Testicular cancer

Research questions of the HTA report:

The aims of this investigation are to

– assess the benefit of testicular cancer screening through clinical palpation and scrotal ultrasound or through testicular self-examination (TSE) in men from 16 years of age in comparison with no screening with regard to patient-relevant outcomes,

– determine the cost (intervention cost) arising from testicular cancer screening in comparison with no screening in asymptomatic men from 16 years of age,

– assess the cost-effectiveness of testicular cancer screening in comparison with no screening in asymptomatic men from 16 years of age, and

– review ethical, social, legal, and organizational aspects associated with the screening.

Conclusion of the HTA report:

Due to a lack of interventional studies on benefit and harm, the question of whether routine screening of asymptomatic men from 16 years of age (at average or higher risk) results in better treatment outcomes in testicular cancer cannot be answered in an evidence-based manner. There is no hint of (greater) benefit or (greater) harm. No studies are available on cost effectiveness.

The theoretical maximum benefit indirectly derived from epidemiological studies in a supplementary presentation for the benefit assessment is relatively small in comparison with other cancers. Testicular cancer is rare, and even in the absence of routine screening, it is discovered in a relatively early stage in most cases and can be treated with correspondingly high cure rates.

Therefore, routine screening for testicular cancer in men from 16 years of age cannot be recommended at this time. This applies to both TSE and clinical palpation /scrotal ultrasound. The low potential benefit is accompanied by potential harm due to unnecessary testicular exploration or removal. Nonmalignant testicular anomalies, which are frequently discovered as a result of targeted examinations, may worry affected men and sometimes involve unnecessary resource consumption. Particularly in case of clinical examinations, it is possible for the expected harm inflicted by additional unnecessary invasive evaluations to outweigh the expected benefit when looking at the entire target population. Therefore, clinical palpation and scrotal ultrasound for screening purposes should be offered neither as a standard statutory health insurance (SHI) benefit nor as an individual out-of-pocket health service. TSE is likely associated with less potential harm. It seems justifiable for young men worried about the risk of testicular cancer – of which there should be few according to psychosocial studies – to regularly practise TSE after they have been educated about the lack of direct evidence on their potential benefit and harm and instructed on how to perform the exam. The use of conventional health education channels to advise men to promptly see a physician for diagnostic evaluation in case of abnormalities of the testis can absolutely be recommended. Further, men should be educated about risk factors for testicular cancer and the generally more favourable benefit–harm ratio of screening for individuals at higher risk.

Given that a relatively low potential benefit is expected due to the comparatively low incidence and often relatively good treatment outlook for testicular cancer, it seems hardly advisable to overcome the lack of evidence by conducting resource-intensive interventional studies of high methodological quality in men at average risk of testicular cancer. Since the benefit of screening measures increases with the risk of developing the disease, such interventional studies should be performed in high-risk groups, if at all.