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Raising awareness and detection of testicular cancer in young men

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Men’s health issues are relatively neglected in comparison with women’s. Men often avail themselves less of medical literature and doctors than do women (Peate, 1997). Although the numbers of men affected by testicular cancer may seem relatively small, its detection is essential because the disease affects young men in their reproductive years. About half of all cases occur in men aged less than 35 years (Cancer Research UK, 2002; see Fig 1).

Abstract

VOL: 99, ISSUE: 01, PAGE NO: 34

Anna Whiteford, BMedSc, is a fourth-year medical student, at the University of Birmingham Medical School

Jo Wordley, MSc, BSc, is a fourth-year medical student, at the University of Birmingham Medical School

Men’s health issues are relatively neglected in comparison with women’s. Men often avail themselves less of medical literature and doctors than do women (Peate, 1997). Although the numbers of men affected by testicular cancer may seem relatively small, its detection is essential because the disease affects young men in their reproductive years. About half of all cases occur in men aged less than 35 years (Cancer Research UK, 2002; see Fig 1).

The incidence of testicular cancer has been increasing since the turn of the 20th century. Young men today are thought to have a one in 500 chance of developing this cancer by the time they are 50, with over 1,800 new cases diagnosed in Britain alone each year (CRUK, 2002).

However, the treatment of this disease by surgery, chemotherapy or radiotherapy has been found to be highly successful, with up to 95 per cent of men being cured (Peate, 1997; Dearnaley et al, 2001), provided that the disease is caught at an early stage (Thornhill et al, 1987). Hence, it is vital to educate men about the detection of this potentially fatal disease (Box 1).

Previous studies have tended to focus on specific groups of men when investigating their knowledge of testicular cancer and its detection by self-examination (Martin, 1990; Singer et al, 1993; Wardle et al, 1994; Moore and Topping, 1999; Tichler et al, 2000).

They have, for example, looked at the knowledge of men belonging to particular occupational groups, academic institutions or socioeconomic classes with regards to testicular cancer, as opposed to identifying those with the least awareness from the population as a whole.

All of these studies have found, as have others that compare women’s knowledge with men’s (for example, Katz et al, 1995), that men have little awareness of testicular cancer, including its epidemiology, aetiology, detection and treatment (Box 2).

This study aimed to identify the group or groups of males who are least aware of the risks of testicular cancer and methods of detection. The study also hoped to determine if there were differences in awareness among men based on their age, ethnicity, socioeconomic class, sexual orientation, highest education level attained and general consciousness of health-related issues.

By determining those who have the greatest lack of knowledge the first target for future education can be identified and a step made towards increasing health awareness in the population at risk.

Method

This study sampled men from a single geographical region in the UK - the West Midlands. A sample of 100 men aged between 16 and 45 years was randomly selected from each of two general practices whose patients were from a range of socioeconomic backgrounds.

Questionnaires with prepaid reply envelopes were sent to those who had been randomly chosen. The questionnaire included:

- Questions regarding demographic information such as age, ethnic origin, marital status, sexual orientation, education and occupation;

- Knowledge-based questions about testicular cancer with multiple choice answers, for example: ‘what is the most common cancer found in men under 45?’; ‘which of the following factors are thought to significantly increase the risk of testicular cancer?’;

- Questions investigating attitudes towards testicular cancer, for example: ‘would you be embarrassed to have your genitals or groin examined by a doctor or nurse?’, ‘do you examine your testicles?’.

Of the 200 questionnaires sent, 61 replies were received, with almost exactly equal numbers of respondents from each general practice. The overall response rate was 30.5 per cent and the attrition rate was 69.5 per cent.

The results were analysed with an SPSS statistics package. In addition to descriptive statistics, Chi-Square, Fisher’s Exact and linear-by-linear associations were used to determine if any of the differences or associations observed were statistically significant.

Results

Although the distribution of ages of the men to whom the questionnaire was sent was broadly representative of the population as a whole, the average age of the respondents was skewed towards older men, with 49 men (80.3 per cent) aged above 31 years. The majority of respondents (78.6 per cent, n=48) were living with another person. Most men were white (95.1 per cent, n=58) and the majority were heterosexual (96.7 per cent, n=59).

In terms of education, 59 per cent (n=36) had been educated until they were at least 18 years of age. More than three-quarters of the respondents were in socioeconomic classes I, II, or III, (78.6 per cent, n=48) as obtained from their occupation by Standard Occupation Classification. Visits to a GP were made on average at least once a year by 68.8 per cent of the respondents (n=42).

It is possible that the results reflect a group that is more educated, conscientious and aware of their health, but less embarrassed by medical issues than are men in the general population. As a consequence these findings may slightly overestimate the actual awareness of testicular cancer in male subjects because non-responders may be less well informed than those who responded.

Our results demonstrated that a significantly higher number of respondents with a higher level of education correctly answered the question regarding the age group most affected by testicular cancer (linear-by-linear association=7.187, df=1, p=0007) and that a significantly higher number of those in socioeconomic classes I and II knew that testicular cancer was curable (Fisher’s exact test = 16.755, p=0.001). However, the lack of consistently significant results suggests that these findings may have been the result of chance.

Thirty-three (54.1 per cent) of our respondents knew that testicular cancer was the commonest type of cancer in men under 45 years of age. Although only 22.9 per cent (n=14) knew the specific age group that was most affected. More than half the respondents (62.3 per cent, n=38) knew that testicular cancer could be cured, but the majority (88.5 per cent, n=54) were unaware of the associated risk factors (Box 2).

Some of the symptoms were correctly identified by our respondents, but their failure to identify all of the symptoms implied an incomplete or an entire lack of education about testicular cancer.

It could be argued that, even though our respondents tended to be older, more health conscious and better educated than men in the general population, their knowledge of testicular cancer was still inadequate. This highlights the importance of improving the information available for all men.

Our results showed no significant differences between the attitudes of men in different demographic groups towards testicular cancer. A high proportion of respondents (71.7 per cent, 43 out of 60 replies) claimed they would not be embarrassed to have their testicles examined and claimed to examine them personally. However, only 25 per cent of those who said they performed self-examination had actually been shown or advised how to do so and 94.1 per cent (n=16) of the 17 who did not currently examine their testicles said they would do so if they knew how.

Thus, although only a small proportion of men have actually received advice about testicular cancer, our results suggest that the majority are keen and willing to learn more about it. Men’s embarrassment, and thus avoidance of being advised about testicular cancer, does not appear to account for the low numbers of men who received direction on this (Box 3).

It could, therefore, be the lack of service provision which accounts for the low numbers of men who have been advised about testicular examination - indeed previous research would suggest this was true (Carlin, 1986; Peate, 1997). If medical professionals and media publications (Pendered, 1991) were to become as conscientious as they are with their female patients in offering advice and knowledge about male disease and its prevention, vast numbers of preventable disease cases could be caught at a reversible stage.

Conclusions and recommendations

This study obviously has its limitations. In addition to the small sample size, perhaps one of the most important of these is the select group of men who responded to the postal questionnaire. As these men appeared to have had attained a high level of education, be from a higher socioeconomic class and be more aware of their health, it is possible they represented a group that was atypical of the West Midlands’ population. The ability to draw general conclusions from the results of this study is, therefore, somewhat limited.

Despite this limitation, this study shows that testicular cancer appears to be an ignored and misunderstood disease. While 54.1 per cent of the respondents indicated that testicular cancer was the most common cancer in men under the age of 45, only 23 per cent knew that it most commonly affected the 20-35 age group; while 62.3 per cent knew that testicular cancer was curable.

Significantly, only 11.5 per cent of the respondents knew that a history of undescended testicles was a risk factor for testicular cancer although 85.2 per cent correctly identified that a lump or swelling in the testicle could be a symptom of the disease. Nearly three-quarters of the respondents indicated that they would not be embarrassed to have their genitals examined by a doctor or nurse and 71.7 per cent reported that they examined their own testicles (48.8 per cent doing so at least once a month).

While men themselves are apparently receptive to education and would gladly accept the opportunity to monitor their health and thus prevent this disease, the resources available to them seem to be scarce and poorly promoted. The opportunity for offering educational information regarding men’s health and disease needs to be seized by health professionals when they are visited by male patients.

Since testicular cancer has a highly successful cure rate when identified early, an education programme could easily be conducted, and should produce valuable results. This education needs to start from a young age because of the epidemiology of testicular cancer. Therefore, the additional involvement of schools in a programme of advice and health promotion would seem particularly relevant.

This study concludes that men of all demographic groups should be targeted for education about testicular cancer. The information made available to men should include its risks, its presentation and detection. In particular men of a young age in social class IV and V should be made aware of the risks.

The provision of information about testicular cancer should begin at an early age, as young men are most at risk. In view of the success of treating this potentially fatal disease, its early diagnosis and treatment is paramount. If men are able to recognise the disease factors in their initial stages, it may be possible to reduce the incidence of this potentially fatal disease.

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