Testicular self-examination amongst genitourinary medicine clinic attendees

Abstract

Advancements in the diagnosis and treatment of testicular cancer now give a five-year survival rate of 97.2%. Delayed presentation remains the primary cause of poor outcome and recommendations have stressed that men, particularly those with risk factors, should undertake regular testicular self-examination. This study aimed to determine testicular self-examination knowledge and practices amongst 740 unselected men attending a genitourinary medicine clinic via questionnaire survey. Of respondents, 75.8% of men had heard of testicular cancer, and 79.9% had heard of testicular self-examination. Of these, 41% of men had been taught testicular self-examination; 73.9% of them by a doctor or nurse. Importantly, 79.2% had previously performed testicular self-examination. The most common reason for not performing testicular self-examination was ‘Don’t really know what to look for’ (59.5%). Men previously taught testicular self-examination were 11.5 times more likely to perform the practice than those untaught. Of respondents, 74.1% wanted more information regarding testicular self-examination whilst attending the clinic. This study shows an increased level of testicular self-examination amongst genitourinary medicine attendees than has been previously demonstrated in other patient groups. There remains room for improvement via further health promotion and research on the effectiveness of testicular self-examination.

Keywords

Europe men prevention testicular cancer testicular self-examination health promotion

Introduction

Testicular cancer (TC) is a relatively rare malignancy with excellent cure rates.¹ However, an increasing incidence over the last 40 years has made early diagnosis an important goal.² The highest incidence of TC occurs in Western Europe, North America, Australia and New Zealand at 3–6 per 100,000 men per year.¹ Although TC makes up just 1–1.5% of all cancers in men, it is most common cancer amongst men aged between 20 and 35 years old.³ Risk factors include a history of undescended testes, infertility, a contralateral tumour or testicular intraepithelial neoplasia, Klinefelter’s syndrome and a family history amongst a first-degree relative.¹ Improvements in treatment over the last 40 years give an overall five-year survival rate of 97.2%.^4–7 One of the most significant factors in reduced survival is a delay in diagnosis.^3–5 Any delay impacts not only survival but also the length and invasiveness of therapeutic options. Proposed reasons for this delay have included a lack of patient knowledge about TC, patient and/or partner anxiety regarding a cancer diagnosis and patient embarrassment about genital examination.^4,6,8 However, in the last two decades, a decrease in the time between men noticing symptoms and presenting to their general practitioner has been described, from a median of five weeks to two weeks.⁴ One reason postulated for this is considered to be in part due to increased awareness of TC and testicular self-examination (TSE) as a result of public health campaigns.^1,4

The most appropriate method of screening to detect early TC, whether patient- or healthcare-directed, has been debated extensively. At present there is no conclusive evidence as to whether investigating concerns raised by TSE findings are offset by the small improvement outcome of earlier diagnosis and treatment. Despite this, in 2011 Cancer Research UK recommended regular TSE (weekly to monthly) for all men on the basis that earlier diagnosis is associated with a more favourable treatment outcome.⁷ In the same year the European Association of Urology recommended that for men with risk factors, TSE was advisable.¹ The following year, the American Cancer Society advised that any cancer-related consultation for men over the age of 20 should include a testicular examination.⁹ Against advocating universal TSE promotion, the United States Preventive Services Task Force concluded in 2010 that there was insufficient evidence to recommend instigating a national screening programme,¹⁰ as did the Royal Australasian College of General Practitioners the following year.¹¹ A Cochrane systematic review in 2011 recommended against screening based on the low incidence of TC and its high cure rates regardless of the stage at diagnosis together with the absence of evidence from randomised controlled trials of the effectiveness of screening in reducing morbidity and mortality.³ The review also concluded by suggesting that men with risk factors should be made aware of them and should have the potential benefits and harms of screening discussed with them in order for them to make an informed decision on the subject.³

In an observational study of 677 men working in a banking institution in Ireland, it was reported that more than 99% were aware of TC but only 4% reported carrying out TSE at monthly intervals while 64% had never examined themselves.¹² Of those aware of TSE, 87% reported examining themselves at some time and 97% responded positively to wanting more information on the subject.¹² Additionally, of those aware of TC only 71% could identify potential symptoms, 61% could identify susceptible age groups and only 48.2% were aware of the high cure rates of TC.¹² In a separate study of 7304 students across Europe, it was found that 87% of men had never practised TSE, 10% had occasionally practised it while regular TSE was only undertaken by only 3%.¹³ In a study of 200 male soldiers and 717 military physicians in Israel, it was reported that 16% of soldiers had received teaching on TSE and 2% examined themselves regularly, with the soldiers being seven times more likely to perform TSE if they had received teaching on the subject.¹⁴ However, only 16% of military physicians surveyed regularly taught the importance of TSE.¹⁴

Performing TSE fares no better among medical professionals. In a cross-sectional study of paediatric trainee doctors in the USA, it was reported that 29% of 129 trainees examined themselves once a month rising to 61% at least once every three months.¹⁵ The most common reason given for not performing TSE was ‘know how, but forget to do it’.¹⁵

Previous studies have positively linked factors such as age,^13,16 white ethnicity,^16,17 a higher knowledge of TC and TSE,^12,16 previous teaching on TSE,¹⁴ attendance at a men’s health clinic¹⁶ and a general examination by a doctor within the last year¹⁷ with the practice of TSE. Knowledge amongst younger patients has raised particular concern with studies showing that the majority of high school age children have never heard of TC.^18,19

There have been no studies to determine TSE practices or factors influencing such behaviour amongst those attending a sexual health clinic.

Aims

The aims of this study were to ascertain the level of TC awareness, along with TSE knowledge and practices amongst men attending a sexual health clinic, and if they differ from previously studied patient populations. Furthermore, it aimed to determine whether the factors of age, occupation, HIV status and prior knowledge of TC and TSE predicted the practice of TSE. Finally, it sought what information men would like to receive from the clinic on TSE. Investigating and contextualising TSE practice amongst sexual health clinic attendees informs patient-focused clinical practice and public health promotion amongst our specific target population, whilst also informing the general evidence base.

Methods

A self-reported paper format question sheet was chosen to allow anonymity. The questionnaire contained 22 closed questions (Figure 1). All men attending the Sexual Health & HIV Clinic Stockport, England were invited to participate. Patients completed questionnaires anonymously prior to their clinic appointment and placed them in an unmarked box at reception. The questionnaire was well received with 99% of men asked opting to participate. Data were inputted manually into the Statistical Package for Social Sciences. The patient’s occupation was classified using the International Standard Classification of Occupations (ISCO) 2008, ISCO-08 (Table 1).²⁰ Range checking was completed to identify data anomalies. Descriptive statistics including frequencies and cross-tabulations were used to analyse the questionnaire results. Statistical analysis of associations with TSE was performed using Chi-squared testing for categorical variables and t-tests for continuous variables. Independent relationships were established using logistic regression. Significance was defined as p ≤ 0.05.

Figure 1.

Patient questionnaire on testicular cancer and testicular self-examination.

Table 1.

Occupations of respondents (classification adapted from ISCO-08).

Occupation	Number	Percentage
Manager	64	9.4
Professional	199	29.1
Technician	19	2.8
Clerical	16	2.3
Service, sales	136	19.9
Agriculture	2	0.3
Craft	79	11.5
Plant, machine	25	3.7
Elementary	22	3.2
Forces	4	0.6
Retired	21	3.1
Student	52	7.6
Unemployed	45	6.6
Total number of answers	684/740	100

Results

A total of 740 men aged between 14 and 78 years (mean age 32.9 years) completed the questionnaire. Individual response rates for each question were variable (80.2–100%) with questions regarding ‘reasons for not carrying out TSE’ the least answered. Individual results are shown in Table 2.

Table 2.

Questionnaire results.

Question	Number answering yes	Percentage answering yes (%)	Response rate (%)
HIV positive	34	4.6	100
Have you ever heard of TC?	561	75.8	100
Do you know anyone who has had TC?	151	20.5	99.7
Have you ever heard of TSE?	588	79.9	99.5
Have you ever been taught how to examine your testicles?	303	41.0	99.9
From your friends?	47	16.4	94.4
From your parents?	19	6.7	93.8
From a doctor/nurse?	210	73.9	93.4
Other answers given: book, magazine, TV, internet, charity, school	12	3.4	N/A
Have you ever examined your own testicles?	581	79.2	99.2
Every week?	106	19.0	95.2
Every month?	214	38.4	95.2
Around every six months?	100	17.9	95.2
Very rarely?	138	24.7	95.2
If you have heard of TC and TSE but do not regularly examine your testicles, why not?
Don’t really know what to look for?	260	59.5	84.7
Don’t feel confident examining myself?	124	29.6	81.2
Don’t feel at risk?	100	24.0	80.6
Worried that might find something?	64	15.3	80.8
Wouldn’t want to know?	40	9.7	80.2
Other answers given: uncomfortable, learned of TSE recently, forget	4	0.5	N/A
When attending a Sexual Health Clinic, would you like more information (any kind):	518	74.1	94.5
Would you like TSE to be discussed with you?	328	45.5	97.4
Would you like to be taught how to do TSE?	261	37.4	94.3
Would you like to be given a leaflet on TSE?	355	50.7	94.6

TSE: testicular self-examination; TC: testicular cancer.

Of those responding, 75.8% had heard of TC and 79.9% had heard of TSE but only 41% had been taught how to perform the practice. The majority of those who had been taught how to perform TSE (73.9%) reported having been taught by a doctor or nurse, while a further 16.4% reported being taught by friends, 6.7% by parents and 3.4% wrote down additional answers of various mixed media sources (press/television/internet/public health campaigning). A total of 79.2% of men respondents reported ever having performed TSE. Of these, 19% reported examining themselves at least once a week and 57.4% at least once a month. Noticeably, 24.7% reported examining themselves very rarely (>6 monthly) with the most common reason for not carrying out TSE (59.5%) being ‘Don’t really know what to look for’ as shown in Figure 2.

Figure 2.

Percentage frequencies of responses for not carrying out TSE (%).

A total of 74.1% respondents indicated that they would want to be informed about how to perform TSE during their clinic visit. A leaflet was the most popular choice for further information with 50.7% of men indicating that they would like one while 45.5% of men responded that they would like a discussion on TSE. A further 37.4% reported that they would like to be taught TSE during their clinic attendance.

Men who had previously heard of TSE prior to their clinic attendance were more likely to carry out the practice than those who had not (86.1% vs. 51.7%, p < 0.001). Men who reported being previously taught TSE had significantly superior practice rates compared to patients who reported never being taught (97% vs. 66.7%, p < 0.001). Logistic regression analysis confirmed these relationships with men who had heard of TSE being 3.4 times more likely to carry this out (p < 0.001) and men who had been taught TSE 11.5 times more likely to perform it (p < 0.001).

There was no statistically significant relationship found between performing TSE and age (mean age 33.1 vs. 32.2, p = 0.42). Interestingly, there were no associations between TSE and having heard of TC (80.6% vs. 74.4%, p = 0.096) or with knowing someone who had been diagnosed with TC (83.2% vs. 78.2%, p = 0.218). Furthermore, there was no association between TSE and HIV status (82.4% vs. 79%, p = 0.800). Logistic regression analysis indicated that there was no independent relationship between TSE and occupation (p = 0.813).

Discussion

This was a sizeable study and is the first to be conducted in a sexual health clinic. The fact that the majority (75.8%) of men in this study had heard of TC has been reported in similar studies of different populations.^12,16,17,21 Interestingly, more men reported having heard of TSE than TC (79.9%), which could reflect a lack of knowledge on the exact purposes of TSE. The percentage of men reporting having been taught TSE (41%) was higher amongst sexual health clinic attendees than in previous studies of different populations,^14,19,22 and a total of 79.2% respondents in this study carried out TSE, a much higher proportion than has been reported in previous studies.^{12,16,17,19,21–23} Previous studies have reported that the percentage of men who carry out TSE around once a month to be between 4% and 29%^{12,15–17,19,21,23} while 57.4% in this study reported carrying out the practice at least once a month.

There were statistically significant relationships between carrying out TSE and the factors of having heard of TSE and being taught TSE. This concurs with previous studies examining TSE rates.^{12,14,16,21,24} The most common reason for not carrying out TSE was ‘Don’t really know what to look for’ suggesting, as has been found previously, that self-rated confidence in self-examination being carried out correctly is a predictor of TSE.⁸

Although the fear of actually finding cancer has been shown to be an independent predictor for not performing TSE,⁸ in this study the reasons ‘Worried might find something’ and ‘Wouldn’t want to know’ were given with percentage frequencies of 15.3% and 9.7%, respectively, suggesting that this is not a major reason for not carrying out the practice in this population. Interestingly, 24% of men in this study gave the answer ‘Don’t feel at risk’ as a reason for not performing TSE.

Previous studies have shown a desire amongst all patient groups for education regarding how to practise TSE.^12,16,21,23 In keeping with previous studies, the majority of men (74.1%) in this study indicated that they would like more information either in the form of a leaflet (50.7%), discussion (45.5%) or being taught the practice (37.4%). With this in mind the type and delivery of information regarding TSE should, therefore, be carefully considered and patient-centred, particularly as previous studies have questioned the effectiveness of short-term interventions in increasing TSE rates.²⁴

It has been suggested that older men are more aware of cancer and therefore be more likely to carry out TSE¹⁹ and awareness of TC and TSE has been shown to be less in adolescents.^18,19 However, no such association was found in this study between age and the practice of TSE. Higher rates for the practice of TSE have also been shown to be associated with increased knowledge of TC or knowing someone with TC^12,16,21; we did not find this.

As with a large number of other malignancies, men with HIV infection have been shown to be at greater risk of TC than HIV-uninfected men.²⁵ This study found HIV-infected men had reasonable rates of performing TSE (82.4%), on par with other male clinic attendees. However, when one considers any at-risk population who have access to a simple self-directed method of cancer screening, we should be aiming for very high levels of effective practice. It should therefore be suggested, as with other male clinic attendees, our current education and interventions may not be sufficient at reaching this at-risk group and encouraging TSE in men living with HIV should be promoted.

Limitations

This study’s primary limitation was its sample size; although the data we present constitute a sizeable sample, larger studies of this at-risk population are required to fully establish the predictors of TSE that have been found in this study. The study population represents a sizeable number of men from a metropolitan urban area but data regarding ethnic origin and sexual orientation were not collected limiting a generalisation of this study’s findings to other geographically and ethnically diverse clinics. There were also on retrospect specific limitations with questionnaire design. Question 6, regarding reasons for not undertaking regular TSE, placed a reliance on patient opinion regarding how often is sufficient to perform TSE – information we could not provide patients without influencing other answers. There was also a lack of any free text entries. Although designed to reflect factors which influenced patients in prior studies of TSE, and facilitate quantitative analysis, a specific ‘yes/no’ response to clinician-designated answers may have missed other factors important in patient understanding and decision making; this was highlighted for example by patients writing additional mixed media information sources for Question 4.

Conclusion

As TC continues to unnecessarily claim the lives of patients, we cannot conclude or celebrate current levels of health promotion with regard to TSE. Our study has found in line with previous work that the majority of patients have some awareness of the risks of TC and the benefits of TSE. Reassuringly for medical professionals, our sample has found amongst sexual health clinic attendees that we are providing the majority of health promotion regarding these issues. This should provide encouragement to continue promoting TSE as part of any clinician’s routine clinical practice. Specifically for staff in sexual health clinics, the majority of patients we sampled expressed a wish for further education regarding TSE during their attendance. A mixed media approach should be considered and should be patient-directed to gain maximum impact and build confidence in patients to perform TSE correctly. The barrier of patient embarrassment to discussing TSE will always persist and therefore utilising the rapport of sexual health professionals, especially the opportunity for discussion during genital examinations, should be encouraged.

Although this study showed an association between prior knowledge and the practice of TSE, further studies are needed to demonstrate how best to impart such knowledge regarding TSE to patients. Further predictors, such as socio-economic background, ethnicity and country of origin could also be investigated to inform future health promotion for TSE. The effectiveness and cost benefit of TSE still needs to be more accurately established in randomised controlled trials, particularly regarding the effect of increased TSE awareness on patient morbidity.

TC has exceptionally high cure rates, particularly if men present and are treated early. Men with established risk factors should be advised to examine themselves regularly. Sexual Health services are ideally placed to actively promote awareness of TC and TSE, particularly amongst young at-risk patients who may otherwise not access healthcare.

Footnotes

Acknowledgements

The authors would like to thank Julie Morris for her statistical support during the analysis of this study.

Conflict of interest

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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