Screening for Aortic Aneurysm

old_codger_3

I paid £95 for one of these scans after reading the article in the Times. I used the company mentioned in the article. I should have looked on here first and got it done at half the price in Hereford. My scan wasn't done by a consultant radiologist either. Still-I got the all clear so that was still money well spent.

Ringo-Starr_2

You did Ok "Old Codger". I found one place (aneurysmscreening.co.uk) charging £150 for a screening scan. Aortascan in Hereford does seem the cheapest at £50. Has anyone tried them?

DrFluffy

beechescomposter wrote: »

Oh dear DrFluffy. Doesn't the GMC say your duty as a doctor include staying up-to-date?
The review you link to was 12 years ago and would have been based on studies from a decade before. The evidence from studies on thousands of scans has accumulated over the last 15 years. The links I gave were from 2005 and 2007 and show that the evidence is now that screening by ultrasound is both beneficial and cost effective.
The evidence supports scans at 65-75 in male smokers or previous smokers. The scan is done once. People with a normal aorta are reassured. If there is a small aneurysm (26-39 mm) they have an annual scan. At 50-55 mm most aneurysms would be treated.
I don't know why you persist in ignoring the evidence that has been accepted by the health services in the USA, Canada and UK.

Sarah- it sounds like you had transoesophageal echo (TOE) to look at the heart. You should also have had a carotid ultrasound. Both use ultrasound but not to look at the abdominal aorta which is a much simpler and quicker scan.

Mojisola- the evidence on people with a family history is less strong and the recommendation is that the screening should be done at 60. However, unlike CT scanning, ultrasound is easy and harmless so a scan at 50 might be reassuring though it seems excessive to repeat it every two years if normal.

Only going on what we've been taught... It has a high negative predictive value, but there are issues with what you class as an anurism for diagnostic purposes - over 1.5mm? Over 3mm? Over 5mm. How do you intervien/ and when. There's been few studies on women either - so how applicable is it in reality? USS has been shown to underestimate the size of an aneurysm too - even when using doppler.

edit: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WMJ-49NX97J-D&_user=10&_coverDate=10%2F31%2F2003&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=ba8438296d45fc17ec56c746fe6a087e

That's before you get to the cost benefit relationship between cost of screening and the subsequent costs of treatment, against the doing no screen and hoping you pick things up.

USS screening for AAA isn't great - there's no easily identifiable, symptomatic prescursor. The natural history is particulally well understood - why do some men grumble on for years, while others go from 0-60 in a very short period of time - how do you treat these people in terms of a risk assessment - as that's what a scan is... A USS is a snap shot of one point in time - and not a good one if you're a bit lardy...

That's before compairing mortalities in repair of a AAA - which can vary from between 5%-40%, depending on centre and the characteristics of the population concerned...

To quote on of our surgeons on the subject: If you're going to screen - do a proper job, not a half arsed one. It's like the new HPV vaccine only being targetted at girls as a result of funding issues... Half a job...

beechescomposter

DrFluffy, I can’t understand why you persist in spreading this misinformation. Screening for abdominal aortic aneurysms is one of the most rigorously studied subjects in surgery and there are no issues regarding what is classed as an aneurysm or when to intervene.
The multicentre aneurysm screening study (MASS) reported in 2002 and was based on scanning almost 68,000 men. This addressed the cost effectiveness of screening in terms of cost per year of life saved. The figure was £36,000 in the first 3 years of screening and was predicted to fall to £8000 after screening had been in place for 10 years. In comparison, treatment with Herceptin for breast cancer costs £42,000 to £108,000 for each year of life saved. Your previous comment that Herceptin is treatment and screening is not is fatuous and irrelevant. A year of life saved is the same whether due to screening or medication and this way of measuring the value of health spending allows comparison of value for money.
The Gloucestershire screening program reported on the results of 13 years of screening the at risk population of the whole of Gloucestershire in 2004. The authors state that screening abdominal aortic aneurysms with ultrasound fulfils all the criteria for a population screening program. They also go on to state:
Men with an aorta < 26 mm in diameter are reassured and discharged. Thus a single scan can largely rule out aneurysm disease for life in 95% of men. Those with an aorta of 26-39 mm are recalled annually for imaging in the surgery with the current year's 65 year old men (the screening intervals are under review). Men with an aorta ≥ 40 mm in diameter are referred to the outpatient clinic of one of Gloucestershire's four vascular surgeons. They have an ultrasound scan every six months because growth patterns become erratic as the aorta enlarges. If the aorta becomes over 55 mm in diameter, elective repair is considered.
This seems pretty unambiguous to me.
Operative mortality in the Gloucester study was 3% and said to be improving during the period of the study and also lower in patients picked up during screening. Contrast this with the 50% operative mortality of the 20% who survive long enough with a ruptured aneurysm to reach an operating theatre or the 5% annual mortality from ruptured aneurysm in patients with aneurysms of 55mm or larger.
These two studies have been accepted as sufficiently strong evidence for a national screening program in male past or current smokers aged 65-75 in the USA, Canada and the UK. The evidence is not sufficiently strong to recommend screening at other ages, in non-smokers or women though that has not stopped some private clinics recommending it. Aortascan - the Hereford Radiologists- base their recommendation on the US Preventative Services Task Force analysis of the evidence. As treatment becomes safer and life expectancy increases it will probably be shown to be cost effective to screen other groups. Of course women and non-smokers die from aneurysms too and the cost-effective equation changes if people are willing to pay for their own screening.
I cannot understand why DrFluffy argues against all the available evidence. I can understand that the government would want to delay offering screening because they will not be able to offer it to the whole at risk group and, even if they could, they would be accused of sex and age discrimination because the science is too difficult for politicians to explain to the public in a sound bite and they would make more enemies than friends.
Readers of MSE need to understand that the objections to aortic aneurysm screening are political not scientific.

Ringo-Starr_2

Had a trip down to Hereford on Saturday and had my scan. All OK. Quite a relief to know I wasn't going to explode anytime soon. My wife had the scan too. Shame the weather was so bad but my wife and I combined the trip with some sightseeing and shopping in Ludlow and Shrewsbury and the £50 for each scan was the best price I have found so the saving more than paid for the day out.