Codesign and Launch of 'On the Ball': An Inclusive Community-Based 'Testicular Awareness' Campaign.

INTRODUCTION: Increased awareness of testicular diseases can lead to early diagnosis. Evidence suggests that men's awareness of testicular diseases is low, with many expressing their willingness to delay help-seeking for symptoms of concern. The risk of testicular diseases is higher in gender and sexual minority groups. In this study, we discuss the codesign, refinement and launch of 'On the Ball', an inclusive community-based 'testicular awareness' campaign. METHODS: The World Café participatory research methodology was used. Individuals from Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, policymakers, media/marketing experts and graphic designers were recruited. Participants were handed a brief for 'On the Ball', which was designed based on feedback from a previous World Café workshop. They were assigned to three tables. Participants rotated tables at random for three 20-min rounds of conversations. Each table had a facilitator who focussed on one element of the campaign brief. Data were collected using audio recorders and in writing and were analysed thematically. RESULTS: Thirteen individuals participated in the workshop. The following themes emerged from the data: (i) campaign identity, (ii) campaign delivery and (iii) campaign impact. Participants recommended enhancements to the campaign logo, slogan, social media posts and poster. They suggested delivering the campaign online via social media and offline using various print and broadcast media. Participants recommended targeting areas with a large number of men such as workplaces. To help measure the impact of the campaign, participants proposed capturing social media analytics and tracking statistics relating to testicular diseases. Recommendations were used to refine the 'On the Ball' campaign and launch it in a university. In total, 411 students engaged with the various elements of the campaign during the soft launch. CONCLUSIONS: 'On the Ball' campaign visuals ought to be inclusive. Online and offline campaign delivery is warranted to reach out to a wider cohort. Campaign impact can be captured using social media analytics as well as measuring clinical outcomes relating to testicular diseases. Future research is needed to implement the campaign online and offline, explore its impact and evaluate its feasibility, acceptability, cost and effect on promoting testicular awareness. PATIENT OR PUBLIC CONTRIBUTION: The 'On the Ball' campaign was codesigned and refined with members of Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, health policymakers, media and marketing experts and graphic designers using the World Café participatory research methodology.

Humor-Based Messaging in Testicular Cancer Awareness Campaigns: A Comparative Critical Review.

Extensive research showcases the extent and efficacy of humor-based messaging in general health promotion. However, the work describing humor's use within testicular cancer (TC) awareness is less developed. The aim of this comparative critical review was to determine the impact of using humor-based messaging in TC awareness campaigns to achieve a baseline assessment from which future research can be modeled. A literature search was conducted using seven databases to locate relevant literature. Three research questions guided this investigation: (1) To what extent has humor been used in TC awareness campaigns? (2) What does the literature reveal about the use of humor-based messaging on relevant health outcomes? (3) What are the limitations within current TC awareness strategies? Six studies were included in the review, of which three directly assessed the use of humor in TC awareness vis-à-vis intervention designs. Humor-based strategies were implemented to enhance knowledge of TC and testicular self-examination (TSE) procedures, reduce anxiety surrounding detection threat, and promote TSE. The rhetoric provided to men via various health interventions relied on humor and slang to promote TSE among males. Despite the small sample size of the included studies, this review determined that humor may be useful in reducing uncomfortable feelings surrounding TSE, increasing awareness of TC, and promoting TSE. When using humor-based messaging, however, the audience and type of humor implemented must be considered. Limited research exists assessing the long-term impact humor in TC promotion on health behavioral changes, easing anxieties related to detection, and increased self-efficacy surrounding TSE.

Promoting 'testicular awareness': Co-design of an inclusive campaign using the World Café Methodology.

INTRODUCTION: Testicular cancer is the most common cancer in men aged 15-44 years in many countries. Most men with testicular cancer present with a lump. Testicular symptoms are more likely to occur secondary to benign diseases like epididymo-orchitis, a common sexually transmitted infection. Gender and sexual minorities are at an increased risk of testicular diseases and health disparities. The aim of this study was to co-design an inclusive community-based campaign to promote testicular awareness. METHODS: This study uses the World Café methodology. Participation was sought from Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, health policy makers, media and marketing experts and graphic designers. Participants engaged in three rounds of conversations to co-design the campaign. Data were collected using drawing sheets, artefact cards, sticky notes, coloured markers and a voice recorder. Deductive thematic analysis was conducted. RESULTS: Seventeen individuals participated in the study. Six themes emerged from the analysis as follows: (i) online communication; (ii) offline communication; (iii) behavioural targeting and education; (iv) campaign frequency and reach; (v) demographic segmentation; and (vi) campaign identity. The use of social media for campaign delivery featured strongly in all conversations. Participants also recommended offline communication using posters and radio/television advertisements to scale up the campaign and achieve wider reach. Advertisements to overcome embarrassment surrounding testicular health were particularly recommended. Participants emphasised that campaign delivery must be dynamic whilst ensuring that the health-promoting messages are not diluted or lost. They stressed the importance of being inclusive and tailoring the campaign to different age groups, gender identities and sexual orientations. CONCLUSIONS: Study recommendations will be used to design and deliver the campaign. Future research will be needed to evaluate the feasibility, acceptability, cost and effect of the campaign on promoting testicular awareness and early detection of testicular diseases. PATIENT OR PUBLIC CONTRIBUTION: A participatory research approach was used to co-design the campaign with members of Lesbian, Gay, Bisexual, Transgender and Queer+ (LGBTQ+) friendly organisations, LGBTQ+ student bodies, LGBTQ+ staff networks, LGBTQ+ sports clubs, men's health organisations, testicular cancer survivors, health policy makers, media and marketing experts and graphic designers.

Association between adjuvant radiation treatment and breast cancer-specific mortality among older women with comorbidity burden: A comparative effectiveness analysis of SEER-MHOS.

BACKGROUND: The National Comprehensive Cancer Network suggested that older women with low-risk breast cancer (LRBC; i.e., early-stage, node-negative, and estrogen receptor-positive) could omit adjuvant radiation treatment (RT) after breast-conserving surgery (BCS) if they were treated with hormone therapy. However, the association between RT omission and breast cancer-specific mortality among older women with comorbidity is not fully known. METHODS: 1105 older women (≥65 years) with LRBC in 1998-2012 were queried from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data resource and were followed up through July 2018. Latent class analysis was performed to identify comorbidity burden classes. A propensity score-based inverse probability of treatment weighting (IPTW) was applied to Cox regression models to obtain subdistribution hazard ratios (HRs) and 95% CI for cancer-specific mortality considering other causes of death as competing risks, overall and separately by comorbidity burden class. RESULTS: Three comorbidity burden (low, moderate, and high) groups were identified. A total of 318 deaths (47 cancer-related) occurred. The IPTW-adjusted Cox regression analysis showed that RT omission was not associated with short-term, 5- and 10-year cancer-specific death (p = 0.202 and p = 0.536, respectively), regardless of comorbidity burden. However, RT omission could increase the risk of long-term cancer-specific death in women with low comorbidity burden (HR = 1.98, 95% CI = 1.17, 3.33), which warrants further study. CONCLUSIONS: Omission of RT after BCS is not associated with an increased risk of cancer-specific death and is deemed a reasonable treatment option for older women with moderate to high comorbidity burden.

Racial and Ethnic Variations in Pre-Diagnosis Comorbidity Burden and Health-Related Quality of Life Among Older Women with Breast Cancer.

BACKGROUND: This study examined racial/ethnic differences in comorbidity burden and health-related quality of life (HRQOL) among older women before breast cancer diagnosis. METHODS: From Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) linked data resource, 2513 women diagnosed with breast cancer at ≥ 65 years between 1998 and 2012 were identified and grouped based on comorbidity burden using latent class analysis. Pre-diagnosis HRQOL was measured using SF-36/VR-12 and summarized to physical (PCS) and mental component summary (MCS) scores. The adjusted least-square means and 95% confidence intervals were obtained according to comorbidity burden and race/ethnicity. The interactions were examined with 2-way ANOVA. RESULTS: The latent class analysis revealed four comorbid burden classes, with Class 1 being the most healthy and Class 4 being the least healthy. African American (AA) and Hispanic women were more likely to be in Class 4 than non-Hispanic white (NHW) women (18.6%, 14.8%, and 8.3%, respectively). The mean PCS was 39.3 and differed by comorbidity burden and race/ethnicity (Pinteraction < 0.001). There were no racial/ethnic differences in Classes 1 and 2, while NHW women reported significantly lower PCS scores than AA women in Classes 3 and 4. The mean MCS was 51.4 and differed by comorbidity burden and race/ethnicity (Pinteraction < 0.001). There was no racial/ethnic difference in Class 3; however, AA women reported lower MCS scores than Asian/Pacific Islander women in Class 1, and AA and Hispanic women reported lower MCS scores than NHW women in Classes 2 and 4. CONCLUSION: Comorbidity burden negatively affected HRQOL but differentially for racial/ethnic groups. As the comorbidity burden increases, NHW women are more concerned with physical HRQOL, while AA and Hispanic women are more concerned with mental HRQOL.

A Call to Action to Review the USPSTF's Recommendation for Testicular Self-Examination.

We urge the United States Preventive Services Task Force (USPSTF) to call for a formal review of the evidence regarding testicular self-examination (TSE). Twelve years have since passed since the evidence was last formally analyzed where normally re-reviews occur in 5-year cycles. If they would decide to move forward with this action, we ask for the USPSTF to review their methods for establishing recommendations to optimize their rating system operationalization process. Finally, emerging evidence demonstrates a net positive effect of TSE. This stands in contrast to the assertions of TSE's supposed harm that is prevalent in the literature as well as the rationale behind the USPSTF's "D" rating of TSE.

Healthy Eating and Mortality among Breast Cancer Survivors: A Systematic Review and Meta-Analysis of Cohort Studies.

This systematic review examined the effect of diet quality, defined as adherence to healthy dietary recommendations, on all-cause and breast cancer-specific mortality. Web of Science, Medline, CINAHL, and PsycINFO databases were searched to identify eligible studies published by May 2021. We used a random-effects model meta-analysis in two different approaches to estimate pooled hazard ratio (HR) and 95% confidence interval (CI) for highest and lowest categories of diet quality: (1) each dietary quality index as the unit of analysis and (2) cohort as the unit of analysis. Heterogeneity was examined using Cochran's Q test and inconsistency I2 statistics. The risk of bias was assessed by the Newcastle-Ottawa Scale for cohort studies, and the quality of evidence was investigated by the GRADE tool. The analysis included 11 publications from eight cohorts, including data from 27,346 survivors and seven dietary indices. Both approaches yielded a similar effect size, but cohort-based analysis had a wider CI. Pre-diagnosis diet quality was not associated with both outcomes. However, better post-diagnosis diet quality significantly reduced all-cause mortality by 21% (HR = 0.79, 95% CI = 0.70, 0.89, I2 = 16.83%, n = 7) and marginally reduced breast cancer-specific mortality by 15% (HR = 0.85, 95% CI = 0.62, 1.18, I2 = 57.4%, n = 7). Subgroup analysis showed that adhering to the Diet Approaches to Stop Hypertension and Chinese Food Pagoda guidelines could reduce breast cancer-specific mortality. Such reduction could be larger for older people, physically fit individuals, and women with estrogen receptor-positive, progesterone receptor-negative, or human epidermal growth factor receptor 2-positive tumors. The risk of bias in the selected studies was low, and the quality of evidence for the identified associations was low or very low due to imprecision of effect estimation, inconsistent results, and publication bias. More research is needed to precisely estimate the effect of diet quality on mortality. Healthcare providers can encourage breast cancer survivors to comply with healthy dietary recommendations to improve overall health. (Funding: University of Central Florida Office of Undergraduate Research, Registration: PROSPERO-CRD42021260135).

A Cross-Sectional Analysis of Testicular Cancer Symptom Recognition and Stage of Diagnosis.

There is a need to further explore the relationship between atypical symptom reporting and stage diagnosis to help develop a clearer defined list of possible testicular cancer (TC) symptoms that could assist physicians diagnose the disease earlier. A cross-sectional study was employed to explore possible associations between TC symptom presentation and stage of diagnosis. An original 40-item survey was distributed among 698 TC survivors to determine the potential impact of several risk factors, experiences, and behaviors upon diagnosis. This analysis aimed to explore how certain patient-driven experiences (e.g., symptoms, perceptions, and behaviors) could serve as catalysts for seeking medical care for testicular health concerns. Experiencing hot flashes or having no symptoms had a positive association with later-stage diagnosis while change in shape had a significant negative association with later-stage diagnosis. While the logistic regression model explained relatively low variance in the data (R2 = .1415), it was statistically significant (χ2p < .001). Pain (odds ratio [OR] = 1.6524, p < .05), hot flashes (OR = 5.7893, p < .01), and no symptoms experienced (OR = 12.4836, p < .01) were all significant predictors of a more advanced stage diagnosis. The concern around uncommon/atypical symptoms are that they are indistinct and do not serve as clear signs that TC is present. However, perhaps in tandem with other more overt symptoms, their discovery can serve in a more confirmatory role for a suspect case. If observed with other uncommonly reported symptoms, these uncommon symptoms could provide another pathway in the TC diagnostic process. Clinical and patient education is warranted to increase awareness of uncommon TC symptoms.

The Association Between Testicular Self-Examination and Stages of Testicular Cancer Diagnosis: A Cross-Sectional Analysis.

Purpose: Testicular cancer (TC) is the most prevalent tumor diagnosed in men 15-40 years of age. Survivorship and quality of life dramatically decrease with late-stage diagnosis. Testicular self-examination (TSE) is a diagnostic method used to discover early-stage tumor incidence. This study examines the relationship between practicing TSE and stage of diagnosis for TC survivors. Methods: A cross-sectional study design was employed, a 40-item survey among TC survivors (n = 619). Bivariate analyses consisted of Spearman Rho correlations of all primary variables with stage diagnosis of TC. Multivariate analysis employed an ordered logistic regression to determine stage diagnosis predictors. Results: "Regular" TSE practice significantly related with awareness (r = 0.4533) and knowledge of (r = 0.4866) TSE, confidence performing TSE (r = 0.4961), and feeling shape/feel differences of the testicle before diagnosis (r = 0.2115). Factors that had a statistically significant negative association with later-stage diagnosis included awareness (r = -0.1180) and knowledge of (r = -0.1586) TSE, confidence performing TSE (r = -0.1138), and feeling shape/feel differences of the testicle before diagnosis (r = -0.2938), among others. Regular TSE practice significantly predicted decreased odds of later-stage diagnosis within the sample subset reporting delay (odds ratio = 0.1628; p < 0.05); however, there was no significant relationship between regular TSE practice and stage diagnosis within the other model variations. Conclusion: This exploratory analysis aimed to provide baseline evidence of the possible association between the practice of TSE and the stage of TC diagnosis, and therefore making an indirect claim that TSE has the potential to improve quality of life and decrease TC mortality, particularly among adolescents and young adults.

Marginalized Males, Disparate COVID-19 Outcomes, and Health Equity: A Profile of Highest Risk.

This paper is a direct response to Smith et al.'s (2020) call for more insight into health equity concerns pertaining to COVID-19 outcomes. The goal of this discussion is to offer the field with an evidence-informed 'avatar' representing the most-impacted group as it pertains to COVID-19 mortality and morbidity. Policy and practice implications are offered as a call to action for public health professionals to support these most impacted and highest risk communities.

Assessing Health-Related Quality of Life Among Survivors of Testicular Cancer: A Systematic Review.

This study aimed to determine if the current health-related quality of life (HRQoL) tools created for survivors of testicular cancer are collecting the highest quality of data via a two-step methodological critique of both the seminal studies that produced a survivor of testicular cancer HRQoL tool (Phase 1) and the actual tool itself (Phase 2). It is the goal of this current article to present and discuss Phase 1.A systematic review aimed to assess the methodological quality of studies conducted to create instruments used to measure survivors of testicular cancer HRQoL. Five reviewers independently assessed each study with the 20-item Appraisal Tool for Cross-Sectional Studies (AXIS). Inter-rater agreement and Fleiss' kappa was also assessed to ensure consistency in reported scores. Assessments for the EORTC QLQ-TC 26 and CAYA-T studies were low (AXIS 52.5%; IRA 95%; κ = 0.779) and fair (AXIS 65%; IRA 80%; κ = 0.599), respectively. Critical appraisal of the scales included issues within the three core AXIS domains. Primary concerns related to sampling methodology and the lack of a qualitative component of their core conceptual development phase.Both reviewed seminal studies have significant methodological concerns that question the tools' quality. Next steps include extensive appraisal of the psychometric properties of the EORTC QLQ TC-26 and the CAYA-T to complete the comprehensive review. Accurate and reliable data are necessary to understand survivor of testicular cancer HRQoL and assist in building the bridge of communication between health care professionals and survivors to help to improve patient outcomes.

Effects of Radiation Therapy and Comorbidity on Health-Related Quality of Life and Mortality Among Older Women With Low-Risk Breast Cancer: Protocol for a Retrospective Cohort Study.

BACKGROUND: The National Comprehensive Cancer Network Breast Cancer Guidelines Committee suggests that the omission of adjuvant radiation therapy (RT) after breast-conserving surgery can be a reasonable option among older women with low-risk breast cancer (early-stage, estrogen receptor-positive, and node-negative) if they are treated with endocrine therapy. However, RT usage in this group of women still exceeds 50%. Conversely, older women tend to forego RT (even when necessary) due to cost, inconvenience, and potential adverse responses associated with RT. Understanding health-related quality of life (HRQOL) change with receipt of RT among older women in the modern era is limited due to the under-representation of this population in clinical trials. OBJECTIVE: The proposed study aims to examine the associations of RT with HRQOL trajectories as well as survival outcomes among older women with 5-10 years of follow-up. We will also assess whether prediagnosis comorbidity burden influences receipt of RT and whether the associations between RT and HRQOL trajectory and survival outcomes are modified by the comorbidity burden. METHODS: We will use a retrospective cohort study design with the population-based Surveillance, Epidemiology, and End-Results database linked to the Medicare Health Outcomes Survey (SEER-MHOS). Older women (≥65 years) who were diagnosed with low-risk breast cancer in 1998-2014, received breast-conserving surgery, and participated in MHOS 1998-2016 are eligible for this analysis. The latent class analysis clustering method will be used to identify each patient's prediagnosis comorbidity burden, and HRQOL will be evaluated using the Short Form 36/Veterans RAND 12-Item Health Survey scales. The inverse-weighted estimates of the probability of treatment will be included to control for treatment selection bias and confounding effects in subsequent analysis. The association of RT with HRQOL trajectory will be evaluated using inverse-weighted multilevel growth mixture models. The inverse-weighted Cox regression model will be used to obtain hazard ratios with 95% CIs for the association of RT with survival outcomes. Differential effects of RT on both outcomes according to comorbidity burden class will also be evaluated. RESULTS: As of October 2020, the study was approved by the institutional review board, and SEER-MHOS data were obtained from the National Cancer Institute. Women with low-risk breast cancer who met inclusion and exclusion criteria have been identified, and prediagnosis comorbidity burden class has been characterized using latent class analysis. Further data analysis will begin in November 2020, and the first manuscript will be submitted in a peer-reviewed journal in February 2021. CONCLUSIONS: This research can potentially improve clinical outcomes of older women with low-risk breast cancer by providing them additional information on the HRQOL trajectories when they make RT treatment decisions. It will facilitate informed, shared treatment decision making and cancer care planning to ultimately improve the HRQOL of older women with breast cancer. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18056.

Profiles of Risk and Protection for Violence and Bullying Perpetration Among Adolescent Boys.

BACKGROUND: Violence and bullying perpetration among boys are major public health problems. We address gaps in the literature by examining: (1) how risk and protective factors co-occur, and (2) how different risk/protection profiles are associated with violence and bullying perpetration among adolescent boys. METHODS: Data came from the population-based 2016 Minnesota Student Survey. The analytic sample included boys in grades 8, 9, and 11 (N = 63,818). Latent profile analyses identified patterns of 22 behavioral, intrapersonal, family, and school and community risk/protective factors. Logistic regression analyses examined how these patterns related to violence and bullying perpetration. RESULTS: We identified 5 groups: Class 1: Low risk, high safety, high connectedness; Class 2: Low risk, moderate safety, moderate connectedness; Class 3: Moderate risk, high safety, moderate connectedness; Class 4: High risk, moderate safety, low connectedness; and Class 5: High risk, low safety, low connectedness. Compared to Class 1, Class 5 students had the highest odds of all for violence and bullying perpetration. Class 4 students also demonstrated high odds of violence and bullying, compared to Class 1. Though not as high as Classes 4 or 5, Class 2 and 3 students showed higher odds for both outcomes, compared to Class 1. CONCLUSIONS: Substantive variations exist in boys who engage in violence and bullying. We highlight cumulative, co-occurring risk factors, connectedness to parents and other prosocial adults (eg, teachers), and school and neighborhood safety as important factors to address in school health programs seeking to prevent violence and bullying perpetration among boys.

Testicular Cancer Incidence and Mortality Within Rural and Urban Regions.

Purpose: Testicular cancer (TCa) is among the most common cancers within adolescent and young adult (AYA) male populations. However, information is limited to variations in incidence and mortality outside of racial/ethnic subgroups. Rural regions historically have a greater overall cancer incidence than urban regions, although some key differences exist regarding site. TCa-specific incidence and mortality disparities are not commonly reported in this context. This study aims to help fill that gap by providing discovery evidence if there is an association between US rural/urban regions and TCa incidence and mortality. Methods: Secondary analysis of Surveillance, Epidemiology, and End Results incidence and mortality data were employed to determine if rural/urban TCa incidence and mortality disparities exist among U.S. males. Results: There was a 2.6% increased rate of TCa in U.S. urban as compared with rural geographic regions from 2011 to 2015. When geographic region is disaggregated, rural regions see higher rates than urban. When factoring in race/ethnicity, White/Caucasians and Hispanics had statistically higher urban rates whereas American Indian/Alaskan Natives and Asian/Pacific Islander groups had statistically higher rural rates. Conclusion: Geographic regional TCa variation research is virtually nonexistent for U.S. males, specifically AYAs of color. Determining preliminary trends in rural and urban regions can assist in the creation of more targeted services, particularly among underserved and vulnerable populations that have tenuous access to health care, to reduce disparate health outcomes. Exploring geographic differences in TCa incidence and mortality can have implications within service industry, health care accessibility, and public health justice areas of research and outreach.

The Connection Between Testicular Cancer, Minority Males, and Planned Parenthood.

Testicular cancer (TCa) is the most prevalent neoplasm diagnosed in males aged 15-40 years. Lack of access to care is a key impediment to early-stage TCa diagnosis. Health equity concerns arise, however, as poor access largely manifests within underserved male populations, therefore, placing them at a higher risk to develop late-stage TCa. Planned Parenthood Federation of America (PPFA) offers a myriad of male reproductive/sexual health care options, including TCa screening and referral services. Therefore, expanding these amenities in traditionally underserved communities may address the concern of TCa screening opportunities. An ecological analysis was performed using data from the United States Cancer Statistics, American Community Survey, and PPFA databases to assess the impact of TCa upon minority males, identify associations between PPFA services and minority males, and provide future implications on the role PPFA may play in bridging health-care access gaps pertaining to TCa screenings. Results indicate that states with higher rates of poverty and uninsured individuals, as well as specifically Black/African American males, have lower TCa incidence and limited access to screening services. PPFA service presence and Black/African American, as well as uninsured, males had a negative association but revealed positive correlations with TCa incidence. Considering the emerging TCa outcome disparities among minority males, expanding PPFA men's health services is crucial in providing affordable options to help identify testicular abnormalities that are early stage or carcinoma in situ. Many at-risk males have limited means to obtain TCa screening services. Expanding this discussion could provide a foundation for future advocacy.

USPSTF Testicular Examination Nomination-Self-Examinations and Examinations in a Clinical Setting.

In 2004, the U.S. Preventive Services Task Force (USPSTF) published a Grade D recommendation for both testicular self-examination (TSE) and clinical evaluation to screen for testicular cancer in asymptomatic males. This review committee reaffirmed these recommendations in 2009 and again in 2011 (Testicular Cancer: Screening Release Date: April 2011. Final Update Summary: Testicular Cancer: Screening. U.S. Preventive Services Task Force. September 2016). The 2011 USPSTF review found no significant evidence that would warrant a change from the last full review in 2004. We believe that the USPSTF erred in its assessments. As acknowledged in the task force report, testicular cancer is not believed to be preventable, and treatment of early detected testicular cancer is generally associated with very favorable outcomes; it is our belief therefore that every encouragement should be given to early detection. We are therefore requesting that the USPSTF review the D rating for testicular examination, both in a clinical setting and as self-examination. We are requesting this, as recent studies and public health warrant a change in grade. The new studies build on earlier studies that support the benefits of regular screening by individuals and their physicians. Further, and equally important, we believe that the current grade and attendant information confuses men and boys about the importance of self-care and wellness and continues to inadvertently reinforce negative cultural attitudes. We believe that adjusting the rating to a Grade B is both warranted and necessary.

Performing Testicular Self-Examination, Driving Automobiles, and Anxiety: What Is the Logical Link?

The debate of whether testicular self-examination (TSE) should be promoted among males generally centers on a harm-benefit corollary. The benefits of TSE include improving health outcomes, inclusive of an increase in both quality of life and knowledge/awareness of potential health concerns, as well as promoting proactivity in achieving wellness. The harms include claims that false-positive results can increase anxiety and produce costs via unnecessary treatments and therapies. Further claims point to the lack of evidence suggesting TSE decreases testicular cancer mortality. This commentary primarily discusses the anxiety portion of this debate from a logic-based perspective. The argument that TSE should not be promoted among males due to the risk of inciting false-positive anxiety appears to be flawed. A 5-point perspective is presented on the illogical discouragement of TSE due to theorized levels of false-positive anxiety while existing evidence suggests late-stage testicular cancer is associated with anxiety and depression.

Recommendations for Treating Males: An Ethical Rationale for the Inclusion of Testicular Self-Examination (TSE) in a Standard of Care.

The phrase "standard of care" is primarily a legal term representing what procedure a reasonable person (i.e., health practitioner) would administer to patients across similar circumstances. One major concern for health practitioners is delivering and advocating for treatments not defined as a standard of care. While providing such treatments may meet certain ethical imperatives, doing so may unwittingly trigger medical malpractice litigation fears from practitioners. Apprehension to deviate, even slightly, from the standard of care may (seem to) put the practitioner at significant risk for litigation, which, in turn, may limit options for treatment and preventive measures recommended by the practitioner. Specific to testicular treatment, certain guidelines exist for cancer, torsion, vasectomy, and scrotal masses, among others. As it relates to screening, practitioner examination is expected for patients presenting with testicular abnormalities. Testicular self-examination (TSE) advocacy, however, is discouraged by the U.S. Preventive Services Task Force, which may prompt a general unwillingness among health practitioners to promote the behavior. Considering the benefits TSE has beyond cancer detection, and the historical support it has received among health practitioners, it is paramount to consider the ethical implications of its official "exclusion" from preventive health and clinical care recommendations (i.e., standard of care). Since good ethics should lead practitioner patient care guidelines, not fear of increased malpractice risks, we recommend the development of a standard of care for counseling males to perform TSE.

Developing the "Control Identity" Typology to Create More Effective Testicular Health Promotional Messaging.

Testicular self-examination (TSE) promotional interventions historically operate without a theoretical framework, which negatively influences their effectiveness. As TSE is critical to the early detection of testicular cancer, this behavior is an essential component to improving overall male well-being. To address this need, the Control Identity personality typology was developed to assist in creating more effective TSE promotional interventions. Four outcome control dispositions were defined a priori based on the dimensions of illusions of control and locus of control. An original 41-item survey, the Control Identity Assessment Scale, was used to assess perceived vulnerability, value of health promotion, and health outcome control among a convenience sample of 300 university males aged 18 to 35 years via a cross-sectional research design. Factor and cluster analyses were employed to extract salient factors in the data and to identify subgroups within the sample. A consistent five-factor structure matrix (~70% explained variance) served as the foundation from which a k-means cluster analysis was employed to classify four types of individuals. Significant differences were detected between clusters on primary variables, including behavioral intentions to conduct TSE. The Control Identity typology aims to provide the needed mechanism for health practitioners to create more effective preventive health messaging to promote TSE. Future implications on employing this typology to segment audiences in order to increase overall effectiveness are offered. Application of this typology could ultimately lead to increasing TSE knowledge retention, behavioral intentions, actual performance, and adherence.