Re: Routine testicular self examination: it’s time to stop
Dr Hopcroft is correct when he states that the chances of discovering a testicular cancer through self-examination is very low, however, he misses the point.
The reason that self-examination is promoted is to increase awareness of the disease amongst men and their partners and so lessen the stigma and fear of presentation that prevailed in the early 1980s, when a significant proportion of men presented with advanced disease.
As Dr Hopcroft points out, he would expect to see a case of testicular cancer once in 20 years. In our practice in Leeds, we see 100 -120 cases per year, which represents around 5-10% of the annual UK incidence of testicular cancer. I can confirm that the vast majority of patients who present have a painless lump and testicular pain is evident in a minority. However, we now have the fortunate situation in which over 75% of our patients present with disease confined to the testis (stage I disease).
In stage I disease the majority of patients can now be managed by surveillance, reserving toxic chemotherapy for the small percentage who relapse. This is in direct contrast to the very real short and long-term toxicities that result from the complex therapies required for advanced disease, comprising several cycles of complex cytotoxic chemotherapy and, very often, radical surgery to the retroperitonem and, on occasion to the thorax. These toxicities result in the death of a small percentage of patients as well as carrying risks of late second cancers and infertility.
In 1985 the mean time taken for patients to attend their general practitioner from the development of symptoms of testicular cancer in Yorkshire was 14.3 weeks (median: 5 weeks and range 0-155 weeks)1. by 2004 that interval had reduced to 5.8 weeks (median: 2, range: 0-104)2. Over the same time the change in mean time from first GP consultation to specialist hospital attendance changed from 3.55 weeks (range: 0-42)1, to 4.8 weeks (range: 0-40)2 (No median figures were available from the 1985 data for this interval).
In the 1980s, over a third of testicular cancer patients had not heard of testicular cancer before their diagnosis and 85% were unaware that they were at risk 3,4. In contrast, in 2004 over 90% of patients had heard of testicular cancer before diagnosis.
Our conclusions, in 2004, were clear. The reduction in time taken by patients with testicular cancer to present to their GPs had reduced significantly and this was through publicity through the Department of Health (DOH) and various cancer charities. It has been remarkably difficult to engage men in health issues and anything that raises the profile of what is one of the greatest risks to life in young men other that trauma or suicide, and which lessens their fear of stigmatisation and embarrassment in coming forward, is to be welcomed, even if it requires an approach that involves humour and peer / celebrity pressure.
It remains a difficult challenge for GPs to sort the wheat from the chaff in symptoms from many diseases, however that is exactly the responsibility that they share with hospital specialists in this and in all cancers if we are to make the improvements in survival rates in this country that the DOH and National Cancer Action Team seeks5.
1. Vasudev NS, Joffe JK, Cooke C, Richards F, Jones WG
Delay in diagnosis of testicular tumours – changes over the past eighteen years.
Br J General Practice. 2004 54: 595:597.
2. Jones WG, Appleyard I. Delay in diagnosing testicular tumours. Br Med J. (Clin Res Ed). 1985; 290(6481):1550
3. Thornhill JA, Conroy RM, Kelly DG, Walsh A, Fennelly JJ, Fitzpatrick JM. Public awareness of testicular cancer and the value of self-examination. Br Med J (Clin Res Ed). 1986; 293(6545): 480-1.
4. Vaz RM, Best DL, Davis SW. Testicular cancer. Adolescent knowledge and attitudes. J Adolesc Health Care. 1988; 9(6): 474-9.