Single Centre Audit of Testicular Examination Practice in Children with Acute Lymphoblastic Leukaemia

Introduction

The second commonest site of extramedullary relapse in boys with acute lymphoblastic leukaemia (ALL) is the testes. As therapy stratifications based on minimal residual disease (MRD) reduce marrow relapses, testicular relapses are becoming relatively more frequent. Currently the only strategy to detect testicular relapse is regular clinical and self examination. Based on previous UK protocols timing of testicular relapses, our centre policy is to perform testicular examinations monthly whilst on maintenance treatment and at each clinic visit until 2 years off treatment. After this time we encourage monthly self/parent examination. Parents, boys, medical and nursing staff are on occasions reluctant for this examination. We performed an audit to evaluate our practice and assess areas to improve testicular relapse detection.

Methods

We retrospectively audited 46 patient records which included 322 consultations over a 6 month period (December 2015 to May 2016) in male patients with ALL. 30 patients (232 consultations) were on maintenance treatment and 16 patients (90 consultations) were within 2 years off treatment. To assess factors and potential barriers to examination, data was collected on age of patient (age 11 and under/age 12 and over), gender of examiner and profession of examiner (Doctor/Advanced Nurse Practitioner (ANP)) in patients on maintenance or off treatment. Differences in testicular examination rates were analysed by chi-squared testing.

Results

Only 4 of the 46 patients had monthly testicular examinations. 24 were not examined at all over a 6 month period. Of the 322 consultations, 42 had documented testicular examinations (13%). Patients off treatment (26 of 90 consultations) were significantly more likely to be examined than patients on maintenance treatment (16 of 232 consultations), (p < 0.0001). There was no significant difference between doctors (10 of 126 consultations) and ANPs (6 of 106 consultations) in patients on maintenance treatment, (p=0.50). More ANPs documented testicular examination (23 of 55 consultations) in patients off treatment than doctors (3 of 35 consultations), (p = 0.0007). Male examiners (11 of 74 consultations) were significantly more likely to document testicular examination in patients on maintenance treatment than female examiners (5 of 158 consultations), (p = 0.001). In patients off treatment, there was no significant difference between male examiners (3 of 15 consultations) and female examiners (23 of 75 consultations), (p=0.41). There was no significant difference between incidence of examinations in children aged 11 and under (13 of 181 consultations) and children aged 12 and over (3 of 51 consultations) on maintenance treatment, (p=0.75). In patients off treatment, children aged 11 and under (23 of 62 consultations) were significantly more likely to be examined than children aged 12 and over (3 of 26 consultations), (p=0.02).

Conclusions

Currently our testicular examination rates are very poor and practice is not adhering to hospital guidance. Male examiners were more likely to perform testicular examinations than female examiners on children on maintenance treatment, however all rates were poor. ANPs were more likely to perform testicular examination than doctors on children off treatment. This may be affected by trainee doctors, not consultants in these clinics. Improved incidence of testicular examination in patients off treatment is maybe due to the clinic pro-forma specifying to document testicular examination, or a difference in clinic focus. In patients off treatment children aged 11 and under were more likely to be examined than those aged 12 and over, highlighting increasing age as a possible barrier. Testicular examination is an area where staff are often hesitant due to the sensitive and intimate nature of the examination. Barriers may include concerns over patient embarrassment, staff embarrassment and time pressures in clinic.

Recommendations

1. Training update for examiners regarding importance of performing testicular examination monthly

2. Pro-forma modification to specify documentation of testicular examination on maintenance treatment

3. Patient/parent teaching of the rationale and importance of testicular examination to improve understanding and normalise the expectation of this examination

4. Re-audit following implementation of afore mentioned recommendations