Thank you for the opportunity to express our views on the draft research plan regarding primary care screening for abdominal aortic aneurysm (AAA). The National Center for Health Research is a nonprofit think tank that conducts, analyzes, and scrutinizes research, policies, and programs on a range of issues related to health and safety. We do not accept funding from companies that make products that are the subject of our work, so we have no conflicts of interest
According to the CDC WONDER database, AAA caused over 96,000 deaths from 1999-2015.1 It is important to develop recommendations for screening because the majority of AAAs do not show symptoms until the development of rupture. Once rupture occurs, treatment is much more difficult, and there is a high risk for death.2 In the U.S., ruptured AAAs are estimated to cause 4% to 5% of sudden death,3 and almost all occur after age 65. Screening for AAA can help detect the presence and size of AAAs at risk of rupture, which can potentially save lives. However, screening can also present harms for certain subpopulations, including surgery with increased risks for disease and death and psychological symptoms.
We support the efforts of the U.S. Preventive Services Task Force (USPSTF) to carefully draft a research plan to guide the systematic review of available evidence for primary care screening to identify and treat AAA.4 USPSTF last reviewed the literature in 2014 and recommended different grades (“B”, “C”, “I”, and “D”) for four unique subpopulations.5 While the previous 2005 recommendation provided one “D” recommendation for AAA screening in all women, the 2014 recommendation divided women into two subgroups. An “I” grade was given for women who have ever smoked, and a “D” recommendation was given for women who have never smoked.
We have two recommendations that would strengthen your research plan:
1) We commend the USPSTF’s inclusion of proposed key questions #1, #2, and #4 that address subgroup analyses. We recommend expanding subgroup analyses to address harms of screening and subsequent treatment for key questions #3 and #5 and strongly support subgroup analyses by age (e.g. 50-64, 65+). Given the availability of new research, we also recommend special attention to subpopulations for which evidence about the benefits of screening is lacking, such as women who smoke and men and women with a family history of AAA.
2) We strongly encourage the USPSTF to provide a thorough analysis of any new information regarding psychological harms and benefits of screening as well as psychological harms and benefits of treatment for asymptomatic, screen-detected individuals with small AAAs. Research on psychological effects was included in the 2014 evidence review, though data was limited and conflicting. We commend the USPSTF for including psychological outcomes (i.e. quality of life, anxiety) in the draft research plan as these are important health outcomes of interest for patients.
In conclusion, we support the USPSTF’s draft research plan regarding primary care screening for AAA as well as their broader efforts to improve the health of all Americans by making evidence-based recommendations about clinical preventive services.
For questions or more information, please contact Megan Polanin, PhD, at email@example.com or at (202) 223-4000.
1) Centers for Disease Control and Prevention (CDC). CDC WONDER Database. Underlying Causes of Death, 1999-2015 Results. Retrieved from https://wonder.cdc.gov/controller/datarequest/D76;jsessionid=F0D5C15EF972A7A15BEC3C000F4A1226.
2) Aggarwal, S., Qamar, A., Sharma, V., & Sharma, A. (2011). Abdominal aortic aneurysm: a comprehensive review. Experimental & Clinical Cardiology, 16(1), 11.
3) Schermerhorn, M. (2009). A 66-year-old man with an abdominal aortic aneurysm: review of screening and treatment. JAMA, 302(18), 2015-2022.
4) U.S. Preventive Services Task Force (2017, August). Draft Research Plan for Abdominal Aortic Aneurysm: Primary Care Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/draft-research-plan/abdominal-aortic-aneurysm-primary-care-screening
5) U.S. Preventive Services Task Force (2014, June). Final Recommendation Statement. Abdominal Aortic Aneurysm: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/abdominal-aortic-aneurysm-screening