Letters

Screening for aortic aneurysm

Human cost should not be dismissed

National screening programme is long overdue

Human cost should not be dismissed

EDITORGreenhalgh and Powell's editorial assesses the economic evaluation of the multicentre aneurysm screening study (MASS), but it masks with numbers a human tragedy at the core of the story: this is a screening study that killed people. ^{1 2}

The authors mention in passing a mortality of 6% among the 322 men who had surgery as a result of the invitation to screening. This figure represents 19 men, comparatively young at retirement age, who before receiving the invitation would have been living their lives unfettered by the knowledge that they had an aneurysm. Now they are dead.

Obviously some of these men might have died anyway from a sudden rupture, but a clear distinction needs to be made between dying naturally and at the instigation of doctors. It could be considered ethically acceptable if the study showed a convincing overall survival benefit in the screened population, but the all cause mortality at the end of the study was the same in both groups, 11%.²

Greenhalgh and Powell confidently announce that the data support a national screening programme. They do not. The National Screening Committee's criteria are not fulfilled, as there is no evidence from randomised controlled trials of overall survival benefit and no evidence that benefit outweighs the physical and psychological harm of screening.

The results of the MASS study are surprisingly similar to a recent study comparing watchful waiting with radical surgery for early prostate cancer.³ The group allocated to radical treatment had a halving of deaths related to prostate cancer, but overall no survival advantage was noted in comparison with the group who were watched.

Supporters of screening put a positive spin on these results,⁴ but the result justified the United Kingdom's decision not to roll out a national screening programme for prostate cancer. Likewise, the results of the MASS study do not justify screening for aortic aneurysm.

Simon Curtis, general practitioner. 
Summertown Health Centre, Oxford OX2 7BS simon.curtis{at}gp-K84011.nhs.uk

National screening programme is long overdue

EDITORIt is a scandal that in the 21st century the United Kingdom has no national screening programme for the detection of abdominal aortic aneurysms in men, and this in spite of compelling evidence in favour of one.

In a randomised controlled trial Scott et al identified a 68% reduction in incidence of rupture at 5 years among those invited for screening compared with age matched controls and a 42% reduction in death from rupture.¹ The benefit persisted at 10 years, but no benefit was detected for women. In men only 4% of deaths from rupture occurred under the age of 65 years; no woman died below this age.

Screening of men aged 65 has been taking place in the English county of Gloucestershire since 1990. The total number of deaths related to aneurysm in this population decreased progressively year by year in the screened portion of the population (P<0.001). No change was observed in the unscreened part of the population.²

Law has estimated that a national screening programme could save 2000 lives a year in men aged 60-79.³ In addition, reducing modifiable risk factors, smoking, hypertension, coronary heart disease,⁵ together with increasing awareness of unusual modes of presentation of ruptured abdominal aortic aneurysm, may save even more lives.

Finally, the multicentre aneurysm screening study (MASS) provides evidence of cost effectiveness of a national screening programme.⁵

Richard M Lynch, specialist registrar, accident and emergency. 
York District Hospital, York YO31 8HE rlynch{at}tinyworld.co.uk