Case finding and testicular selfexamination

Case finding is similar to screening but involves detecting disease in a symptomatic patient or one who presents to the physician with concerns that he might have the disease in question. As can be surmised from the prior discussion regarding delay in diagnosis, case finding for testicular cancer is critically important for the man who presents with scrotal symptoms, such as a mass, pain, or swelling, or after trauma. As previously noted, testicular cancer should not be overlooked when initial signs or symptoms are related to distant metastases. Case finding may be enhanced by patient education about testicular cancer and by TSE.

TSE is the process of instructing patients to examine themselves periodically for testicular masses, swelling, and other changes, and is patterned on the well-accepted concept of breast self-examinations [43-56]. The American Cancer Society and the National Cancer Institute [57,58] recommend that all postpuberal males perform a monthly TSE. Not all authorities agree that TSE is beneficial, however. The US Preventive Services Task Force [37] contends that there is insufficient evidence for or against counseling patients to perform periodic TSE. This group contends that reliable information on the accuracy of TSE is lacking and that it is unknown whether counseling men to perform TSE actually motivates them to adopt the practice or to perform it correctly [37]. Others, citing the lack of evidence that TSE is effective, advised physicians against routinely devoting time to discussing TSE [59,60]. Some have argued that the yield does not offset the increased anxiety that emphasis on TSE causes among men in an age group that already has many bodily concerns [47]. Conversely, Friman and Finney [61] point out that TSE would not cause excess anxiety but would reduce anxiety with regular practice. Furthermore, teaching young men to conduct TSE may result in these men taking increased responsibility for their own health care [61].

Despite the knowledge and perceived benefit of TSE by most health care professionals, little of this knowledge has been transferred to the public. Sheley and colleagues [62] studied 415 men from different regions of the United States and found that only 2% reported correctly performed, monthly TSE. These investigators concluded that there was a technology transfer problem regarding awareness of testicular cancer and TSE, teaching proper TSE, and conveying a benefit to the individual for performing TSE. Dachs and colleagues [63] similarly found that only 4.7% of New England college students performed monthly TSE in the mid-1980s. Even after being provided written material and a lecture on TSE by a physician, only 36% of the students changed their behavior and began performing monthly TSE [63].

Brubaker and Wickersham [64] postulate that the reason for this failure of TSE education is based on the theory of reasoned action, which proposes that performance of a behavior, such as TSE, is a direct result of a person's reasoned intention to perform that behavior. Behavioral intention, in turn, is a function of the individual's attitude toward the behavior and his or her perception of whether significant others would approve. Attitude toward the behavior reflects salient beliefs about the outcomes of performing the behavior, weighted by the value of each outcome. Brubaker and Wickersham [64] studied 232 college men exposed to educational lectures, reading materials, and posters about TSE. A student's attitude about the potential benefit of TSE and the perceived value of TSE by other peers affected his intention to perform TSE. Likewise, intention helped to determine who actually performed TSE. Clearly, we must convey a benefit to performing TSE to change a young man's intention to carry through with the behavior. Simple education without conveying a benefit of the behavior will not succeed in increasing the practice of TSE.

Having concluded that TSE may be beneficial at least for men who have risk factors for testicular cancer, if not for all young men, its teaching should emphasize the following points. First, men must gain familiarity with the surface, texture, and consistency of their testicles in the normal state. Second, the ideal time for TSE is during or after a warm bath or shower. Third, the man examining himself should rotate both testicles between thumb and forefinger until he determines that the entire surface of each is free of lumps. Fourth, the man should learn the location of the epididymis and that this structure is not a tumor. Fifth, any detected lump should be reported to a physician immediately [65]. Most importantly, as noted earlier, physicians must convey the benefit of TSE to affect the intention to perform it regularly. Education must include possible consequences of not performing TSE, such as delay in diagnosis with resulting advanced stage of disease; the need for intensive treatment, such as chemotherapy; and death. One approach may be to have a testicular cancer survivor discuss his experiences to convey the benefit of TSE [51]. Regarding the actual technical procedure itself, the message is that TSE is easily learned and should be practiced regularly [61]. Studies have shown that TSE teaching improves knowledge and performance of the self-examination [53,64,66].

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