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
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".
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.
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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).
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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
Elford RW. Screening for testicular cancer. In: Canadian Task Force
on the Periodic Health Examination. Canadian
Guide to Clinical Preventive Health Care. Ottawa: Health Canada,
1994; 892-98.
Other
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Canadian Task Force on the Periodic Health Examination: The periodic health
examination: 2. 1984 update. Can Med Assoc J 1984;130:1278-85.
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Frame PS. A critical review of adult health maintenance. Part 3. Prevention
of cancer. J Fam Pract 1986;22:511-20.