Although there is no expert consensus on screening for TC, early detection is associated with smaller tumor size at presentation, higher curability, and reduced treatment costs (10). There is no high-level evidence to support screening programs (11, 12). However, the AUA, EAU, and ACS advise monthly self-examination in men with risk factors (personal or familial history of TC, cryptorchidism) since stage and prognosis are related to early diagnosis (2, 5), and the ACS details how TSE should be performed (13). Therefore, the primary purpose of strategies to prevent TC should be the implementation of educational programs designed to increase awareness and knowledge about the risk factors of TC and the practice of TSE in higher-risk men (14).
We launched this online awareness campaign using social media during the COVID-19 pandemic to prevent the spreading of the virus. We used the online survey method for data collection because it offers easy access to respondents, rapid data collection with low cost, particularly with large samples, and enables the construction of random samples avoiding selection bias (15). To optimize the patients' responses, we used an e-mail pre-notification to invite them to participate in the study, a reminder to complete the survey, a semi-automatic log-in, a simple design, and a short survey that takes less than 10 minutes (16). We also sent a personalized phone message for all male students, with a small explicative text and a link to the survey, because a personalized approach was shown to produce significantly higher response rates (17).
We got a response rate of 28.95%, which is relatively low but common in web-based surveys in specific populations (students in our study), and comparable to the literature (15). We had good participation from all faculties, reflecting that the subject interested all young men, regardless of their specialties. The low rate of nursing students' responses (0.4% of total responses) can be explained by the low ratio of men to women in this school (a total of 8 male students in the nursing faculty, with 3 respondents).
The lack of education about testicular cancer in schools, universities, and mass media was apparent, with low rates of correct identification of the risk factors (13%), exposure to previous awareness (14%), and previous testicular examination by a HCP (31%). This poor knowledge about TC and TSE was also found in the systematic review of Saab et al., which included 25 articles and had the same research question (18).
Family history was not associated with an increased practice of TSE, in contrast to the results of June et al., who found a significant association between familial TC and family members' awareness (19). This finding underlines the importance of focusing education on the risk factors.
Higher knowledge scores were associated with increased TSE, and previous awareness and education on TC were positively and significantly associated with the practice of TSE on bivariate and multivariate analysis. Ryszawy et al (20) reported the same finding, which raises the importance of implementing awareness campaigns to increase the knowledge of men concerning TC.
Medical students were the only students with significant practice of TSE. This finding is in line with the previous work of Yazici et al. (21) and highlights the importance of targeting non-medical students.
Our method, using SM exclusively for awareness, increased the level of engagement of men and doubled the rate of self-examination, which is a crucial element in early detection. Almost all the participants found this virtual awareness campaign good. It stimulated 43% to transmit knowledge to others, which means an exponential spreading of awareness. Our results are comparable with previous studies about the effect of SM on cancer awareness (22). It allows the dissemination of health messages rapidly and at a low cost to large numbers of people across large geographical areas (23). Although SM improves attitudes and practices related to health (24, 25), there is little evidence about whether it improves cancer screening and early diagnosis (26, 27). Older adults are usually largely obscured in SM representation of cancer and cancer experience (25). However, this is not an issue for consideration, particularly for TC, since the targeted population is young men, the biggest users of social media (24).
Our study had several limitations. First, it is a single institution study which limits its generalizability. Second, we could not analyze the non-response bias since the survey was anonymous. However, if data collection were not anonymous, the response rate would probably have been lower since there are questions about personal and family history of TC and TSE, which are still taboo in our middle eastern society (relating to fertility and masculinity themes). Third, the beneficial effect of this campaign on the practice of TSE was only evaluated in the short term. Long-term observation is needed to evaluate its effect in the long term.