Is aspirin effective for primary prevention of colon cancer?

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Is aspirin effective for primary prevention of colon cancer?
EVIDENCE-BASED ANSWER

IT’S UNCLEAR, DUE TO CONFLICTING EVIDENCE. Aspirin probably shouldn’t be used for routine prevention because of its potential risks (strength of recommendation [SOR]: B, systematic review of inconsistent evidence). However, aspirin is likely to be effective for secondary prevention of colorectal adenomas (SOR: A, systematic review).

 

Evidence summary

A systematic review conducted for the US Preventive Services Task Force (USPSTF) addressed the use of aspirin for primary prevention of colorectal carcinomas (CRC) and colorectal adenomas (CRA).

Pooled data from 2 randomized-controlled trials (RCTs) with a total of 61,947 patients showed no decrease in CRC incidence (relative risk [RR]=1.02; 95% confidence interval [CI], 0.84-1.25) with regular aspirin use (325 mg every other day for 5 years or 100 mg every other day for 10 years). Six cohort studies that followed a total of 231,252 patients did report a decrease in CRC incidence over 4 to 10 years (RR=0.78; 95% CI, 0.63-0.97).1

In a pooled analysis evaluating 2 primary prevention RCTs (the British Doctors Aspirin Trial and UK-TIA Aspirin Trial, total N=7588), aspirin was found to reduce the incidence of colorectal cancer (hazard ratio [HR]=0.74; 95% CI, 0.56-0.97; P=.02 overall; for aspirin given for 5 years or longer, HR=0.63; 95% CI, 0.47-0.85; P=.002). The effect was significant only at 10 to 14 years of follow-up (0 to 9 years: HR=0.92, 95% CI, 0.56-1.49, P=.73; 5 to 9 years: HR=1.08, 95% CI, 0.55-2.14, P=.83; 10 to 14 years: HR=0.51, 95% CI, 0.29-0.90, P=.02; 15 to 19 years: HR=0.70, 95% CI, 0.43-1.14, P=.15; ≥20 years: HR=0.90, 95% CI, 0.42-1.95, P=.79).2

Adverse effects, including stroke, are dose-dependent
The USPSTF review also summarized the harms associated with aspirin use. When aspirin was given for secondary prevention of stroke, the risk of hemorrhagic stroke was dose-dependent, varying from 0.3% to 1.1% (100 mg/d: 0.3%, 95% CI, 0.2%-0.4%; 100-325 mg/d: 0.3%, 95% CI, 0.2%-0.3%; 325 mg/d: 1.1%, 95% CI, 0.7%-1.5%).

Aspirin also was associated with an increased risk of gastrointestinal (GI) symptoms (odds ratio [OR]=1.7; 95% CI, 1.5-1.8), GI bleeding (RR=1.6-2.5), and hospitalization for GI bleeding (OR=1.9; 95% CI, 1.1-3.1). The risks of GI bleeding or perforation were dose-dependent.1

 

 

 

Low-dose aspirin promotes secondary prevention of adenomas
In a Cochrane review evaluating the effects of aspirin on CRA, pooled data from 3 RCTs with a total of 1839 subjects (1322 with a history of CRA and 517 with a history of CRC) showed that aspirin in a daily dose of 81 mg is effective for secondary prevention of sporadic CRA over a 1- to 3-year follow-up period (RR=0.77; 95% CI, 0.61-0.96; number needed to treat=12.5). The outcome measured in these 3 trials was an intermediate clinical finding, CRA, and not the more relevant end point of CRC.3

Recommendations

The USPSTF recommends against routine use of aspirin and nonsteroidal anti-inflammatory drugs to prevent colorectal cancer in people at average risk (grade D recommendation: ineffective or harm outweighs benefits).4

The American Gastroenterological Association (AGA) doesn’t recommend aspirin for primary CRC prevention, but acknowledges a possible role in secondary prevention. Aspirin should be considered for patients with a personal history of CRC, advanced CRA, or a strong family history but no history of peptic ulcer disease or hemorrhagic stroke. The AGA notes that 1 in 100 people taking aspirin for 2 years will develop significant GI bleeding.5

References

1. Dube C, Rostom A, Lewin G, et al. The use of aspirin for primary prevention of colorectal cancer: a systematic review prepared for the US Preventive Services Task Force. Ann Intern Med. 2007;146:365-375.

2. Flossmann E, Rothwell PM. British Doctors Aspirin Trial and the UK-TIA Aspirin Trial. Effect of aspirin on long-term risk of colorectal cancer: consistent evidence from randomised and observational studies. Lancet. 2007;369:1603-1613.

3. Asano TK, McLeod RS. Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin for preventing colorectal adenomas and carcinomas. Cochrane Database Syst Rev. 2004;(2):CD004079.-

4. Calonge N, Petitti DB, DeWitt TG, et al. Routine aspirin or nonsteroidal anti-inflammatory drugs for the primary prevention of colorectal cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2007;146:361-364.

5. Burt R, Winawer S, Bond J, et al. Preventing Colorectal Cancer: A Clinician’s Guide. The American Gastroenterological Association, 2004. Available at: www.nccrt.org/documents/EducationalResources/CRCpreventionMonograph.pdf. Accessed March 7, 2010.

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University of Colorado, Denver

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EVIDENCE-BASED ANSWER

IT’S UNCLEAR, DUE TO CONFLICTING EVIDENCE. Aspirin probably shouldn’t be used for routine prevention because of its potential risks (strength of recommendation [SOR]: B, systematic review of inconsistent evidence). However, aspirin is likely to be effective for secondary prevention of colorectal adenomas (SOR: A, systematic review).

 

Evidence summary

A systematic review conducted for the US Preventive Services Task Force (USPSTF) addressed the use of aspirin for primary prevention of colorectal carcinomas (CRC) and colorectal adenomas (CRA).

Pooled data from 2 randomized-controlled trials (RCTs) with a total of 61,947 patients showed no decrease in CRC incidence (relative risk [RR]=1.02; 95% confidence interval [CI], 0.84-1.25) with regular aspirin use (325 mg every other day for 5 years or 100 mg every other day for 10 years). Six cohort studies that followed a total of 231,252 patients did report a decrease in CRC incidence over 4 to 10 years (RR=0.78; 95% CI, 0.63-0.97).1

In a pooled analysis evaluating 2 primary prevention RCTs (the British Doctors Aspirin Trial and UK-TIA Aspirin Trial, total N=7588), aspirin was found to reduce the incidence of colorectal cancer (hazard ratio [HR]=0.74; 95% CI, 0.56-0.97; P=.02 overall; for aspirin given for 5 years or longer, HR=0.63; 95% CI, 0.47-0.85; P=.002). The effect was significant only at 10 to 14 years of follow-up (0 to 9 years: HR=0.92, 95% CI, 0.56-1.49, P=.73; 5 to 9 years: HR=1.08, 95% CI, 0.55-2.14, P=.83; 10 to 14 years: HR=0.51, 95% CI, 0.29-0.90, P=.02; 15 to 19 years: HR=0.70, 95% CI, 0.43-1.14, P=.15; ≥20 years: HR=0.90, 95% CI, 0.42-1.95, P=.79).2

Adverse effects, including stroke, are dose-dependent
The USPSTF review also summarized the harms associated with aspirin use. When aspirin was given for secondary prevention of stroke, the risk of hemorrhagic stroke was dose-dependent, varying from 0.3% to 1.1% (100 mg/d: 0.3%, 95% CI, 0.2%-0.4%; 100-325 mg/d: 0.3%, 95% CI, 0.2%-0.3%; 325 mg/d: 1.1%, 95% CI, 0.7%-1.5%).

Aspirin also was associated with an increased risk of gastrointestinal (GI) symptoms (odds ratio [OR]=1.7; 95% CI, 1.5-1.8), GI bleeding (RR=1.6-2.5), and hospitalization for GI bleeding (OR=1.9; 95% CI, 1.1-3.1). The risks of GI bleeding or perforation were dose-dependent.1

 

 

 

Low-dose aspirin promotes secondary prevention of adenomas
In a Cochrane review evaluating the effects of aspirin on CRA, pooled data from 3 RCTs with a total of 1839 subjects (1322 with a history of CRA and 517 with a history of CRC) showed that aspirin in a daily dose of 81 mg is effective for secondary prevention of sporadic CRA over a 1- to 3-year follow-up period (RR=0.77; 95% CI, 0.61-0.96; number needed to treat=12.5). The outcome measured in these 3 trials was an intermediate clinical finding, CRA, and not the more relevant end point of CRC.3

Recommendations

The USPSTF recommends against routine use of aspirin and nonsteroidal anti-inflammatory drugs to prevent colorectal cancer in people at average risk (grade D recommendation: ineffective or harm outweighs benefits).4

The American Gastroenterological Association (AGA) doesn’t recommend aspirin for primary CRC prevention, but acknowledges a possible role in secondary prevention. Aspirin should be considered for patients with a personal history of CRC, advanced CRA, or a strong family history but no history of peptic ulcer disease or hemorrhagic stroke. The AGA notes that 1 in 100 people taking aspirin for 2 years will develop significant GI bleeding.5

EVIDENCE-BASED ANSWER

IT’S UNCLEAR, DUE TO CONFLICTING EVIDENCE. Aspirin probably shouldn’t be used for routine prevention because of its potential risks (strength of recommendation [SOR]: B, systematic review of inconsistent evidence). However, aspirin is likely to be effective for secondary prevention of colorectal adenomas (SOR: A, systematic review).

 

Evidence summary

A systematic review conducted for the US Preventive Services Task Force (USPSTF) addressed the use of aspirin for primary prevention of colorectal carcinomas (CRC) and colorectal adenomas (CRA).

Pooled data from 2 randomized-controlled trials (RCTs) with a total of 61,947 patients showed no decrease in CRC incidence (relative risk [RR]=1.02; 95% confidence interval [CI], 0.84-1.25) with regular aspirin use (325 mg every other day for 5 years or 100 mg every other day for 10 years). Six cohort studies that followed a total of 231,252 patients did report a decrease in CRC incidence over 4 to 10 years (RR=0.78; 95% CI, 0.63-0.97).1

In a pooled analysis evaluating 2 primary prevention RCTs (the British Doctors Aspirin Trial and UK-TIA Aspirin Trial, total N=7588), aspirin was found to reduce the incidence of colorectal cancer (hazard ratio [HR]=0.74; 95% CI, 0.56-0.97; P=.02 overall; for aspirin given for 5 years or longer, HR=0.63; 95% CI, 0.47-0.85; P=.002). The effect was significant only at 10 to 14 years of follow-up (0 to 9 years: HR=0.92, 95% CI, 0.56-1.49, P=.73; 5 to 9 years: HR=1.08, 95% CI, 0.55-2.14, P=.83; 10 to 14 years: HR=0.51, 95% CI, 0.29-0.90, P=.02; 15 to 19 years: HR=0.70, 95% CI, 0.43-1.14, P=.15; ≥20 years: HR=0.90, 95% CI, 0.42-1.95, P=.79).2

Adverse effects, including stroke, are dose-dependent
The USPSTF review also summarized the harms associated with aspirin use. When aspirin was given for secondary prevention of stroke, the risk of hemorrhagic stroke was dose-dependent, varying from 0.3% to 1.1% (100 mg/d: 0.3%, 95% CI, 0.2%-0.4%; 100-325 mg/d: 0.3%, 95% CI, 0.2%-0.3%; 325 mg/d: 1.1%, 95% CI, 0.7%-1.5%).

Aspirin also was associated with an increased risk of gastrointestinal (GI) symptoms (odds ratio [OR]=1.7; 95% CI, 1.5-1.8), GI bleeding (RR=1.6-2.5), and hospitalization for GI bleeding (OR=1.9; 95% CI, 1.1-3.1). The risks of GI bleeding or perforation were dose-dependent.1

 

 

 

Low-dose aspirin promotes secondary prevention of adenomas
In a Cochrane review evaluating the effects of aspirin on CRA, pooled data from 3 RCTs with a total of 1839 subjects (1322 with a history of CRA and 517 with a history of CRC) showed that aspirin in a daily dose of 81 mg is effective for secondary prevention of sporadic CRA over a 1- to 3-year follow-up period (RR=0.77; 95% CI, 0.61-0.96; number needed to treat=12.5). The outcome measured in these 3 trials was an intermediate clinical finding, CRA, and not the more relevant end point of CRC.3

Recommendations

The USPSTF recommends against routine use of aspirin and nonsteroidal anti-inflammatory drugs to prevent colorectal cancer in people at average risk (grade D recommendation: ineffective or harm outweighs benefits).4

The American Gastroenterological Association (AGA) doesn’t recommend aspirin for primary CRC prevention, but acknowledges a possible role in secondary prevention. Aspirin should be considered for patients with a personal history of CRC, advanced CRA, or a strong family history but no history of peptic ulcer disease or hemorrhagic stroke. The AGA notes that 1 in 100 people taking aspirin for 2 years will develop significant GI bleeding.5

References

1. Dube C, Rostom A, Lewin G, et al. The use of aspirin for primary prevention of colorectal cancer: a systematic review prepared for the US Preventive Services Task Force. Ann Intern Med. 2007;146:365-375.

2. Flossmann E, Rothwell PM. British Doctors Aspirin Trial and the UK-TIA Aspirin Trial. Effect of aspirin on long-term risk of colorectal cancer: consistent evidence from randomised and observational studies. Lancet. 2007;369:1603-1613.

3. Asano TK, McLeod RS. Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin for preventing colorectal adenomas and carcinomas. Cochrane Database Syst Rev. 2004;(2):CD004079.-

4. Calonge N, Petitti DB, DeWitt TG, et al. Routine aspirin or nonsteroidal anti-inflammatory drugs for the primary prevention of colorectal cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2007;146:361-364.

5. Burt R, Winawer S, Bond J, et al. Preventing Colorectal Cancer: A Clinician’s Guide. The American Gastroenterological Association, 2004. Available at: www.nccrt.org/documents/EducationalResources/CRCpreventionMonograph.pdf. Accessed March 7, 2010.

References

1. Dube C, Rostom A, Lewin G, et al. The use of aspirin for primary prevention of colorectal cancer: a systematic review prepared for the US Preventive Services Task Force. Ann Intern Med. 2007;146:365-375.

2. Flossmann E, Rothwell PM. British Doctors Aspirin Trial and the UK-TIA Aspirin Trial. Effect of aspirin on long-term risk of colorectal cancer: consistent evidence from randomised and observational studies. Lancet. 2007;369:1603-1613.

3. Asano TK, McLeod RS. Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin for preventing colorectal adenomas and carcinomas. Cochrane Database Syst Rev. 2004;(2):CD004079.-

4. Calonge N, Petitti DB, DeWitt TG, et al. Routine aspirin or nonsteroidal anti-inflammatory drugs for the primary prevention of colorectal cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2007;146:361-364.

5. Burt R, Winawer S, Bond J, et al. Preventing Colorectal Cancer: A Clinician’s Guide. The American Gastroenterological Association, 2004. Available at: www.nccrt.org/documents/EducationalResources/CRCpreventionMonograph.pdf. Accessed March 7, 2010.

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How useful are genital exams during boys’ sports physicals?

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How useful are genital exams during boys’ sports physicals?
EVIDENCE-BASED ANSWER

EXAMINATION MAY BE USEFUL to identify hernia but not testicular cancer. Insufficient evidence exists to recommend for or against screening genital exams for boys playing sports. Given the low risk of harm, screening for hernias as a part of a preparticipation physical evaluation (PPE) is recommended by several specialty organizations (strength of recommendation [SOR]: C, expert opinion).

Screening for testicular cancer doesn’t benefit asymptomatic adolescents and adults. Because clinical outcomes are excellent without cancer screening, routine screening isn’t recommended (SOR: C, expert opinion).

 

Evidence summary

No patient-centered studies have evaluated the effectiveness of male genital examinations during a PPE. Examination is performed mainly to identify an inguinal hernia. The incidence of infantile inguinal hernia is 0.8% to 4.4%, with a male-to-female ratio of 6 to 1.1 About 4% of the population will develop an inguinal hernia, but its incidence among adolescents and young adults isn’t known.1 The natural history of inguinal hernias is poorly understood.

Screening turns up hernia more often than other genital problems
In a study involving juniors and seniors attending a Richmond County, Georgia high school, 48 of 562 students (9.1%) and 34 of 706 students (4.8%) were found to have genital problems or a hernia during examinations conducted in 2 consecutive years of preparticipation physicals.2 No data were available to differentiate the type or severity of the genitourinary problems identified.

A study of 3205 elementary school boys 6 to 12 years of age in western Iran found that 213 (6.64%) had inguinal hernia and penoscrotal abnormalities. The most common abnormality was indirect inguinal hernia (2.4%).3 The rates of other external genital abnormalities, such as retractile testes (1.22%), undescended testes (1.12%), hydrocele (0.87%), and hypospadias (0.78%), were lower.

Students’ attitudes toward screening aren’t known
Students’ knowledge of, and attitude toward, genital screening during PPE are unknown. In 1 study, 50% of junior high school, high school, and college athletes in northeastern Ohio didn’t know why a genital examination is performed during the PPE.4

Sensitivity and specificity of physical examination for hernia
The sensitivity and specificity of physical examination hasn’t been well studied. One study, assessing the accuracy of methods of diagnosing inguinal hernia in 55 laparoscopically documented cases, found that the sensitivity and specificity were 74.5% and 96.3%, respectively, for physical examination; 92.7% and 81.5% for ultrasound; and 94.5% and 96.3% for MRI.5 The patients were symptomatic, however, which makes it likely that the accuracy of these diagnostic methods in screening asymptomatic patients would be overestimated.

 

 

 

Managing hernia. Surgery isn’t the only option for managing inguinal hernia.6 Watchful waiting is safe and acceptable for asymptomatic or minimally symptomatic individuals. Acute complications are rare, and patients who delay surgery don’t have a higher risk of operative or postoperative complications.

What about routine testicular cancer screening?
The US Preventive Services Task Force (USPSTF) hasn’t made a recommendation on hernia screening, but recommends against routine screening for testicular cancer in asymptomatic adolescents and adults.7 The recommendation is based on the low prevalence of testicular cancer and the unknown accuracy of testicular examination in detecting it. Even without screening, current treatments produce very favorable health outcomes.

Although the USPSTF didn’t identify any potential harm from screening for testicular cancer, no evidence suggests that screening provides any benefit over current case-finding practices. Moreover, because some evidence suggests that testicular cancer is often misdiagnosed initially, resources might be better dedicated to proper evaluation of patients with symptoms.

Recommendations

Routine male genitourinary examination during the PPE, including testicular and hernia evaluation, is recommended by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.8

The latest AAFP position statement reflects the USPSTF recommendation against routine screening for testicular cancer in asymptomatic adolescents and adults.9

References

1. Warner BW. Pediatric surgery. In: Townsend CM, ed. Sabiston Textbook of Surgery. 18th ed. Philadelphia: WB Saunders; 2008:2047-2089.

2. Linder CW, DuRant RH, Seklecki RM, et al. Preparticipation health screening of young athletes. Results of 1268 examinations. Am J Sports Med. 1981;9:187-193.

3. Yegane RA, Kheirollahi AR, Bashashati M, et al. The prevalence of penoscrotal abnormalities and inguinal hernia in elementary-school boys in the west of Iran. Int J Urol. 2005;12:479-483.

4. Congeni J, Miller SF, Bennett CL. Awareness of genital health in young male athletes. Clin J Sport Med. 2005;15:22-26.

5. van den Berg JC, de Valois JC, Go PM, et al. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34:739-743.

6. Turaga K, Fitzgibbons RJ, Jr, Puri V. Inguinal hernias: should we repair? Surg Clin North Am. 2008;88:127-138, ix.

7. US Preventive Services Task Force. Screening for Testicular Cancer: Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Available at: www.ahrq.gov/clinic/3rduspstf/testicular/testiculrs.htm. Accessed July 9, 2008.

8. American Academy of Family Physicians. Preparticipation Physical Evaluation. 3rd ed. Minneapolis: McGraw-Hill; 2005:50.

9. American Academy of Family Physicians. Summary of Recommendations for Clinical Preventive Services. Revision 6.8. Leawood, KS: American Academy of Family Physicians; 2009. Available at: www.guideline.gov/summary/summary.aspx?doc_id=14452&nbr=7242&ss=68&xl=99. Accessed January 2, 2010.

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University of Colorado, Denver

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University of Colorado, Denver

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University of Colorado, Denver

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EVIDENCE-BASED ANSWER

EXAMINATION MAY BE USEFUL to identify hernia but not testicular cancer. Insufficient evidence exists to recommend for or against screening genital exams for boys playing sports. Given the low risk of harm, screening for hernias as a part of a preparticipation physical evaluation (PPE) is recommended by several specialty organizations (strength of recommendation [SOR]: C, expert opinion).

Screening for testicular cancer doesn’t benefit asymptomatic adolescents and adults. Because clinical outcomes are excellent without cancer screening, routine screening isn’t recommended (SOR: C, expert opinion).

 

Evidence summary

No patient-centered studies have evaluated the effectiveness of male genital examinations during a PPE. Examination is performed mainly to identify an inguinal hernia. The incidence of infantile inguinal hernia is 0.8% to 4.4%, with a male-to-female ratio of 6 to 1.1 About 4% of the population will develop an inguinal hernia, but its incidence among adolescents and young adults isn’t known.1 The natural history of inguinal hernias is poorly understood.

Screening turns up hernia more often than other genital problems
In a study involving juniors and seniors attending a Richmond County, Georgia high school, 48 of 562 students (9.1%) and 34 of 706 students (4.8%) were found to have genital problems or a hernia during examinations conducted in 2 consecutive years of preparticipation physicals.2 No data were available to differentiate the type or severity of the genitourinary problems identified.

A study of 3205 elementary school boys 6 to 12 years of age in western Iran found that 213 (6.64%) had inguinal hernia and penoscrotal abnormalities. The most common abnormality was indirect inguinal hernia (2.4%).3 The rates of other external genital abnormalities, such as retractile testes (1.22%), undescended testes (1.12%), hydrocele (0.87%), and hypospadias (0.78%), were lower.

Students’ attitudes toward screening aren’t known
Students’ knowledge of, and attitude toward, genital screening during PPE are unknown. In 1 study, 50% of junior high school, high school, and college athletes in northeastern Ohio didn’t know why a genital examination is performed during the PPE.4

Sensitivity and specificity of physical examination for hernia
The sensitivity and specificity of physical examination hasn’t been well studied. One study, assessing the accuracy of methods of diagnosing inguinal hernia in 55 laparoscopically documented cases, found that the sensitivity and specificity were 74.5% and 96.3%, respectively, for physical examination; 92.7% and 81.5% for ultrasound; and 94.5% and 96.3% for MRI.5 The patients were symptomatic, however, which makes it likely that the accuracy of these diagnostic methods in screening asymptomatic patients would be overestimated.

 

 

 

Managing hernia. Surgery isn’t the only option for managing inguinal hernia.6 Watchful waiting is safe and acceptable for asymptomatic or minimally symptomatic individuals. Acute complications are rare, and patients who delay surgery don’t have a higher risk of operative or postoperative complications.

What about routine testicular cancer screening?
The US Preventive Services Task Force (USPSTF) hasn’t made a recommendation on hernia screening, but recommends against routine screening for testicular cancer in asymptomatic adolescents and adults.7 The recommendation is based on the low prevalence of testicular cancer and the unknown accuracy of testicular examination in detecting it. Even without screening, current treatments produce very favorable health outcomes.

Although the USPSTF didn’t identify any potential harm from screening for testicular cancer, no evidence suggests that screening provides any benefit over current case-finding practices. Moreover, because some evidence suggests that testicular cancer is often misdiagnosed initially, resources might be better dedicated to proper evaluation of patients with symptoms.

Recommendations

Routine male genitourinary examination during the PPE, including testicular and hernia evaluation, is recommended by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.8

The latest AAFP position statement reflects the USPSTF recommendation against routine screening for testicular cancer in asymptomatic adolescents and adults.9

EVIDENCE-BASED ANSWER

EXAMINATION MAY BE USEFUL to identify hernia but not testicular cancer. Insufficient evidence exists to recommend for or against screening genital exams for boys playing sports. Given the low risk of harm, screening for hernias as a part of a preparticipation physical evaluation (PPE) is recommended by several specialty organizations (strength of recommendation [SOR]: C, expert opinion).

Screening for testicular cancer doesn’t benefit asymptomatic adolescents and adults. Because clinical outcomes are excellent without cancer screening, routine screening isn’t recommended (SOR: C, expert opinion).

 

Evidence summary

No patient-centered studies have evaluated the effectiveness of male genital examinations during a PPE. Examination is performed mainly to identify an inguinal hernia. The incidence of infantile inguinal hernia is 0.8% to 4.4%, with a male-to-female ratio of 6 to 1.1 About 4% of the population will develop an inguinal hernia, but its incidence among adolescents and young adults isn’t known.1 The natural history of inguinal hernias is poorly understood.

Screening turns up hernia more often than other genital problems
In a study involving juniors and seniors attending a Richmond County, Georgia high school, 48 of 562 students (9.1%) and 34 of 706 students (4.8%) were found to have genital problems or a hernia during examinations conducted in 2 consecutive years of preparticipation physicals.2 No data were available to differentiate the type or severity of the genitourinary problems identified.

A study of 3205 elementary school boys 6 to 12 years of age in western Iran found that 213 (6.64%) had inguinal hernia and penoscrotal abnormalities. The most common abnormality was indirect inguinal hernia (2.4%).3 The rates of other external genital abnormalities, such as retractile testes (1.22%), undescended testes (1.12%), hydrocele (0.87%), and hypospadias (0.78%), were lower.

Students’ attitudes toward screening aren’t known
Students’ knowledge of, and attitude toward, genital screening during PPE are unknown. In 1 study, 50% of junior high school, high school, and college athletes in northeastern Ohio didn’t know why a genital examination is performed during the PPE.4

Sensitivity and specificity of physical examination for hernia
The sensitivity and specificity of physical examination hasn’t been well studied. One study, assessing the accuracy of methods of diagnosing inguinal hernia in 55 laparoscopically documented cases, found that the sensitivity and specificity were 74.5% and 96.3%, respectively, for physical examination; 92.7% and 81.5% for ultrasound; and 94.5% and 96.3% for MRI.5 The patients were symptomatic, however, which makes it likely that the accuracy of these diagnostic methods in screening asymptomatic patients would be overestimated.

 

 

 

Managing hernia. Surgery isn’t the only option for managing inguinal hernia.6 Watchful waiting is safe and acceptable for asymptomatic or minimally symptomatic individuals. Acute complications are rare, and patients who delay surgery don’t have a higher risk of operative or postoperative complications.

What about routine testicular cancer screening?
The US Preventive Services Task Force (USPSTF) hasn’t made a recommendation on hernia screening, but recommends against routine screening for testicular cancer in asymptomatic adolescents and adults.7 The recommendation is based on the low prevalence of testicular cancer and the unknown accuracy of testicular examination in detecting it. Even without screening, current treatments produce very favorable health outcomes.

Although the USPSTF didn’t identify any potential harm from screening for testicular cancer, no evidence suggests that screening provides any benefit over current case-finding practices. Moreover, because some evidence suggests that testicular cancer is often misdiagnosed initially, resources might be better dedicated to proper evaluation of patients with symptoms.

Recommendations

Routine male genitourinary examination during the PPE, including testicular and hernia evaluation, is recommended by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.8

The latest AAFP position statement reflects the USPSTF recommendation against routine screening for testicular cancer in asymptomatic adolescents and adults.9

References

1. Warner BW. Pediatric surgery. In: Townsend CM, ed. Sabiston Textbook of Surgery. 18th ed. Philadelphia: WB Saunders; 2008:2047-2089.

2. Linder CW, DuRant RH, Seklecki RM, et al. Preparticipation health screening of young athletes. Results of 1268 examinations. Am J Sports Med. 1981;9:187-193.

3. Yegane RA, Kheirollahi AR, Bashashati M, et al. The prevalence of penoscrotal abnormalities and inguinal hernia in elementary-school boys in the west of Iran. Int J Urol. 2005;12:479-483.

4. Congeni J, Miller SF, Bennett CL. Awareness of genital health in young male athletes. Clin J Sport Med. 2005;15:22-26.

5. van den Berg JC, de Valois JC, Go PM, et al. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34:739-743.

6. Turaga K, Fitzgibbons RJ, Jr, Puri V. Inguinal hernias: should we repair? Surg Clin North Am. 2008;88:127-138, ix.

7. US Preventive Services Task Force. Screening for Testicular Cancer: Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Available at: www.ahrq.gov/clinic/3rduspstf/testicular/testiculrs.htm. Accessed July 9, 2008.

8. American Academy of Family Physicians. Preparticipation Physical Evaluation. 3rd ed. Minneapolis: McGraw-Hill; 2005:50.

9. American Academy of Family Physicians. Summary of Recommendations for Clinical Preventive Services. Revision 6.8. Leawood, KS: American Academy of Family Physicians; 2009. Available at: www.guideline.gov/summary/summary.aspx?doc_id=14452&nbr=7242&ss=68&xl=99. Accessed January 2, 2010.

References

1. Warner BW. Pediatric surgery. In: Townsend CM, ed. Sabiston Textbook of Surgery. 18th ed. Philadelphia: WB Saunders; 2008:2047-2089.

2. Linder CW, DuRant RH, Seklecki RM, et al. Preparticipation health screening of young athletes. Results of 1268 examinations. Am J Sports Med. 1981;9:187-193.

3. Yegane RA, Kheirollahi AR, Bashashati M, et al. The prevalence of penoscrotal abnormalities and inguinal hernia in elementary-school boys in the west of Iran. Int J Urol. 2005;12:479-483.

4. Congeni J, Miller SF, Bennett CL. Awareness of genital health in young male athletes. Clin J Sport Med. 2005;15:22-26.

5. van den Berg JC, de Valois JC, Go PM, et al. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34:739-743.

6. Turaga K, Fitzgibbons RJ, Jr, Puri V. Inguinal hernias: should we repair? Surg Clin North Am. 2008;88:127-138, ix.

7. US Preventive Services Task Force. Screening for Testicular Cancer: Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Available at: www.ahrq.gov/clinic/3rduspstf/testicular/testiculrs.htm. Accessed July 9, 2008.

8. American Academy of Family Physicians. Preparticipation Physical Evaluation. 3rd ed. Minneapolis: McGraw-Hill; 2005:50.

9. American Academy of Family Physicians. Summary of Recommendations for Clinical Preventive Services. Revision 6.8. Leawood, KS: American Academy of Family Physicians; 2009. Available at: www.guideline.gov/summary/summary.aspx?doc_id=14452&nbr=7242&ss=68&xl=99. Accessed January 2, 2010.

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The Journal of Family Practice - 59(7)
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