Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
AAA screening
- Andrew McIrvine (25 June 2009)
-
Dr Heath's breast screening lessons apply to AAA too
- John D Middleton (4 July 2009)
-
Consenting adults
- John Doherty (16 July 2009)
-
To screen or not to screen?
- Ashok I Handa, Ed Sideso, Clinical Research Fellow (24 July 2009)
|
|
|||
|
Andrew McIrvine, Consultant Vascular Surgeon King's College Hospital, SE5 RS
Send response to journal:
|
Endovascular repair has now taken over as the majority treatment in most major
vascular centres (90% in ours). It is probably not much more expensive as
although the device costs more the reduced hospital stay and reduction of need
for intensive care balance this out.
Once screening is established it would be political dynamite to cancel it even if
cost ineffectiveness is later proven - cf breast screening
Competing interests: None declared |
|||
|
|
|||
|
John D Middleton, Director of Public Health Sandwell PCT, 438 High Street, West Bromwich, B709 LD
Send response to journal:
|
It was timely that your issue, BMJ, June 27th 2009, juxtaposed Dr Iona Heath’s observations about the personal impact of breast screening with rarefied and inconclusive health economic analyses of aortic aneurysm (AAA) screening. Dr Heath quotes Sackett’s descriptions of preventive medicine as ‘aggressively assertive pursuing symptomless individuals and telling them what they must do to remain healthy… and presumptuous, confident that the interventions it espouses will, on average do more good than harm to those who accept and adhere to them’. But if this is indeed the case with well established breast screening, how much more so for the new AAA screening programme. There is an ethical imperative to screening which is much more demanding than that for the treatment of ill patients who present to their doctor for help. Screening is offered to people who believe themselves to be well. The doctor’s duty to first do no harm is all the greater in this case. Emergency aneurysm surgery carries a grave prognosis but even with elective aneurysm surgery, there is an operative mortality, between 1%- and 8% depending which audit series is being reported. To inflict on otherwise innocent patients the choice to have major surgery which may kill them tests the bounds of doing no harm too far. It is also grossly unfair on the surgeons who are a part of this decision and I know several who are uneasy about this programme. AAA screening places an onus on patients to be part of a risk assessment and decision that they have not been asking to make- to live with the knowledge of their aneurysm and have it on their heads if it ruptures, or accept a major surgical procedure that may kill them. On a population basis, well men will die because of their agreement to surgery. Net benefit to some, if there is any, over loss to others does not adequately justify AAA screening. AAA screening does not meet the basic ethical imperative for a screening programme. The question of cost effectiveness becomes a secondary consideration. But cost effectiveness is not the same as affordability. Given the impending need to cut the NHS budgets in accordance with the dire national financial position, it would be foolish to embark on a new unaffordable, high risk programme of contested cost effectiveness, which may benefit some but will cost others their lives. Competing interests: None declared |
|||
|
|
|||
|
John Doherty, Occupational physician Vienna 1040 Austria
Send response to journal:
|
The evidence base supporting screening for abdominal aortic aneurysm (AAA) is not as solid as Professor Buxton asserts.(1) The U.S. Preventive Services Task Force (USPSTF) does not endorse such screening. Their rationale is that there is good evidence that screening and early treatment leads to important harms, including an increased number of surgeries with associated clinically-significant morbidity and mortality, and short-term psychological harms. The USPSTF concludes that the balance between the benefits and harms of screening for AAA is too close to make a general recommendation for screening.(2) The men invited for screening should be given this information as well as the likelihood that they will benefit — about one in a thousand. Consent for screening is only valid if it is well informed. (1) Buxton MJ, Screening for abdominal aortic aneurysm. BMJ 2009; 338: b2185. (2) U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf05/aaascr/aaars.htm * Competing interests: None declared |
|||
|
|
|||
|
Ashok I Handa, Reader and Consultant Surgeon John Radcliffe Hospital, Oxford, Ed Sideso, Clinical Research Fellow
Send response to journal:
|
We agree with Martin Buxton that the present evidence favours screening for AAA in the United Kingdom. We also agree that the results from MASS pertain to the UK population and the important caveat of the introduction of EVAR needs addressing in light of cost effectiveness. However, the Danish study by Ehlers et al uses a probabilistic model to attempt to address the same issue in Denmark. Their findings conflict with the MASS study. One study is a randomised control trial producing robust evidence for screening in a specific cohort and the other is a computational study, albeit using existing data, in a different cohort. Comparing the 2 studies is akin to a comparison between apples and oranges. Until a RCT is performed in the Danish cohort, we suggest that the best evidence for the benefits of screening in the UK population rest with data from the MASS trial with the intervention of choice being open surgery. References: 1. Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. Multicentre |Aneurysm Screening Group. BMJ 2002 Nov 16;325(7373):1135. 2. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. Thompson SG; Ashton HA; Gao L; Scott RA; Multicentre |Aneurysm Screening Group. BMJ 2009 Jun 24;338:b2307. 3. Analysis of cost effectiveness of screening Danish men aged 65 for abdominal aortic aneurysm. Ehlers L, Overvad K, Sørensen J, Christensen S, Bech M, Kjølby M. BMJ. 2009 Jun 24;338:b2243. Competing interests: None declared |
|||