USPSTF Finalizes AAA Screening Recommendations

By Erik L. Ridley, AuntMinnie staff writer

June 24, 2014 -- Adhering mostly to its draft statement published in January, the U.S. Preventive Services Task Force (USPSTF) included no big surprises in its new recommendations in favor of ultrasound screening for abdominal aortic aneurysms (AAAs).

In a notable change from its previous 2005 statement, the task force added nuance to its recommendations for ultrasound screening for AAA in women, providing separate guidance for women who have smoked and those who haven't. In 2005, USPSTF recommended against screening in all women; however, the task force has now concluded that current evidence is insufficient to assess the balance of benefits and harms of ultrasound screening in women 65 to 75 who have ever smoked. It continues to recommend against screening in women who have never smoked.

The final recommendations, which were published online June 23 in the Annals of Internal Medicine, also retained the task force's 2005 B-grade recommendation for one-time ultrasound screening for AAA in men 65 to 75 who have ever smoked. In keeping with a change to the definition of its C grade level, USPSTF now suggests selective screening for men of this age group who have never smoked. In 2005, the same C grade level indicated that the task force made no recommendation for or against screening.

AAA screening in women

The task force noted that only one randomized, controlled trial on AAA screening included women, and the trial found no difference in AAA rupture, AAA-specific mortality, or all-cause mortality between screened women and a control group. The group also pointed out that women age 70 years who have ever smoked have an overall AAA rupture prevalence of approximately 0.8%, while current smokers have a prevalence of approximately 2%.

"However, the single [randomized, controlled trial] of screening for AAA that included women was underpowered to draw definitive conclusions by sex, and the prevalence of AAA in women who currently smoke approaches that of men who have never smoked," they wrote. "As such, a small net benefit might exist for this population and appropriate, high-quality research designs should be used to address this question."

As a result, the task force determined that the evidence was inadequate to conclude whether one-time ultrasound screening for AAA was beneficial in women ages 65 to 75 years who have ever smoked.

The task force also said that the prevalence of AAA in women who have never smoked ranges from only 0.03% to 0.6% for ages 50 to 79, and there is no evidence of apparent benefit of screening for AAA in this group of women.

"The USPSTF therefore concludes that adequate evidence shows that the absolute benefit of one-time screening for AAA with ultrasonography in women who have never smoked can effectively be bounded at none or almost none," the group wrote.

The task force also observed that women had a slightly higher risk of AAA surgery-related death than men. Women had 7% operative mortality with open repair, compared with 5% for men, and 2% for endovascular repair, compared with 1% for men.

"Convincing evidence shows that the harms associated with one-time screening for AAA with ultrasonography are at least small in all populations and potentially higher in women because of their higher risk for operative mortality," they wrote.

AAA screening in men

The task force reiterated that there is convincing evidence that one-time ultrasound screening for AAA yields a moderate benefit in men ages 65 to 75 years who have ever smoked. However, the lower prevalence of AAA in men who have never smoked substantially reduces the absolute benefit of screening in this group of men.

"Despite the demonstrated benefits of screening for AAA in men overall, the lower prevalence of AAA in male never-smokers versus male ever-smokers suggests that clinicians should consider a patient's risk factors and the potential for harm before screening for AAA rather than routinely offering screening to all male never-smokers," the task force wrote.

The group noted that important risk factors for AAA include older age and a first-degree relative with an AAA; other risk factors include a history of other vascular aneurysms, coronary artery disease, cerebrovascular disease, atherosclerosis, hypercholesterolemia, obesity, and hypertension. Also, factors associated with a reduced risk for AAA include African-American race, Hispanic ethnicity, and diabetes.

Draft changes

Changes made to the draft version included clarification of the definition of an "ever-smoker" and information about the absolute benefits of screening for AAA to provide additional context for the reported reductions in relative risk, according to the task force. USPSTF also expanded the discussion relating to the risks and benefits of screening and treatment in women compared with those in men.

"Finally, the USPSTF emphasized that more research -- including high-quality modeling studies -- is required to better understand the relative benefits and harms of screening for AAA in men and women with a family history of AAA and for women who have ever smoked," they wrote.

Related Reading

EHR alerts boost participation in AAA screening, February 12, 2014

USPSTF revises stance on ultrasound AAA screening, January 28, 2014

Longer US surveillance intervals fine for men with small AAAs, February 26, 2013

VC goes extra innings with AAA screening, November 12, 2012

AAA ultrasound screening hasn't saved many lives in Medicare, October 2, 2012

Copyright © 2014 AuntMinnie.com

Analysis Finds Evidence Lacking for HCC Screening

By Erik L. Ridley, AuntMinnie staff writer

June 18, 2014 -- Screening for hepatocellular carcinoma (HCC) in patients with chronic liver disease can detect early-stage cancer, but it's unclear whether systematic screening would yield a survival advantage over clinical diagnosis, according to an analysis published on Tuesday in the Annals of Internal Medicine.

The review included 22 studies in the literature and assessed the utility of methods such as ultrasound and serial alpha-fetoprotein screening. The team of researchers, led by Dr. Devan Kansagara of Portland Veterans Affairs Medical Center, found that "the body of evidence on which current recommendations for screening are based has substantial shortcomings."

The research project was commissioned by the U.S. Veterans Health Administration.

Controversial recommendations

A number of professional societies recommend using imaging methods and tumor markers for HCC screening, primarily in patients at higher risk due to chronic hepatitis B or cirrhosis; however, these recommendations remain controversial due to concerns over the quality and paucity of existing evidence to support screening, and the potential of overdiagnosis and patient harms, according to the researchers.

To better understand the incremental benefits and harms of routine HCC screening compared with clinical diagnosis, the study team conducted a systematic review of the literature. They searched Medline, PsycInfo, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from the inception of the databases to June 2013. They later updated the Medline, PsycInfo, and ClinicalTrials.gov searches in April 2014 (Ann Intern Med, June 17, 2014).

Kansagara and colleagues included all English-language controlled clinical trials and observational studies that assessed the effects of screening on HCC-specific and all-cause mortality in adults. Studies also had to include a comparison group of patients who did not have routine screening. Observational studies that did not consider important confounding factors were excluded. Using a tool developed by the Cochrane Collaboration, two reviewers independently assessed each included trial's quality, and disagreements were resolved through discussion.

Two reviewers also graded the strength of evidence for outcomes by using published criteria that considered a body of evidence as well as the internal validity of individual studies, according to the researchers. In addition, existing tools were adapted to evaluate the quality of observational studies.

Low-strength evidence

Of the 286 potentially relevant studies gathered from the literature search, 22 studies met the group's inclusion criteria. Of these 22, two trials and 18 observational studies provided only very-low-strength evidence regarding the effect of HCC screening on mortality.

The researchers concluded that the two trials -- both conducted in China -- had substantial methodological flaws that threatened their internal validity, and their findings have limited applicability beyond the hepatitis B patient population. They also noted, though, that the observational studies, most of which included patients with cirrhosis and hepatitis B, hepatitis C, or alcoholic liver disease, showed that screening detects patients with earlier-stage disease and who more frequently receive curative therapy.

"However, it is impossible to say whether the longer survival in patients with screen-detected disease was a true effect of screening or reflects lead- and length-time biases inherent to all observational studies, as well as selection biases that were common in many of the studies," they wrote.

Two additional trials compared ultrasound screening intervals: One was a Taiwanese study that compared four-month and 12-month screening intervals in patients with serologic evidence of hepatitis B or C. Despite more patients in the four-month screening interval group having early-stage disease, survival rates were similar among both screening intervals. Furthermore, the "study had an unclear risk of bias because of poor reporting of outcome assessment and statistical analyses," they wrote.

The other trial, which had a low risk of bias, compared three-month and six-month ultrasound screening intervals, and found similar all-cause mortality rates among both groups.

Observational studies

The 18 observational studies compared survival in patients with screening-detected HCC and those diagnosed with HCC incidentally as part of another workup or because of symptoms. The researchers noted that patients in these studies who had undergone screening had earlier-stage HCC than those who hadn't received screening. They also determined that more screened patients received potentially curative treatment, and survival was generally higher among screened patients.

However, several methodological considerations temper confidence for drawing conclusions from these studies, according to the researchers.

"Most of the studies were single-center retrospective cohort studies in which all patients with diagnosed HCC were first identified and screening status was subsequently determined," they wrote. "Few studies reported data on loss to follow-up, and many did not report using a comprehensive method to assess mortality outcomes equally in screening and nonscreening groups."

In addition, selection bias was a concern for 15 of the studies, and none of the studies reported any direct harms of screening or examined the psychological effects of screening, the authors noted.

Kansagara and colleagues concluded that there is very-low-strength evidence from which to draw conclusions about the effects of HCC screening on mortality in high-risk patients with chronic liver disease.

"Screening can identify more patients with earlier-stage disease who are candidates for potentially curative treatments, but there is limited evidence from which to draw firm conclusions about the balance of health outcome benefits and harms of using routine screening to identify HCC," the researchers wrote.

They noted, though, that their findings neither support nor refute current policy recommendations for HCC screening.

Related Reading

HCC screening boosts survival rate in cirrhosis patients, April 1, 2014

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