Neil Osterweil

May 22, 2014

ORLANDO, Florida — The cost of evaluations prompted by a patient's testicular self-examination is far outweighed by the financial and human costs of treating late-stage testicular cancer, according to a new cost-utility analysis.

"We can calculate that 300,000 negative clinical examinations, based on a testicular self-examination, could have been performed for the cost of all the metastatic testicular cancer treated in 2013," said investigator Michael Aberger, MD, a urology resident at the University of Kansas Medical Center in Kansas City.

He reported the results here at the American urological Association 2014 Annual Scientific Meeting.

Questioning Task Force Recommendations

The findings contradict US Preventive Services Task Force (USPSTF) recommendations published in 2004, 2009, and 2011. The USPSTF recommends against screening for testicular cancer in adolescent or adult males.

'"Most cases of testicular cancer are discovered accidentally by patients or their partners. There is inadequate evidence that screening by clinician examination or patient self-examination has a higher yield or greater accuracy for detecting testicular cancer at earlier [and more curable] stages," the 2011 recommendations state (Ann Intern Med. 2011;154;483-486).

They go on to say that '"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."

However, none of the articles reviewed by the USPSTF met inclusion criteria for the study of testicular self-examination as a screening tool, said Dr. Aberger.

In addition, the panel did not include cost estimates of carrying out the recommendations, despite an annual cost of treating testicular cancer in the United States of approximately $21.8 million (in year 2000 dollars), he explained.

Clinical Scenarios

Dr. Aberger and his colleagues created practical clinical scenarios that a clinician could encounter after a patient discovers a mass during testicular self-examination. Four that assume that the disease is benign, 2 assume that it is malignant, and 2 assume that an advanced-stage cancer was previously missed.

The researchers used Medicare reimbursement data to estimate the cost of care, and assumed that care would be provided in accordance with National Comprehensive Cancer Network guidelines.

They determined that the cost of a clinical examination to rule out a patient's suspicion of cancer would be $156.47.

The most expensive benign-disease scenario assumes that a self-exam leads to clinical examination, a scrotal ultrasound showing an intratesticular lesion ($115.87), laboratory tests ($135.89), radical inguinal orchiectomy with benign pathology ($7249.29), and chest x-ray ($28.52), for a grand total of $7,686.04.

Looking at malignant disease, they found that the total treatment cost for an advanced-stage seminoma ($48,877) or nonseminoma ($51,592) equaled the cost of 313 benign office visits ($156), 180 office visits with scrotal ultrasound ($272), 79 office visits with serial scrotal ultrasounds and labs ($621), 6 office visits resulting in radical inguinal orchiectomy for benign pathology ($7,686), or 3 office visits resulting in detection, treatment, and surveillance of an early-stage testicular cancer.

Dr. Aberger's team acknowledges that the study was limited by the use of Medicare reimbursement data even though testicular cancer is predominantly seen in men younger than 65. Nonetheless, Medicare data are the best way to estimate medical costs nationwide.

In fact, said Dr. Aberger, actual costs might be much higher than the models assume because Medicare typically reimburses at rates 20% to 30% below those of private insurers.

"This is a great study," said Benjamin Davies, MD, associate professor of urology at the University of Pittsburgh Medical Center, who moderated the briefing during which the data were presented.

"It highlights the fact that testicular self-exam is not that expensive if there is benign pathology, and that missing a diagnosis of malignancy is extremely expensive," he explained.

Dr. Davies told Medscape Medical News that it could add significantly to the strength of the study findings if the researchers could determine the proportion of patient self-referrals for possible testicular cancer that turned out to be benign. A small pilot study might be sufficient to answer that question, he said.

The study was internally funded. Dr. Aberger and Dr. Davies have disclosed no relevant financial relationships.

American Urological Association (AUA) 2014 Annual Scientific Meeting. Abstract MP10-11, Presented May 17, 2014.

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