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David Nolan thinks that the health promotion campaign around testicular cancer is a load of balls

The truth about testing your testicles

Two new health promotion leaflets have appeared in GPs' surgeries, Well Men clinics and branches of Boots throughout the country. 'A whole new ball game' and 'A message for men' have been produced as part of a Department of Health campaign to raise awareness about testicular cancer and encourage men to take steps to spot the warning signs.

The leaflets are alarming. Testicular cancer, we are told, is the most common form of cancer in men aged between 15 and 45, and the risk of developing the condition has doubled in the past 20 years. The Department of Health hopes that by making men more aware of what is normal, and what is not, about their bodies, more cases of testicular cancer will be spotted at the early, treatable stage. Just as women are supposed to be breast-aware and examine their breasts for sinister signs every month, chaps are being advised to be testicle-aware.

The leaflets advise all men to practice monthly testicular self-examination (TSE). This involves sitting in your bath and rolling your testes between forefinger and thumb to spot irregular or unusual growths, lumps, knobbly bits or anything else. The leaflets suggest that this may well save your life. The Imperial Cancer Research Fund, which is collaborating with the Department of Health's campaign and which wrote one of the leaflets, is concerned that only about three per cent of men regularly check their tackle.

Their figures may well be optimistic. How many men do you know who regularly examine their testicles? Probably none. (Other forms of bathtime handling do not count.) And I will wager it does not matter a jot. Testicular cancer is quite simply not a problem for young and middle-aged men. Distributing leaflets advising them about TSE is at best a token gesture to make men feel included in the current wave of health advice (nearly all of which is aimed at women). At worst, it is a way of encouraging health neuroticism among young men who have every right to feel indestructible.

When you take a careful look at the information provided about cancer of the testes you find a curious mix of facts which illustrate that the condition is not a problem, and advice that tells you to act as though it is. The facts that could be reassuring are presented in the most alarming way possible. Incidence of the condition, we are told, has increased by more than 300 per cent since 1911 among men aged 25-29. Sounds scary. But, despite that increase, the actual risk is still tiny. Fewer than 40 in every million men in their late 20s will get testicular cancer. To put this in perspective, one woman in 10 suffers breast cancer at some time in her life.

Testicular cancer may be the most common form of cancer in young men, but then cancer is generally an older person's disease anyway so even the most common form is likely to be extremely rare. One of the reasons that cancer rates have been increasing generally is because people are living to be old enough to develop it. Tragic definitely, for those involved, but surely increased longevity is better than the opposite?

Furthermore, even without wide-spread TSE, the annual number of deaths from testicular cancer is plummeting. Just 83 men died from testicular cancer in 1995, less than a third of the toll in 1978 when 273 men died of the disease. More men died of breast cancer in 1994 (the last year we have figures for) than died of testicular cancer in 1995, yet we never hear about male incidence of that.

All in all, there appears to be no rationale to the idea that testicular cancer is a major killer of men, or even a serious risk to our health.

Even when men do get testicular cancer it is almost invariably cured. Of the 1200 to 1500 men who get cancer of the testes each year more than 90 per cent make a complete recovery. The introduction of new drugs and less toxic treatments has improved success rates phenomenally. In the 1970s fewer than 20 per cent of men with one form of testicular cancer, metastatic teratoma, survived. Now it is 90 per cent.

Cancer research organisations insist that there are certain 'high risk' groups where testicular cancer is concerned. For instance, those who had an undescended testicle, or those whose brother has had the cancer, are considered to be especially susceptible. But they are not being specifically targeted. The approach is a blanket one aimed at alarming all men. The fact that other 'high-risk groups' singled out include such broad categories as white men, professional men, single men and young men gives an idea of how generalised this health scare has become.

Deep-seated fear

Even if the health promotion campaign did target specific individuals, the evidence to hand suggests that it is unlikely to have much effect. Dr Joan Morris, an epidemiologist from the Wolfson Institute of Preventative Medicine has worked out that if 50 000 men tested themselves regularly over 10 years it might save one life - and that was only if the screening cut the death rate by 50 per cent, which would be an unusually high result. She claims that the campaign was aimed at our heads more than anything else. 'The campaign seems to be mainly a psychological one and not a step on the path towards taking health seriously. The figures do not justify the campaign or its cost. There is a high level of misdiagnosis (as doctors are not always sure themselves as they see the condition so rarely) and can cause needless and extreme anxiety.' A localised campaign in Glasgow bears this view out. It had no effect whatsoever on the numbers of cancers found, but did a lot to boost the numbers of healthy men who became worried about their balls, visiting their GPs and wasting everybody's time.

We are not talking about prevention. Nobody knows exactly what causes testicular cancer. Some argue it is mainly genetic, others say it is hormonal and still more are inclined to suggest that it is environmental. The wise ones say that it is probably a mix of all three. Other, more specific and probably more absurd reasons have been put forward. Over the years sexual activity, a variety of traumas, mumps, orchitis and even temperature variations have all been blamed. Even watching TV and riding motorbikes can result, apparently, in radioactive emissions affecting the testes. Synthetic oestrogens, contained in the old favourite, the contraceptive pill, which seems to be blamed for everything these days, also get a look in.

In short nobody knows, and while investigations continue, the scaring of men does too. The reality is if you already have had one testicle removed due to cancer, you may well lose the other one. If you have not you probably don't have to worry.

But the absence of a definite cause is one of the things that makes testicular cancer an ideal candidate for an emotive health promotion campaign on the cheap. There are no resource-consuming mass screening programmes, no expensive mass immunisations. In fact, apart from the leaflets, there is little involved in this campaign

Solution to hand

Gary Ward, spokesman for the Health Education Authority spells out clearly the justification for the campaign: 'Self-examination is something specific that men can do. It is a reasonably easy message to get across and it is not a complicated procedure. Men can do it in the bath and they needn't be embarrassed about it.' Ward also said that campaigns which called for specific action were likely to be more successful than others, such as getting men to reduce drinking. 'Where the health risks and benefits cross over is a difficult message to get across, getting people to understand units of alcohol and the way they affect different people is a complex message, whereas self-examination is perfectly straightforward.' In other words if you can get them to do as they are told by the professionals, who cares if it's necessary or not.

If these campaigns were simply a waste of time and money they would not be worthy of too much comment. But they are not benign. Needlessly alarming men about their testicles is one more drip into the pool of health panics in which society is drowning. The underlying message is that you, and you alone, are responsible for your health and well-being, and unless you change your lifestyle and personal behaviour, and become more aware about the workings of your body, you and your loved ones are going to suffer. I am just waiting for the campaign which pictures the crying orphan (as in past anti-drink- driving campaigns) with the caption: 'Her father never felt his balls. Have you practised TSE this month?'

Pocket billiards

TSE may not do much for health awareness, but it certainly can make you aware of - and worried by - your own vulnerability . Purely in the interests of research I tried it out. While I did not find anything unexpected, I did find the whole experience makes you uncom- fortably conscious of how vulnerable you are, and starts you thinking about how many things you have not considered can go wrong with your body.

Some say that TSE might save a life. And it just might conceivably save a single life sometime - but the price is far too high. The increase in general anxiety shown in the Glasgow study alone would be enough to convince me that we would be better off without it. We all have much better things to do with our time than worry ourselves sick about non-existent health problems.

What the DoH might do is encourage prophylactic testectomies for us all, then the incidence rate will be down to zero and the Health of the Nation statistics will be in credit. But cutting the balls off the nation's manhood is hardly a feasible solution. Whatever happens this sort of health promotion campaign is set to continue, and indeed proliferate, under the New Labour regime. They are low resource, high impact propaganda campaigns which focus attention on self-awareness and endorse the completely wrong idea that good healthcare is about how we examine ourselves rather than the availability of doctors and treatments. But I suppose if we all walk around with our hands in our pockets, it stops us making trouble elsewhere.

Causes of male deaths in the UK 1995
Cause Number of Deaths
Total male deaths 272709
Diseases of the circulatory system  
(incl. heart attacks) 116127
All cancers 72445
Diseases of the respiratory system 41291
Cancer of the prostate 8848
Diseases of the digestive system 8523
Suicide 2790
Various Accidents 2183
Breast Cancer (1994) 88
Testicular cancer 83
Appendicitis 43
CJD (1994) 20
Meningococcal meningitis (1994) 7
Whooping cough 2
Measles 1
Source: Office Of National Statistics

Percentage of men surviving five years after an incidence of metastatic teratoma
Pre-1970Early 1970sLate 1970sToday
If the cancer is caught early enough today, the survival rate is about 98 per cent.
Source: Cancer Research Campaign

Reproduced from LM issue 101, June 1997



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