Elsevier

Preventive Medicine

Volume 41, Issue 2, August 2005, Pages 386-398
Preventive Medicine

Testicular cancer awareness and self-examination among adolescent males in a community-based youth organization

https://doi.org/10.1016/j.ypmed.2005.02.003Get rights and content

Abstract

Background

Testicular cancer (TC) is the most common neoplasm affecting males between 15 and 35, and testicular self-examination (TSE) has been recommended for early detection. Studies have found that young adult men have poor awareness of TC and low rates of performing TSE, but little research has examined adolescents.

Methods

In a comprehensive survey of health behaviors among adolescent boys (n = 213, mean age 15.4 years) who participated in a community-based youth organization (Boy Scouts of America), we assessed whether respondents had heard of TC and the frequency of performing TSE.

Results

Nearly 73% of scouts had heard of TC, but only 10.3% performed TSE at levels consistent with current recommendations (10 or more times per year). Compared to whites, blacks were less knowledgeable about TC and less likely to perform TSE. Knowledge of TC also was associated with participation in physical education classes and the intention to graduate from college. TSE was associated with greater health care access and the use of personal flotation devices during water activities.

Conclusion

TSE is underutilized as an early cancer detection tool. Efforts are needed to increase TC knowledge among black adolescents and to integrate TSE education with promotion of healthy behaviors in community organizations.

Introduction

Testicular cancer (TC) is the most common solid tumor affecting males between the ages of 15 and 34, accounting for 20% of cancer diagnoses in this age group [1]. Although this disease is relatively rare (incidence rate of 6.3 cases per 100,000 for men under 50 years of age), incidence in the US rose nearly 50% between 1975 and 1999 [2]. Incidence rates currently are five times higher in whites than blacks, but the rise in rates from 1992–1999 was six times higher in blacks [2]. The American Cancer Society (ACS) estimates that 8980 new cases of testicular cancer will be diagnosed in the United States in the year 2004 and that 360 men will die of the disease [3]. Occurring usually during the prime of life, TC can have a substantial impact on psychosocial adjustment and quality of life [4], [5].

Treatment for TC is highly effective, particularly when detected before metastatic involvement. Five-year survival rates are more than 95% for Stage I and Stage II TC but drop to approximately 75% for Stage III, in which cancer has spread beyond local lymph nodes [2], [6]. Early diagnosis is especially critical since the growth rate of germ cell tumors, which account for the vast majority of TC, is very high, doubling every 10–30 days [7].

Unfortunately, many men delay consulting a physician regarding symptoms due to lack of awareness or misattribution of symptoms, procrastination, or denial of symptomatology [8]. Contributing to this delay is the fact that symptoms are often minor, including a nodule or thickening, increased size or heaviness of the scrotum, discomfort, and, less often, pain. In addition, initial misdiagnosis is not uncommon, resulting in symptoms being present for 17–87 weeks before a correct diagnosis is made [8], [9], [10]. Such delay has resulted in 50–88% of males with testicular cancer presenting with metastases at the time of diagnosis, which greatly increases morbidity and mortality [11], [12].

Because the key to successful intervention in TC is early detection, several organizations, including the American Cancer Society and American Urological Association, recommend that physicians include testicular examination as part of routine physicals [3], [9]. Recommendations also exist that physicians and other primary health care providers teach and encourage testicular self-examination (TSE) to their male patients between the ages of 15–35 years [6], [9], [13], [14], [15].1

Although TSE is recommended for males beginning at age 15, there is surprisingly little data available on the prevalence of TC awareness and TSE practice among adolescents. Among a sample of 1364 ninth grade males (mean age 14.9), only 28% had heard of TC and none knew how to perform TSE [16]. In a study that tested a brief school-based TSE education program, only 5% of high school males at pre-test had ever performed TSE [17]. Among 66 15–20-year-old males recruited for a health clinic-based TSE education program, fewer than half (47%) had heard of TC and only 1.5% regularly performed TSE [18]. Furthermore, a recent survey of pediatric residents found that fewer than half teach TSE to their adolescent patients [19].

Studies assessing TC knowledge and TSE practice in young adult men have identified a pattern of results similar to that found in adolescents. There generally appears to be substantial lack of knowledge about TC among young men and correspondingly low adherence to TSE. Only 25–61% of American college students across several samples had heard of testicular cancer [16], [20], [21], [22], and fewer than 20% regularly performed TSE [21], [23], [24], [25], [26], [27], [28]. In a survey conducted between 1988–1991 in more than 7000 European college students, TSE was uniformly low across the 20 nations assessed, with 87% of students reporting that they never performed TSE and only 3% doing so on a monthly basis [29].

Most studies on the prevalence of TSE were conducted in the 1970s and 1980s well before the diagnosis of TC in two celebrities that lead to widespread media attention of this disease. World champion cyclist Lance Armstrong was diagnosed in 1996 with advanced TC. He was given a 50-50 chance of surviving but after a year of aggressive treatment was declared cancer-free and returned to cycling in 1998, winning his first of six Tour de France races a year later. Armstrong's story highlights some of the common problems with TC diagnosis: his symptoms were subtle, and he ignored them for a year due to lack of awareness about TC, getting medical attention only after the symptoms had become severe, at which point the cancer had metastasized to his lungs and brain. Subsequent to Armstrong's disclosure of his TC diagnosis, another high-profile figure disclosed a diagnosis of TC. In 2000, comedian Tom Green held a 1-h television special on his own experience with his TC diagnosis and treatment. This special was broadcast on MTV, which reaches a large number of adolescent and young adult men. The show included Green discussing his feelings related to his TC diagnosis and treatment, surgical scenes, and a demonstration of how to perform TSE [30].

Interestingly, despite the widespread international media attention about TC generated by Armstrong's and Green's stories, recent studies did not find much of an increase in the performance of TSE by young men. A survey of 191 18–35-year-old men, conducted at occupational health fairs in the Midwest during 1999–2001, indicated that 64% rarely or never performed TSE [31]. Another recent study among 15–19-year-old Dutch adolescents found that 26% had heard of TC, 3% had heard of TSE, and only 2% reported regularly performing TSE [32]. Knowledge of TC was much higher in a recent sample of 203 male undergraduate and graduate students in the United Kingdom, with the vast majority (90.6%) reporting that they had heard of TC. Unfortunately, only 23% regularly practiced TSE [33]. Trumbo [30] specifically examined the effects of media information on factors related to TSE among college students by conducting a survey of students who had or had not watched the Tom Green special. He similarly found increases in awareness and knowledge of TC and TSE. Students who watched the show compared to those who did not had small but statistically significant improvement in intent to perform TSE, positive attitudes toward performing TSE, and accurate knowledge of TC and TSE. Since Trumbo did not collect information on TSE performance, it is difficult to draw conclusions about how the Tom Green show impacted the actual practice of TSE. However, based on the limited data available, the practice of TSE does not appear to have changed significantly in recent years.

Interventions that have been designed to increase adherence to TSE recommendations have targeted college-age young adults in either health-related classes [22], [24], [34], [35] or health care facilities [18], [36] with little attention being given to high school students [17]. The majority of these studies demonstrate increases in intentions or actual practice of TSE after relatively brief educational interventions and/or instruction on TSE. Typically, however, high percentages of subjects fail to adapt adequate TSE practices, and treatment effects tend to dissipate rather quickly [12], [37].

Given the professional recommendations to perform TSE and the fact that so little information exists on adolescents and their knowledge of TC and performance of TSE, a first step would be to determine the level of awareness of TC and level of performance of TSE in adolescent boys. Secondly, in order to help identify potentially useful interventions to increase TC awareness and teach TSE to adolescent boys, it is necessary to determine which characteristics and behaviors are associated with awareness of TC and performance of TSE. No studies have yet been conducted in adolescents to evaluate how TSE tracks with other health behaviors. It is known, however, that several other health behaviors tend to cluster together in adolescents including: early initiation of sexual activity and alcohol use [38], [39] and smoking, sedentary behavior, and poor diet quality [40], [41], [42], [43].

To this end, we examined knowledge of TC, the prevalence of TSE practice, and correlates of TSE among adolescent male participants in a large community-based organization, Boy Scouts of America (BSA). As an organization, BSA has a considerable reach into the community. The organization enrolls approximately three million youth in their programs and is considered a highly viable resource for health promotion efforts [44], [45], [46]. Thus, to address some of the questions that still remain, information on TC awareness and performance of TSE was collected from adolescent boys who participated in BSA. Data were collected as part of a comprehensive assessment of health risk behaviors among this population and allowed us to broadly sample demographic, social, and health behavior correlates of TSE.

Section snippets

Overview

Data for this paper are derived from the Boy Scout Health and Safety Survey, a joint undertaking of the Chickasaw Council of The Boy Scouts of America and the University of Memphis Center for Community Health (CCH). A comprehensive survey of modifiable health risk behaviors was administered to scouts in the Council during the Winter and Spring of 2000. Demographic, personal, and family characteristics were assessed along with several health risk behaviors, including tobacco, alcohol, and drug

Comparison of participating and non-participating troops

A total of 3592 Boy Scouts (10–19 years of age, in grades 4–12) were registered in the Chickasaw Council at the time of the survey in 231 troops. A total of 92 troops agreed to participate (39.8% of all troops), which included 827 scouts (23.0% of all enrolled scouts).

We compared participating and non-participating troops on socioeconomic status and organizational sponsor, factors which conceivably could be related to the awareness of TC and TSE. As a proxy for socioeconomic status, we

Discussion

Our goals for this study were to (1) determine the prevalence of TC awareness and TSE among a group of adolescent boys who participate in a community-based organization (Boy Scouts of America); and (2) to identify other behaviors or characteristics associated with TC awareness and performing TSE for the same group.

Acknowledgments

This research was supported by a grant from LHS, Inc., Memphis, TN. We wish to thank Mr. Gene Stone, Mr. Fred Blair, and the scouts and leaders of the Chickasaw Council, Boy Scouts of America for making this work possible and Dr. Catherine Hoerster and Mr. Michael Butler for their assistance in conducting the study.

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