Routine testicular self examination: it’s time to stopBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2120 (Published 28 March 2012) Cite this as: BMJ 2012;344:e2120
- Keith Hopcroft, general practitioner, Basildon, Essex
What do Robbie Williams and the Leicester Tigers rugby team have in common? Answer: testicles. Plenty of them. Enough cojones, in fact, to be leading lights in testicle cancer awareness.1 2 And they’re not alone. We are regularly bombarded by celebrity exhortations to be “testicle aware,” typically via some attention (and testicle) grabbing stunt.3
The specific message that cancer charities and men’s health tub thumpers ram home is that any self respecting bloke should regularly examine his testicles. Or grope his gonads. Or caress his crown jewels. Or whatever the prevailing vernacular might be—so long as it sounds non-threatening and wacky.
It’s easy for the profession and the public to get carried away with earnest health promotion dressed up as fun and assume that routine testicular self examination is self evidently A Good Thing. The trouble is, it isn’t. It’s an activity based purely on well meaning whimsy, with the potential to do harm.
There is no good evidence that routine testicular self examination is of any benefit.4 5 6 Nor will there ever be: a study of adequate power would require millions of men, simply because testicular cancer is so rare.4 This fact is distorted by all the well meaning evangelism—few consumers of men’s health media would realise, for example, that the average general practitioner will see only one new case every 20 years.7
Another myth is that testicular cancer is a silent killer. In fact, nearly half of patients have testicular pain.8 And, though a painless testicular swelling is described as the typical presentation, this is often symptomatic—through causing a heaviness, a mass effect, or other symptoms.9 10 This may, understandably, prompt self examination, in which case the activity is typically misinterpreted as a life saving triumph. But this is simply a victory for common sense—for taking notice of symptoms and acting on them. It’s a world away from the notion of routine self examination in asymptomatic men, as advocated by the enthusiasts. The chances of discovering something significant from routine self examination of the testicles are minuscule—at least 50 000 men would need to examine themselves for 10 years to prevent one death.11
What will self examination elicit, though? Incidentalomas—because benign scrotal swellings such as varicoceles and epididymal cysts are relatively common.7 These will provoke anything from mild concern to incapacitating anxiety.4 And that anxiety can be infectious, worrying general practitioners into unnecessary ultrasound requests or referral, thereby lengthening the queue for patients who really do need further assessment.
It seems odd that there hasn’t been a more critical assessment of routine testicular self examination given that an analogous activity—routine breast self examination in women—has been discredited. There is no evidence that routine breast self examination is of benefit, but it is known to cause harm, through generating anxiety and unnecessary biopsies.12 Medical professionals have been slow to implement this evidence—perhaps because it seems counterintuitive, or because the Department of Health’s current policy of so called self awareness is difficult to understand or convey.
Or perhaps the real problem is the public’s confused and disbelieving reaction when the medical profession makes an about face. For example, when Michael Baum, professor emeritus of surgery and visiting professor of medical humanities at University College London, once explained the lack of evidence behind routine self examination of the breast to an audience of women in Miami, “About half the audience stormed out knocking over their chairs in their fury and one shouted out loudly, ‘We don’t need to listen to this crap.’” My own previous attempts to debate the merits of routine testicular self examination have been met, by men’s health groups and charities, with either disbelief or hostility—with the accusation, at one point, that I was “wishing cancer on men.”
All of which impels the question: how was the idea of routine self examination dreamt up in the first place? The earliest ever mention in the literature appeared in 1977. An article entitled, “Various ways in which individuals can help detect cancers early” cites a film produced by the American Urological Association instructing men how to examine their testicles.13 This film was subsequently distributed to the armed forces, and the concept took off—a Google search on testicular self examination now generates a third of a million hits. One of the three men behind the film, John Ravera, is still practising and is currently head of the Oncology Research Department, Cancer Center of Irvine, in California.
Recalling how the idea for the testicle examination film first came about, he comments, “We were sat around with Beatles’ haircuts and striped trousers, thought how men were lagging behind women—who had breast self examination—and did it almost as a lark.” And he has no regrets. After all, the concept of routine self examination was conceived in an era when evidence based medicine was unheard of, and must have seemed trailblazing at the time. We may be accustomed to the sight of television doctors demonstrating testicular self examination on breakfast TV but in the 1970s this must have been radical for both screen and screening movement. Besides, as Ravera points out, “Back then, testicular cancer was a lethal disease.”
The context is now very different, with cure rates high,14 and public health policy increasingly evidence based, which is why various authorities in the US recommend against routine self examination of the testicles.6 Yet the Department of Health and UK charities continue to encourage the activity,15 16 even when key UK authorities in cancer and prevention advise against it.4 17
Surely it’s time for sense and science to put the brakes on the men’s health bandwagon? Routine testicular self examination is an activity that is illogical and potentially harmful, and is based not on evidence but on something that, many years ago, simply seemed like a good idea at the time.
In fact, such evidence as there is suggests that a key issue is not so much men failing to notice swellings but men failing to act on them,4 18 with one study recording, in over a quarter of patients, a delay of at least three months before presentation.19 This might be a useful message to convey to men, if there’s one to convey at all. But at present it’s drowned out by the noise from campaigns that succeed only in turning the nation’s blokes into ball watching neurotics.
Cite this as: BMJ 2012;344:e2120
Competing interests: None declared.
Provenance and peer review: Not commissioned, not externally peer reviewed.