Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial
BMJ
2002;
325
doi: https://doi.org/10.1136/bmj.325.7373.1135
(Published 16 November 2002)
Cite this as: BMJ 2002;325:1135
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Although no screening program for abdominal aortic aneurysm
exists in the UK at the present time despite much published
evidence(1,2,3), opportunistic screening should be performed in
the interim. Radiologists and ultrasonographers should be alerted
to the benefit of routinely examining the abdominal aorta in all
males over the age of 65 years who present to the ultrasound
department. This may mean a few more minutes of scanning time
per patient but is certainly worthwhile if it means a reduction in
mortality from rupture by early detection at no extra cost.
Reference:
1) Multicentre Aneurysm Screening Study Group. Multicentre
aneurysm screening study (MASS): cost effectiveness analysis of
screening for abdominal aortic aneurysms based on four year
results from randomised controlled trial. BMJ 2002;325:1135-8
2) Heather BP, Poskitt KR, Earnshaw JJ, Whyman M, Shaw E.
Population screening reduces mortality rate from aortic aneurysm
in men. Br J Surg 2000;87(6):750-753
3) Lindholt JS, Juul S, Fasting H, Henneberg EW. Hospital costs
and benefits of screening for abdominal aortic aneurysms. Results
from a randomised population screening trial. Eur J Vasc
Endovasc Surg 2002 Jan;23(1):55-60
Competing interests:
None declared
Competing interests: No competing interests
Editor – It is a scandal that in the 21st century there is no
national screening programme, in the United Kingdom, for the detection of
abdominal aortic aneurysms in men. This in spite of some very compelling
evidence in favour of one.
In a randomised controlled trial Scott et al [1] identified a 68%
reduction in incidence of rupture at 5 years among those invited for
screening compared with age-matched controls and a 42 per cent reduction
in death from rupture. The benefit persisted at 10 years but there was no
detectable benefit for women. In men, only 4 per cent of deaths from
rupture occurred under the age of 65 years, no woman died below this age.
Screening of men aged 65 years has been taking place in the county of
Gloucestershire, UK since 1990. The total number of aneurysm-related
deaths 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 per year in men aged 60 – 79 years [3]. In addition reduction of
modifiable risk factors, smoking, hypertension, coronary heart disease
[4], together with increased awareness of unusual modes of presentation of
ruptured abdominal aortic aneurysm may save even more lives. Finally the
multicentre aneurysm screening study provides evidence of cost
effectiveness of a national screening programme [5].
1. Scott RAP, Vardulaki KA, Walker NM, Day NE, Duffy SW, Ashton HA.
The long-term benefits of a single scan for abdominal aortic aneurysm
(AAA) at age 65. Eur J Vasc Endovasc Surg 2001; 21: 535-40.
2. Heather BP, Poskitt KR, Earnshaw JJ, Whyman M, Shaw E. Population
screening reduces mortality rate from aortic aneurysm in men. Br J Surg
2000; 87(6): 750-753.
3. Law M, Screening for abdominal aortic aneurysms. Br Med Bulletin
1998; 54: 903-913.
4. Lederle FA, Johnson GR, Wilson SE, Littooy FN, Krupski WC, Bandyk
D, et al. Yield of repeated screening for abdominal aortic aneurysm after
a 4-year interval. Aneurysm Detection and Management Veterans Affairs
Cooperative Study Investigators. Arch Intern Med 2000; 160(8): 1117-21.
5. Multicentre Aneurysm Screening Study Group. Multicentre aneurysm
screening study (MASS): cost effectiveness analysis of screening for
abdominal aortic aneurysms based on four year results from randomised
controlled trial. BMJ 2002; 325:1135-8.
Competing interests:
None declared
Competing interests: No competing interests
Sirs,
I am very delighted with MASSG’s article (1) as well as with similar
papers, which come to the conclusion: “Even at four years the cost
effectiveness of screening for abdominal aortic aneurysms is at the margin
of acceptability according to current NHS thresholds. Over a longer period
the cost effectiveness will improve substantially, the predicted ratio at
10 years falling to around a quarter of the four year figure”. Surely, the
cost at 10 years improves in comparison with that of the former randomised
controlled trial, in which patients were individually allocated to
invitation to ultrasound screening (intervention), due to the fact that
individuals are selected somehow.
In reality, I like such articles, emphasing the urgency of spreading a
new physical semeiotics, i.e., Biophysical Semeiotics, in a medical world,
ruled by high technology, in order to recognize at the bed-side disorders
otherwise undiagnosed in unexpensive way (Stagnaro S., BMJ.com, Rapid
Response, A new physical semeiotics in detecting disorders otherwise
undiagnosed. 30 Marz 2001). As far as abdominal aortic aneurysms diagnosis
in both older and young men, a 45-year-long clinical experience allows me
to state that its diagnosis – although clearly overlooked or totally
ignored all around the world – is primarily a “bed-side” “quantitative”
diagnosis , regardless its size and not to speak of its precious clinical
monitoring (2, 3, 4). Sophisticated semeiotics can then corroborate the
clinical diagnosis in individual "rationally" selected with appreciable
reduction in cost. For further information, See my site HONCode,
http://digilander.libero.it/semeioticabiofisica, Practical Appplications,
Abdominal Aortic Aneurism, and the Page I hold in italian site
www.katamed.it.
1) Multicentre Aneurysm Screening Study Group. Multicentre aneurysm
screening study (MASS): cost effectiveness analysis of screening for
abdominal aortic aneurysms based on four year results from randomised
controlled trial. BMJ 2002;325:1135 ( 16 November )
2) Stagnaro-Neri M., Stagnaro S., Aneurisma Aortico Addominale: una
Diagnosi clinica con la Semeiotica Biofisica. Acta Cardiol. Medit. 14, 17,
1986.
3)Stagnaro-Neri M, Stagnaro S., Valutazione clinica percusso-ascoltatoria
del sistema nervoso vegetativo e del sistema renina-angiotensina,
circolatorio e tessutale. Arch. Med. Int. XLIV,173, 1992.
4) Stagnaro-Neri M., Stagnaro S., Stadio pre-ipertensivo e monitoraggio
terapeutico della ipertensione arteriosa. Omnia Medica Therapeutica.
Archivio, 1-13, 1989-90
Competing interests:
None declared
Competing interests: No competing interests
Is the confidence interval for cost per life year gained a misprint
at
£15000 to £145000 or should readers be highly sceptical about
the economic case set out?
Competing interests:
None declared
Competing interests: No competing interests
Screening for aortic aneurysm
Imagine this hypothetical scene – Thursday morning surgery (tends to be quieter,
thank goodness). First patient, Mr Bland, enters. He is a fit 65 yr old.
‘Hello, Mr Bland’
‘Hello Doc’
I pause. He rummages in his pocket and brings out A4 sheet. ‘Its this ..
aortic aneurysm screening thing, what’s it all about?’
Discussion follows about aortas, near certainty of death from rupture,
risk of death of 1 in 1000 pre year (approx), and the ease of the
screening test.
‘So, if I have this done I’m going to live longer?’
‘Well, no, I can’t say that. The trial showed that 11% died whether they
had the screening or not, over the four years of the trial.’
‘Hmmm. OK then. But if I was found to have one of these things and had the
operation, I’d be OK?’
‘Well, no. I can’t say that. The trial showed that if you had the
operation before the aneurysm burst, 19 out of twenty would survive, but
one would die.’
‘So that means that I might actually die sooner than I would have?’
I pause, ‘Well, yes, it does.’
‘So, if I have the screening, and survive the operation, if I have one,
what would I die of? Would it be cancer or would I end up like my sister
with dementia in that nursing home?’
‘Well, I’m sorry I cannot tell you that.’
‘Right.’ He’s getting a bit red in the face .. ‘ OK. You’re the
professional. What do you think I should do?’
I pause. ‘It really is up to you, Mr Bland. It’s your decision entirely. I
suggest you go home and chat to your wife about it. You could come back
and see me again if you want.’
‘Cheerio, then.’
Was it my imagination, or did the door close more firmly than normal?
But I couldn’t tell him that personally (at this point in my life), I
would want to take my chances, could I?
Life has 100% mortality. It follows that doctors can only prolong
life (usually). I believe that a prime end point in research in the latter
years of life must be related to final outcomes. Otherwise it is like a
story with no ending. If we are suggesting that people swap a quick death
(albeit painful) for something else, I think we need to know what that is.
Otherwise can we really say that we have informed consent? Other
information might be useful too - nearly one percent of the screened group
had a major operation, what is the morbidity? With small aneurysms, the
editorial states that there is a 1% annual chance of rupture – what about
those greater than 5.5cms (presumerably it is higher than the 6% mortality
from elective operation)? What is the life expectancy of a 65 yr old male?
Scientific research tends to look at life if there are many unrelated
aspects. Therefore the conclusion is that undoubtedly aortic aneurysm
screening is justified. However I think we should apply the results
holistically. This is undoubtedly more messy, but probably more realistic.
Competing interests:
None declared
Competing interests: No competing interests