Alain Joffe, MD, MPH

In many ways, this article was a landmark. First, it was one of the few articles in the burgeoning specialty of adolescent medicine to focus on young men. Second, it suggested an approach that would help pediatricians engage the male adolescent; guidance that was much needed at the time it was published. Finally, it offered the promise of early detection, just as breast self-examination (BSE) held out the hope that women would detect cancerous lesions at an earlier, more curable stage. 

Why then, does the United States Preventive Services Task Force (USPSTF) recommend against teaching TSE, stating that the "harms of screening exceed any potential benefits"?

  There are several reasons. First, advances in treatment of testicular cancer (ie, chemotherapy) have significantly improved survival and cure rates for this malignancy, with five-year survival rates exceeding 96% even in the absence of a screening program.

  Currently, there are only 380 deaths per year from testicular cancer in the US.

  With these survival rates in the absence of a screening program, it becomes much more difficult to demonstrate the benefits of screening, unless the incremental benefits are truly dramatic.  

The conventional wisdom in 1985 was that teaching TSE was not associated with any "costs." But because testicular cancer is relatively rare-especially in comparison to other palpable lesions in the scrotum (spermatocele, varicocele, hydrocele, head of the epididymis, appendix testis)-adolescents who perform TSE may wind up with bills for physician visits, urinalyses, and/or radiologic procedures (eg, a scrotal ultrasound) to evaluate a benign lesion.  

Besides these medical costs, it is difficult to estimate the cost of the anxiety an adolescent might experience until the scrotal lesion he finds during TSE is fully evaluated and determined to be benign. Since physician time with each patient is limited, there are also "opportunity costs" associated with TSE: time spent teaching TSE is time that is not available to counsel about seat belt use, drinking and driving, bicycle helmet use, or other potentially risky behaviors. However, the USPSTF does acknowledge that there are no studies that address the "harms" or costs associated with testicular cancer screening. 

The USPSTF recommends against teaching TSE to young men; it does not recommend that physicians skip the genital exam in their male patients. Goldenring wrote that one of the major causes of delay in diagnosis is the failure by physicians to recognize the tumor when an adolescent male is examined. Older literature suggests that one quarter to one half of young men with testicular cancer evaluated by a physician are first diagnosed as having some other scrotal pathology.

  The easy accessibility of ultrasound and enhanced teaching of adolescent medicine in pediatric residency programs may have altered these numbers. But even so, it is essential that all pediatricians be comfortable performing a genital exam on a young man as part of a routine well-adolescent exam, and be knowledgeable about the various types of scrotal pathology and variants of normal they are more likely to encounter than a testicular mass. 

Hence, while Goldenring's 1985 recommendation to teach TSE is not supported by current evidence, the article is still worth reading as a primer on an important aspect of health care for adolescent males.    

is Director of Johns Hopkins University Student Health & Wellness Center, and is Associate Professor of Pediatrics, Johns Hopkins University School of Medicine, Baltimore. The author has nothing to disclose in regard to affliliations with, or financial interest in, any organization that may have an interest in any part of this article.

1. Goldenring JM: Teaching testicular self-examination to young men. 

2. Elford RW: Screening for testicular cancer. In: 

Canadian Task Force on the Periodic Health Examination.

 Canadian Guide to Clinical Preventive Health care. Ottawa: Health Canada, 1994:8942 

3. Agency for Healthcare Research and Quality: Screening for testicular cancer, Topic page. US Preventive Services Task Force. Rockville, Md. February, 2004 

4. National Cancer Institute: Cancer Statistics: Surveillance Epidemiology and End Results. Available at: 

http://seer.cancer.gov/statfacts/html/testis.html

Articles

The eighth in a year-long series of commentary reviewing topics published in Contemporary Pediatrics 25 years ago. This month's review reexamines the evidence for teaching testicular self-exams to young men.

Should we teach testicular self-exam?

The source of the next wave of adolescent drug abuse is found in the home medicine cabinet and on supermarket and pharmacy shelves. An adolescent can also obtain these drugs from a friend or even a parent. Because the drugs are not, like heroin or cocaine, illegal, they do not have to be hidden or purchased from drug dealers. These are some of the worrisome trends confirmed by three national surveys of drug use among adolescents. 

Although overall drug use is down among adolescents, abuse of prescription medications and over-the-counter cough remedies appears to be on the rise.  

Another national survey on drug use, the 2004 National Survey on Drug Use and Health (NSDUH) estimates that 980,000 12- to 17-year-olds engaged in nonmedical use of prescription pyschotherapeutic drugs for the first time in 2004. This statistic represents approximately 2,700 new users every day-a number that, because the survey is administered in the home where a parent may be present, is likely to be an underestimation. 

Abuse of prescription medications and OTC cough preparations by adolescents is more common than abuse of crack-cocaine, Ecstasy, methamphetamine, LSD, ketamine, heroin, and gamma-hydroxybutyrate; only marijuana and inhalants are abused more frequently by adolescents, according to the 2005 Partnership Attitude Tracking Study, conducted by the non-profit Partnership for a Drug-Free America. 

One in three adolescents reports having a close friend who abuses prescription pain relievers to get high, and one in four has a close friend who abuses cough medicine to get high. The active ingredient in many cough medications, dextromethorphan, is a synthetic opioid, the dextro-isomer of the codeine analogue levorphanol. Whereas the recommended dosage for cough suppression affects the cough center in the brain to the same degree as codeine, higher doses have dissociative effects. Dextromethorphan ingested in large quantities is converted to dextrophan, a substance that has an effect similar to phencyclidine and ketamine. High doses can be achieved by consuming four to eight ounces of cough medication, or pills, which contain twice the amount of dextromethorphan as the liquid preparations. 			

Results of a forthcoming study to be published in the 

Archives of Pediatrics and Adolescent Medicine

 demonstrate that dextromethorphan abuse is most common among 15- to 17-year-olds. The rate of calls related to dextromethorphan use to the California Poison Control System among all calls from 9- to 17-year-olds increased from 0.11/1,000 calls in 1999 to 1.71/1,000 calls in 2004. The mean age of the subject of the calls fell from 21.5 years to 16.6 years over the same period. The rise of dextromethorphan-related calls among adolescents in California parallels trends seen in national poison control call systems. 

Why the rise in abuse of prescription drugs?  							

There is much we need to learn about this relatively new phenomenon of adolescents' abuse of OTC and prescription drugs before we can understand its rise, but several explanations seem plausible.  

Awareness of over-the-counter and prescription drug abuse among adolescents is a first step you can take toward curtailing this worrisome trend. Take care, however, not to risk interfering when patients need these medications.

Alain Joffe, MD, MPH

Articles

Should we teach testicular self-exam?

Your role in curbing prescription and OTC drug abuse by adolescents