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Abdominal Aortic Aneurysms and the Pulitzer Prize Certainly, the morning’s headlines were a belated April fool’s joke. A Pulitzer Prize for reporting about abdominal aortic aneurysms? The glory of journalism’s highest honor for a swollen blood vessel? Where’s the news here? Why, the law of Laplace, which explains the fluid dynamics of aneurysms, was de- scribed 200 years ago, a century be- fore the Pulitzer was even created. What about a prize for a story about decoding the human ge- nome? Unlocking the secrets of the brain with functional imaging? Re- lieving paralysis with neural pros- thetics? Some scientific advances that excite real physicians and sci- entists? Not so fast. On second thought, maybe reporters Kevin Helliker and Thomas M. Burton are on to something. After all, the Wall Street Journal didn’t become one of the world’s most influential newspa- pers without having an ear for their readers’ interests. In fact, it takes only a little reflec- tion to see the newsworthiness of aneurysms: a silent, sudden killer heretofore virtually unknown to the public; more fatalities in the United States each year than caused by AIDS; a new, minimally invasive alternative to surgery; a collision of specialists seeking control in one of the rare vacuums in medicine. The 2003 series of articles in the Wall Street Journal began with an explanation of aneurysms, moved to the personal story of Helliker’s aneurysm and his encounters with the medical profession, and closed with an account of the efforts to begin a national screening cam- paign [1]. First, much of the Journal ’s cov- erage of abdominal aortic aneu- rysms was old news to physicians. They are more common in men (by a factor of three to one); increase in frequency with age, especially after 65; and are associated with cigarette smoking. Aneurysms grow slowly, by about 0.2 to 0.3 cm annually. The risk for rupture, which carries a mortality rate of 90%, increases with greater diameter. But some recent reports have shaken things up a bit. A large, ran- domized trial in Great Britain vali- dated the survival benefit in pa- tients with aneurysms larger than 5.5 cm in diameter undergoing sur- gery compared with surveillance [2]. Similarly, two studies affirmed the advantage of monitoring pa- tients with aneurysms smaller than 5.5 cm in diameter [3,4]. However, to exclude interval expansion, this monitoring must be aggressive, with repeat studies as often as every 6 months. Stent grafts, which can be in- serted percutaneously during a 2-day hospitalization, were first de- scribed in 1991, approved by the U.S. Food and Drug Administra- tion in 2002, and soon thereafter become the standard of care in an- eurysm management, rapidly re- placing open surgery. Finally, minified ultrasound units have made the portable diagnosis of aneurysms practical and reason- ably accurate [5]. Portable can be the bedside, as in this study, but portable can also be a health fair at a mall. Undertaking a nationwide screen- ing program is no small feat. There’s lots of competition for scarce resources. Other advocacy groups (e.g., colorectal cancer, ovarian cancer) have been around a lot longer and have yet to convince insurance companies to cover screening examinations for asymp- tomatic patients. Indeed, mam- mography was widely accepted for three decades before Medicare be- gan coverage for screening in 1998. Strict criteria must be met before consideration for screening can be considered. These parameters in- clude (1) the cost, invasiveness, and accuracy of a screening test; (2) the prevalence of a disease; (3) the effi- cacy of an intervention; and (4) the cost of an intervention. For practical purposes, accuracy is not an issue, because noninvasive duplex ultrasound is nearly fool- proof in the diagnosis of significant abdominal aortic aneurysms. The Multicentre Aneurysm Screen- ing Study revealed that 4.9% of screened men in Great Britain aged 65 to 74 years had aneurysms of the abdominal aorta. In the United States, there are 8.3 million men in this age group, implying that as many as 406,000 could har- bor aneurysms. Because 12% of these could be expected to be larger than 5.5 cm in diameter, 48,000 of these men might possibly be surgi- cal candidates. Yet annually in the United States, only 33,000 men and women of all ages undergo an- eurysm repair. Estimates of annual mortality from ruptured aneurysms in the United States range from 9000 to 30,000 (the larger number is based on an estimate of how many pa- tients with sudden death succumb to a ruptured aneurysm). Annual mortality rates from other condi- tions such as breast cancer, AIDS, MICHAEL J. PENTECOST, MD WASHINGTON WATCH © 2004 American College of Radiology 0091-2182/04/$30.00 DOI 10.1016/j.jacr.2004.04.007 545

Abdominal aortic aneurysms and the Pulitzer Prize

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Page 1: Abdominal aortic aneurysms and the Pulitzer Prize

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MICHAEL J. PENTECOST, MDWASHINGTON WATCH

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bdominal Aortic Aneurysms andhe Pulitzer Prize

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ertainly, the morning’s headlinesere a belated April fool’s joke. Aulitzer Prize for reporting aboutbdominal aortic aneurysms? Thelory of journalism’s highest honoror a swollen blood vessel? Where’she news here? Why, the law ofaplace, which explains the fluidynamics of aneurysms, was de-cribed 200 years ago, a century be-ore the Pulitzer was even created.

What about a prize for a storybout decoding the human ge-ome? Unlocking the secrets of therain with functional imaging? Re-

ieving paralysis with neural pros-hetics? Some scientific advanceshat excite real physicians and sci-ntists?

Not so fast. On second thought,aybe reporters Kevin Helliker

nd Thomas M. Burton are on toomething. After all, the Wall Streetournal didn’t become one of theorld’s most influential newspa-ers without having an ear for theireaders’ interests.

In fact, it takes only a little reflec-ion to see the newsworthiness ofneurysms: a silent, sudden killereretofore virtually unknown tohe public; more fatalities in thenited States each year than causedy AIDS; a new, minimally invasivelternative to surgery; a collision ofpecialists seeking control in one ofhe rare vacuums in medicine.

The 2003 series of articles in theall Street Journal began with an

xplanation of aneurysms, movedo the personal story of Helliker’sneurysm and his encounters withhe medical profession, and closedith an account of the efforts toegin a national screening cam-aign [1].

First, much of the Journal ’s cov- g

004 American College of Radiology1-2182/04/$30.00 ● DOI 10.1016/j.jacr.2004.04.007

rage of abdominal aortic aneu-ysms was old news to physicians.hey are more common in men (byfactor of three to one); increase in

requency with age, especially after5; and are associated with cigarettemoking. Aneurysms grow slowly,y about 0.2 to 0.3 cm annually.he risk for rupture, which carries aortality rate of 90%, increasesith greater diameter.But some recent reports have

haken things up a bit. A large, ran-omized trial in Great Britain vali-ated the survival benefit in pa-ients with aneurysms larger than.5 cm in diameter undergoing sur-ery compared with surveillance2]. Similarly, two studies affirmedhe advantage of monitoring pa-ients with aneurysms smaller than.5 cm in diameter [3,4]. However,o exclude interval expansion, thisonitoring must be aggressive,ith repeat studies as often as everymonths.Stent grafts, which can be in-

erted percutaneously during a-day hospitalization, were first de-cribed in 1991, approved by the.S. Food and Drug Administra-

ion in 2002, and soon thereafterecome the standard of care in an-urysm management, rapidly re-lacing open surgery.Finally, minified ultrasound units

ave made the portable diagnosisf aneurysms practical and reason-bly accurate [5]. Portable can behe bedside, as in this study, butortable can also be a health fair at aall.Undertaking a nationwide screen-

ng program is no small feat.here’s lots of competition for

carce resources. Other advocacy

roups (e.g., colorectal cancer, t

varian cancer) have been around aot longer and have yet to convincensurance companies to covercreening examinations for asymp-omatic patients. Indeed, mam-ography was widely accepted for

hree decades before Medicare be-an coverage for screening in 1998.

Strict criteria must be met beforeonsideration for screening can beonsidered. These parameters in-lude (1) the cost, invasiveness, andccuracy of a screening test; (2) therevalence of a disease; (3) the effi-acy of an intervention; and (4) theost of an intervention.

For practical purposes, accuracys not an issue, because noninvasiveuplex ultrasound is nearly fool-roof in the diagnosis of significantbdominal aortic aneurysms.

The Multicentre Aneurysm Screen-ng Study revealed that 4.9% ofcreened men in Great Britainged 65 to 74 years had aneurysmsf the abdominal aorta. In thenited States, there are 8.3 millionen in this age group, implying

hat as many as 406,000 could har-or aneurysms. Because 12% ofhese could be expected to be largerhan 5.5 cm in diameter, 48,000 ofhese men might possibly be surgi-al candidates. Yet annually in thenited States, only 33,000 men

nd women of all ages undergo an-urysm repair.

Estimates of annual mortalityrom ruptured aneurysms in thenited States range from 9000 to0,000 (the larger number is basedn an estimate of how many pa-ients with sudden death succumbo a ruptured aneurysm). Annualortality rates from other condi-

ions such as breast cancer, AIDS,

545

Page 2: Abdominal aortic aneurysms and the Pulitzer Prize

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546 Washington Watch

nd prostate cancer are seen in Ta-le 1.Both surgical and percutaneous

nterventions are well accepted andffective therapies for abdominalortic aneurysms. The experienceith surgery is much longer, of

ourse, with 30-day mortality ratesf 2.7% to 6.0%. The mortalityith stent grafts is of similar mag-itude, and the morbidity is much

ess than with surgery.Regarding cost-effectiveness, the

ost per quality-adjusted life-yearor aneurysm screening ranges from6850 to $11,285 (depending onhe charges for ultrasound scan-ing) in men aged 60 years and over6]. Costs per quality-adjusted life-ear for other common proceduresre $9500 for coronary artery by-ass grafting for left main diseasend $16,000 for mammography.

So, the need exists, the toolstand ready, and the public isrimed for action. What’s the nexttep? A little political leadership. As

Table 1. Annual mortalityCondition Deaths

Abdominal aorticaneurysm

9000 to30,000

Breast cancer 42,000AIDS 16,000Prostate cancer 30,000

ecounted in the Wall Street Journal w

eries, the professional movers andhakers in the medical communityave been led by surgeons Dr. K.raig Kent, of Cornell University,

nd Dr. Robert Zwolak, of Dart-outh University.Although no radiologist has

tepped into the spotlight so far, asgroup, they have been powerful

nd effective advocates for publicealth screening: witness mam-ography. And the Legs for Life

rogram, sponsored by the Societyf Interventional Radiology, haseen a very successful initiative increening patients for peripheralascular disease and could serve as aemplate for widespread aneurysmesting.

Personal leadership is all well andood but probably not enough intself without the support of profes-ional societies. Major specialtyroups, including the ACR and themerican College of Surgeons,ave signed on to a bill introduced

n Congress in April 2004 [7].he bill would require Medicare

o cover aneurysm screening insymptomatic men aged 65 yearsnd older and women with appro-riate cardiovascular risk factors.he legislation is sponsored by Sen-

tors Christopher Dodd (D-onn.) and Jim Bunning (R-Ky.),

s well as Congressmen Genereen (D-Texas) and Jim Green-

ood (R-Pa.).

Of course, it’s a long way fromossing a bill in the hopper tohanging Medicare payment pol-cy, but the facts and the timing

ight be right for prompt action inhis case.

Hats off to Kent, Zwolak, andthers, and especially to Hellikernd Burton. Sometimes, a greattory is right under your nose.

EFERENCES

. Burton TM. Test for aneurysms might save alot of lives, some say. The Wall Street Journal.January 13, 2003.

. The Multicentre Aneurysm Screening StudyGroup. The Multicentre Aneurysm Screen-ing Study (MASS) into the effect of abdomi-nal aortic aneurysm screening on mortality inmen: a randomised controlled trial. Lancet2002;360:1531-9.

. Lederle FA, Wilson SE, Johnson GR, et al.Immediate repair compared with surveillanceof small abdominal aortic aneurysms. N EnglJ Med 2002;346:1437-44.

. The UK Small Aneurysm Trial Participants.Long-term outcomes of immediate repaircompared with surveillance of small aortic an-eurysms. N Engl J Med 2002;346:1445-52.

. Lin PH, Bush RL, McCoy SA, et al. A pro-spective study of a hand-held ultrasound de-vice in abdominal aortic aneurysm evalua-tion. Am J Surg 2003;186:455-9.

. Lee TY, Korn P, Heller JA, et al. The cost-effectiveness of a quick-screen program forabdominal aortic aneurysms. Surgery 2002;132:399-407.

. Burton TM. Support gathers to force cover-age of aneurysm test. The Wall Street Journal.

March 23, 2004:D3.

ichael J. Pentecost, MD, Department of Radiology, Georgetown University Medical Center, 3800 Reservoir Road, NW,ashington, DC 10007-2197; e-mail: [email protected].