From ‘D’ to ‘I’: A critique of the current United States preventive services task force recommendation for testicular cancer screening

Abstract

In 2004, the United States Preventive Services Task Force (USPSTF) gave testicular cancer (TCa) screening a ‘D’ recommendation, discouraging the use of this preventive service. The USPSTF suggested that screening, inclusive of testicular self-examination (TSE) and clinician examination, does not reduce TCa mortality rates and that the high risk of false positives could serve as a detriment to patient quality of life. Others suggests that TCa screening is ineffective at detecting early-stage cases of TCa and readily highlights a lack of empirical evidence demonstrating said efficacy. These assertions, however, stand in stark contrast to the widely held support of TCa screening among practicing public health professionals, advocacy groups, and clinicians.In this present study, a review was conducted of the methods and processes used by the USPSTF in their 2011 reaffirmation of the ‘D’ grade recommendation. The evidence base and commentary offered as to why TSE, as part of the overall recommendation for TCa screening, was given a ‘D’ grade were analyzed for logical reasoning and methodological rigor.Considering the methodological flaws and the veritable lack of evidence needed to grant a conclusive recommendation, the question is raised if the current ‘D’ grade for TCa screening (i.e. discourage the use of said service) should be changed to an ‘I’ statement (i.e. the balance of benefits and harms is indeterminate). Therefore the purpose of this paper is to present the evidence of TCa screening in the context of efficacy and prevention in order for the field to reassess its relative value.

A Call to Action to Review the USPSTF’s Recommendation for Testicular Self-Examination

“…This current commentary, in fact, is not the first request for the USPSTF to review the evidence and make a call for evidence review. There have been several public pleas by members of the academy, clinical practice, and male health think tanks for the USPSTF to take up the call to review the evidence again (for example, see Fadich et al, 2018 ; Rovito et al, 2016 ; Rovito & Nangia, 2019 ). Each piece concluded with a call to action for the USPSTF to rethink their “D” rating recommendation for TSE and to make the call for a formal review of the evidence.…”

Testicular Awareness: The What, the Why, and the How

“…The U.S. Preventive Services Task Force 44 and the National Cancer Institute 45 discourage TC screening due to the potential harms of false positives and concomitant anxiety. Proponents of routine TC screening, on the other hand, argue that recommendations discouraging this practice are based on speculations rather than empirical evidence, 46 especially that early detection of TC is linked to a reduced cost of treatment, 47 and public health initiatives promoting TSE are believed to be linked to a reduced tumour size at diagnosis. 48 The third position is to: (i) promote TC screening among at-risk men only; (ii) leave the decision to undergo TSE to the men themselves; and (iii) encourage awareness of the normal testes and testicular symptoms over routine TSE.…”

A Cross-Sectional Analysis of Testicular Cancer Symptom Recognition and Stage of Diagnosis

“…Black/African Americans, further, have higher proportions of more advanced stage TC diagnoses and mortality in addition to males of lower socioeconomic status (SES) and more rural communities ( Adams et al., 2018 ; Kamel et al., 2016 ; Markt et al., 2016 ). This may be attributed to the lack of endorsement of preventive practices ( Rovito et al., 2016 ), such as testicular self-examination (TSE), a historically consistent lack of knowledge about TC symptoms among males ( Cronholm et al, 2008 ; Kuzgunbay et al, 2013 ; Moore & Topping, 1999 ; Saab et al, 2019 ), environmental exposures ( De Toni et al, 2019 ; Kollerud et al, 2020 ), or any combination of the above.…”

“…This, Saab et al continue, lowers their intentions for seeking prompt medical attention for testicular symptoms. Another issue of concern that could affect disease symptom registration among males includes the United States Preventive Services Task Force’s (USPSTF) recommendation against testicular examinations to screen for cancer (see Fadich et al, 2018 ; Rovito et al, 2016 ). Although the USPSTF states that their recommendations are just that (i.e., recommendations), others report that they have much more influence pertaining to if clinicians decide to advocate for TSE in their clinic or not, which affects if males perform the behavior ( Rovito et al, 2018 ).…”