What is the best screening test for a 65-75 year old heavy smoker?

AAA Screening is the Best Choice for a Heavy Smoker in This Age Group

For a 65-75 year-old heavy smoker, one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography is the best screening test, as it can reduce AAA-specific mortality by approximately 50%. 1, 2

Why AAA Screening Takes Priority

Mortality Benefit is Substantial

• Men ages 65-75 who have ever smoked represent the highest-risk population for AAA, and screening with ultrasound followed by appropriate treatment reduces their risk of dying from a ruptured AAA by about half 1
• This is a Grade B recommendation from the U.S. Preventive Services Task Force, indicating that the benefits clearly outweigh the harms 1, 2
• AAA rupture carries a mortality rate as high as 81%, making prevention through screening critically important 3

The Evidence is Strongest for This Population

• Older male smokers have the highest risk of developing an AAA compared to all other demographic groups 1
• The quality of evidence demonstrating that screening prevents AAA ruptures and death is much better for men than for women, and specifically strongest for male smokers 1
• An "ever smoker" is defined as someone who has smoked at least 100 cigarettes in their lifetime 1

Screening Method and Follow-Up

Ultrasound is the Gold Standard

• AAA screening is performed using abdominal ultrasonography, which is safe, painless, and uses sound waves to measure the width of the abdominal aorta 1, 2
• The test should be performed in an accredited facility with credentialed technologists to ensure adequate quality assurance 1, 2
• Ultrasound has high sensitivity and specificity for detecting AAAs 1, 4

Management Based on Size

• Small aneurysms (<5.5 cm): Periodic monitoring with repeat ultrasound is recommended 1, 2
• Large aneurysms (≥5.5 cm or rapidly growing): Surgical intervention is generally recommended 1, 2
• This is a one-time screening; there is negligible benefit in rescreening those with normal aortic diameter on initial screening 5

Important Clinical Considerations

Additional Risk Factors to Consider

• First-degree family history of AAA requiring surgical repair significantly elevates risk and may warrant screening even outside typical age ranges 1, 5
• Other risk factors include age >60 years, hypertension, and Caucasian ethnicity 4

Potential Harms to Discuss

• Screened individuals are approximately twice as likely to undergo AAA surgery within 3-5 years compared to unscreened individuals 1
• Surgery carries clinically significant morbidity and mortality risks 1
• Short-term psychological harms from knowing about an aneurysm exist but are generally outweighed by mortality benefits in this high-risk population 1

Why Not the Other Options?

While colon cancer screening and osteoporosis screening may also be appropriate for this patient depending on other factors, AAA screening provides the most dramatic mortality reduction specifically tied to the smoking history in this age group, with a 50% reduction in AAA-specific deaths 1. The evidence supporting this intervention is robust, consistent, and specifically targets the highest-risk population that this patient represents.