More than 8,000 men in the United States are diagnosed with testicular cancer each year. The disease is often curable even when at an advanced stage. To find out what men should know about testicular cancer, Cancer.Net talked with Larry Einhorn, MD, a medical oncologist who treated cyclist and seven-time Tour de France champion Lance Armstrong and Olympic swimmer Eric Shanteau, both survivors of testicular cancer. Dr. Einhorn has been credited with major advances in the treatment of testicular cancer, including the use of platinum-based chemotherapy.
Q: What are some signs and symptoms of testicular cancer?
A: The most common symptoms are pain, swelling, or feeling a mass in either testicle. These are symptoms of the disease in the testicles itself. If the cancer spreads to abdominal lymph nodes, it could also cause abdominal or back pain, usually flank pain on the side where the cancer had spread. Testicular cancer can secrete a hormone, human chorionic gonadotropin (hCG). When the hCG levels are very elevated, it can produce breast tenderness and breast enlargement.
Q: What are some factors that can raise a man’s risk of developing testicular cancer?
A: The only known factors are being born with one or both undescended testicles (a condition called cryptorchidism) or having a previous testicular cancer. If an infant is discovered to have an undescended testicle, a surgical procedure is usually done to find the undescended testicle and properly place it back in the scrotum (sac-like pouch where the testicles are located). Even with this procedure, there still is an increased risk of testicular cancer.
Patients who are cured of testicular cancer are at risk of developing a second independent testicular cancer on the other side. That risk is only 1% for the life of the patient. However, since in the general population this is a relatively rare disease, and only one out of 400 men during their lifetime get testicular cancer, this does represent an increased risk for developing testicular cancer on the opposite side.
Q: What should younger men know about testicular cancer?
A: Lance Armstrong went public in 1996 when he was diagnosed with testicular cancer to increase public awareness, so that young men would be aware that there is such a disease as testicular cancer. Knowing the signs and symptoms, as listed above, are important. If a young man (typical age group for testicular cancer is 15 to 35) feels a lump or pain in one of his testicles, he should see his doctor.
Q: What are some common treatment options for testicular cancer?
A: Treatment options vary depending on the stage of the disease. If the cancer is seminoma (a relatively slow-growing type of testicular cancer) and is stage I (a small tumor that has not spread), and the man has a normal medical history and physical examination; normal abdominal, pelvic, and chest computed tomography (CT) scans, and a normal serum level of hCG and alphafetoprotein (AFP, a blood protein), the most common option is close observation (active surveillance). Other options include radiation therapy to the appropriate abdominal lymph nodes, or a single day of a chemotherapy called carboplatin (Paraplat, Paraplatin).
If a patient has stage I non-seminoma (a faster growing type of testicular cancer), the three options are active surveillance, retroperitoneal lymph node dissection (RPLND, removing the lymph nodes near the back of the abdomen), or one course of chemotherapy with a three-drug regimen referred to as BEP (bleomycin [Blenoxane] + etoposide [VePesid, Etopophos, Toposar] + cisplatin [Platinol]). If an RPLND is performed, this should preferably be done by a urologic oncologist with experience in this type of surgery.
A patient with stage II seminoma (shown by enlarged abdominal lymph nodes on the abdominal [CT] scan) is treated with either radiotherapy or chemotherapy, depending upon the size of the lymph nodes. For non-seminoma, the treatment is either RPLND or chemotherapy, depending upon the size of the lymph node and whether hCG and AFP levels have reverted to normal after an orchiectomy (removal of a testicle).
For stage III disease, this means that there is disease above the diaphragm, either in lymph nodes between the lungs or lymph nodes in the neck, or disease that has spread to the lungs. In these instances, the only option is chemotherapy. The type and duration of chemotherapy depends on several factors.
Q: What are some research and treatment advances in testicular cancer?
A: Fortunately, 95% of men who are diagnosed with testicular cancer will be cured. Research and treatment advances continue to look at better defining men who can be comfortably observed with clinical stage I disease, improving results with second-line or third-line chemotherapy for men not cured with their initial BEP or similar chemotherapy, and developing improvements in supportive care for side effects, such as chemotherapy-induced nausea and vomiting.
Q: What should men with testicular cancer know about fertility, and what questions should they ask their doctor?
A: When a young man is diagnosed with testicular cancer, he will often have a low sperm count because of the cancer itself and even before the orchiectomy. Interestingly, sometimes the diagnosis of testicular cancer is first suggested because a couple is unable to conceive. The wife is found to be healthy, but the husband is found to have a mass in a testicle due to testicular cancer, and the infertility is due to the cancer itself. If an RPLND is to be performed, it is important that a nerve-sparing RPLND be done by an expert urologist who is experienced with this procedure. When done in capable hands, close to 100% of patients will have normal ejaculation and little or no impairment in fertility (ability to father a child) after an RPLND. When chemotherapy is necessary, 60% of the men will recover their sperm count to a normal level and have no problems with fertility. However, it takes at least a year for recovery to occur. The lower the sperm count at the start of chemotherapy, the lower the probability the sperm count will completely return spontaneously. Therefore, most patients should be offered sperm banking prior to starting chemotherapy.
Q: What other issues should men be aware of after finishing treatment for testicular cancer?
A: Men should be aware, as mentioned above, that there is a 1% chance of getting cancer in the remaining testicle. We recommend self-examination of the remaining testicle on a weekly basis. Pursuing a healthy lifestyle is important for everyone and perhaps even more so for someone who has received chemotherapy for testicular cancer. This includes quitting smoking, regular exercise, and avoiding obesity. Because there is a small chance of recurrent metastatic testicular cancer despite chemotherapy, regular follow-up with their treating oncologist is done, not just for the first five years, but annually thereafter.
Dr. Einhorn is Distinguished Professor, Department of Medicine, Division of Hematology/Oncology at Indiana University School of Medicine and is the Lance Armstrong Foundation Chair in Oncology. Dr. Einhorn is a past president of ASCO and is a member of The ASCO Cancer Foundation Board of Directors.
More Information
Cancer.Net Guide to Testicular Cancer
Fertility and Cancer Treatment
What to Know: ASCO’s Guideline on Fertility Preservation
Survivorship
Last Updated: August 19, 2009
