Nine features of testicular cancer should prompt further evaluation

Reuters Health Information: Nine features of testicular cancer should prompt further evaluation

Nine features of testicular cancer should prompt further evaluation

Last Updated: 2018-07-03

By Will Boggs MD

NEW YORK (Reuters Health) - Nine features of testicular cancer in men aged 17 and older should prompt further investigation, including ultrasound, according to a study of UK Clinical Practice Research Datalink (CPRD) records.

"The work that we do as part of the DISCO group (DIagnosis of Symptomatic Cancer Optimally) aims to identify which symptoms of cancer matter," Dr. Elizabeth A. Shephard from University of Exeter Medical School in the UK told Reuters Health by email. "We want to help GPs diagnose cancer earlier. We do this by studying what patients have reported to their physician in the year before their cancer diagnosis, rather than studying them after their diagnosis when they are in hospital with a potentially later stage of cancer."

Current UK National Institute for Health and Care Excellence (NICE) guidelines for testicular cancer recommend urgent specialist referral for men with nonpainful enlargement or a change in shape or texture of the testis and support direct-access ultrasound for men with persistent or unexplained other testicular symptoms.

Dr. Shephard and Dr. William T. Hamilton used CPRD electronic patient records to identify clinical features of testicular cancer in primary care and to quantify their risk using a risk assessment tool in an effort to improve the selection of men for investigation of possible testicular cancer.

Nine features emerged as significant predictors of testicular cancer in men ages 17 to 49: testicular swelling, testicular lump, testicular pain, abdominal pain, scrotal swelling, groin pain, orchitis/epididymitis, hydrocele, and raised inflammatory markers.

Testicular lump, testicular swelling, and hydrocele each produced risk estimates in excess of 1%, and the highest positive predictive values were produced when testicular lump occurred in combination with testicular swelling (17%), testicular pain (10%), and abdominal pain (6.1%), all in excess of the NICE 3% threshold for urgent referral.

Other combinations with risk estimates above the threshold for referral included testicular pain and abdominal pain, testicular pain with raised inflammatory markers, and testicular pain with groin pain, according to the July 3rd online report in the British Journal of General Practice.

Several other symptoms, alone and in combination, had risks of testicular cancer in the 1-3% range for which an ultrasound is appropriate, according to NICE guidelines.

"The main messages really for physicians are to use our risk assessment tool to aid which men need referral based on their presenting clinical profile," Dr. Shephard said. "So testicular enlargement (lump or swelling) is confirmed as the most significant single risk marker of testicular cancer, but physicians should also consider urgent referral if their patient reports certain multiple symptoms, even when they may be months apart. A painful testicular lump, testicular pain with abdominal pain, or testicular swelling with abdominal pain are examples of this. Also, physicians may want to consider testicular cancer in men whose diagnosis of hydrocele or orchitis or epididymitis may be uncertain."

"This research is about establishing who should be given an ultrasound," she explained. "We need to make sure that we are capturing those men who have testicular cancer, and to do this we need to know what the symptom profile of testicular cancer looks like. The actual level of cancer risk would depend on what symptom or multiple symptoms each man had. To put this in context, the UK's cancer guidelines suggest referral for symptoms showing a 3% risk of cancer of higher. So our paper serves to guide physicians based on which symptom or combination of symptoms reach or exceed that risk level, suggesting that patient should see a specialist."

"We wouldn't suggest an ultrasound for a man presenting solely with testicular pain, as the individual risk is so low," Dr. Shephard said. "However, a man who reports having testicular pain and abdominal pain now has a testicular cancer risk of over 6%, so he should be referred to a specialist."


Br J Gen Pract 2018.

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