Posted on 02/01/2005 7:45:22 AM PST by neverdem
In a sharp change from current policy, an influential medical advisory group is recommending that all men ages 65 to 75 who have ever smoked have an ultrasound screening test to see if they are developing a condition that could kill them in minutes by bursting a major artery in the abdomen.
The group, the United States Preventive Services Task Force, is an independent panel of medical experts that advises the federal Agency for Healthcare Research and Quality. Its recommendations help set government policy and are generally followed by primary care doctors.
The task force last looked at the condition, abdominal aortic aneurysms, in 1996 and concluded that there was insufficient evidence that a screening test would save lives. But now, it said, four large clinical trials have provided the evidence it needs, at least for those most at risk.
Finding aneurysms early, with a scan that can cost $350 to $400, and repairing them with an operation that can cost $15,000 to $20,000 if there are no complications, can cut the death rate by a third. Although the surgery can itself cause death, the risk that a large aneurysm will suddenly rupture and kill the patient is greater, the group said.
The condition kills at least 9,000 people a year in the United States. With screening, "the science comes down to saying this is worth doing," said Dr. Ned Calonge, chairman of the task force and chief medical officer of the Colorado Department of Public Health and Environment.
"We think our recommendation will translate into physicians incorporating screening into their practice," said Dr. Calonge, who does not screen for or repair aneurysms nor determine payments for health care, and said he has no conflicts of interest in making the recommendation.
The recommendation affects about 9.8 million Americans, the 70 percent of the nation's 14 million men ages 65 to 75 who are smokers or have ever smoked. The task force defined the group to include any man who had smoked at least 100 cigarettes in his life.
The test was not recommended for women because they are at much lower risk of developing the aneurysms.
The task force estimated that for every 500 men who meet its criteria and are screened, one death would be prevented over five years. In comparison, the only test for colorectal cancer that was evaluated in a randomized controlled trial, the fecal occult blood test, requires that 1,374 people be screened to prevent one death over five years.
"This is huge," said Dr. Frank A. Lederle of the University of Minnesota and the Minneapolis Veterans Affairs Medical Center, who reviewed the clinical trial data for the task force. "A major test for a major disease - it just doesn't come along very often."
Almost no one is screened now for abdominal aortic aneurysms, vascular surgeons say. Medical researchers suspect the true death rate is higher than 9,000 a year because often the swift deaths are attributed to a heart attack or stroke.
"If it ruptures, you're dead," Dr. Lederle said. Most bleed to death so quickly that they never make it to the hospital. And half of those who do make it to the hospital do not survive.
The review of the trial data on abdominal aortic aneurysms, along with the task force's recommendations, is published today in the Annals of Internal Medicine.
An abdominal aortic aneurysm is a small weakened area of the aorta, the large artery that carries blood from the heart and winds down along the spinal cord to the abdomen. Over the years, the weak spot slowly balloons and eventually bursts. There are no symptoms as the aneurysm grows. But once it reaches five and a half centimeters, or a little over two inches, in diameter, it may burst at any moment. That is the time to repair it, medical researchers say, explaining that smaller aneurysms posed too little danger to be worth the risk of operating on them.
Of course, finding small aneurysms also leads to a screening dilemma: patients will discover that they have a time bomb in their body but will have to wait and monitor it before getting it fixed. Still, vascular surgeons say, that is far better than the current situation, in which most aneurysms are not found until they rupture and the few that are discovered earlier are found by accident.
"Frequently we end up with someone who has back pain and gets a CT scan or an M.R.I. of the back," said Dr. Samuel Money, the chief of vascular surgery at the Ochsner Clinic Foundation in New Orleans. The doctor, he said, looks at the scan and says, "Holy smoke, you have a 6.2-centimeter aneurysm."
The task force limited its recommendations to men aged 65 to 75 who have smoked because rupture is rare in people under age 65 and is at least three times as likely in people who have smoked. The condition is about four times as common in men as in women. Anyone with a family member who had an aneurysm is at increased risk. High blood pressure is a more minor contributor to risk and cholesterol does not seem to make much difference, researchers say.
After 75, the life expectancy is considered too short and the operation too risky.
The group recommended neither for nor against screening men ages 65 to 75 who never smoked. Those men should consult their doctors, it said. Women, however, should not be screened, the task force said, because it is much less likely that they will have a ruptured aneurysm and, if they do, the rupture usually occurs in their 80's.
Screening can be costly. It usually involves a complete ultrasound scan of the abdomen, at $350 to $400. There also are quick ultrasound tests that cost about $50 to $100. If they show an aneurysm, patients are referred for a more complete test to confirm the diagnosis.
Medicare does not pay for preventive medicine unless Congress requires it. But vascular surgeons say the new recommendation should give Congress an impetus to make screening for the aneurysms, like screening for colon and breast cancer, part of Medicare's benefits.
Lobbying for Medicare coverage has been intense, said Dr. Robert Zwolak, professor of surgery at Dartmouth Medical School. Dr. Zwolak lobbies Congress as chairman of the National Aneurysm Alliance, a group of doctors, professional societies and companies. But, he said, one holdup has been the Preventive Services Task Force, which, until now, had not recommended screening.
"I would say that in two-thirds of the offices I visit, they ask, 'What does the task force say?' " Dr. Zwolak said.
Now, he says, he expects Congress will pass a bill requiring Medicare to pay for screening.
"It's just wonderful what the task force has done," Dr. Zwolak said.
His main concern, shared by his colleague Dr. Jack L. Cronenwett, the chief of vascular surgery at Dartmouth-Hitchcock Medical Center, is that the recommendations do not go far enough. Women with a family history of the aneurysms and who have smoked have the same risk as a nonsmoking man, Dr. Cronenwett said.
"If Medicare bases a coverage decision on the recommendations, a woman could have three brothers with aneurysms and she could be a smoker and she still wouldn't get reimbursement," Dr. Cronenwett said.
Medicare does pay for the repair of aneurysms by either of two methods.
One involves opening the abdomen and replacing the damaged area with a synthetic tubing. In the other method, endovascular repair, a doctor threads a catheter through the groin to the aneurysm and relines the damaged section of blood vessel from the inside, inserting a segment of synthetic material.
About 4 percent of surgery patients die. The death rate from putting in an endovascular graft is about 1.5 percent. But researchers worry that those grafts may not provide lasting results and are awaiting data from large clinical trials comparing the two methods.
"Some of us think the long-term benefits of grafts are not proven," said Dr. Lederle, an internist who is directing one of the clinical trials and takes no money from the industry. But grafts, he said, are a huge market, widely promoted. "This has created tension in the field," he added.
Dr. Calonge of the task force said the question for insurers was going to be whether to pay for the screening. He knows that world well, he says, because until a few years ago he was the chief of preventive medicine for the Kaiser Permanente health care company in Colorado and had to decide whether new tests and services should be provided.
"People don't sit down and say: 'Here's $60,000. I want a year of life,' " he said. "What you end up doing is to say, what's the cost of the program and how does that affect what I charge and does it help or hurt in the marketplace?"
The task force's role was a bit different, he said. "Cost does not enter into the task force's recommendations," Dr. Calonge said. "We're looking for a balance of harm to potential risk. You will have the benefit in terms of lives saved and years given back to those men."
But for insurers the question is a bit different, Dr. Calonge said, "They will say, 'At what cost and can we afford this?' "
My first instinct is to wonder who on the advisory board owns how much stock in which companies that do these scans.
We got sold all this crap by a fast talking salesman and now we got to pay for it. OK, heart scans for anyone who ever smoked a cigarette and colonoscopies for anyone who ever ate a hamburger. Hire some grad students at minimum wage to publish a "study."
Me too, or a thought much like it - who gets money from this. It is hard for me to recommend to a 79 yr old man to go get this test because he may have a 6% higher risk to die of this. Chances are there he has much higher risks than that of dying of many other things. After all, he is 79!
After age 75 the scans are not recommended, due to declining longevity expectations.
It's a $300 ultrasound test. You can get one at any doctor's office or clinic anywhere in the US. Don't know many doctor's offices that are public companies, sorry.
My father died from this at age 52. He had a burning pain in the chest and went to the ER. Heart was beating normally, but they admitted him for observation. He passed away in his sleep that night and only an autopsy revealed the aneurism. Grandfather also passed away in his 50's from unkown causes. Both drank heavily and smoked like chimneys. If either has this test, their lives may have been saved. I'm in my 30's and paid for the test. This gives me some peace of mind and a baseline for future testing.
There's all sorts of ways to make money off of unnecessary medical tests. That's not much of a refutation... someone has to sell/maintain the machines, and analyze the data, at a minimum.
An aneurysm. Isn't that what John Ritter died of? Anyone know?
Actually at age 79, the smoker has almost an 8% risk, versus the nonsmoker's 2.5% risk. That's a 220% higher risk...
The big problem I have with the article is that about 1 in 1,000 male smokers (ex-smokers) die each year from this, yet the study presumes to save one life for each 500 patients screened over a 5 year period; seems like they expect to save more lives that originally being lost.
Thank you for this article. I am going to send it to my father.
My father smokes and looks like hell. I hadn't seen him in 25 years, and when I saw him again last summer he looked like a small old man and he is only 61. He also has deep vein thrombosis from flying and smoking and he knows that a clot can go into his lungs and kill him. I so wish he would quit smoking. Both of his parents died from smoking.
My mother stopped smoking last year when they took out one of her lungs due to cancer.
BUMP FOR LATER REPLY, I HAVE TO GO OUT, but, My husband just had two operations for this. I have some information to share.
It depends on how you want to skew the numbers. If you want to go for the emotional impact, you take the 2.5% as the basis. But if you look at it in reality, you see that 2.5 men out of 100 will die from it compared to 8 out of 100. The difference is 5.5%. (I said 6% before because I just glanced at the graph and couldn't remember the exact height of the bar).
Too many people who have an agenda do the same type of number crunching you do. I am surprised that they don't look at the first group and say there is a 1000% increase. (Eyeballing of about .1% compared to 1%)
And to be honest, there just isn't that much difference between 2.5% and 8%. If it were 2% compared to 30% oreven 15, then that might be worth a lifting of an eyebrow. But for the oldest group they recommend - it is about only a 3% higher risk - from about 1 in 100 to about 4 in 100. I don't know if that is statiscally significant. It wouldn't seem that it is - but I never paid much attention to the statistics I had to take. But still, it seems very small percentage of risk compared to the amount of time and money required by the screenings but more for the surgeries - all of which eventually come out of other people's pockets - either taxes or higher premiums. And we haven't even mentioned the errors involved in the screening process that may produce false results.
Because one can use correct data to assert something that does not follow. Take global warming or the endless quest for a "gay gene" as a couple of examples.
That's way statistically significant. And the odds aren't for dying, they're for having a 3cm size or larger aneurysm of this sort. For a cheap $300 you can find out if you have a condition that'll eventually abruptly kill you. And if you're a 60 year old former smoker the chances are 1 in 16 that you do. When I hit the age, I'll fork over the $300. Maybe you don't fit the category. Or maybe peace of mind isn't worth it to you. C'est la vie.
I don't think you really understand ultrasounds and aneurysms.
My husband just had two surgeries for this, but I am leaving soon and can't post much longer. I would like to share our experience so it will take awhile to post. Will do this when I come back. We learned a lot.
"Some of us think the long-term benefits of grafts are not proven," said Dr. Lederle, an internist who is directing one of the clinical trials and takes no money from the industry. But grafts, he said, are a huge market, widely promoted. "This has created tension in the field," he added. Dr. Calonge of the task force said the question for insurers was going to be whether to pay for the screening. He knows that world well, he says, because until a few years ago he was the chief of preventive medicine for the Kaiser Permanente health care company in Colorado and had to decide whether new tests and services should be provided.
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