Testicular Self-Examination Cost-Effective Compared with Missed Advanced Cancer

Michael Aberger, MD

Testicular self-examination remains highly cost-effective despite a negative recommendation from the United States Preventive Services Task Force (USPSTF), a cost-utility analysis suggested.

More than 300 negative clinical evaluations triggered by a self-exam would be required to match the cost of care for one missed advanced or metastatic testicular cancer, the study found. The number of clinical evaluations rises to more than 300,000 to equal the cost of all advanced testicular cancers diagnosed and treated each year.

A similar benefit could not be shown for detection of early disease, but a cost-benefit ratio of 3:1 remained, Michael Aberger, MD, a urology fellow at the University of Kansas Medical Center in Kansas City, reported at the American Urological Association meeting in Orlando, Florida.

“A large number of clinical evaluations prompted by testicular self-examination can be made for the cost of one missed advanced-stage tumor,” Aberger said. “Testicular self-examination remains cost-effective and should be recommended, not discouraged.”

The USPSTF has evaluated risk:benefit data for testicular self-exam on several occasions, most recently in 2011. In each case, the task force recommended against self-exam for asymptomatic adolescents and men, giving it a “D” rating.

In the 2011 update, the panel concluded, “Based on the low incidence of this condition and favorable outcomes of treatment, even in cases of advanced disease, there is adequate evidence that the benefits of screening for testicular cancer are small to none.”

Aberger acknowledged that testicular cancer is not a common malignancy, with an estimated lifetime risk of 1:260 men. Nonetheless, the disease burden is not inconsequential, as 8,000 new cases were diagnosed in 2013, and 370 men died of the disease. Moreover, he said, testicular cancer is the most common solid malignancy in men 15-34 years of age.

As compared with many other malignancies, testicular cancer has a favorable prognosis, associated with a 5-year survival of 99% for disease that is localized at diagnosis and 74% for metastatic disease, Aberger continued.

In stating a case for testicular self-examination, he pointed out that no formal screening algorithm exists, and that, even in metastatic disease, only 10-20% of patients have symptoms at diagnosis.

Despite the uncommon occurrence of the disease and its favorable prognosis, the cost of care for newly diagnosed advanced testicular cancer is substantial, estimated at $21.8 million in 2000. Whether testicular self-examination could reduce the cost has remained unclear. To address that issue, Aberger and colleagues performed their cost-utility validation for testicular self-examination.

“Our objective was to determine the potential fiscal ramifications of testicular self-examination performed by patients presenting with both localized and advanced-stage testicular cancer,” he said.

Even though testicular cancer affects young men, the analysis relied on Medicare reimbursement data for practical reasons, Aberger said. Treatment schema for the different scenarios were based on National Comprehensive Cancer Network guidelines.

To estimate costs associated with testicular self-examination, investigators developed eight clinical scenarios. Four of the eight involved diagnosis of benign disease, and two led to diagnosis and treatment of malignant disease. The remaining two scenarios estimated the costs associated with missed advanced-stage testicular cancer, one a seminoma and the other a nonseminoma.

The costs associated with the benign-disease scenarios ranged from $156 to $7,686, depending on the resources required to exclude cancer. The scenarios leading to cancer diagnoses resulted in total costs of $17,283 and $26, 190. The two missed advanced-stage cancers had associated costs of $48,877 and $51,592, with an average of $50,234.

Aberger and colleagues estimated the costs for testicular self-examination based on the costs of the other scenarios. The $50,234 average cost of missed disease equaled:

• 322 office visits for benign disease
• 185 office visits with scrotal ultrasound
• 81 office visits with serial scrotal ultrasound studies and lab work
• 7 office visits resulting in radical inguinal orchiectomy for benign pathology
• 3 office visits resulting in detection, treatment, and surveillance of an early-stage testicular cancer

Of the 8000 new cases of testicular cancer in 2013, an estimated 960 were advanced or metastatic at presentation, meaning the total cost of care for the condition reached about $48 million that year, Aberger said. Based on those numbers, the doctor and colleagues found that 307,692 negative clinical examinations resulting from testicular self-exam would have been required to match the cost of all metastatic testicular cancer treated in 2013.

Reference

Aberger M, Wilson B, Holzbeierlein J, Griebling T, Nangia A. Testicular self-examinations: a cost analysis. Presented at: the Annual Meeting of the American Urological Association; May 16-21, 2014; Orlando, Florida. Abstract MP10-11.

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