13. Screening for Testicular Cancer
RECOMMENDATION
There is insufficient evidence to recommend for or against routine
screening of asymptomatic men in the general population for testicular
cancer by physician examination or patient self-examination.
Recommendations to discuss screening options with selected high-risk
patients may be made on other grounds (see Clinical Intervention).
Burden of Suffering
Testicular cancer is a relatively uncommon disease, with an overall
annual incidence of about 4/100,000 men.1 It is, however, the most
common form of cancer in young men between ages 20 and 35,2 accounting
for an estimated 7,100 new cases and 370 deaths in the U.S. in 1995.3 The
peak annual incidence ranges from 8 to 14/100,000 men between 20 and
35 years of age, with a smaller peak in early childhood.4 The incidence in
black men is less than one fifth that of white men.4 The major
predisposing risk factor is cryptorchidism.1 In men with a history of
cryptorchidism, 80-85% of testicular tumors occur in the cryptorchid
testicle, while 15-20% occur in the contralateral testicle. Other risk
factors include previous cancer in the other testicle, a history of mumps
orchitis, inguinal hernia, or hydrocele in childhood, and high
socioeconomic status.1
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 5-year survival.3 Even among the small
proportion of patients (12%) with advanced disease at diagnosis, 5-year
survival is close to 70%.4
Accuracy of Screening Tests
The two screening tests proposed 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 of tissue.
There is no information on the sensitivity, specificity, or positive
predictive value of testicular examination in asymptomatic persons
whether done by providers or by patients. Even if they were known,
measures of sensitivity and specificity for palpation of the testes might
not be very meaningful because of the low incidence of testicular cancer
and the high cure rate. If sensitivity is defined as the probability that
disease, when present, is detected at a curable stage, then sensitivity is
probably high because the overall cure rate (in the absence of systematic
screening) 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,6-8 and these patients often receive treatment for
these conditions before the cancer is diagnosed.7,9,10
There have been few studies of whether counseling 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.11,12 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; they were also able to recall
the contents of the checklist in a telephone survey months later.13 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.6
Finally, no studies have been conducted to test whether persons who
perform testicular self-examination are more likely to detect early-stage
tumors or have better survival than those who do not practice self-
examination.5 Published evidence that self-examination can detect
testicular cancer in asymptomatic persons is limited to a small number of
case reports.14
Tumor markers, including a-fetoprotein and human chorionic gonadotropin
are useful in following nonseminomatous testicular cancers but are not
useful for early detection or screening.1,15
Effectiveness of Early Detection
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 greater than 80%.5,16 Survival,
however, is still better for patients with Stage I cancer than in 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 5-year
survival for Stage I seminoma treated with radiotherapy is 97%.3 Stage I
nonseminomatous cancers (e.g., teratoma, embryonal carcinoma,
choriocarcinoma) treated with radical retroperitoneal lymph node
dissection have a reported 3-5-year survival approaching 90%.17 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.3,5,16
Although lead-time and length biases may account for part of the
improved survival observed for persons with early-stage testicular
cancer, it is likely that the prognosis is better for persons with less
advanced disease. No studies have been done to determine whether
screening increases the proportion of cancers diagnosed at early stages,
or improves outcomes. Even without screening, 60-80% of seminomas are
Stage I at diagnosis.17 There is evidence that once testicular symptoms
have appeared, diagnostic delays are associated with more advanced
disease and lower survival.6,7,18
The appropriate management and follow-up of patients with a history of
an undescended testicle is controversial.19,20 It is known that orchiopexy
at puberty does not reduce malignant transformation. It is uncertain
whether earlier orchiopexy prior to school age, which is now common
practice, will prevent development of testicular cancer.19 Giwercman et
al. found carcinoma in situ in 2% of men with a history of cryptorchidism
who had testicular biopsies.20 They predicted 50% of these lesions would
progress to invasive cancer and recommended that testicular biopsy be
offered to all men with a history of cryptorchidism. Many experts
recommend that intraabdominal testes should be removed.1 The survival
for patients with a history of cryptorchidism who develop testicular
cancer is excellent, as it is in noncryptorchid patients. No studies have
been done to evaluate benefits of formal screening of men with a history
of cryptorchidism.
Recommendations of Other Groups
The American Cancer Society recommends a cancer checkup that includes
testicular examination every 3 years for men over 20 and annually for
those over 40.21 No recommendation is given for testicular self-
examination. The American Academy of Family Physicians recommends a
clinical testicular examination for men aged 13-39 years who have a
history of cryptorchidism, orchiopexy, or testicular atrophy; this policy is
currently under review.22 The American Academy of Pediatrics
recommends testes self-examination beginning at age 18 years.23 The
Canadian Task Force on the Periodic Health Examination concluded that
there is insufficient evidence to include or exclude routine screening for
testicular cancer by palpation in the periodic health examination.24
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. It seems unlikely that screening would
substantially improve the already favorable outcome in this uncommon
disease. If a population of 100,000 men aged 15-35 years were screened
with a 100% sensitive test, at most 10 cancers would be detected. At
least nine 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.,
biopsy or inguinal exploration) before malignancy could be ruled out.17
These interventions would incur considerable costs and possible
morbidity.
Men with a history of undescended testes or testicular atrophy 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 than screening in the general
population.
CLINICAL INTERVENTION
There is insufficient evidence to recommend for or against routine
screening of asymptomatic men for testicular cancer by physician
examination or patient self-examination ("C" recommendation). Patients
with an increased risk of testicular cancer (those with a history of
cryptorchidism or atrophic testes) should be informed of their increased
risk of testicular cancer and counseled about the options for screening.
Such patients may then elect to be screened or to perform testicular self-
examination. Adolescent and young adult males should be advised to seek
prompt medical attention if they notice a scrotal abnormality.
The draft update of this chapter was prepared for the U.S. Preventive
Services Task Force by Paul S. Frame, MD.
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