Is the AAA screening of any value in women?

Transcription

1 Is the AAA screening of any value in women? A. Karkamanis Vascular Surgeon Dept. of Vascular Surgery Uppsala University SWEDEN

2 Why screening women for AAA? consistently display a much lower AAA prevalence than of the same age (1:4-1:6) have a worse outcome after elective repair + were also less likely to undergo repair if their AAA ruptured; mortality was higher after repair + displayed a threefold increased rupture rate compared with with equal diameter of AAA + Women, in general, have a longer life expectancy than men

3 Limited evidence for screening in women the only RCT being underpowered 3, years screened AAA prevalence of 1.3% No difference in AAA rupture incidence over 5 and 10 years follow-up A study to detect differences in lethal events with AAA prevalence/rupture incidence so low would, however, require randomization of more than elderly women

4 Thompson et al. Health Technology Assessment Report 2018 Discrete event simulation model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations Input parameters specifically for women were employed, and parameter uncertainty addressed by deterministic and probabilistic sensitivity analyses The base-case model adopted the same age at screening (65 years), definition of AAA (3.0cm), surveillance intervals and AAA diameter for consideration of surgery (5.5 cm) as for men. The prevalence was low (0.43%) and operative mortality rates about twice as high as in men. The simulation model showed that the base case and all alternative scenarios (including screening at older ages, definition of AAA as 2.5 cm, intervention at lower thresholds) resulted in minimal QALY gain and probably would not be cost-effective, to suggest that population screening of women should not be considered

5 Current prevalence of AAA in women 6930 invited 5141 screened 11 history of AAA repair 19 AAA 0,4% 7 elective 4 rupture 18 Ever smoker 95% 1 Icnon-smoker 5%

6 Smoking strongly linked to AAA in women with 95% of AAAs occurring among women who had ever smoked % 5 4 Men Women Current Smokers Former Smokers Never Smokers All 1.7% 0.4%

7 What do the GLs say? Population screening of older women for AAA does not reduce the incidence of aneurysm rupture. Level 1b, Recommendation B Population screening of older female smokers for AAA may require further investigation. Level 3c, Recommendation B Screening of older men and women having a family history of AAA might be recommended. Level 3a, Recommendation C We recommend a one-time ultrasound screening for AAAs in men or women 65 to 75 years of age with a history of tobacco use. Level of recommendation 1 (Strong), Quality of evidence A (High) Screening should be performed in first-degree relatives who are between 65 and 75 years of age or in those older than 75 years and in good health. Level of recommendation 2 (Weak), Quality of evidence C (Low)

8 Conclusion Due to a very low prevalence (<0.5%), general screening of elderly women is not recommended despite a reported much higher rupture rate Smoking women have a high prevalence (similar to men in general), and may be a suitable target for selective screening. This may, however, be counterbalanced by a lower life-expectancy and higher operative risk for this subgroup. So far, there is no supporting evidence for such a strategy Screening of older women (and men) having a family history of AAA is recommended