Aneurysm screening plan falls short of expectations

Men between the ages of 65 and 75 who have ever smoked now have the government's stamp of approval for a one-time ultrasound screening for abdominal aortic aneurysm. Medical specialty organizations praised the move but want women and nonsmoking men to receive the same imprimatur.

The U.S. Preventive Services Task Force (USPSTF) last considered AAA screening in 1996 but made no recommendations. Since then, several population-based clinical trials have shown that screening in older men with a history of smoking reduces AAA-related mortality.

For men who have never smoked, there is evidence that screening improves health outcomes, but a comparison between benefits and potential risk from an increased number of surgeries with associated morbidity and mortality was too close to justify a general recommendation, according to the report (Ann Intern Med 2005;142:203-11). The USPSTF also found evidence that screening is ineffective in women and recommended against the practice.

The Society of Interventional Radiology urged the task force to recommend screening for all male nonsmokers and women with a family history of AAA. It said there should be no recommendation regarding women without family histories, rather than issuing a fiat against screening for that population.

A four-year study of the SIR's national Legs For Life program, which offers free AAA screenings, found that one in four participants were at risk and one in 20 had an aneurysm. More than 46,000 people have been screened for AAA in the program, according to Dr. Katherine Krol, who presented the study at the 2004 SIR meeting.

"As a practitioner, it's hard to say that we're not going to screen women because we know we will pick up otherwise undetected aneurysms," said Krol, interventional radiology director for Corvasc in Indianapolis.

The Society for Vascular Surgery recommends screening all men aged 60 to 85, women aged 60 to 85 with cardiovascular risk factors, and men and women older than 50 with a family history of AAA. The task force's exclusion of all women and of men who never smoked has the potential to miss one-third of existing aneurysms, said Dr. William Flinn, vice chair of the American Vascular Association, a foundation of the Society for Vascular Surgery.

About 1% of the people screened annually in the American Vascular Association's free screening program have an AAA. Of these, 60% never smoked, and 40% do not have hypertension. These people would go undiagnosed under the current recommendation, Flinn said.

"When you have the chance to eliminate a fatal disease, we think you should take it," he said.

Medicare does not pay for preventive medicine unless Congress requires it, and the screening scan, which can cost between $45 and $75, is not reimbursable. That could change if advocates are successful on Capitol Hill. Last year, the National Aneurysm Alliance, a coalition of medical specialty societies, foundations, and industrial partners, lobbied for legislation approving a one-time ultrasound screening for at-risk Medicare beneficiaries. With the added weight of the task force recommendation, the group will redouble its efforts to gain passage of the SAAAVE (Screen Abdominal Aortic Aneurysms Very Efficiently) bill in the 109th Congress, Flinn said.

"We will insist the legislation include women at the highest risk," he said.