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. 1998 May 2;316(7141):1387. doi: 10.1136/bmj.316.7141.1387

Prevalence study of carcinoma in situ of testis in oligozoospermic men

Study was too small to show potential benefits of screening

Ramesh Rajentheran 1, Joanne Kenworthy 1, Michael Cunnington 1
PMCID: PMC1113086  PMID: 9564007

Editor—Giwercman et al evaluated the need for screening for carcinoma in situ of the testis in oligozoospermic men from infertile couples.1 They concluded that these men do not have an increased risk of carcinoma in situ, therefore implying that screening is not justified.

Their study fails to provide the information required to form a proper judgment on the potential benefits of screening. Although no cases of carcinoma in situ of the testis were detected among the 207 men studied, the confidence intervals reported are compatible with a prevalence of almost 18 in every 1000 men and a relative risk 4.6 times that in the general population. This represents a significantly increased risk. To put this in context, the detection rate for breast cancer in the first wave of the NHS breast screening programme was 6.2/1000 women screened.2

No consideration was given to the suitability of testicular biopsy as a screening test. While the uptake rate in the study was 94%, the acceptability of such a highly invasive technique should be addressed.

The study population comprised men referred to Danish infertility clinics. The authors claim that this population represents the target group for screening. They admit, however, that not all oligozoospermic men are currently referred. If screening were implemented, referral rates would probably change; therefore the study group may not be representative of the target population for screening.

The basis for evaluating possible screening tests is well established.3 In this instance we believe that the study group was too small for the true prevalence of carcinoma in situ of the testis to be accurately established. Any future evaluation should be carried out in a more representative population and should more fully assess the acceptability of testicular biopsy.

References

  • 1.Giwercman A, Thomsen JK, Hertz J, Berthelsen JG, Jensen V, Meinecke B, et al. Prevalence of carcinoma in situ of the testis in 207 oligozoospermic men from infertile couples: prospective study of testicular biopsies. BMJ. 1997;315:989–991. doi: 10.1136/bmj.315.7114.989. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Chamberlain J, Moss SM, Kirkpatrick AE, Michell M, Johns L. National Health Service breast screening programme results for 1991-2. BMJ. 1993;307:353–356. doi: 10.1136/bmj.307.6900.353. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Wilson JMG, Jungner F. Principles and practice of screening for disease. Geneva: WHO; 1968. (Public health papers No 34.) [Google Scholar]
BMJ. 1998 May 2;316(7141):1387.

Author’s reply

Aleksander Giwercman 1

Editor—Although I agree with some of the theoretical considerations in Rajentheran et al’s criticism, our study also needs to be seen from a practical point of view. It would be desirable to investigate more than the 207 men who were included in our study. Performing large scale screening studies in which testicular biopsy is used as a diagnostic tool is not, however, feasible, particularly if the patients cannot be informed beforehand about the magnitude of the risk of testicular malignancy. Although we could not exclude some increase in the risk of carcinoma in situ among men with moderate oligozoospermia, our study showed that this group of men is not, as has been suggested,1-1 a target group for screening. On the other hand, as we also indicated in our paper, our preliminary data and other reports suggest that men with severe oligozoospermia and an irregular ultrasonic echo pattern may be a more appropriate target group for screening.1-2

I agree that men from couples referred to an infertility clinic are a highly selected group. On the other hand, if the magnitude of the risk of malignancy and the available diagnostic procedures are taken into consideration it is evident that screening for carcinoma in situ of the testis cannot be offered to a broader group of infertile men.

Finally, the authors question the suitability of testicular biopsy as a screening test. The sensitivity of the procedure in diagnosing carcinoma in situ is discussed in our paper; the complications are few and not significant.1-3 Both in the current study and in previous screening studies a fairly high proportion of men who were offered a biopsy accepted it once the benefits of early diagnosis were explained to them.1-4 Undoubtedly, however, a non-invasive screening procedure—for example, one based on semen analysis—must be developed. Screening for carcinoma in situ of the testis might then be offered to a broader population.

Our study is, to my knowledge, the first prospective study assessing the risk of carcinoma in situ of the testis in men attending an infertility clinic. A study of a larger group of men from infertile couples, not limited to those referred to infertility clinics, would be desirable, but I do not think that it is feasible.

References

  • 1-1.West AB, Butler MR, Fitzpatrick J, O’Brien A. Testicular tumors in subfertile men: report of 4 cases with implications for management of patients presenting with infertility. J Urol. 1985;133:107–109. doi: 10.1016/s0022-5347(17)48810-0. [DOI] [PubMed] [Google Scholar]
  • 1-2.Lenz S, Giwercman A, Skakkebæk NE, Bruun E, Frimodt-Møller C. Ultrasound in detection of early neoplasia of the testis. Int J Androl. 1987;10:187–190. doi: 10.1111/j.1365-2605.1987.tb00182.x. [DOI] [PubMed] [Google Scholar]
  • 1-3.Bruun E, Frimodt-Møller C, Giwercman A, Lenz S, Skakkebæk NE. Testicular biopsy as an outpatient procedure in screening for carcinoma-in-situ: complications and the patient’s acceptance. Int J Androl. 1987;10:199–202. doi: 10.1111/j.1365-2605.1987.tb00184.x. [DOI] [PubMed] [Google Scholar]
  • 1-4.Giwercman A, Grindsted J, Hansen B, Jensen OM, Skakkebæk NE. Testicular cancer risk in boys with maldescended testis: a cohort study. J Urol. 1987;38:1214–1216. doi: 10.1016/s0022-5347(17)43553-1. [DOI] [PubMed] [Google Scholar]

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