Performing Testicular Self-Examination,Driving Automobiles,and Anxiety: What Is the Logical Link?

Abstract

The debate of whether testicular self-examination (TSE) should be promoted among males generally centers on a harm–benefit corollary. The benefits of TSE include improving health outcomes, inclusive of an increase in both quality of life and knowledge/awareness of potential health concerns, as well as promoting proactivity in achieving wellness. The harms include claims that false-positive results can increase anxiety and produce costs via unnecessary treatments and therapies. Further claims point to the lack of evidence suggesting TSE decreases testicular cancer mortality. This commentary primarily discusses the anxiety portion of this debate from a logic-based perspective. The argument that TSE should not be promoted among males due to the risk of inciting false-positive anxiety appears to be flawed. A 5-point perspective is presented on the illogical discouragement of TSE due to theorized levels of false-positive anxiety while existing evidence suggests late-stage testicular cancer is associated with anxiety and depression.

A recent news story reported that a 20-year-old man was found dead from respiratory failure due to an undiagnosed case of testicular cancer (TCa) spreading to his lungs (Barber, 2015). It appears that this young man may not have been aware of the signs and symptoms of TCa. It is a very troubling story to read as a simple testicular self-examination (TSE) could have, arguably, saved his life. Had he been made aware of the lump on his testicles, assuming it was palpable, he may have been able to speak to his physician about it and receive the necessary care. Sadly, he is not the only male to experience this, nor will he be the last.

TSE is generally supported as a method for detecting TCa early in order to improve health outcomes, including mortality reduction (Avci & Altinel, 2015; Jones et al., 2015; Rovito, Leone, & Cavayero, 2015). The claim is that TSE can help save lives and promote overall wellness among males by increasing informed decision-making skills and improving quality of life by being more proactive with their well-being. The arguments against promoting TSE among males, most notably from the U.S. Preventive Services Task Force (USPSTF; 2011), claim that the behavior causes more harm than good because false-positive results can increase anxiety and produce costs via unnecessary treatments and therapies (Casey, Grainger, Butler, McDermott, & Thornhill, 2011). Others contributing to this line of reasoning further claim that there is no evidence suggesting TSE decreases TCa mortality (Hopcroft, 2012).

The following commentary will discuss the anxiety portion of this debate from a more logic-based perspective. The argument that TSE should not be promoted among males due to the risk of inciting false-positive anxiety appears to be rationally, and methodologically, flawed.

• First point: The USPSTF, among others, do not support TSE due to the favorable outcomes from TCa treatment. This would be an acceptable position if survivorship was the only relevant outcome. With survivorship, however, comes financial and quality of life costs that need to be considered (Aberger, Wilson, Holzbeierlein, Griebling, & Nangia, 2014; Gilligan, 2015). Not factoring in all costs introduces error to the harm–benefit corollary.

• Second point: Trained clinicians fail to achieve a 100% success rate of discovering a palpable testicular mass (see, e.g., Das, Badhe, Bibi, & Mohanty, 2015). How can we, therefore, expect males who have never been taught how to properly perform TSE to detect testicular masses at high rates of success? It is unreasonable for us to expect lower rates of false-positives resulting from TSE at the moment.

• Third point: There is no real evidence produced by the USPSTF (2011) nor by others advocating against TSE (i.e., Casey et al., 2011; Hopcroft, 2012; Lin & Sharangpani, 2010) suggesting that anxiety is significantly raised from a false-positive result. If it has been measured, it has not been replicated in any sort of detail that the tenets of scientific rigor demands nor readily available for peer-review scrutiny. It would be in our collective best interest to analyze the psychometric properties of the tool to ensure the data are reliable and valid. No such tool exists, which means that no such data exist, which means that no such analyses are possible.

• Fourth point: Even if we did measure anxiety levels in males before they performed TSE, and then prospectively measured them every month to retest them for anxiety, we should expect anxiety levels to be elevated because they have very limited knowledge of TCa and TSE. There are similar arguments in the breast self-examination literature (Oeffinger et al., 2015).

• Fifth and final point: Gilligan (2015) indicates that late-stage TCa cancer treatment leads to significantly higher anxiety levels and incidence rates of mood disorders than early-stage treatment. The argument, therefore, that anxiety from false-positive TSEs is reason enough to not perform self-exams is very weak. Refraining from performing TSE could, again, lead to a later-stage diagnosis of TCa if the disease is present. Arguably, the anxiety experienced from invasive surgeries, radiation, and chemotherapy is likelier more intense and distressing to the patient than the anxiety felt when palpating an unknown lump on his testicles (Gilligan, 2015; Saab, Noureddine, Huijer, & DeJong, 2014). Essentially, anti-TSE arguments use theorized anxiety from false-positives as a reason to not perform TSE but fail to mention anything about the anxiety experienced during late-stage TCa diagnoses.

An example could prove useful in summarizing this piece: Did you have anxiety the first time you drove an automobile? Probably. You are driving a large machine that can reach very fast speeds and can be deadly if not operated properly. It would be expected for you to be a bit anxious. What if you smelled something burning while driving and/or you heard a loud noise when turning on the ignition? You probably had very limited experience with driving itself, let alone what to do if something went wrong with your automobile, so you were probably, again, anxious, perhaps nervous, or even scared.

Fast forward to the present day. Do you have the same levels of anxiety now driving your automobile? Probably not. If you do, it is perhaps nowhere near the level as it once was. Even if you smell or hear something odd, you (probably) think whether or not if it is something significant. If you decide it is, you make an appointment with a mechanic to confirm your suspicions. If it is something serious, you are presented options to remedy the issue before it becomes a more costly one. If it is not serious, you became further versed on how your automobile operates. You paid the labor costs but at least it was not a major problem. The same smells and sounds could occur but you are now more aware of what they could or could not mean.

How is the aforementioned hypothetical scenario so much different than performing TSE and detecting masses on your testicle? Anxiety levels resulting from a positive TSE (either true- or false-positives) would be inflated due to the TCa/TSE knowledge gap. Males who detect masses are probably anxious because they have no idea what is really going on, let alone know someone (or feel comfortable enough with that person) to talk to about their health concern. Similar trends are seen in cervical cancer literature pertaining to anxiety and abnormal smears (Fylan, 1998).

In closing, it appears that the evidence supporting rises in anxiety and depression stemming from late-stage TCa has little influence in the anti-TSE literature, which solidly uses a theorized anxiety level from false-positive TSEs as a part of their base logic (Lin & Sharangpani, 2010). It is a fundamental tenet of evidence-based research and practice that to take official positions/conduct actions without sufficient data is very problematic, possibly irresponsible.

We are failing to properly teach these males how to palpate their testicles, due in large part, arguably, by the USPSTF’s “D” rating influence (see Barocas et al., 2015, for a discussion on the USPSTF influence on prostate cancer screening). If males were properly taught how to perform TSE and what their options are if they detect a lump, one would expect that false-positive results would become rarer (Finney, Weist, & Friman, 1995). Until they get to a certain level of familiarity with the behavior and why they are performing it, this will continue to be a concern.

Delayed TCa detection brings more invasive and toxic treatments, thus lessening overall quality of life. Is it logical for us to discourage TSE due to theorized levels of false-positive anxiety while evidence exists suggesting treatment of late-stage cases significantly reduces quality of life, inclusive of anxiety and depression? Probably not. I believe the field needs to reassess our approach to deciding on the harm–benefit corollary, particularly with the anxiety-inducing concerns.

The USPSTF (2011), among others (i.e., Lin & Sharangpani, 2010), suggest that no evidence exists demonstrating TSE effectiveness in reducing mortality. The burden of proof, this author claims, lies on demonstrating TSE harm instead of demonstrating TSE benefits. But, if the game must be played, there is in fact evidence demonstrating TSE promotional interventions raising knowledge and awareness, among other positive outcomes, including reducing overall costs associated with treating the disease (Aberger et al., 2014). It therefore appears that evidence exists on TSE benefit with little, if any, existing on its detriment. However, we proceed on the side of caution that it might be harmful despite the proof that it is helpful. In this author’s opinion, this seems illogical.

If TSE can be properly taught, it can serve to be a very convenient and helpful tool. Males, however, have very limited knowledge about TCa and TSE. Whose fault is it? No one can say. Information dissemination on the topic is anemic at best.

This is not an oversimplification of the issue. It is a call to adjudicate preconceived notions of TSE and anxiety with actual evidence. It is a call to increase informed decision-making among males about TSE and TCa. And just like when you first started driving, your limited knowledge of how to drive made you anxious, confused, and frightened. How is this any different at its core than performing TSE for the first time?