Screening Programs for Abdominal Aortic Aneurysms: Luxury or Necessity?

Controversial Issues Regarding AAA Screening Programs As the authors mention, since January 1, 2007, provisions of the Screening Abdominal Aortic Aneurysm Very Efficiently Act in the United States have provided free, one-time, ultrasound AAA screening for qualified Medicare beneficiaries as part of their Welcome to Medicare examination. Men who have smoked at least 100 cigarettes during their life, as well as both men and women with a family history of AAA qualify. The UK Multicenter Aneurysm Screening Study (MASS) demonstrated that a one-time screening program for men leads to an incremental cost-effectiveness ratio of £7600 (roughly US$10 500) per quality-adjusted life-year gained at 10 years. The long-term results of the MASS trial showed that 216 men need to be invited to screening to save 1 AAArelated death. Other studies have also reported favorable cost-effectiveness of offering AAA screening to men. Despite the lower prevalence of AAAs in women, screening women for AAAs may also be cost-effective because of the higher AAA rupture rate in women (and at smaller AAA diameters). A single screening ultrasound for AAA in asymptomatic men aged >65 years has been shown to be cost-effective in the United Kingdom and through Markov modeling. In the United Kingdom, the cost per life-year saved with screening men >50 years was US$1173, which is less than for breast, cervical, and colorectal cancer screening programs. Despite the robust data on the benefit of AAA screening programs and their cost-effectiveness, there is evidence that such screening programs are underutilized. Analysis of the Medicare data revealed that <10% of eligible patients undergo screening with abdominal ultrasonography. Extrapolating screening benefits from 2007 to 2012 through 2025 showed that an additional 291 000 life-years can be saved by 2025 (or 131 life-years per 1000 persons screened) if screening rates increased from the 2007 to 2012 (<10%) to 80% by the end of 2018. Despite this large body of evidence, others support that not only AAA screening programs are not beneficial but they also cause more harm than good. According to this interpretation, “for every 10,000 people invited to screening, 46 men avoid dying from a ruptured AAA. But for every avoided death, 4 men are diagnosed with an AAA that would never have been detected or caused health problems in their lifetime without screening; they have been overdiagnosed, which causes substantial physical and psychological harms for many of them”. Admittedly, this interpretation may apply to specific categories of patients, such as those who are frail, who have several comorbidities, and/or who are at high risk for surgery. In a recent report, 112 patients with AAA turned down for elective repair were followed up for a minimum of 2 years. Within 2 years, 64 (57.1%) of 112 had died. Of these, 30 of 64 had a recorded cause of death. Ruptured AAA was the cause of death in only 11 (36.7%) of 30 patients. In other words, the majority of this group of frail patients with an AAA who were turned down for elective repair because of their comorbidities did not die of a ruptured AAA, but as a result of their comorbidities. Another, independent study retrospectively analyzed 692 patients with AAA over a period of 20 years. Overall, 214