Topics relating specifically to men’s health are arguably the least publicised and most ignored of any of the major healthcare issues. Whereas there appears to be a multitude of books, clinics and self-help groups on subjects affecting women, adolescents and infants, libraries and health centres can be remarkably bereft of similar resources for men.

While a study into male health in the community remains beyond the scope of this essay, the intention is to focus in on one condition in particular, and discuss it within the context of the primary health care team, and its roles in the management of the disorder.

Most cancers, including those of the lung and breast can affect both men and women. A few, however, only affect one gender and, just as cervical cancer can, obviously, only affect women, so there are three main cancers that only affect men; they are prostate cancer, testicular cancer and penile cancer. Of these, testicular cancer is by far the most common form of cancer in young men up to the age of 35 (Blank, 1998) and it is on this, and to this age group, that the essay will focus.

Public awareness of testicular cancer is growing, partly owing to the increasing incidence of the cancer in itself (SIGN, 1998), but also, sadly, due to high profile cases such as the jockey, Bob Champion (Bob Champion Cancer Trust, 1998) and, more recently, the death of Shetland fiddler, Michael Ferrie (Fraser, 1998). Television serial, "Hollyoaks", is also tackling the issue at the time of writing ("Hollyoaks", 1998).

The cause, or causes, of testicular cancer are unknown, though there is a correlation between men who had a maldescended testicle in infancy, and those who later develop testicular cancer (American Cancer Society, 1998). There is no solid evidence to suggest that trauma, such as sports injury, increases the likelihood of developing the cancer (Slevin, 1990).

There are two types of testicular tumours – teratomas and seminomas – although to the young man who has just been diagnosed as having the cancer, any differences are academic as the main treatment for both is the same – removal of the testis (orchidectomy). Any further treatment will then be determined by the type of growth, and whether it has spread to other parts of the body (metastases).

"Due to the... variable, complex and toxic treatments, it is imperative that the patient’s general practitioner and other community services are well informed and involved throughout treatment and follow-up" (SIGN, 1998, p2)

Although treatment of testicular cancer is largely confined to non-primary health care services, such as specialist oncology units, the GP and nursing professionals in the community are usually the "first-line" in the presentation of testicular growths. They will also need to be involved in certain aspects of the subsequent diagnosis and treatment of the cancer.

The primary health care team is typically considered to be those core members of the community health care team with which most members of the public will deal during the courses of their lives. They are often all based at the same health centre or medical practice, and act as a first contact between the public and other health professionals.

Generally, and for the purposes of this essay, the primary health care team is deemed to consist of the general practitioner, district nurse, health visitor and practice nurse.

However, other professionals may also be considered part of the primary team. These include the practice manager and the GP receptionist, who is usually the first port of call for all patients. School nurses, dentists and community practice nurses (CPN’s) may also be perceived in this role of primary health care provider.

Primary health care input into the issue of testicular cancer can be classified under four broad categories: initial presentation; health education; counselling and advice; and home nursing.

The GP is usually the first point of contact when a young man presents with any symptoms which may, or may not, prove to be testicular cancer. Most presentations will exhibit the common symptoms of a lump or swelling in the testis, accompanied by a dull pain in the groin (Blank, 1998) and possibly inflammation (SIGN, 1998).

The GP will then refer any suspected testicular growths for an ultrasound scan and urological assessment and, if he or she feels it necessary, to an oncology specialist (SIGN, 1998).

By far the major portion of community involvement with testicular cancer is concerned with health education, and promoting awareness of the condition.

"There is evidence to suggest that delay in presentation is more of a problem than delay in referral." (SIGN, 1998, p2)

It is therefore crucial that public awareness of the risks of testicular cancer, and the means for early detection, is as high as possible.

Just as self-examination of the breast is a significant factor in early detection of breast cancer, so it is argued that testicular self-examination (commonly referred to as TSE) is one of the best ways to detect testicular cancer while still in the early stages (American Cancer Society, 1998). This is particularly true when it is considered that testicular cancer is one of the few cancers that has a high cure success rate if treatment is started early, even if it has metastasised (Slevin, 1990).

The ideal would be for nurse led clinics to promote self-examination, although in practice many men are reluctant to attend well-man style clinics, even when such services are provided.

Nowadays, it is common for some school nurses and social education teachers to promote self-examination in the school setting, especially between the ages of 15 and 18. It could be argued, as with many matters, that this is too young to begin teaching about such topics and under the Education Act 1993, the parent of the young man has the right to remove them from any such classes (Koshti-Richman, 1996). However, youths as young as 15, and even younger, can be considered at risk and so many believe that it is best to teach this skill as early as possible.

However, there is also evidence to suggest that teaching self-examination at all could lead to an increase in the number of people who may worry if they "find" a lump, which may be perfectly normal, for example if there has been previous trauma. It has been argued that this unnecessary anxiety, coupled with relatively high numbers of avoidable operations compared to those who actually turn out to have a testicular malignancy, perhaps makes self examination not as worthwhile as has been suggested (Morris, 1996).

Nevertheless, testicular self-examination remains the "best hope for early detection of testicular cancer" (American Cancer Society, 1998).

With early detection a high priority, it is also important that men understand the significance of early detection, and not just how to go about it. The statistics show that the five year survival rate is actually nearing 100 per cent in cases which are caught early (American Cancer Society, 1998). As such, the community health care team should also be promoting the importance of doing something about suspected testicular growths. Many men are very reluctant to visit their doctors, and will only do so under pressure from partners and peers.

It is, therefore, part of the primary health care team’s role to also promote use of health centres and medical practices in general. The setting up of men’s health clinics, where a man can perhaps be assured of speaking to a male member of staff, be they doctor or nurse, can only go so far in addressing this problem. Particularly in the younger age group primarily affected by testicular cancer, there is a feeling that matters involving urinary and / or sexual health are a very personal and private, even embarrassing, concern. Again, this is where social and sexual education at school can help to overcome such prejudices. Otherwise, the members of the team can only do their best to encourage regular check-ups and the like.

The health visitor is probably the best person to help here. It is often the case that the health visitor will have contact with a family over a period of many years, and it is not uncommon for her or him to be dealing with the two year screening of one child and the pre-school check-up of another sibling, while the oldest boy in the family is in his teens. Here, the health visitor will still have contact with such young men, and be able to offer advice, as well as having contacts within the primary health care team for other resources relating to men’s health.

All members of the primary health care team should also have a knowledge and awareness of other resources on which they can draw.

Agencies such as the British Association of Cancer United Patients (BACUP) provide information and various publications on various types of cancer. BACUP, the Tayside Area Cancer Support group (TACS) and other similar agencies offer support and advice to cancer patients and their families and friends. It is important that the health care team members dealing with cancer patients are aware, not only that such groups exist, but also the differences between them so that the correct information can be given to the patients. It would be unwise just to hand a patient a telephone number or address if the health care professional himself does not know what the organisation offers.

The media, too, can be very useful in health promotion. Although, as previously mentioned, "Hollyoaks" is the first television "soap" to specifically cover fears about testicular cancer ("Hollyoaks", 1998), other series are well-known for covering health issues, most notably meningitis and HIV, in a sensible manner.

Prominent figures, like Bob Champion and Michael Ferrie, can also raise the profile of a condition. This was seen most recently when Linda McCartney tragically died from breast cancer.

Although, organisations like BACUP and TACS offer advice and counselling services, the first contact of a patient is going to be the members of the primary health care team, particularly the GP but also, perhaps, the health visitor or district nurse. Again, these people must know about other counselling services, but in the first instance, they will have to offer as much support and encouragement as they can.

They must be aware of referral procedures for services such as MacMillan Nursing and TACS, and also provide advice on who else might be able to help, including ministers and priests and hospital-based counsellors. For example, within Dundee Teaching Hospitals there is a "Patient Advisor", trained in body image counselling who can talk about altered body image with patients who have had mastectomies, orchidectomies and other body altering surgery.

It is also partly up to the community team to identify, in advance, any stressors which may lead to further emotional distress, and to approach these with the patient in order to overcome them before they become a problem (Servellen, 1996)

Issues likely to particularly affect testicular cancer patients include altered body image, sexual aspects and fears over other, non-surgical, treatments, including radiotherapy and chemotherapy.

Orchidectomy is a fairly radical alteration of a young man’s body and he is likely to have many worries. Although a prosthesis of similar shape, size and texture is always offered, the patient may feel uncomfortable with the thought of only having one testicle. He may feel unable to continue with a normal sex life. It is the job of the health care professional to allay any such fears, as full sexual activity is perfectly possible after surgery and recovery.

Most patients will also be offered the opportunity to bank their sperm, in case of further problems, or, for example, if chemotherapy is required, which would temporarily lower the sperm count. This may raise moral doubts within the patient’s mind and he may turn to a well-kent GP, rather than a hospital-based counsellor, to talk over such problems. In these situations, the GP, or community nurse, will need all their listening and communication skills in order to help talk through the issues.

Chemotherapy and radiotherapy are both very toxic and potentially life-altering treatments. The side effects are many and varied and include nausea, lethargy and hair loss (Slevin, 1990). Hair loss can be particularly traumatic for the young man in his early twenties, and he may wish just to talk to someone about it. He may also want advice on using hats or wigs to cover up his hair loss.

Practical advice is one of the areas where all health professionals are expected to be knowledgeable. If the GP or nurse cannot help personally, then they should try and find out who can help, in both statutory and non-statutory services, and where they can get more information if needed. Resource centres, such as the Caring and Disability Information Centre and The Corner Young People’s Project, both in Dundee, can help with practical advice on State Benefits, Sick Pay and the like.

With testicular cancer being one of the more curable cancers, home nursing is seen quite rarely. However, in late diagnosed cases and where the prognosis is poor, some cancer patients may require physical, as well as psychological and social support. Particularly if the cancer has spread to other parts of the body, some district nurse, or Marie Curie nurse support may be required (Dundee Healthcare NHS Trust, 1996). Again, in the age group studied, most patients will be fully independent as regards drug regimen compliance and so on. However, referrals for independence promoting aids such as the Nomad dispensing system may need to be made.

Chronic pain control is rarely needed in testicular cancer cases, but where it is, the nursing team must be able to advise accordingly. Syringe drivers may need to be ordered and used, although, again, most patients will be independent as regards their use.

Many cancer patients turn to complementary therapies for pain relief, and even just relaxation and the community nurse may be asked about various methods. He or she may even use certain techniques such as therapeutic massage, and introduce them into the treatment. However, it should be remembered that alternative therapies are just that and should in no way replace the very successful "conventional" forms of treatment.

Various complementary therapies that have been used in the care of testicular cancer include reflexology, kinesiology and therapeutic massage for pain control (Izod, 1996), and some Chinese medicines and shark cartilage in the actual treatment of the tumours (Bell, et al, 1996). Why shark cartilage should have any effect on the cancer is unknown, but it does seem to have a therapeutic effect on some people (Brewer, 1998).

The community nurse also has the responsibility for, and must be aware of how to make, referrals to statutory home services such as Crossroads and Meals on Wheels, should they be needed and liaise with these services where necessary.

Unfortunately, these ideals of primary health care involvement are rarely seen in their entirety in practice.

Men are notoriously reluctant to attend their GP practice anyway and so the input that the community team could have is lessened from the outset. This is also a primary factor in why few health centres run dedicated men’s health clinics, resulting in a vicious circle where men’s health is, apparently, largely ignored.

Testicular cancer illustrates this rather well. Although it is recognised as the most common cancer in the age group selected (15 – 35), there is surprisingly little in the way of public health promotion aimed at reducing its incidence. Consequently, there is also a lack of relevant research in the nursing and medical journals, although this situation has been changing over the last few years.

More positive is the fact that more and more nurses are recognising this reality and men’s health is being slowly given a higher profile and a greater priority. It may not be the described "ideal" situation in any one given medical practice, but the resources are there elsewhere in the community and it is largely up to the primary health care team to utilise them.

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