Beebe S, Scimeca A, Diab D et al: Testicular cancer knowledge and viewpoints of American men. Urol Pract 2021; 9: 72.

Testicular cancer (TC) is the most common cancer in men aged 20-40 and has excellent oncologic outcomes with treatment. Survivorship issues associated with long-term toxicities relating to treatment in this young population are being increasingly recognized. The burden of treatment in TC is stage dependent, suggesting that early diagnosis of TC should reduce long-term treatment toxicities.

In 2004, an era when TC survivorship issues were less recognized, the USPSTF (U.S. Preventive Services Task Force) reviewed evidence surrounding screening for TC and recommended against screening adolescent or adult males.¹ This was upheld following updates in 2009 and 2011.¹ The rationale for this recommendation was that screening examinations performed by patients are unlikely to provide meaningful health benefits because of the low incidence rate and high survival rate of TC.¹ However, delay in treatment of testis cancer has a negative impact on disease stage, treatment outcomes and mortality, and poor public awareness of the disease and possible prevention strategies (eg self-examination) could be improved. Testicular self-examination (TSE) presents an easy and cheap way to monitor the signs and symptoms of testicular cancer,² thus making it a potentially ideal screening and prevention tool for a wide demographic. In an effort to better understand how practitioners should approach TC education and screening with patients, we surveyed the general American male population regarding this topic.

We performed an institutional review board approved study which included a web-based survey pertaining to general viewpoints on TC and TSE, with full findings recently published.³ This was a prospectively designed survey that included 51 questions, including demographics, personal knowledge of TC and personal knowledge of TSE, including from whom they received this information, whether their doctor had discussed and/or demonstrated TSE with them, awareness of current guidelines and potential reasons to perform TSE.^4,5 After iterative review, the survey was distributed and participants were accrued via Amazon Mechanical Turk (MTurk; Amazon, Seattle, Washington), an online crowdsourcing platform seeking individuals to perform specific tasks for minimal compensation.

The final sample size included 250 participants. Men’s self-perceived knowledge was moderate to low, with no men considering themselves “very knowledgeable” (fig. 1) Although 91.2% of men knew they could get cancer of the testicle, only a minority (26.4%) knew it was curable most of the time. Objective knowledge (eg what age range is most likely to develop TC) was also low (fig. 2).

Figure 1. Objective measures of testicular cancer knowledge were variable, with only minority (26.4%) knowing that it is curable most of time.

Figure 2. Many men consider their knowledge of testicular cancer limited, with no respondents considering themselves “very knowledgeable.”

Of the men 68.6% had heard they should check their testicles for cancer and, on average, participants said they checked themselves for TC once per year, although 20% said they had never performed TSE (fig. 3). A total of 90.3% of men felt their doctor had a role in discussing TC/TSE with them (fig. 4). Preferences for wanting their doctor to discuss TC/TSE were mixed: about two-thirds of men wanted to discuss this at least once, while 20% did not want to discuss the topic at all. Married men, men with higher education and those who felt more knowledgeable about TC were more likely to want to discuss this with their doctor (p<0.01). Despite an increased risk of false-positives when conducting TSE, 52.4% of men thought TSE was important for cancer screening, while only 8% thought TSE was not worth the risk. Men reported that they would be more likely to follow up with their doctor if they found something concerning, even with the increased cost and time (see table).

Figure 3. Only two-thirds of men had heard that they should check their testicles for cancer, with that information primarily coming from doctors, the Internet and media.

Figure 4. Total of 90.7% of men thought their doctor should have some role in addressing testicular cancer risk with them. Despite increased risk of false-positives, 52.4% of men thought TSE was important for cancer screening, while only 8% thought it was not worth the risk.

American men are indeed aware of TC, with the majority of survey respondents indicating that they have heard of both TC (91%) and TSE (69%). This is increasing, with older studies reporting much lower awareness of TC and TSE.⁶ Despite the awareness, few feel that they are very knowledgeable on these topics. This is exemplified by only a minority of men being able to correctly answer basic questions about TC. Unsurprisingly, knowledge of TC was related to income and education level. These findings support well-described disparities in male health knowledge and outcomes, likely originating from health care access limitations and/or societal normative values and nonconformity for males to seek help.^4,7

Current recommendations by the USPSTF against TSE are likely being heeded by many primary care providers, with 68% of respondents stating that their doctor had not shown them how to conduct a TSE. This is unsurprising given that the USPSTF is the main body that makes cancer screening recommendations for primary care physicians in the United States. Despite this, respondents have significant interest in learning about TC from their doctor, and additional knowledge about TC correlates with a willingness to both learn more about and perform TSE.

Respondents who would perform TSE are highly likely to bring an abnormal finding to their doctor’s attention, theoretically allowing for an earlier pre-symptomatic diagnosis. This is supported by prior studies, which have shown that TSE creates a 90% possibility of early diagnosis.^8,9 Furthermore, other studies have reported that patients are agreeable to the ease, privacy and accessibility of TSE.^4,5 Given that treatment of TC is less intensive at earlier stages, earlier diagnosis should reduce long-term treatment toxicities experienced by survivors. Early diagnosis is also cost-effective. A cost-utility study equated the treatment for advanced-stage testicular tumor (seminoma at $48,877 USD and nonseminoma at $51,592 USD) to 313–330 benign office visits ($156/visit) or 180–190 office visits with scrotal ultrasound ($272/visit).¹⁰ This study illustrated that there is an average of 2.4:1 cost-benefit ratio for early detection of TC compared to advanced stage disease. This cost analysis is consistent with the views of respondents to our survey, with only 8% feeling that the potential for false-positives outweighed the potential benefits of TSE.

Overall, American men don’t feel knowledgeable about testicular cancer. They are aware TC exists, have a favorable attitude toward screening with TSE and want their doctors to discuss both of these topics. Although additional clinical studies are certainly warranted before widespread endorsement of TSE, our study supports a greater emphasis on TC education in the primary care setting and shared decision making regarding TSE given patients’ interest and the low risk of patient harm.