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MICHAEL J. PENTECOST, MDWASHINGTON WATCH
© 2009
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- g004 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, tvarian 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
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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].