Comment: Testicular self-examination

These were comments to the article “Monday’s medical myth: testicular self-examination is a waste of time” by Mark Frydenberg, published in The Conversation.

Thank you for your opinion, Prof Frydenberg, but can this really be considered a “myth”? I appreciate that your affiliated organisation Andrology Australia recommends routine testicular self-examination, but this is not the position of the Royal Australian College of General Practitioners, nor the US Preventive Services Task Force.

If I’ve read your article correctly, your rationale is that routine self-examination will lead to earlier detection and better survival, and that it has no harm. These claims need to be examined carefully. As has been pointed out already, there is no evidence that routine screening improves survival, and indeed, it is unlikely that any screening procedure will. This is not only because testicular cancer is relatively uncommon but because treatments are so effective at all testicular cancer stages.

Secondly, I suspect that you under-estimate the psychological harms of health anxiety (even if transitory) from self-examination, as well as the cost of unnecessary investigations. The obvious analogy is breast self-examination which was supported by the same type of reasoning. Breast self-examination does cause harm and little if any benefit.

Although it is entirely reasonable for men to be aware and familiar with their bodies, it does not follow that routine testicular self-examination should be recommended.

And second comment:

“Although there is no evidence that TSE leads to a reduction in mortality or morbidity i can’t find that there is evience that it does not.”

This is true. However, I would argue that widespread population-based interventions (and recommendations for men to routinely perform TSE is an intervention) should be based on evidence rather than “hope”. It is widely acknowledged that TSE or any other form of testicular cancer screening is unlikely to reduce mortality.

My experience as a GP (and yes, I recognise this is anecdotal but I believe that it is consistent with the primary care experience) is that the discovery of of a scrotal lump is a highly anxiety provoking event for men. Moreover, even the presence of a perfectly benign physical examination is insufficiently reassuring without an ultrasound. Effectively, discovery of a scrotal lump means an ultrasound by default. The vast majority of scrotal lumps that present to primary care are not due to testicular cancer and this is even in the present situation where few men self-examine. The most likely result of recommending routine TSE for men is a substantial increase in presentations of benign testicular lumps (with its associated anxieties) with no reduction in testicular cancer death. As before, this is basically the situation with breast self-examination.

Routine TSE as policy may have population benefits (earlier diagnosis and less intensive treatment) but also entirely imaginable harms. There are many more ways for an intervention to be unhelpful than helpful – thus clinicians should follow a precautionary principle. There is substantial risk in advocating public health policy in the absence of good empirical evidence; if it turns out to be wrong it can be difficult to reverse course without shaking public confidence in public health (e.g., the difficulty the United States has in realigning the practice of prostate and breast cancer screening with evidence-based guidelines).