“Off-Label” Usage of Testicular Self-Examination (TSE): Benefits Beyond Cancer Detection

Abstract

Testicular cancer (TCa) is the most common cancer among 15- to 34-year-old males. Treatments are highly effective, which help foster approximately 98% 5-year survival rate. There are very few known causal factors of the disease (e.g., cryptorchidism and family history), thus possibly limiting primary prevention methods. Secondary preventative measures, on the other hand, most notably testicular self-examination (TSE), are well-known and are promoted to help prevent late-stage diagnosis of TCa. However, debate ensues as to whether or not TSE provides any benefit. In light of a recent systematic review conducted by these authors assessing the effectiveness of TSE promotion interventions, we propose that the behavior can serve as a tool not just for detection of TCa, but other male-specific urogenital health concerns, including varicoceles, hydroceles, among others. Furthermore, we suggest that TSE can also help foster informed decision-making skills among males with regard to health concerns and treatment options. However, our advocacy is in direct conflict with U.S. Preventive Services Task Force’s influential “D” rating of TSE and others who recommend against performing TSE. This article offers an overview of the dispute over TSE’s purpose and net benefit. We conclude that TSE is a behavior that is beneficial beyond detecting cancer. These proposed “off-label” uses of the procedure make for an effectual means to promote testicular health, self-awareness, and wellness among males. Recommendations for future research and advocacy are presented to the academy.

Overview

Incidence rates of testicular cancer (TCa) are rising among the 15- to 54-year-old demographic, with the majority of those cases affecting males under the age of 40 years (Kennett, Shaw, & Woolley, 2014; van As et al., 2008). Recent data suggest that rates for new testis cancer cases have been rising on average of nearly 1% each year in the past decade (Howlader et al., 2013). Previous research indicated that screening for TCa by a health care provider and/or testicular self-examination (TSE) was rarely performed, or underperformed, with little or no documented regularity (see Brenner, Hergenroeder, Kozinetz, & Kelder, 2003). McGlynn, Devesa, Graubard, and Castle (2005) note that TCa late-stage diagnoses disproportionately present within minority male populations, although TCa primarily affects White/Caucasian males.

There is an increasing amount of research in the field aiming to raise awareness to TCa and TSE among male populations. Kennett et al. (2014), for example, suggest that among their 740 male respondents, between 75% and 80% heard of TCa with approximately 40% stating that they were informed of TSE. Among those 40%, nearly 74% said they were taught by a physician or a nurse. This is in stark contrast to Vaz, Best, and Davis’s (1988) work that indicated approximately 72% of their sample never heard of TCa, nearly 90% never heard of TSE, with no respondent indicating they knew how to perform the behavior. Cronholm, Mao, Nguyen, and Paris (2009) suggest that knowledge of TCa among males has increased in recent years partly due to high-profiled celebrity cases (i.e., athlete Lance Armstrong and media personality Tom Green) that called attention to the disease.

Community-based interventions teaching males about TCa and TSE are much more limited (see Rovito, Cavayero, Leone, & Harlin, 2014), but do exist, with varying degrees of effectiveness. These interventions primarily focus on increasing participant knowledge and awareness of TCa and TSE, although some do empirically test intention to perform TSE (e.g., Lechner, Oenema, & de Nooijer, 2002; McClenahan, Shevlin, Adamson, Bennett, & O’Neill, 2007, among others), with even fewer testing message effectiveness on actual behavior change (e.g., Steadman & Quine, 2004; Wanzer, Foster, Servoss, & LaBelle, 2014). Cronholm et al. (2009) note that increased knowledge of TCa translating into TSE action is currently unsubstantiated, which parallel Trumbo (2004) and Brewer, Roy, and Watters’s (2010) findings.

As awareness of the disease has dramatically increased in the previous two decades (see Barling & Lehmann, 1999; Cronholm et al., 2009), there is a concern among health professionals on the varying degrees of proper technique among males who actually perform TSE (Rovito, Gordon, Bass, & DuCette, 2011). Kennett et al. (2014) indicate that nearly 60% of their sample reported that they did not perform TSE because they did not know what to look for. Due to limited knowledge of what they are actually searching for when examining their testicles, males may be dissuaded from performing the behavior despite the known benefits. This indicates that teaching proper technique is paramount in promotional campaigns.

Despite the methodological challenges of health education interventions aiming to increase knowledge of TCa, its risks, and how to discover it (i.e., TSE), it appears that there is a surge in efforts to promote wellness among males (Rovito et al., 2014). Challenges still exist pertaining to TSE research, including (a) the variable scientific rigor psychometrically testing instruments and analytically assessing behavioral outcomes, (b) the dearth (or near absence) of hard evidence demonstrating the effectiveness (or not) of TSE to reduce TCa mortality rates, and (c) the limited scope of TSE’s usefulness. These concerns present challenges to properly assessing if TSE is “worth the effort.” We assert that considering the large gaps in the evidence-based literature, a much more comprehensive, and perhaps contentious, discussion than what currently exists is warranted.

The TSE Debate

The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 and Healthy People 2020 (hereafter referred to as ACA and HP2020, respectively) call for an expansion of preventative health services. Furthermore, both policy pieces focus on long-term cost-reduction potential of preventative health methods. As TCa is the most common cancer among 15- to 34-year-old males (Howlader et al., 2013), prevention of the disease within this population would appear to be a tenet in the foundation of building a true public health infrastructure. At least in theory, the behavior assists males in detecting TCa earlier, which not only increases survivorship probabilities but also can cut treatment costs (Aberger, Wilson, Holzbeierlein, Griebling, & Nangia, 2014). This narrative fits ideally into the chronicle of promoting wellness for all vis-a-vis the ACA and HP2020. However, the notion of TSE net benefit is not consistent within certain sectors of our health care system.

The U.S. Preventive Services Task Force (USPSTF; 2011) recommends against performing TSE due to concerns of increases in anxiety from false-positive examinations and a lack of clinical trials demonstrating its mortality reduction capabilities. This stance has been supported by other researchers (see Casey, Grainger, Butler, McDermott, & Thornhill, 2011; Hopcroft, 2012; Lin & Sharangpani, 2010). However, there is a robust volume of work and advocacy from the past few decades supporting TSE as the preferred method for TCa screening due to its privacy, convenience, and ease (see Aberger et al., 2014; Brewer et al., 2010; Rosella, 1994; Steadman & Quine, 2004). Both camps offer evidence in support of their opinion and recommendations, each with varying degrees of persuasiveness.

Considering this conflict, and in light of TSE’s potential role in helping achieve ACA and HP2020 goals, we feel it necessary to review the discourse and evidence surrounding the behavior. Our aim is to introduce into the health policy zeitgeist, a renewed perspective of TSE, by presenting the core arguments on both sides of the issue. Furthermore, we aim to provide to the academy a discussion framework on expanding TSE’s use beyond cancer detection.

Our presented “off-label” uses of the behavior can provide for a much more comprehensive and cost-effective mechanism to promote health among boys and men. When referring to “off-label” uses of TSE, we are referring to the general definition of the term as it pertains to pharmaceutical use (i.e., unintended indication). Examination of the testicles has been historically unidimensional in its “indication”—TCa detection. However, other “indications” are now evident for TSE.

The following discussion addresses the historical “indication” of TSE and the negative rating it has received from the USPSTF and a select few other researchers. Other uses of TSE are then presented to the academy to assist in reshaping the conversation of the uses and benefits of TSE beyond cancer detection.

Arguments Against TSE

The USPSTF originally recommended in 2004 (and subsequently reaffirmed the decision in 2011) against screening for TCa in males via TSE. The body gave TSE a “D” rating suggesting that there were no net benefits to performing the behavior. The recommendation was largely influenced by: (a) TCa’s relative rarity and highly favorable treatment outcomes, (b) a lack of evidence demonstrating accuracy of clinical or self-examination, and (c) the lack of evidence for mortality reduction capabilities.

In 2009, the USPSTF called for a critical review of the 2004 recommendations with the following criteria to help shepherd the reaffirmation process:

1. What are the benefits of screening asymptomatic men for TCa?

2. What are the harms of screening asymptomatic men for TCa?

3. Consider TCa when diagnosing other testicular health concerns.

Lin and Sharangpani (2010) conducted an evidence-based review of USPSTF recommendations based on the aforementioned criteria. The following rationale was offered by the authors for their reaffirmation of the 2004 recommendations:

1. The authors found no new studies looking at the harms and/or benefits of TSE among asymptomatic males since the 2004 USPSTF recommendations.

2. The author’s review of evidence among studies investigating cases of TCa among symptomatic males suggested that TCa cases are discovered when considered for other testicular health concerns, the incidence of such discoveries is very low.

One other ubiquitous argument against the practice and promotion of TSE is the possibility of false-positives and the anxiety that may result from such a diagnosis (Casey et al., 2011; Hopcroft, 2012). The primary concern is that considering TCa’s very high cure rate and the potential detriment a false-positive examination can lead to in terms of unnecessary diagnostic and invasive procedures to confirm the diagnosis, that the benefits offered are outweighed by the very likely harms.

Essentially, the argument suggests that there is no need to raise fear and concern as the disease is curable, even in later stages, and that it is so rare, that to raise anxiety for such an infrequent presentation is superfluous. In fact, the argument suggests, physicians may only see a handful of TCa cases in their entire career due to its rarity (Casey et al., 2011). Concerns over unnecessary invasive confirmatory procedures stemming from false-positive TSE’s can increase health care expenditures. Casey et al. (2011) succinctly summarizes the aforementioned position pertaining to scrotal screening: “ . . . the costs do not justify the benefits” (p. 387).

Our Response

In response to the USPSTF (2004) “D” rating recommendation for TSE, we offer the following discourse:

Pertaining to TCa’s relative rarity, the disease is the most prevalent cancer observed in the 15- to 34-year-old male demographic among developed nations (Casey et al., 2011; Howlader et al., 2013; USPSTF, 2011). Furthermore, van As et al. (2008), Kennett et al. (2014), and even Lin and Sharangpani (2010) indicate that TCa incidence among developed nations have been steadily increasing since 1975. Howlader et al. (2013) indicate that in the United States, there are approximately 4,000 new cases and approximately 400 deaths expected in a given year. Furthermore, van As et al. (2008) state that approximately 1,900 new cases are expected in the United Kingdom per year. Baade, Carriere, and Fritschi (2008) and Casey et al. (2011) suggest that TCa incidence is increasing in many, if not most, of the industrialized world. We must note that due to lack of surveillance and/or accurate reporting in developing nations, these numbers may be underreported, thus, suggesting more cases globally.

TCa is a rare cancer compared with other types (Haugnes et al., 2012; Wanzer et al., 2014), but it is the most common cancer seen among 15- to 40-year-old males (Kennett et al., 2014; van As et al., 2008). Caucasian males typically have the highest incidence rates of the disease, but minority males present at later stages as compared with their White/Caucasian counterparts (Howlader et al., 2013; McGlynn et al., 2005), which suggest the existence of a health inequity as it pertains to health care and treatment access. We posit that flatly denying promotion of TSE due to TCa’s rarity is a bit shortsighted, in our collective opinion. If all members of society are to have equal opportunities to maintain wellness, failing to provide a portion of the population with every tool possible to combat the disease, they are most at risk to develop, introduces a health equity issue into the debate. This conflicts with the goals and objectives of the ACA and HP2020, particularly when the issue of racial/ethnic disparities in presentation rates are introduced into the discourse.

With regard to the lack of evidence demonstrating accuracy of clinical or self-examination, we identified that the operationalization process of execution efficacy was ambiguous. Not only is there a dearth of available literature discussing how well males perform TSE (see Finney, Weist, & Friman, 1995), there is no known rubric used throughout the evidence that researchers use as a gold-standard comparison with the observed behavior in their sample. Despite this methodological concern, denying the promotion of TSE due to the lack of evidence demonstrating accuracy of TSE clinically or via self-examination errs on conclusory judgment. We suggest that more research is needed in the field with demonstrated outcomes stemming from rigorous experimental designs before any such argument is used to support any side of the debate.

With regard to the assertion that treatment has highly favorable outcomes, we agree if a “favorable” outcome equates to survivorship only. Cost-benefit and quality-of-life analyses must be considered alongside survivorship when discussing any outcome related to a cancer diagnosis. This is particularly true with late-stage diagnoses when treatment gets more expensive and more invasive.

Aberger et al. (2014) suggests there is an average of 2.4:1 cost-benefit ratio between cases of TCa detected early versus more advanced-stage cases. In terms of quality of life, Vidrine et al. (2010) and Haugnes et al. (2012) discuss TCa treatment and resultant quality of life among patients. These pieces allow the reader to understand the positive impact TCa management has on survivorship as well as the negative impact it has on quality of life, particularly if management involves chemotherapy. We must not lose sight of the physical toll treatment has on TCa patients when we speak of “favorable outcomes.”

With regard to the notion that mortality has not been significantly lowered from performing TSE, as stated before with available evidence demonstrating accuracy of exams, there is a dearth of rigorous science to make such an assertion. In fact, to these authors’ knowledge, the exact methodology from which the original “D” rating recommendation was offered is unattainable and therefore unable to be critiqued as was conducted on the Lin and Sharangpani (2010) piece. We call on the academy to conduct more methodologically sound research that produces reliable and valid data before any such conclusions are presented. Furthermore, the information used to create the ratings need to be more easily accessible to the general public.

In response to Lin and Sharangpani (2010), the authors did not identify any studies screening asymptomatic men (either TSE, health care provider exams, or other screening methods) to comment on the harms/benefits of performing TSE. The USPSTF called for an expanded search for such literature in the reaffirmation process of their 2004 recommendation. Lin and Sharangpani (2010) did, however, examine three studies screening “symptomatic” men aiming to observe TCa incidence when TCa was considered as secondary diagnosis.

Two of the three observed studies had small sample sizes (Bennett, Middleton, Bullock, & Teefey, 2001: n = 104; Kawakami, Okamoto, Ogawa, & Okada, 2004: n = 25), which affected the validity of findings. The other study (Carmignani et al., 2003) indicated that out of 1,320 symptomatic men screened, only 27 tumors were detected. The authors defined symptoms as “infertility, scrotal swelling, scrotal pain, varicocele, scrotal trauma, or erectile dysfunction” (p. 1783), which is not an exhaustive list of predisposing factors. The reviewed studies failed to clearly discuss cryptorchidism or family history as part of that list, which would naturally pull the results toward a null of TCa absence.

Symptoms in all three studies varied, causing concern for reliable outcome data. Lin and Sharangpani (2010) also suggested that testicular microlithiasis (essentially, a calcification process in the testicles) be considered as a predisposing factor of TCa, but there is contention on whether or not it has any link to TCa (see Richenberg & Brejt, 2012). There was no clear operational definition of “screening benefit” offered by the authors, which further called into question the quality of the reported findings.

The available evidence presented by the USPSTF and Lin and Sharangpani (2010) offer us doubts on their “D” rating recommendations and reaffirmations pertaining to TSE serving as a tool to detect TCa. There is not enough evidence supporting the claims of “no net benefit.” One can argue that there are similar concerns with regard to a pro-TSE stance. We propose that there are a variety of uses beyond the detection of TCa for which TSE can be of benefit. We posit that when these more “off-label” uses of the behavior are incorporated into the milieu of TSE’s practicality, there will be a clear “net benefit” from performing the procedure.

A Reinvention of TSE

We argue that TSE is a beneficial procedure and can be used to (a) prevent late-stage diagnoses of TCa and other urogenital health issues [clinical applications] and (b) foster informed decision-making (IDM) skills among males to increase knowledge about their health and body as well as comfort with regard to sharing concerns with others [public health applications]. These added benefits will increase the overall “net benefit” of TSE, therefore assisting all health professionals to endorse the procedure and its promotion within male populations.

Clinical Applications

Germ cell tumors account for approximately 95% of all testicular tumors (Ghazarian et al., 2014). Germ cell tumors can be further subdivided into seminomatous and nonseminomatous tumors (van As et al., 2008) with seminomas serving as the most common type of germ cell neoplasms. The majority of these tumors respond well to treatment, even in more advanced stages (van As et al., 2008); however, a significant portion (35%-50%) of these cases present as mixed tumors with seminomatous and nonseminomatous components (Mosharafa et al., 2004). Unfortunately, such tumors tend to be more aggressive, resulting in advanced clinical disease (Stages II/III) in approximately 60% of patients (Sheinfeld, 1994).

As seminomas often present as enlarged, bulky, homogenous masses, we posit that they lend themselves well to the concept of self-examination. It is with this fact in mind that we can appreciate TSE as a helpful tool in preventing late-stage TCa diagnoses, with specific regard to mixed tumors. If a male performs TSE and feels his testicle enlarged or abnormally shaped, he can then present his concerns to his health care provider for consultation and/or a confirmation of his discovery.

Although, TSE has been developed as a modality to safeguard against late-stage TCa diagnosis, it seems that the technique can be expanded to a variety of pathological genitourinary conditions. For example, indirect inguinal hernias are a relatively common complication, specifically in aging men (Ruhl & Everhart, 2007). While those protruding grossly into the scrotal sac can be obvious on inspection, others that lie within the spermatic cord cannot be visualized. Fortunately, the spermatic cord can be palpated for this purpose.

It is not unreasonable to believe that this technique can be incorporated into a routine self-examination. Although most asymptomatic/minimally symptomatic patients will not require surgery (Fitzgibbons et al., 2006), early discovery of any such abnormality may allow tracking hernia progression. This can allow better outcomes specifically in the emergency event of hernia strangulation. We acknowledge, of course, that proper technique is key to such use of TSE.

Another nonmalignant condition that can be discovered with TSE is a varicocele, or an abnormal tortuosity of the plexus of veins within the spermatic cord. Often described as feeling like “a bag of worms,” varicoceles are clinically important as they are the leading correctable cause of infertility in men who present to an infertility clinic for evaluation (Cozzolino & Lipshultz, 2001). Although most varicoceles are termed idiopathic, others are notable for their link with renal cell carcinoma in the so called “nutcracker syndrome” (Ahmed, Sampath, & Khan, 2006).

Hydroceles, or illuminable fluid collections resulting from a defect in the tunica vaginalis of the scrotum, are often of little consequence. However, if the collection of fluid is large enough, the scrotal blood supply may be compromised resulting in testicular atrophy (Graham, Keane, & Glenn, 2010). It seems that both of these conditions, varicoceles and hydroceles, should be amenable to TSE as progressive testicular enlargement and/or atrophy may occur.

Although often overlooked, several infectious conditions may present with testicular involvement. Mumps cause an acute epididymo-orchitis in 15% to 30% of cases in postpubertal males (Street & Wilson, 2014). Although initial chlamydia infection may be asymptomatic in males, an acute epididymo-orchitis may be the initial clue of infection in a subset of patients (Mulcahy et al., 1987). This is of particular importance as chlamydia continues to be the most frequently reported infectious disease in the United States (Centers for Disease Control and Prevention, 2010). Considering recent reports of rising incidence of mumps (i.e., Sane et al., 2014, among others) and high prevalence of chlamydia (Centers for Disease Control and Prevention, 2011), health care providers should promote TSE to help monitor for such inflammation.

Although exceedingly rare, melanoma of the scrotum is notable because of its unusual aggressiveness and difficult diagnostic patterns (Agrawal & Kumar, 2012). Early detection is likely the most realistic way to improve outcomes as prognoses generally depends on spread to regional lymph nodes and distant metastases. Similar to any skin lesion, a simple visual sweep in the self-exam may be the only extra step required to improve prognosis. We suggest that a thorough visual sweep of the scrotum has many potential benefits beyond cancer detection. Inspection of the scrotal skin can assist in identifying sexually transmitted infections (e.g., human papillomavirus, warts, etc.) in earlier stages, and other skin infections/disorders, which can lessen the risk of transfer to sexual partners.

We present this clinical application not only as a way to detect malignancies, but more important, as an avenue to familiarize the male with expected palpatory and visual findings. While we stress the importance of self-exam, the goal is not to diminish the role of the health care provider. We argue that any improvement in male health awareness, coupled with education regarding proper technique and urogenital abnormalities, may encourage discussion, possibly discovery, thus assisting the health care provider in improving outcomes of their male patients. This narrative nicely parallels the goals and objectives of the ACA and HP2020.

Public Health Applications

Seeing the “forest among the trees” seems to be an apt comment when viewing the relative value of TSE. Similar to pharmaceuticals and biologics that can be useful in the treatment of more than one health condition, we propose that TSE also has a defined “off-label” use (i.e., “off-label health”). Buproprion (Wellbutrin™ . . . ), not only helps treat depression but also acts as an efficacious medication for smoking cessation (Lerman et al., 2002). Not only has TSE demonstrated variable efficacy in identifying TCa (McClenahan et al., 2007; Rudberg, Nilsson, Wikblad, & Carlsson, 2005) but also has potential to foster greater familiarity and comfort with one’s body.

We view the latter point as an opportunity to improve health literacy for males. As education, consciousness raising, and practice may help foster increased IDM skills among patients through becoming more comfortable with their body, this sense of increased comfort will allow males to discuss possibly sensitive urogenital issues with their health care provider more comfortably and openly, as discussed in the previous section.

As TCa is most prevalent in younger aged males (Aberger et al., 2014; Lin & Sharangpani, 2010; van As et al., 2008), raising awareness, teaching the value of self-monitoring of one’s body, and increasing comfort with interactions with the health care system may serve as a secondary (“off-label health”) benefit of TSE promotional efforts. Research confirms that males are far less likely to regularly access health care, particularly for preventative services, where they often wait until something has gone wrong with their health before seeking attention (Addis & Mahalik, 2003; Bertakis, Azari, Helms, Callahan, & Robbins, 2000; Fortuna, Robbins, & Halterman, 2009). Adopting health-promoting behaviors earlier in one’s life, likely will yield greater returns in terms of primary and secondary prevention efforts specific to male health outcomes. We envision these behaviors translating to males becoming more comfortable and accountable for their health behaviors.

Therefore, we advocate viewing TSE as a means to inform and promote males to not only screen for TCa and to improve execution efficacy but also to monitor their urogenital system for potential abnormalities as previously discussed. This also may parlay into discussions about other body systems and health concerns overall (e.g., hypertension, cardiovascular disease). Familiarity with an often-viewed “private” part of one’s body may help promote confidence and thus, empower younger and older males to translate this confidence to be able to discuss health concerns with their partners and health professionals. IDM can then be approached by both the provider and patient should any medical issue/health abnormality present. When viewed inclusively and comprehensively, the positive public health end products of TSE become overtly apparent.

Closing Remarks and Recommendations

TSE can serve as a two-pronged health promotion method that can assist with: (a) Preventing late-stage diagnosis and/or presentation of TCa, hydroceles, varicoceles, and so forth, in most age categories and (b) Fostering increased IDM skills among patients through becoming more comfortable with their body. This sense of increased comfort and knowledge can empower males to discuss possible sensitive urogenital and other health issues with their doctor more comfortably and openly. We do acknowledge that this is possible only with appropriate education and outreach resources to properly inform males of the procedure and the health concerns it aims to discover.

The USPSTF indicates that clinicians and policy makers should consider other bodies of evidence besides the presented recommendations to come to a conclusion whether to promote TSE among male patients/populations. We believe that the USPSTF’s recommendations carry much more weight than what is being suggested. For example, Bhindi et al. (2015) outlined the impact of the USPSTF recommendation on prostate specific antigen (PSA) screening among males. The authors indicate that a change in the amount of biopsies have decreased, most likely due to the decreased use of PSA screening. They call concern to the fact that although less low-risk prostate cancer (PCa) cases are being diagnosed, they caution that sudden decreases in detecting more aggressive cases have occurred.

Relatedly, Catalona et al. (2012) provided a chiding response to the USPSTF PSA recommendations:

The recommendations of the USPSTF carry considerable weight with Medicare and other third-party insurers and could affect the health and lives of men at high risk for life-threatening disease. We believe that eliminating reimbursement for PSA testing would take us back to an era when prostate cancer was often discovered at advanced and incurable stages. At this point, we suggest that physicians review the evidence, follow the continuing dialogue closely, and individualize prostate cancer screening decisions on the basis of informed patient preferences. (p. 138)

It would behoove us to also mention the debate ensuing over mammography as it relates to USPSTF recommendations, influence, and possible negative reactions from other health professionals. The American Cancer Society has recently taken a stand against USPSTF mammography recommendations suggesting that American Cancer Society screening standards will not change according to the sanctions provided by the USPSTF (American Cancer Society, 2009). It appears that there is contention with the provided guidelines not only with TSE, as argued in this article, but with others as well.

The prominence of the USPSTF recommendations could possibly influence the forum, where TSE promotional messages are advertised and which audiences are exposed to them. As supporters of TSE trumpet, the tool’s ability to detect TCa and its usefulness in getting males to be proactive with their testicular health, this influence might hamper future promotional campaigns and their communication outlets. Therefore, we felt it necessary to revisit the evidence presented by the USPSTF in this review.

We continue to press the USPSTF to revisit their “D” rating recommendation for TSE serving as a tool to detect TCa and prevent late-stage diagnoses; however, we also stress that TSE must be looked at in a more comprehensive and holistic light as a tool that has many more benefits beyond detection of cancer. We most notably support TSE for serving as a conduit to promoting proactivity with health and wellness maintenance, which is the manifestation of a new “indication” of the behavior beyond the historical cancer detection purpose. Coupled with an informative presentation on urogenital abnormalities and proper TSE technique, male participants/patients can have at their disposal a powerful tool to help promote wellness and prevent late-stage diagnoses.

Recommendations

We provide the following recommendations to the academy with regard to TSE practice and promotion:

1. Expand the evidence base of TSE effectiveness in response to the USPSTF’s harm/benefit corollary to truly judge effectiveness (TCa specific).

If TSE behavior is not observed as a result of an education intervention, monitoring the effectiveness of the behavior is a moot endeavor. Essentially, if the effectiveness of TSE cannot be properly observed, coming to a conclusion on whether it has benefits in detecting cancer would be contrived and speculative at best, irresponsible at worst.

• 2. View TSE as a useful tool beyond the confines of TCa detection.

Our “off-label” use of TSE (e.g., IDM skill building, patient proactivity, discovery of urogenital, and other health concerns) is an empowering tool for the health care industry, as it will ultimately improve outcomes, which, again, is widely promoted by the ACA and HP2020. The USPSTF itself suggested that TCa cases are many times discovered when considered for other testicular health concerns and that any future reviews of the evidence need to consider this phenomenon. We are hard-pressed to make a clearer case on why TSE should be practiced and promoted and why the USPSTF needs to reevaluate their recommendations for, and the rubric they are utilizing to assess, the procedure. These new “indications” of TSE can assist in bringing about true public health for all males.

• 3. Broaden the scope of male health research and practice.

Wenger and Oliffe (2013) discuss PCa developing into the flagship of male cancer. The authors purport that there is value in such research, but suggest that other cancers, and we suggest other morbidities and mortalities beyond cancer, are being overshadowed by PCa. We further suggest that this includes prevention procedures, namely, TSE.

Wenger and Oliffe (2013) go on to note that gender dynamics must be factored into the discussion of PCa and male health. We agree that male health cannot be “tethered to male sex-specific biology” (p. 138), but suggest that the notion of only males having testicles can be used as an empowering force of unity around wellness. Of course, we must be careful to avoid defining male health as “penises and prostates,” but the fact that testicles are indeed male-specific can and should be used positively to promote wellness. We posit that males can find a sense of unity around this sex-specific health concern, which health professionals can use to their advantage through unique tailored health marketing campaigns.

We argue that TSE promotes as much long-term, life course benefit that many other widely promoted and practiced behaviors (many times age-defined, mostly toward latter lifespan periods) provide. Preventative screenings such as blood cholesterol and glucose monitoring, among many other routine procedures, provide very effective “canary in the coal mine” services to discovering longer term, and many times deadly conditions. We posit that TSE can be just as effective with proper education and promotion efforts, including utilization for more “off-label health” uses.