Wednesday, December 17, 2014

Testicular Self-Exam: Why There Is Nothing Wrong with a Regular Feel


This blog entry is a continuation of "The Importance of Testicular Self-Examination," posted December 1, 2014.

In summation, the cure rate for localized testicular cancer approaches 99% and drops to 75% for men with metastatic disease – often requiring chemotherapy and/or major surgery to achieve cure. The United States Preventative Services Task Force (USPSTF) recommends against regular testicular self-exam (TSE), citing a "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits."[1] The USPSTF recommendation is based on the relatively low incidence of testicular cancer, the high cure rate, unknown performance statistics of examination (when performed by patient or physician) for diagnosis and uncertainty if TSE leads to finding earlier stage disease; and the risks and costs associated with a false-positive test.

Each of the shortcomings mentioned by the USPSTF are addressed here:

LOW INCIDENCE, HIGH CURE RATE

It is true that testicular cancer only affects 8,000 men per year and that the survival for all comers in approximately 95%.[2] Thankfully, only a few hundred men die per year of testicular cancer – however that means there are hundreds of thousands of survivors in the US and around the world. These young men have been exposed to chemotherapy, radiation treatments, major surgeries and repeated CT scans for surveillance. Most, if not all treatments, influence hormone function, fertility and general quality-of-life – translating into a huge impact on a young population with many life-years ahead of them! Therefore, while there are fewer testicular cancer patients than other diseases, these patients have longer to live and the consequences of treatment are just as important as other cancers!!

UNKNOWN PERFORMANCE OF TESTICULAR SELF-EXAMINATION

It has to be conceded that there is no evidence that TSE is effective for the diagnosis of testicular cancer or helps find men at an earlier stage of disease. However, lack of evidence does not mean that TSE is not effective – it means that no study has effectively investigated the role of TSE in an at-risk population. We do know that length of patient- and physician-related delay is directly related to the stage of cancer at diagnosis; the median delay for men with Stage I, II and III cancer was 75, 101 and 134 days respectively.[3] In addition, delay in diagnosis has been associated with higher rates of chemotherapy and lower survival rates.[4]

THE RISKS/HARMS OF TESTICULAR SELF-EXAM

TSE is a painless, easy to perform self-examination technique. The risks of performing a TSE are undergoing an unnecessary office visit, ultrasound or surgery for a benign mass. Associated with a false-positive TSE can be anxiety-provoking and lead to other psychological stresses. Overcoming the risks of TSE requires education; both that an abnormality on TSE does not necessarily mean cancer and that when found early, the treatments are minor and the cure-rate high!

COST-EFFECTIVENESS

A recent study by Aberger and colleagues, from the University of Kansas Medical Center, investigated the costs associated with TSE in a theoretical model.[5] The most expensive treatment for testicular cancer is the combination of chemotherapy and surgery for an advanced testicular cancer, costing on average $50,000 per patient. Compared only to the immediate costs of an office-visit with a physician or a scrotal ultrasound, the treatment of one advanced stage testicular cancer is equal to:
  • 320 office visits for a benign, but worrisome TSE
  • 185 office visits with a scrotal ultrasound for a worrisome TSE
  • 81 office visits with scrotal ultrasound and tumor markers for a suspicious TSE
  • 6-7 office visists with scrotal ultrasound and tumor markers leading to a radical orchiectomy
  • 2-3 early-stage testicular cancers treated with active surveillance for five years
Given the nearly $48 million spent on the men with metastatic cancer in 2013, any improvement in early diagnosis and stage could dramatically improve costs for this disease. Importantly, this cost analysis does not consider the long-term sequelae of the treatment of testicular cancer including hormone replacement or fertility treatments which can be extremely expensive over a lifetime.

 

SUMMARY

The USPSTF recommendations regarding TSE are based on very little existing evidence. From the perspective of the USPSTF, the potential for harms, outweighs the lack of demonstrable benefit for TSE. I would respectfully disagree, stating that while the cure rate of testicular cancer is wonderful, the burden of the disease is greatly underappreciated. Even if a free, painless self-examination leads to an unnecessary doctor's visit, saving one man from advanced disease is well worth the "risks and costs" of TSE.

 

This blog was written by Phillip M. Pierorazio, MD, Director of the Division of Testicular Cancer at the Brady Urological Institute at Johns Hopkins.

 









[1] U.S. Preventive Services Task Force. Screening for Testicular Cancer: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Intern Med. 2011;154(7):483-486.

[2] SEER Stat Fact Sheets: Testis Cancer, http://seer.cancer.gov/statfacts/html/testis.html

[3] Bosl, G. J., N. J. Vogelzang, A. Goldman, E. E. Fraley, P. H. Lange, S. H. Levitt, et al. 1981. Impact of delay in diagnosis on clinical stage of testicular cancer. Lancet 2:970–973.
[4] Moul JW, Paulson DF, Dodge RK, et al: Delay in diagnosis and survival in testicular cancer: impact of effective therapy and changes during 18 years. J Urol 1990; 143: pp. 520-523
[5] Aberger M, Wilson B, Holzbeierlein JM, Griebling TL, Nangia AK. Testicular self-examination and testicular cancer: a cost-utility analysis. Cancer Med. 2014 Aug 8. doi: 10.1002/cam4.318. [Epub ahead of print]

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