Structured Abstract
Please note: In 2003, the CTF updated its Grades of
Recommendations to include an "I Recommendation" for situations where
insufficient evidence exists to allow a recommendation to be made.
(Formerly, these situations were captured under a "C
Recommendation".) This change is not retroactive, and all
"C Recommendations" made prior to 2003 have not been
reevaluated in light of the new "I" recommendation grade. For a
discussion of these recommendation grades, please link to the 2003 article in
the Canadian Medical Association Journal here.
Screening for Testicular Cancer
Adapted to the Canadian context by R. Wayne Elford,
MD, CCFP, FCFP, Professor and Director of Research and Faculty Development,
Department of Family Medicine, University of Calgary, Alberta, from
the report prepared for the U.S. Preventive Services Task Force
These recommendations were finalized by the Task Force in January 1994
Contents
Objective
To make recommendations about screening for testicular cancer in general
and high-risk populations in Canada. This updates the 1984 Canadian Task
Force recommendations.
Burden
of Suffering
Testicular cancer is a relatively uncommon disease. The lifetime probability
of developing the condition is 0.30% and of dying from it 0.03%. Testicular
cancer represents 1.1 percent of cancers among men. Rates peaked in the
age group 30 to 39 in the 1970s. By the 1980s the peak had shifted downward
to the age group 25 to 34 years, where almost half the cases now occur.
Testicular cancer is the most common cancer in men aged 15 to 34 years,
and the incidence has been rising only in this age group. The major predisposing
risk factor is cryptorchidism which increases the risk 2.5 to 40 times.
80-85% of these tumors occur in the cryptorchid testicle while 15-20% occur
in the contralateral testicle. Other risk factors include previous cancer
in the contralateral testicle, a history of mumps orchitis, inguinal hernia
or hydrocele in childhood, and high socioeconomic status.
Ninety-six percent of testicular cancers are of germ cell origin of
which seminoma is the most common type. Prognosis and treatment depend
on the cell type and stage of disease, however recent advances in treatment
have resulted in a 92% overall five-year survival. Even in studies of advanced
cases cure rates of 85% are now being reported.
Options
Physician examination or patient self-examination of the testes; tumour
markers (e.g., alpha-fetoprotein and human chorionic gonadotropin). Treatment
options are surgical removal of the involved testicle, radiotherapy and
chemotherapy.
Outcomes
Sensitivity, specificity, positive predictive value, 3- and 5-year survival
rates.
Evidence
These recommendations were adapted for the Canadian context from a report
prepared for the 1989 U.S. Preventive Services Task Force. MEDLINE was
searched for the years 1986 to 1992 using the main heading "testicular
cancer" with subheadings "prevention", "screening" and "epidemiology".
Recommendations were graded as:
|
A
|
Good evidence to support the recommendation that the condition
be specifically considered in a PHE. |
|
B
|
Fair evidence to support the recommendation that the condition
be specifically considered in a PHE. |
|
C
|
Poor evidence regarding inclusion or exclusion of the condition
in a PHE, but recommendations may be made on other grounds. |
|
D
|
Fair evidence to support the recommendation that the condition
be specifically excluded from consideration in a PHE. |
|
E
|
Good evidence to support the recommendation that the condition
be specifically excluded from consideration in a PHE. |
Quality of evidence was rated according to 5 levels:
|
I
|
Evidence from at least 1 properly randomized controlled
trial (RCT). |
|
II-1
|
Evidence from well-designed controlled trials without randomization. |
|
II-2
|
Evidence from well-designed cohort or case-control analytic
studies, preferably from more than 1 centre or research group. |
|
II-3
|
Evidence from comparisons between times or places with
or without the intervention. Dramatic results in uncontrolled experiments
could also be included here. |
|
III
|
Opinions of respected authorities, based on clinical experience,
descriptive studies or reports of expert committees. |
Values
The 13-member Task Force of experts in family medicine, geriatric medicine,
pediatrics, psychiatry and epidemiology used an evidence-based method for
evaluating the effectiveness of preventive health care interventions. Recommendations
were not based on cost-effectiveness of options. Patient preferences were
not discussed.
Background papers providing critical appraisal of the evidence and tentative
recommendations prepared by the chapter author were pre-circulated to the
members. Evidence for this topic was presented and deliberated upon in
1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993.
Consensus was reached on final recommendations.
Benefits,
Harms, and Costs
No studies have evaluated the sensitivity, specificity or positive predictive
value of physician or patient testicular examination. Little or no evidence
exists regarding the effectiveness of patient counselling about self-examination
in terms of patient performance and follow-up of positive findings, detection
of early-stage tumours or improved survival. Tumour markers such as alpha-fetoprotein
and human chorionic gonadotropin are not useful for screening purposes
(p893). Potential adverse effects of screening include morbidity and costs
associated with follow-up of false positive results (p895).
Lifetime probability of developing testicular cancer is 0.30% and probability
of dying from it is 0.03%. Current cure rates exceed 80% and outcomes are
better for early stage than advanced stage cancers. Current surgical, radiotherapy
and cisplatin-based chemotherapeutic approaches result in 3- to 5-year
survival rates of over 90%. There is no evidence that screening increases
detection of Stage I cancers or improves outcomes. Approximately 60% to
80% of Stage I tumours are detected without screening (p894).
Men with a history of an undescended testicle (cryptorchidism) have
an increased risk (2.5 to 40 times) for developing testicular cancer. Opinion
about management varies, and no studies examine the benefits of routine
screening for this group (p892,4).
Recommendations
Recommendation grade [A, B, C, D, E] and level of evidence
[I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations
in support of individual recommendations are identified in the guideline
text.
-
There is insufficient evidence to include or exclude (from the PHE) routine
physician examination or patient self-examination for general or high-risk
populations [C, III].
However, it may be prudent to perform regular examinations on men at high
risk (cryptorchidism, testicular atrophy, ambiguous genitalia).
-
Fair evidence exists to exclude screening using tumour markers such as
alpha-fetoprotein or chorionic gonadotropin [D,
III].
Validation
This report was externally peer reviewed. The 1989 U.S. Preventive Services
Task Force also found insufficient evidence to support a recommendation
for or against routine screening. The American Cancer Society and the National
Cancer Institute recommend inclusion of testicular examination in the PHE
and instruction of all postpubertal boys and men in the performance of
monthly testicular self-examination.
Sponsors
The Canadian Task Force on Preventive Health Care
developed this guideline with funding from Health Canada.
Selected
References
Source Document
Other
-
Canadian Task Force on the Periodic Health Examination: The periodic health
examination: 2. 1984 update. Can Med Assoc J 1984;130:1278-85.
-
Frame PS. A critical review of adult health maintenance. Part 3. Prevention
of cancer. J Fam Pract 1986;22:511-20.
Link to Full Text of this
review
Link to Summary Table of Recommendations of this review
Link to Selected References list of this review
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