Screening for Abdominal Aortic Aneurysm is the Most Important Priority
For a 65-75 year-old man with a history of heavy smoking, one-time screening for abdominal aortic aneurysm (AAA) with ultrasound is the most critical preventive intervention, as it can reduce the risk of dying from a ruptured AAA by approximately 50%. 1
Why AAA Screening Takes Priority
Mortality Benefit is Substantial and Evidence-Based
Men aged 65-75 who smoke or have ever smoked represent the highest-risk group for AAA, and screening with ultrasound followed by appropriate treatment reduces AAA-specific mortality by about half. 1
The U.S. Preventive Services Task Force gives this a Grade B recommendation (moderate certainty of moderate net benefit), meaning the benefits clearly outweigh the harms for this specific population. 1, 2
Ruptured AAA carries a mortality rate of 65-85%, and most AAAs are asymptomatic until rupture occurs, making screening the only way to prevent this catastrophic outcome. 3
The Screening Process is Simple and Effective
One-time ultrasound screening is sufficient - there is negligible benefit to repeat screening if the initial aortic diameter is normal. 4, 5
Ultrasound has 95% sensitivity and nearly 100% specificity for detecting AAA, is non-invasive, safe, and cost-effective. 5, 6, 7
The screening defines AAA as aortic diameter ≥3.0 cm, with surgical intervention typically recommended when diameter reaches ≥5.5 cm or if rapid growth occurs. 6, 2
Why Other Options Are Less Critical
Colon Cancer Screening (Option B)
- While colon cancer screening is important for this age group, it applies broadly to all adults 50-75 years old regardless of smoking status, making it less specifically indicated by this patient's unique risk profile. The heavy smoking history creates a specific, time-sensitive indication for AAA screening that supersedes general population screening recommendations.
Prostate Cancer Screening (Option D)
- Prostate cancer screening remains controversial with unclear mortality benefit and significant potential for overdiagnosis and overtreatment. The USPSTF gives this a Grade C recommendation (selective offering), which is weaker than the Grade B for AAA screening in male smokers.
Osteoporosis Screening (Option A)
- Osteoporosis screening is primarily recommended for women ≥65 years and men at increased risk (typically ≥70 years or with specific risk factors beyond smoking). Smoking is a risk factor, but the mortality impact of undetected AAA far exceeds that of osteoporosis in this demographic.
Clinical Implementation
Order a one-time abdominal ultrasound to measure aortic diameter. 1, 6
Management Based on Results:
Normal aorta (<3.0 cm): No further AAA screening needed. 4, 5
Small AAA (3.0-5.4 cm): Surveillance ultrasound at intervals based on size; address cardiovascular risk factors including smoking cessation. 6, 7
Large AAA (≥5.5 cm): Refer for surgical evaluation (open repair or endovascular repair). 1, 6
Critical Pitfall to Avoid
Do not rely on physical examination to detect AAA. Only about 30% of asymptomatic AAAs are detected as a pulsatile abdominal mass on routine examination, and physical exam has poor accuracy as a screening test. 5, 7 Ultrasound screening is essential for this high-risk patient.
The answer is C. Abdominal aortic aneurysm.