Check Your Conkers!

Article by Dr Jeff Foster, GP

From an early age, boys become aware of their testicles, and as they progress through life, they become more conscious of their presence, their function, and also their disease risk.

It is now commonplace for various public health messages to remind us of the importance of self-examination and there have been multiple media campaigns and celebrity advocates who have stressed the importance of being aware of the symptoms and signs of testicular cancer.

In fact, testicular cancer is a rare disease that has received a lot of attention, probably for the wrong reasons.

Testicular cancer has an incidence of around 2400 new cases in the UK per year. In men, it is the 17th most common cancer, accounting for only 1% of all cancers affecting males. Interestingly, over the last ten years, the incidence of testicular cancer has increased by almost a tenth.

This is unlikely to be due to any changes in true disease prevalence, but more likely a greater awareness of the condition, and the changing attitudes of men towards their own health.

In general, survival rates from testicular cancer are very good, with Cancer Research quoting a 98% survival rate at ten years (approximately sixty deaths per year). Given that other cancers - of the prostate, lung, bowel, head and neck, kidney, lymphoma, bladder, oesophageal, and melanoma and leukaemia - are all more common than testicular cancer, why do we focus so much on its awareness and self-examination?

There are several reasons, probably the main reason for testicular cancer awareness, is the association we have as men with our own testicles. Testicles are part of what makes us male, they are responsible for sperm production and testosterone, two of the core elements that make up what it is to be a man. More so, men tend to have a protective obsession about their genitalia and a general awareness of the disease processes that can occur.

While every man should be concerned about the risk of lung cancer, most men worry more about the personal impact of testicular cancer. It does though help to set risk factors in context. For any illness, they are usually divided into two types: modifiable risk factors - those we can alter through medication or lifestyle, and non-modifiable risk factors - such as age or sex.

For testicular cancer, nonmodifiable risk factors include the following:

• Being Caucasian.

• Having a genetic abnormality that results in an extra X chromosome.

• Undescended testicles (cryptorchidism).

• Previous testicular cancer.

• Being tall. Men who are taller than average, have been shown to have an increased risk of testicular cancer.

• Family history. Men whose father had testicular cancer are around 4 times more likely to develop it, just as men with a brother who had testicular cancer are around 8 times more likely.

• Fertility problems. There is some association between men with a lower sperm count, or high levels of abnormal sperm, and an increased risk of testicular cancer. But the underlying pathophysiology is unclear.

• Men who have a long-standing inguinal hernia are more likely to develop testicular cancer.

• Hypospadias. Those born an abnormality of the penis and urethra.

• Having HIV or AIDS.

• The presence of calcium specks in the testicles (testicular microlithiasis). Testicular cancer is not increased in men with microlithasis who are otherwise healthy. But men who have this condition along with other testicular cancer risk factors (such as fertility problems or undescended testicle) may have an increased risk.

As for modifiable risk factors for testicular cancer, the situation is much more complicated. Testicular cancer is unlike the more common cancers such as bowel cancer or lung cancer, where known carcinogens such as processed meat or smoking have a direct causal association. As such, reducing risk of testicular cancer through lifestyle is more difficult.

A systematic review performed in 2018 looked at the link between exercise and testicular cancer, and found that while some studies showed a decreased risk of the disease, others showed an increased risk.

Overall, for this modifiable risk factor, the evidence is inconclusive. It is important that children identified as having undescended testes are surgically corrected as soon as possible and immune-suppressing conditions are treated effectively.

There have also been some studies that have suggested that pregnant women exposed to certain chemicals could increase the risk of their future male offspring being either infertile, or having an increased risk of testicular cancer.

This, however, is not really a modifiable risk factor, as an adult male can do nothing about events that occurred while he was in the womb. Overall, there are no proven ways to reduce the risk of getting testicular cancer through lifestyle modification.

How to Check Your Conkers

1. Check your testicles once a month whilst in or after the shower. If possible, stand in front of a mirror. Check for any swelling on the scrotal skin.

2. Check one testicle at the time, gently rolling it between the fingers, remember to feel up the spermatic cords on the back side of the testicles.

3. Look for hard lumps, smooth or round bumps, changes in size, shape or consistency and any painful areas.

The other reason that men are so conscious of testicular cancer, is the promotion of testicular self-examination. It is accepted that finding cancer early on helps improve survival rates, and this is where the notion of self-examination becomes important.

One of the earliest known recommendations to perform testicular self-examination dates back to 1977 in an article entitled “Various ways in which individuals can help detect cancers early”. At that time, there was no evidential base for this recommendation, and indeed, even now, the chance of discovering a significant abnormality from routine testicular self-examination is so low that it would take 50,000 men examining themselves for 10 years to prevent one death from testicular cancer.

Testicular cancer has an incidence of around 2400 new cases in the UK per year. In men, it is the 17th most common cancer, accounting for only 1% of cancer affecting males

Even so, that is not really the point of self-examination. Many cancers affecting males, such as prostate cancer and testicular cancer have no screening process or screening tests available, and there are virtually no modifiable risk factors, especially for testicular cancer.

To compound the problem, funding for research into male cancers remains much lower than for female cancers (for multiple reasons). Rather, the greatest benefit for self-examination of the testicles in men is to raise general awareness. It is, admittedly, likely to promote unnecessary anxiety in the majority of patients that find a lump and which turns out to be a benign epididymal cyst, but it is also likely to lead to a much better chance of finding that 1% of patients who do have testicular cancer.

For men’s health conditions which lack funding, screening tests, or even ways we can make changes to their lives to reduce risk, the one thing we can all do regularly is feel our balls, and though for the majority it will not alter the outcome, for a few men at least, it may save their lives.

Dr Jeff Foster

www.drjefffoster.co.uk

Dr. Jeff Foster is a GP with an interest in Men's Health. If you have any questions on men's health, please contact Dr. Foster at contact@drjefffoster.co.uk