribute to these reactions, Youssefzadeh and colleagues 19 have found a high level of anxiety, with females being more anxious than males. Also to be considered, the risk of a finding that may lead to a life-changing diagnosis may be greater with a WB-MRI examination for early cancer detection than for a routine MRI performed in response to symptomatic disease. In support to this, the Affect Heuristic described by Slovic et al 20 showed a positive correlation between perceived risk and negative affect associated with a specific situation. In this perspective, individuals’ risk perception affects: (1) how individuals process information deriving from the health-related situation and (2) the adoption of preventive behaviours. 21,22 It is now well known that an individual’s emotional reaction influences the attitude towards a technology and the intention to use it. According to the Technology Acceptance Model (TAM; Bagozzi et al 23 ; Venkatesh 24 ), perceived usefulness and easy to use, including the emotional reactions patients experienced, were identified as the key antecedents of the attitude towards technology.
In addition, emotional reactions, one’s expectations, level of information and perception of the examination utility are also likely to affect willingness to utilize an early diagnosis technique and the level of users’ satisfaction. 23,24 Both Oliveri 25 and Evans 26 have found WB-MRI to be perceived as acceptable by most cancer patients. In a later study however, Evans et al 27 found WB-MRI to be marginally less acceptable and more burdensome than standard scans, particularly for patients with pre-existing distress and comorbidities. As far as we know, no studies have investigated the satisfaction and acceptability of WB-MRI in the context of early cancer diagnosis in self-referring asymptomatic subjects.
In the present study, we evaluated subjects’ expectations, satisfaction and acceptability of WB-MRI for early cancer diagnosis amongst asymptomatic subjects that self-referred to the examination.
We explored also the association of personal variables such as gender, education, personal perceived risk to get a disease, with expectations and experience of discomfort and concerns related to WB-MRI.
Methods and materials
Participants
Our institution offers WB-MRI to self-referring asymptomatic subjects who pay out of pocket for the examination as an adjunct to the nationally sanctioned cancer screening tests (under the Italian National Health Service, programmed screening involves mammography, Papanikolau “Pap test” and faecal occult blood test “FOBT” 28 ).
Inclusion criteria for the study were that participants were asymptomatic subjects undergoing WB-MRI for early cancer diagnosis between August 2019 and November 2019 without contraindication to the MRI examination (e.g. pacemaker, pregnancy in the first trimester).
The study was approved by our Institution’s Ethics Committee (1032_UID_1810) and participants provided written informed consent for the study. A point of information was that WB-MRI does not replace screening offered by the National Health Service.
Procedure and questionnaire
On arrival in the MRI facility, each participant was interviewed by a single psychologist before WB-MRI. The interview first examined the participant’s previous experience with screening examinations, MRI and WB-MRI, and recorded socio-demographic information. This was followed by a questionnaire assessing perceived risk to get a disease, concerns, expected discomfort, expected usefulness of the procedure and knowledge relative to the WB-MRI (Supplementary Material 1). Within 30 min after completing the WB-MRI, all participants had a meeting with the radiologist, who provided the radiological report and discussed all the findings, including possible incidental findings. Relative to this last point, WB-MRI may have different outcomes: an oncologically not suspicious finding, a probably benign finding requiring follow-up or completion of investigation, or a suspicious finding that requires further investigation, histological examination and/or immediate clinical classification. All oncologically not suspicious findings (ex. disc protrusions, colon diverticula, emangiomas, cysts, etc.) or findings not relevant for the main purpose of the exam (cancer screening) are considered as incidental findings.
After the meeting with the radiologist, a further questionnaire was administered to assess the participant’s experience of concern and discomfort and their level of acceptability and satisfaction relative to WB-MRI (Supplementary Material 1). Health risk perception was assessed with regard to the subject’s personal risk to develop specific diseases, expressed in terms of absolute personal risk. In order to capture the absolute risk to get a disease, participants were asked to indicate how likely they thought it was they would develop or contract a disease with serious health implications if not cured: diabetes, tumour, heart attack, HIV and meningitis. More specifically, to compute the absolute risk, the perceived risks for all the diseases were averaged. We were interested to explore whether such a personal risk could affect subjects’ expectations towards and experience of WB-MRI. 29 To assess asymptomatic subjects’ expectations, experience, acceptability and satisfaction a questionnaire was used, that was previously utilized by Oliveri et al 25 in cancer patients undergoing WB-MRI (Supplementary Material 1).
Imaging technique
The WB-MRI protocol consisted of sagittal fat-saturated (STIR) T 2-weighted images of the spine, and axial short echo-time gradient-echo images of the lungs, along with axial T 1-weighted Dixon, T 2-weighted and diffusion-weighted images (DWI) extending from the orbits to mid-thigh as described in Zugni et al 6 . This protocol differs from the core protocol for detection of metastatic disease in advanced prostate cancer 30 and multiple myeloma 31 in that it excludes sagittal T 1-weighted imaging of the spine and includes specific coverage of the lungs. All examinations were performed on a 1.5 T scanner (Magnetom Avanto Fit, Siemens Healthineers, Erlangen, Germany) with a typical cumulative WB-MRI data acquisition time of 30–40 min. In-line reconstruction of the T 1-weighted Dixon images was performed to generate water and fat images, while ADC maps were calculated from the DWI images were processed to produce ADC maps. Offline reconstruction on a clinical workstation was performed to generate relative fat fraction maps (rF%), and inverted grey-scale maximum intensity projections (MIPs) of the high b-value DWI images.
Statistical analysis
This exploratory pilot study was not designed to test a specific hypothesis. The main aim was to measure acceptability, satisfaction and the difference between expected and actual experience with WB-MRI in asymptomatic subjects self-referring to WB-MRI.
Based on prior works, we expected good (‘high’ and ‘very high’) satisfaction after the examination, for at least 80% of the sample.
A sample size of 65 subjects permits good precision of the resulting estimate with the two-sided 95% CI extending from 68 to 89%.
Five-point Likert scales (Supplementary Material 1) were used to measure levels of discomfort, concerns, perception of risk related to the procedure, perceived usefulness and information received about WB-MRI, and were considered as categorical variables in the analysis. Accordingly, we considered the percentage of patients in each Likert score. In order to analyse acceptability, a new variable labelled “General Acceptability” was created, by aggregating the variables “usefulness”, “general discomfort” and “perceived risk related to the procedure”.
In order to investigate whether differences (pre- minus post-examination) in scores were influenced by socio-demographic factors (age, gender, education level), the personal risk perception to get a disease, and previous experience with MRI, non-parametric Wilcoxon-rank tests were performed. Significant results were presented by box-plots. The statistical analyses were performed with the Statistical Analysis System V. 9.4 (SAS Institute, Cary, NC). Statistical significance was defined as two-sided p < 0.05.
Results
Characteristics of the participants
Out of the 68 subjects invited to participate in the study, two refused to participate and one abandoned the study because he did not complete the WB-MRI examination due to claustrophobia.
The 65 participants had a median age of 51 years (range: 30–73); 29 (45%) were females, 33 (52%) had a university degree, 48 (74%) had undergone a previous MRI, and 20 (31%) had undergone a previous WB-MRI. Most participants of both genders follow regularly the recommended public health screening tests (Table 1).
Descriptive analysis
The majority of participants neither expected nor experienced discomfort due to noise, shortness of breath and claustrophobia. The duration of the examination was expected to cause no discomfort by 31 (48%) participants in the pre-examination assessment, and this proportion increased to 41 (63%) participants in the post-examination phase (see Figure 1).
Figure 1.
Percentages score of subjects discomfort pre- and post-WB-MRI for each aspect of examination.
Usefulness of WB-MRI was perceived as high or very high by 64 (98.5%) participants (Table 2). After the examination, the majority of participants (n = 54, 83.1%) indicated a high or very high level of satisfaction. We did not find a significant association between history of a previous WB-MRI, or the other evaluated variables, and the level of satisfaction. Indeed, 62 (95.4%) subjects indicated that they would repeat this type of examination in the future (two answers were missing and only one subject indicated he will not repeat the examination).
The percentage of subjects that indicated high satisfaction decreased with the number of incidental findings (p = 0.05). The level of post-examination concern, on the other hand, did not change based on the number of incidental findings (p = 0.76) (Figure 2).
Figure 2.
Pre- and post-examination results due to measures of assessment.
Both before and after the assessment, the majority of participants (n = 58; 89,2%) considered WB-MRI not to be a risky examination.
More than half of the participants (n = 42; 65%) had previous experience with other types of diagnostic examination, such as CT scan. Of these 42 subjects, 17 answers were missing and 25 answered.
Of these 25, 12 (48%) of subjects considered WB-MRI much more acceptable compared to other diagnostic procedures.
Comparison of pre- versus post-examination assessments
Significant differences in discomfort were found between pre- and post-examination assessments for all causes except duration. When considering the aggregation of the four types of discomfort, the pre- versus post-examination difference remained significant (p = 0.0007). In particular, significant pre- versus post-examination reductions were found for discomfort due to noise (p = 0.01), shortness of breath (p = 0.003) and claustrophobia (p = 0.0007).
As for the association between personal absolute risk to get a disease and WB-MRI perception, we first analysed the perception participants had relative to the risk of getting a disease. Descriptive analysis showed that 15 (23%) participants considered themselves likely to suffer one of the indicated diseases in the near future, while 32 (49%) considered it unlikely and 18 (28%) very unlikely to be affected. Subjects with a higher perception of personal absolute risk of getting a disease had a greater reduction in discomfort due to shortness of breath between the pre- and post-examination (p = 0.03) assessments. Similarly, subjects with lower education level also showed a greater reduction due to shortness of breath (p = 0.01). A similar difference regarding claustrophobia was significantly associated with gender (p = 0.02): females before the examination indicated a higher expected discomfort due to claustrophobia compared to males (Figure 3).
Finally, comparison of the acceptability of WB-MRI between pre- and post-examination assessments based on “General Acceptability” showed an increase in “General Acceptability” after the examination (p = 0.0001).
No significant differences were observed for discomfort between those subjects with and without prior WB-MRI (p = 0.29).
Level of information on WB-MRI
Prior to the WB-MRI examination, 29 (44.6%) subjects felt they had good to very good level of information about the examination. After WB-MRI, 27 (41.5%) participants felt they received more or much more additional information after the completion of the examination and the meeting with the radiologist. Unsurprisingly, most of the subjects who had not undergone a previous WB-MRI considered themselves to possess more information after the examination (33 out of 45 subjects; 73%), than those who had a prior WB-MRI (10 out of 20 subjects; 50%; p = 0.06). Those who had experienced a WB-MRI previously, indicated that they received little additional information. When asked to specify, they tend to indicate that no additional information was added nor needed, compared to what they already knew during their previous examinations and meetings with radiologists.
Discussion
In our small cohort, participants expected WB-MRI to be significantly more uncomfortable than their experience in respect to noise, shortness of breath and claustrophobia. They further indicated good levels of “General acceptability” of WB-MRI. The level of satisfaction with WB-MRI was also high, but decreased with the increasing number of incidental findings. While the impact of incidental findings on the individual’s emotional state may be understandable, their impact on the satisfaction with the examination suggests the presence of an outcome bias, 32 that is the tendency to focus on and use the final outcome of an event to infer the quality of a decision instead of analysing the entire process. In this perspective, the subjects in our study may have transferred the emotional reaction associated with the outcome of the examination (the incidental findings) to the examination itself.
Several factors have been reported to increase the likelihood of premature MRI scan termination, including age and gender (middle age or female), prior experience (first scan or prior negative experience) and comorbidity (pain, anxiety). 33–35 Claustrophobia is amongst the most frequently cited negative aspects of MRI. 36,37 Considering the specific characteristics of WB-MRI, we can reasonably expect the last to be more challenging regarding this psychological reaction. WB-MRI, in fact, involves a longer duration compared to MRI and requires the subject to be covered from head to mid-thigh with receiver coils, instead of a single part of the body being enclosed in receiver coils typical of MRI. Indeed, one subject failed to complete the study due to claustrophobia.
We found a difference between expectation and experience regarding claustrophobia associated with gender: females had negative expectations about this feeling, in line with a previous study by Youssefzadeh et al 19 and population results about gender differences in anxiety prevalence. 38,39
We also found that experienced discomfort due to shortness of breath was significantly lower than expected. This difference was associated inversely with subjects’ educational level and positively with personal absolute risk perception to get a disease. Prior studies could help explain our findings on the effect of educational level and personal absolute risk. For example, Rossi Ferrario and colleagues showed that lower educational level increases one’s risk of emotional problems. 39 If we consider shortness of breath as a possible symptom of negative emotional reaction such as anxiety, 41 it could be that subjects with a lower/medium educational level presented a higher expected than experienced shortness of breath, as result of a higher anticipated emotional reaction. However, this finding must be further investigated.
As regards risk perception, participants presenting higher personal absolute risk to get a disease tend to show a greater reduction in discomfort between pre- and post-examination. This is in line with previous studies on the association between risk perception and anticipated emotional reactions. In fact, as shown by Wilson and Gilbert 42 , while individuals are very good in anticipating the expected emotional reactions they will experience in a particular situation, they are less able to accurately anticipate the intensity and the duration of such a reaction. Such tendency is called impact bias, and more specifically it describes people tendency to overestimate the length or the intensity of future emotional states. These findings may explain our results about the reduction of discomfort: most likely our participants showed such impact bias related to the anticipated potential discomfort due to shorten of breath. Moreover, some previous studies demonstrated 43 an association between risk perception and emotional reactions in judgement and decision-making. According to Yates and Stone, 44 risk perception is determined by the anticipation of future negative consequences and the judgement of how painful their experience would be. Coherently with such findings, our subjects with higher levels of perceived risk to get a disease showed a higher expected discomfort before the examination that exceeded the actual experience.
Our results illustrate the effect of personal characteristics of subjects undergoing WB-MRI for early cancer diagnosis on their expectations and experience. The difference found between expected and experienced discomfort associated with WB-MRI has interesting implications for clinical practice. As suggested by Oliveri et al 25 , health professionals can work preventively to make expectations more similar to what patients will experience. For example, anticipated emotional reactions and discomfort during MRI scanning can be decreased through provision of additional personalized information, 45 combined with interventions to improve staff–patient interaction, 46,47 and subjects’ emotional state by using relaxation techniques 48 to be provided before the examination.
Amongst the obstacles to large-scale adoption of WB-MRI for early cancer diagnosis is the heterogeneity of practice in WB-MRI. This is in part due to the evolutions in MR techniques and hardware, as well as in thinking regarding what imaging to perform in a WB-MRI examination. A response to that has been the emergence of WB-MRI protocols for particular clinical needs. These recommendations tend to share many features. The WB-MRI protocol used herein is slightly shorter (roughly 4 min) than the core protocol for metastasis detection recommended for advanced prostate cancer 30 and multiple myeloma 31 because it lacks a T1W sagittal spine acquisition. As the hardware used has been commercially available for several years, the protocol with only slight variations in duration should be feasible on most modern scanners.
The current study presents several limitations that have implications for the generalizability of the results. Firstly, only asymptomatic subjects who had self-referred to WB-MRI for early cancer diagnosis participated in this study, thus representing a small fraction of all individuals. That said, as scan times for WB-MRI continue to diminish and greater clinical experience is obtained, its use for early cancer diagnosis by both high-risk individuals and people with high levels of health-related worries, can be expected to continue growing outside public health services. Furthermore, while we examined the subject’s perspective of WB-MRI for early cancer diagnosis in addition to conventional screening practices, this preliminary study does not cover all aspects that are of interest in defining a screening programme.
In addition, our cohort was mainly composed by participants who had a prior MRI (n = 48; 74%) or WB-MRI examination (n = 20; 31%). Further studies should be fostered to investigate the perception of people who have never undergone a MRI or WB-MRI.
A study in oncological patients showed that a previous MRI examination decreased the perception of discomfort and anxiety, 25 thus our results may underestimate the expectations of discomfort to be encountered in a first cycle of screening.
Conclusions
In our experience, subjects self-referring to WB-MRI for early cancer diagnosis showed high levels of satisfaction with the examination. Notably, their experience related to discomfort due to noise, claustrophobia, shortness of breath and exam duration was better than their expectations. This difference between experience and expectation suggests that it may be worthwhile for radiologists, MR technologists and psychologists to personalize information delivery and support interventions based on individual expectations, emotional reactions and personal characteristics. Low educational level identified a group at risk for emotional problems.
Footnotes
Acknowledgements: This work was partially supported by the Italian Ministry of Health with Ricerca Corrente and 5x1000 funds and by Fondation IEO-CCM.
Conflicts of interest: Dr Summers is part owner of QMRI Tech, a company offering research support services in MRI. The other authors indicate no conflicts of interest.
Contributor Information
Derna Busacchio, Email: derna.busacchio@ieo.it.
Ketti Mazzocco, Email: ketti.mazzocco@ieo.it.
Sara Gandini, Email: sara.gandini@ieo.it.
Paola Pricolo, Email: paola.pricolo@ieo.it.
Marianna Masiero, Email: marianna.masiero@unimi.it.
Paul Eugene Summers, Email: paul.summers@ieo.it.
Grabriella Pravettoni, Email: gabriella.pravettoni@ieo.it.
Giuseppe Petralia, Email: petralia.giuseppe@ieo.it.
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