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Rapid Responses: Rapid Responses published:
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Should we screen for AAA?
- Jonathan Beard (23 April 2008)
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Emotional impact of AAA screening: the evidence
- Theresa M Marteau (23 April 2008)
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Abdominal aortic aneurysm screening paradox
- Idris Guessous, Jacques Cornuz (25 April 2008)
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Should we screen for AAA? Management of screen detected AAA.
- R. Alan .P Scott (1 May 2008)
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Jonathan Beard, Consultant Vascular Surgeon Sheffiel;d Vascular Institute, Northern General Hospital, Sheffield S5 7AU
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Sir Johnson argues that a death rate of 1 in 14 from elective Abdominal Aortic Aneurym (AAA) repair means that screening is futile. Many specialist vascular units have elective mortality rates of 5% or less for open repair and mortality rates of less than 2% for endovascular repair (as confirmed by the EVAR trial and Dr Foster). Even a 1 in 14 mortality rate is better than the 80% mortality rate from rupture. I and many of my colleagues (including nursing staff) have grown weary of counselling the grieving wives and children of men who suffer unexpected, agonising and bloody deaths. The detection of an AAA provides one important benefit that Johnson ignores: patient choice. Patients who die of rupture are denied that choice. Johnson suggests that screening leads to unacceptable levels of anxiety for those placed on surveillance programmes. This claim is not supported by the literature. AAA screening also compares very favourably, in cost-effectiveness terms, to Breast and Cervical Screening. I suspect that the real reason the government has not funded AAA screening (and even now is providing only lukewarm support) is because there are few votes to be won (and more pensions to be paid) by saving the lives of men of retirement age. As a politician, Johnson should understand this all too well. Competing interests: None declared |
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Theresa M Marteau, Profeesor of Health Psychology Kings College, London SE1 9RT UK
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Johnson argues that screening for abdominal aortic aneurysm (AAA) may cause untold psychological damage by alerting individuals that they have “a life threatening condition that is liable to cause sudden death and that nothing can be done about it” (1). Those aware of the evidence however will not be persuaded as this argument is contradicted by a large literature both on how individuals actually respond to AAA screening (2,3,4,5,6) and health risk information more generally (7,8). It is also at odds with psychological theories of self-regulation that describe the complex ways in which humans maintain an equilibrium while responding both practically and emotionally to threats both smaller and larger than those posed by AAA screening (9, 10). While anxiety is a common and adaptive initial response to risk notification, this has usually dissipated within a month (8). Pre-test preparation can mitigate anxiety but there is no evidence to support the statement that “any member of the public taking the test will need intensive counselling about the possible consequences that screening might have for their future lives and psychological wellbeing”(1). In the few studies that have assessed how people are thinking and feeling before screening, these are stronger predictors of post-screening states than test results: those who are depressed before screening will be depressed afterwards, regardless of screening test results (11). In the context of AAA screening, poorer self-assessed health seems to be a predictor not a consequence of the detection of an aneurysm (12). This evidence is not perfect. Not everyone participates or responds to questionnaires assessing emotional states. Drawing upon studies in other contexts, those who do not respond seem to have poorer emotional outcomes (13, 14). That said, the large, robust studies that have assessed emotional outcomes following detection of an AAA provide no evidence to suggest that this generates psychological harm of the kind imagined by Dr Johnson. References 1. Johnson JN Should we screen for aortic aneurysm? No BMJ 2008; 336: 863 2. Multi-centre Aneurysm Screening Study Group. The Multi-centre Aneurysm Screening Study (MASS): a randomised controlled trial into the effect of screening on mortality in men: a randomised controlled trial. The Lancet 2002; 360: 1531-1539 3. Lucarotti ME, Health BP, Shaw E, Poskitt KR. Psychological morbidity associated with abdominal aortic aneurysm screening. Eur J Vasc Endovasc Surg 1997; 14: 499-501 4. Khaira HS, Herbert LM, Crowson MC. Screening for abdominal aortic aneurysm does not increase psychological morbidity. Ann R Coll Surg Eng 1998; 80: 341-2 5. Lindholt JS, Vammen S, Fasting H, Henneberg EW. Psychological consequences of screening for abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2000; 20: 79-83 6. The UK Small Aneurysm Trial Participants. Health service costs and quality of life for early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 1998; 352: 1656- 60 7. Meisser B Psychological impact of genetic testing for cancer susceptibility : An update of the literature Psycho-Oncology 2005; 14: 1060-1074 8. Shaw C, Abrams K, Marteau TM. Psychological impact of predicting individuals' risk of illness: a systematic review. Soc Sci Med 1999; 49:1571-1598 9. Carver CS & Scheier MF. On the Self-Regulation of Behavior. Cambridge University Press 1998 10. Cameron LD & Leventhal H (Eds) The Self-Regulation of Health and Illness Behavior Routledge 2003 11. Broadstock M, Michie S, Marteau TM. The psychological consequences of predictive genetic testing: a systematic review. European Journal of Human Genetics 2000; 8: 731-738 12. Marteau TM, Kim LG, Upton J, Thompson SG, Scott AP. Poorer self assessed health in a prospective study of men with screen detected abdominal aortic aneurysms: a predictor or a consequence of screening outcome? Journal of Epidemiology and Community Health 2004; 58: 1042-1046 13. Timman R, Roos R, Maat-Kievit A & Tibben A. Adverse effects of predictive testing for Huntington's disease underestimated: long-term effects 7−10 years after the test. Health Psychol 2004; 23: 189−197 14. French DP, Maissi E & Marteau TM. The psychological costs of inadequate cervical smear test results: Three month follow-up. Psycho- Oncology 2006; 15; 498-508 Competing interests: None declared |
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Idris Guessous, senior research fellow Department of ambulatory care and community medicine, Lausanne University Hospital, 1011 Lausanne, Jacques Cornuz
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In the 19th April issue, Brearley and Johnson nicely debated about the rationale of abdominal aortic aneurysm (AAA) screening. Although recommended for years by health organizations, including the US Preventive Services Task Force (1), AAA screening has generally not been implemented in practice, notably because health care providers are not convinced that it is “worth” screening for AAA. The debate around AAA screening is in part due to the AAA screening paradox. Contrary to other accepted and implemented screening programs (breast and colorectal cancer screening) for which the efficacy of screening is based on their capacity to identify a large proportion of early stages (e.g. TNM stage) -the smaller the better-, the efficacy of AAA screening is inversely correlated to the stage (size) of the disease –the larger the better-. The assertion “AAA can be treated much more effectively at the asymptomatic stage than once rupture has occurred”(2) is only true for large AAA, generally defined as AAA diameter >5.5cm. Most of the AAAs detected by screening are small and clinical trials have shown that early, elective surgery of small AAA does not save lives (3,4). Current management recommendations for patients with small AAA propose interval measurements of aneurysm size until elective surgical repair is indicated based on rapid expansion or size criteria (1). The debate regarding AAA screening is taking place because AAA screening does not follow the usual medical view of screening. Instead of throwing out the baby with the bathwater, we propose to work on finding ways to keep the evidence-based benefice of early surgery to patients with large AAA, while offering more effective interventions to patients with screen-detected small AAA than they would have received if they had not been screened. A possible strategy would be to identify AAAs by screening and then to intervene therapeutically to slow down AAA expansion with preventive measures (5). As Johnson stressed, patients with AAA are seldom “otherwise healthy” (6). Actually, patients with AAA are more likely to be smoker, to have coronary artery disease and peripheral arterial disease (7). AAA screening may actually provide an excellent opportunity to offer effective general cardiovascular prevention interventions including advice for smoking cessation and physical activity, as well as prescription of cardioprotective therapy. Current treatment of cardiovascular risk is suboptimal in patient with AAA, and if improved, could reduce cardiovascular morbidity and mortality (8). In addition, pharmacotherapy appear to have a direct benefice on AAA mortality by reducing the rate of AAA expansion (9). Only a dual approach combining both preventive interventions and early surgery may fulfill the conditions of screening by decreasing the dramatic mortality rate of large AAA while offering, instead of a “time bomb”, effective interventions for patient with small AAA. (1) Fleming C, Whitelock EP, Beil TL, Lederle FA. Screenning for abdominal aortic aneurysm : a best-evidence systematic review for the U.S Preventive Sevices task Force. Ann Intern Med 2005;142:203-11. (2) Brearley S. Should we screen for abdominal aortic aneurysm? BMJ 2008;336:862 (3) Lederle FA, Wilson SE, Johnson GR, Reinke DB, Littooy FN, et al. Aneurysm Detection and Management Veterans Affairs Cooperative Study Group. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002;346:1437-44. (4) The UK Small Aneurysm trial Participants. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysm. Lancet 1998:352:1649- 1655. (5) Guessous I, Cornuz J. Abdominal aortic aneurysm screening: 2006 recommendations. Expert Rev Pharmacoeconomics Outcomes Res 2006;6:555-561. (6) Johnson JN. Should we screen for abdominal aortic aneurysm? BMJ 2008;336:863 (7) Cornuz J, Sidoti Pinto C, Tevaearai H, Egger M. Risk factors for asymptomatic abdominal aortic aneurysm: systematic review and meta- analysis of population-based screening studies. Eur J Public Health. 2004 Dec;14(4):343-9. (8) Lloyd GM, Newton JD, Norwood MG, Franks SC, Bown MJ, Sayers RD. Patients with abdominal aortic aneurysm: are we missing the opportunity for cardiovascular risk reduction? J Vasc Surg. 2004 Oct;40(4):691-7. (9) Guessous I, Periard D, Lorenzetti D, Cornuz J, Ghali WA. The efficacy of pharmacotherapy for decreasing the expansion rate of abdominal aortic aneurysms: a systematic review and meta-analysis. PLoS ONE. 2008 Mar 26;3(3):e1895. Competing interests: None declared |
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R. Alan .P Scott, Director of the Multi-centre aneurysm screening studt ( MASS) Scott research Unit . St. Richards Hospital Chichester W. Sussex PO196SE
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Should we screen for AAA? Management of screen detected AAA. Both authors make valid points about AAA screening, in relation to the proposed National Screening Programme for men age 65 or over, but there some errors of fact. Stephen Brearly states that a reduction in all cause mortality was only seen in one trial from Western Australia. A reduction in all cause mortality was also shown in the recently published 7 year results of the MASS trial.( hazard ratio 0.96( CI 0.93 to 1.00))1. James Johnson raises the question of anxiety generated by detecting an aneurysm. It is clear that a person informed that they have a “time bomb” inside them, may well become anxious. If instead the risk of having a small aneurysm is explained in proportion to that of surgery ( the reason for delay), along with reassurance that surveillance and treatment when indicated, greatly reduces the risk, compared to those not being followed up, anxiety can be minimised. In the MASS trial initial anxiety levels were shown to be low, and adverse emotional effects were not apparent after a month 2 James Johnson also raises the spectre of a cohort of “many patients left with the knowledge that they have a life threatening condition that is liable to cause sudden death”. This cohort was of concern on starting screening, but has not appeared over the subsequent 20 years of running an AAA screening programme. The reason is that those who are sufficiently unfit to make surgery more hazardous than the aneurysm itself are few; the severity of their co-morbidity tends to dominate their concerns, and if untreatable, quite rapidly overtakes them. In others, detection and treatment of their co-morbidity returns them to sufficiently good health to allow the aneurysm to be treated. Diagnosis of any disease may cause anxiety, but a skilled and well informed clinician should be able to achieve a balance between information and reassurance that would allow a man aged 65 or over to put the findings into proportion. The risk of surgery quoted is for a wide age group. The presence of a screening programme has been shown to reduce the surgical mortality with time, 3 possibly due to the lower age group entering surgery, the time for treatment of any co-morbidity, and the increased volume of elective surgery being done in the unit.. 1. Kim LG, Scott RAP, Ashton HA, Thompson SG, for the Multi-centre Aneurysm Screening Study Group. A sustained mortality benefit from screening for Abdominal Aortic Aneurysm. Annals Internal Medicine.2007; Vol. 146;699-706. 2. The multi-centre aneurysm screening study group The multi-centre aneurysm screening study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial Lancet. 2002; Vol.360: 1531-1539 3. Irvine C D, Shaw E, Poskitt KR, Whyman MR, Earnshaw JJ, Heather BP . A comparison of the mortality rate after elective repair of aortic aneurysms detected by screening or incidentally. Eur J Vasc Endovasc Surg 2000; 20:374-8 Competing interests: None declared |
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