Canadian Task Force on Preventive Health Care

Full Text Review

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

Up Contents

Overview

In 1984, the Canadian Task Force on the Periodic Health Examination recommended that screening should be performed only on patients with a history of cryptorchidism, testicular atrophy or ambiguous genitalia.< 1> In our current review we find insufficient evidence to include or exclude routine screening for testicular cancer in the general population (C Recommendation).

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. This age-specific trend has been observed in all regions of Canada, although the rates remain lowest in Quebec and the Atlantic region. Rates in the Prairies have been the most stable. Increasing rates have been observed in other countries but remain unexplained.<2> The major predisposing risk factor is cryptorchidism which increases the risk 2.5 to 40 times.<3> 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.<3>

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.<4> Even in studies of advanced cases cure rates of 85% are now being reported.

Maneuver

Two modalities proposed as screening tests for testicular cancer are physician palpation of the testes and self-examination of the testes by the patient. Detection of a suspicious testicular mass constitutes a positive test, and the diagnosis is confirmed by biopsy and histologic examination. There is no information on the sensitivity, specificity or positive predictive value of testicular examination in asymptomatic persons, whether done by physicians or by patients.

Due to the low incidence of the disease and the high cure rate, measures of sensitivity and specificity of these examinations, even if they were known, might not be very meaningful. If sensitivity is defined as the ability to detect disease at a curable stage, sensitivity is probably high since the overall cure rate is 92%. The negative predictive value is probably also quite good due to the low incidence of the disease. The positive predictive value, however, of palpation of the testes is probably very low due to the low incidence of disease and large number of other causes of scrotal masses. There is evidence, from older literature, that between 26% and 56% of patients presenting initially to their physician with testicular cancer are first diagnosed as having epididymitis, testicular trauma, hydrocele, or other benign disorders,<5> and they often receive treatment for these conditions before the cancer is diagnosed.<6>

There have been few studies of whether counselling men to perform self-examination motivates them to adopt this practice or to perform it correctly. Research to date has demonstrated only that education about testicular cancer and self-examination may enhance knowledge and self-reported claims of performing testicular examination.<7> One study found that men who reviewed an educational checklist on how to perform self-examination were able to demonstrate greater skill when self-examination was performed moments later, and they were able to recall the contents of the checklist in a telephone survey months later.<8> Few studies, however, have examined whether education or self-examination instructions actually increase the performance of self-examination. It is also unclear whether persons who detect testicular abnormalities seek medical attention promptly. Patients with testicular symptoms may wait as long as several months before contacting a physician.<9> Finally, no studies have shown that persons who perform testicular self-examination are more likely to detect early-stage tumors or have improved survival than those who do not practice self-examination.< 10> Published evidence that self-examination can detect testicular cancer in asymptomatic persons is limited to a small number of anecdotal reports.

Tumor markers, including alpha-fetoprotein and human chorionic gonadotropin are useful in following non-seminomatous testicular cancers but are not useful for early detection or screening.<3>

Effectiveness of Early Detection and Treatment

The prognosis for advanced stages of testicular cancer has improved dramatically in the past decade with the introduction of better chemotherapy. Current cure rates are over 80%.<10,11> However, the outcome of treatment is still better for patients with Stage I cancer than for those with more advanced disease and the treatment of early cancer has less cost and morbidity. Treatment for all types and stages of testicular cancer includes removal of the involved testicle. The current five-year survival for Stage I seminoma treated with radiotherapy is 97%.<4> Stage I nonseminomatous cancers (e.g., teratomas, embryonal carcinoma, choriocarcinoma) treated with radical retroperitoneal lymph node dissection have a reported 3- to 5-year survival approaching 90%.<12> With the advent of cisplatin-based chemotherapeutic regimens, a 3-year survival of 90-100% has been reported. Reported survival in patients with disseminated testicular cancer, however, is lower (about 67-80%), and these persons require intensive treatment with chemotherapeutic agents that produce a variety of systemic side effects.<4,11>

Although lead-time and length-time biases may account for part of the improved survival observed for persons with early-stage testicular cancer, it is likely that the prognosis is, in fact, better for persons with less advanced disease. There is, however, no evidence that screening causes more cancers to be diagnosed when Stage I, or improves outcome. Even without screening, 60-80% of seminomas are diagnosed in Stage I.<12> There is evidence that once testicular symptoms have appeared, diagnostic delays are associated with more advanced disease and lower survival.<5,9,13>

The appropriate management and follow-up of patients with a history of an undescended testicle is controversial.<14,15> It is known that orchiopexy at puberty does not prevent malignant transformation. It is uncertain whether earlier orchiopexy (prior to school age), which is now common practice, will prevent development of testicular cancer.<14> One study found carcinoma in situ in 1.7% of men with a history of cryptorchidism who had testicular biopsies. They projected that 50% of these lesions would progress to invasive cancer and recommended testicular biopsy be offered all men with a history of cryptorchidism.<15> Many experts recommend that intra-abdominal testes should be removed.<3> The survival for patients with a history of cryptorchidism who develop testicular cancer is excellent as it is in non-cryptorchid patients. No studies have been done to evaluate outcome benefits of formal screening of men with a history of cryptorchidism.

Discussion

There is no direct experimental evidence on which to base a recommendation for or against screening for testicular cancer by either physician examination or patient self-examination since no studies of screening have been done. One can calculate, however, that it is highly unlikely screening would significantly improve the already good outcome in this uncommon disease. If a population of 100,000 men aged between 15-35 years were screened with a 100% sensitive test, at most 10 cancers would be detected. At least 9 of these would be expected to be cured in the absence of a formal screening program. It is unknown whether the tenth patient would also be cured as a result of the cancer being detected by screening. A primary care physician with 1,500 males in his/her practice could expect to detect one testicular cancer every 15-20 years.

The vast majority of men screened by either physician or self-palpation would have normal examinations; of those with suspicious masses, most would have benign disease (false positives). Many of these cases, however, would require referral to urologists, radiographic studies, or invasive procedures (e.g., orchiectomy, inguinal exploration) before malignancy could be ruled out.<14> These interventions would incur considerable costs and possible morbidity.

Men with a history of undescended testes have a much greater incidence of testicular cancer. Although screening in this population has also not been shown to improve outcome it would be expected to have a much higher yield.

Recommendations of Others

In 1989, the U.S. Preventive Services Task Force found that there was insufficient evidence of clinical benefit or harm to recommend for or against routine screening of asymptomatic men for testicular cancer but that clinicians should advise adolescent and young adult males to seek prompt medical attention for testicular symptoms such as pain, swelling, or heaviness.<16> This recommendation is currently under review.

The American Cancer Society<17> and the National Cancer Institute<18> recommend that testicular examination be included as part of the periodic health examination of men. Recommendations differ on whether patients should be counselled to perform testicular self-examination. The American Cancer Society<19> and the National Cancer Institute<20> recommend that all postpubertal males should perform monthly testicular self-examination. Physicians have been advised to instruct male patients on how to perform this examination and some authorities believe the techniques should be reviewed at every periodic health visit beginning with puberty and continuing throughout life.<21> Others, citing the lack of evidence that self-895 examination is effective, have advised physicians against routinely devoting time to discussing testicular self-examination.<10,22>

Conclusion and Recommendations

Because no studies of screening for testicular cancer by physician or patient self-examination have been reported, there is insufficient evidence to include or exclude screening for this cancer in the periodic health examination of men (C Recommendation). Based on the low incidence of disease and the current high cure rate it is unlikely formal screening would improve the already excellent prognosis. Patients with a history of cryptorchidism, orchiopexy, or testicular atrophy should be informed of their increased risk for developing testicular cancer and counselled about screening options. The optimal frequency of such examinations has not been determined and is left to clinical discretion. Clinicians should advise adolescent and young adult males to seek prompt medical attention if a testicular mass is noted.

Evidence

A MEDLINE search was conducted using the main heading of testicular cancer with subheadings of prevention, screening and epidemiology from 1986 to 1992. This review was initiated by the Task Force in November 1993 and the recommendations finalized in January 1994.

 Full Citation

Link to Structured Abstract of this review

Link to Summary Table of this review

Link to Selected References list of this review

Top of Page

Home PageCTFPHC Home Page

Reprinted in modified format by the Canadian Task Force on Preventive Health Care
with permission.
For any technical issues please contact: webmaster@ctfphc.org
Original Copyright © 1994 Minister of Supply and Services Canada.
Last modified March 27, 1998.