Late last year, “Today” show anchors Willie Geist and Carson Daly took one for the men’s team when they underwent testicular cancer exams on live TV. Lots of predictable joking ensued, especially from co-anchor Savannah Guthrie, who ad-libbed: “When I heard what you guys were doing, I thought it was nuts!” The “attending” urologist, David Samadi of Lenox Hill Hospital in New York, also took to wordplay, asking: “Who’s going to play ball first?” Geist stepped up.
Within minutes both anchors received clean bills of health along with Samadi’s congratulations for getting the exams. Samadi also encouraged the rest of maledom to perform testicular self-exams monthly in the interest of early detection, which he said can save lives — but do they?
Nearly 9,000 cases of testicular cancer in the United States are diagnosed every year — especially among men ages 15 to 34, where it’s the most common cancer — so the “Today” segment seemed like a useful public service announcement.
But unfortunately there’s no evidence that self-exams detect testicular cancer at an earlier stage, according to Durado Brooks, director of colon and prostate cancer prevention programs for the American Cancer Society. Even if these exams did, says Kenny Lin, an assistant professor of family medicine at Georgetown University Medical Center, early detection has little, if any, bearing on outcomes for those who are diagnosed. Lin calls the “Today” segment “a stunt cloaked as a health message,” and he points out that even the august U.S. Preventive Services Task Force recommends against testicular cancer screening — a change from the past.
Other routine screening tests have also earned a thumbs down from the medical establishment in recent years, as more clinical evidence has been gathered showing them to be less beneficial than once thought. Among the tests no longer universally recommended: PSA screening for prostate cancer, breast cancer self-exams for women and mammograms for women younger than 50, and Pap smears for cervical cancer for women younger than 21. Not only do these exams have nearly no effect on outcomes, the task force said, they can sometimes do more harm than good.
Regarding testicular screening in particular, it “is unlikely to offer meaningful health benefits, given the very low incidence and high cure rate of even advanced testicular cancer” while “potential harms include false-positive results, anxiety and harms from diagnostic tests or procedures,” according to the task force.
So why do some doctors continue to recommend these screenings — and why do some patients still want them? Enter Peter Ubel, a Duke University physician and behavioral scientist, who (along with co-author David Asch) argues in a new article in the journal Health Affairs that as hard as it is for physicians to adopt new practices, “it is often even harder for them to de-innovate to give up old practices, even when the new evidence reveals that those practices, well-meaning in their day, turn out to offer little value.”
As for physicians, Ubel says that it’s not really the money that radiologists make from mammograms or that urologists earn by performing prostate biopsies that creates attachments to outmoded practices even when they have been shown to be harmful. Rather, he says, these doctors are “influenced by several psychological biases that make it difficult for them to de-innovate.”
For example, he told me that many physicians are exposed to a biased selection of patients that reinforce long-held views. He points, for instance, to urologists who care for prostate cancer patients, some of whose cancers have advanced because they did not receive routine screening. What they don’t see are patients who were not screened and so were never referred for further care. Had they been tested, many of these men would have been found to have tiny areas of prostate cancer. But in the vast majority of cases, Ubel says, those tiny cancers would never have progressed to the point where they caused symptoms, much less ended lives.
Ubel also cautions against the “availability heuristic,” a mental shortcut that emphasizes recent or more vivid examples over more-typical cases in evaluating risk.
For instance, he says a breast cancer surgeon is more likely to remember a single, tragic case of a young patient who didn’t have routine mammograms and then died from advanced disease than the hundreds (if not thousands) of others whose tests were negative or resulted in false-positive diagnoses, negative and costly biopsies, and much angst. “These physicians might have a hard time believing that only one in a thousand women’s lives are saved by mammograms,” said Ubel, citing a Dartmouth study.
As hard as it may be for doctors to de-innovate, it can be even more difficult for patients. I know. I’m now into my third decade as a testicular-cancer survivor, and for years I was a vocal public advocate for regular self-exams. I’m no longer that cheerleader, now that I know my outcome would probably have been the same no matter when my cancer was found. In my case, it took more than three months — after several rounds of antibiotics because my doctor thought I had an infection — before I was finally diagnosed with advanced disease. Even in the mid-1980s, survival rates were high for all stages of testicular cancer. But how could I not believe that early detection via self-exam saved my life, especially after enduring two surgeries and four rounds of chemotherapy?
Patients also don’t want to lose screening tests — even the ones we hate — once we’ve been persuaded that they are potentially lifesaving innovations. We feel denied and suspicious, even when new science replaces older findings. When my primary-care doctor first told me in 2013 that she was going to forgo the annual PSA, I said: “What? You’re taking that away from me?”
It had been a key component of my annual physical, and losing it made me nervous, even though my dad perfectly illustrated its inherent problem. He had had two elevated PSA results, which led to a painful and anguishing biopsy of his prostate, only to be told by his doctor, “Never mind. Everything’s okay.”
Says Ubel, “Nothing makes people feel more attached to something than the threat of having it be taken away.”
Patients are also unduly influenced by individual success stories, which may or may not translate into a mass benefit. For instance, former New York mayor Rudolph Giuliani revealed that a routine PSA test in 2002 helped diagnose his prostate cancer, and he concluded that early detection and treatment saved his life. Ubel cautions: “Most people probably believed Giuliani when he said his life was saved by the test. But it’s impossible to know whether that was true or not. The best guess, based on scientific evidence, is that he would still be alive today whether or not he had received that test. It just doesn’t feel that way to Giuliani, or the rest of us.”
“In other words,” he says, “despite our best efforts to think rationally, sometimes we can’t help ourselves.”
Rational or not, the “Today” show’s “stunt” does have value if only by raising awareness of men’s cancers.
While the screening might not improve longevity, hearing a discussion on TV that “a lump in your nut could be cancer” has another benefit, said Brant Inman, vice chief of urology at Duke University Medical Center (who has been my doctor). “We just don’t talk about men’s cancers on TV. You hear about breast cancer all the time.”
He also acknowledged that men are embarrassed to talk with their doctors about their own health issues, especially those “down there.” Inman says he recently suffered from a case of hemorrhoids, and while “in theory I should be the most comfortable of everyone on the planet to get it checked out,” he hesitated to do so. Why? “I was quite embarrassed,” he said.
Among his patients, Inman practices what he calls “informed screening.” He explains to his patients the current screening recommendations, focusing on cost, risk and potential benefits. Even inexpensive PSA blood tests have costs, since they can lead to biopsies that cost thousands and carry the risk of infection and bleeding — all for a cancer that is unlikely to be a lethal risk.
My personal experience with a lump made it especially hard for me to de-innovate on self-exams. But now I am better able to compare the evidence on the potential benefit of regular screening (nearly none) vs. its cost: the many anxiety-fueled trips to my urologist that result in costly ultrasounds and even an unnecessary surgery, not to mention the psychological toll of those false alarms that started when I thought I felt a bump down there. Finally, I think I may have learned that it’s smarter to keep my hands to myself.