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Testicular Cancer - Introduction

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Testicular Cancer. Use the menu to see other pages. Think of that menu as a roadmap for this complete guide.

Testicular cancer begins when healthy cells in a testicle change and grow out of control, forming a mass called a tumor. A cancerous tumor is malignant, meaning it can spread to other parts of the body.

Another name for testicular cancer is testis cancer.

About the testicles

The testicles are part of a man’s reproductive system. Normally, each man has 2 testicles, and they are located under the penis in a sac-like pouch called the scrotum. They can also be called testes or gonads. The testicles produce sperm and testosterone. Testosterone is a hormone that plays a role in the development of a man’s reproductive organs and other masculine characteristics.

About testicular cancer

Most types of testicular cancer develop in the sperm-producing cells known as germ cells and are referred to as germ cell tumors. Germ cell tumors in men can start in several parts of the body:

  • The testicles, which is the most common location

  • The back of the abdomen near the spine, called the retroperitoneum

  • The central portion of the chest between the lungs, called the mediastinum

  • The lower spine

  • Very rarely, a small gland in the brain called the pineal gland

Testicular cancer is almost always curable if found early, and it is usually curable even when found at a later stage.

Types of testicular cancer

There are 2 main categories of germ cell tumors that start in the testicles.

  • Seminoma. A tumor is only called a seminoma if it is 100% seminoma. This means that the cancer does not include any of the types of tumor listed below.

  • Non-seminoma. A non-seminoma contains at least 1 of the following types of tumor:

    • Choriocarcinoma

    • Embryonal carcinoma

    • Yolk sac tumor

    • Teratoma

Each of these can occur alone or in any combination. Most non-seminomas are a mix of at least 2 different subtypes of germ cell tumor. Non-seminomas may also be partly seminoma at any percentage level less than 100%. For example, a tumor that is 99% seminoma and 1% yolk sac tumor is still diagnosed and treated as a non-seminoma.

Generally, non-seminomas tend to grow and spread more quickly than seminomas, but prompt diagnosis and treatment are important for both types of tumors.

Other, less common types of testicular tumors include:

  • Leydig cell tumor

  • Sertoli cell tumor

  • Carcinoma of the rete testis, which is a part of the testicles

  • Testicular lymphoma

This article provides information only on seminoma and non-seminoma of the testicles in men who have reached puberty. Testicular cancer is uncommon in boys who have not yet reached puberty. Childhood testicular cancer that occurs before puberty is treated differently than cancer that develops after puberty in teenagers and adults.

Other types of cancer, such as lymphoma and leukemia, occasionally spread to the testicles. To find out more about cancer that started in another part of the body and spread to the testicles, read about that specific type of cancer.

Looking for More of an Introduction?

If you would like more of an introduction, explore the following item. Please note that this link will take you to another section on Cancer.Net:

  • ASCO Answers Fact Sheet: Read a 1-page fact sheet that offers an introduction to testicular cancer. This free fact sheet is available as a PDF, so it is easy to print out.

The next section in this guide is Statistics. It helps explain the number of people who are diagnosed with testicular cancer and general survival rates. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Statistics

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will find information about the number of men who are diagnosed with testicular cancer each year. You will also read general information on surviving the disease. Remember, survival rates depend on several factors. Use the menu to see other pages.

This year, an estimated 9,560 men in the United St ates will be diagnosed with testicular cancer. About 1 out of 250 men and boys will be diagnosed with the disease during their lifetime. The average age of diagnosis is 33.Testicular cancer is very rare before puberty and becomes more common afterward. It is most commonly diagnosed in young and middle-aged men but can occur at any age, with 6% of cases are diagnosed in boys and adolescents and 8% of cases are diagnosed in men 55 or older.

For unknown reasons, the number of testicular cancer cases has increased for the past 40 years. However, the rate of increase has slowed down recently. Death rates also slowly declined from 1990 to 2014.

It is estimated that about 410 deaths from this disease will occur this year. These deaths are either from cancer that spread from the testicles to other parts of the body and could not be effectively treated with chemotherapy, radiation therapy, and/or surgery or from complications from treatment.

The 5-year survival rate tells you what percent of men live at least 5 years after the cancer is found. Percent means how many out of 100. The general 5-year survival rate for men with testicular cancer is 95%. This means that 95 men out of every 100 men diagnosed with testicular cancer will live at least 5 years after diagnosis.

The survival rate is higher for men diagnosed with early-stage cancer and lower for men with later-stage cancer. For men with cancer that has not spread beyond the testicles (Stage 1; see Stages), the survival rate is 99%. Approximately 68% of men are diagnosed at this stage.

For men with cancer that has spread to the lymph nodes in the back of the abdomen, called the retroperitoneal lymph nodes, the survival rate is about 96%. But, this depends on the size of the lymph nodes with cancer. For men with cancer that has spread outside the testicles to areas beyond the retroperitoneal lymph nodes, such as to the lungs or other organs, the survival rate is 74%. About 11% of testicular cancer is diagnosed at this stage.

It is important to remember that statistics on the survival rates for men with testicular cancer are an estimate. The estimate comes from annual data based on the number of men with this cancer in the United States. Also, 5-year survival estimates are based on information that is at least 5 years old. So the estimate may not show the results of better diagnosis or treatment available for less than 5 years. Talk with your doctor if you have questions about this information. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's (ACS) publications, Cancer Facts & Figures 2019 and Cancer Facts & Figures 2017: Special Section – Rare Cancers in Adults, and the ACS website (January 2019).

The next section in this guide is Medical Illustrations. It offers drawings of body parts often affected by testicular cancer. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Medical Illustrations

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGEYou will find a drawing of the main body parts affected by testicular cancer. Use the menu to see other pages.

This illustration shows a cross section of a man’s testicle, or testis, which is a rounded organ, located under the penis in a sac-like pouch. At the top of each testis is the epididymis, a tightly coiled tube. The head of the epididymis connects to the testis through a series of ducts, ductuli efferentes, ending at the mediastinum. The tail of the epididymis connects to the ductus deferens. The spermatic cord surrounds the epididymis and ductus deferens and the blood vessels that nourish the testis. Copyright 2004 American Society of Clinical Oncology. Robert Morreale/Visual Explanations, LLC.

The next section in this guide is Risk FactorsIt explains the factors that may increase the chance of developing testicular cancer. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Risk Factors

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will find out more about the factors that increase the chance of developing testicular cancer. Use the menu to see other pages.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. Knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors can raise a man’s risk of developing testicular cancer. However, it is important to note that the cause of testicular cancer is not known.

  • Age. More than half of the men who are diagnosed with testicular cancer are between age 20 and 45. However, men of any age can develop this disease, including men in their teens and in their 60s, so it is important that any man with symptoms of testicular cancer visit the doctor.

  • Cryptorchidism. Cryptorchidism is an undescended testicle, meaning that 1 or both testicles do not move down into the scrotum before birth as they should. Men with this condition have an increased risk of developing testicular cancer. This risk may be lowered if surgery is used to fix the condition before puberty. Some doctors recommend surgery for cryptorchidism between ages 6 months and 15 months to reduce the risk of infertility. Infertility is the inability to produce children. Because cryptorchidism is often fixed at a young age, many men may not know if they had the condition.

  • Family history. A man who has a close relative, particularly a brother, who has had testicular cancer has an increased risk of developing testicular cancer.

  • Personal history. Men who have had cancer in 1 testicle have an increased risk of developing cancer in the other testicle. It is estimated that out of every 100 men with testicular cancer, 2 will develop cancer in the other testicle.

  • Race. Although men of any race can develop testicular cancer, white men are more likely than men of other races to be diagnosed with testicular cancer. Testicular cancer is rare in black men. However, black men with testicular cancer are more likely to die of the cancer than white men, particularly if the cancer has spread to the lymph nodes or other parts of the body when it is diagnosed.

  • Human immunodeficiency virus (HIV). Men with HIV or acquired immune deficiency syndrome (AIDS) caused by HIV have a slightly higher risk of developing seminoma.

The next section in this guide is Screening. It explains how tests may find cancer before signs or symptoms appear. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Screening

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will find out more about screening for testicular cancer. You will also learn the risks and benefits of screening. Use the menu to see other pages.

Screening is used to look for cancer before you have any symptoms or signs. Scientists have developed, and continue to develop, tests that can be used to screen a person for specific types of cancer. The overall goals of cancer screening are to:

  • Lower the number of people who die from the disease, or eliminate deaths from cancer altogether

  • Lower the number of people who develop the disease

Learn more about the basics of cancer screening.

Screening information for testicular cancer

Most often, testicular cancer can be found at an early stage. Many men find the cancer themselves while performing a self-examination. Or a man’s sexual partner may notice a change that leads to a diagnosis.

Some doctors recommend that men ages 15 to 55 perform a monthly self-examination to find any changes. Monthly testicular self-examinations, performed after a warm shower, can help find the cancer at an early stage, when it is more likely to be successfully treated. Men who notice a lump, hardness, enlargement, pain, or any other change in 1 or both of their testicles should visit their doctor immediately.

The next section in this guide is Symptoms and Signs. It explains what body changes or medical problems testicular cancer can cause. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Symptoms and Signs

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. Use the menu to see other pages.

People with testicular cancer may experience a variety of symptoms or signs. Sometimes, men with testicular cancer do not have any of these changes. Or, the cause of a symptom may be a different medical condition that is not cancer. So, having these symptoms does not mean that a man definitely has cancer.

Usually, an enlarged testicle or a small lump or area of hardness are the first signs of testicular cancer. Any lump, enlargement, hardness, pain, or tenderness should be evaluated by a doctor as soon as possible. Other symptoms of testicular cancer usually do not appear until after the cancer has spread to other parts of the body.

Symptoms of testicular cancer may include:

  • A painless lump or swelling on either testicle. If found early, a testicular tumor may be about the size of a pea or a marble, but it can grow much larger.

  • Pain, discomfort, or numbness in a testicle or the scrotum, with or without swelling.

  • Change in the way a testicle feels or a feeling of heaviness in the scrotum. For example, 1 testicle may become firmer than the other testicle. Or testicular cancer may cause the testicle to grow bigger or to become smaller.

  • Dull ache in the lower abdomen or groin

  • Sudden buildup of fluid in the scrotum

  • Breast tenderness or growth. Although rare, some testicular tumors make hormones that cause breast tenderness or growth of breast tissue, a condition called gynecomastia.

  • Lower back pain, shortness of breath, chest pain, and bloody sputum or phlegm can be symptoms of later-stage testicular cancer.

  • Swelling of 1 or both legs or shortness of breath from a blood clot can be symptoms of testicular cancer. A blood clot in a large vein is called deep venous thrombosis or DVT. A blood clot in an artery in the lung is called a pulmonary embolism and causes shortness of breath. For some young or middle-aged men, developing a blood clot may be the first sign of testicular cancer.

Many symptoms and signs of testicular cancer are similar to those caused by noncancerous conditions. These are discussed below:

  • Change in size or a lump in a testicle

    • A cyst called a spermatocele that develops in the epididymis. The epididymis is a small organ attached to the testicle that is made up of coiled tubes that carry sperm away from the testicle.

    • An enlargement of the blood vessels from the testicle called a varicocele.

    • A buildup of fluid in the membrane around the testicle called a hydrocele.

    • An opening in the abdominal muscle called a hernia.

  • Pain

    • Infection. Infection of the testicle is called orchitis. Infection of the epididymis is called epididymitis. If infection is suspected, a patient may be given a prescription for antibiotics. If antibiotics do not solve the problem, tests for testicular cancer are often needed.

    • Injury

    • Twisting

If you are concerned about any changes you experience, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help figure out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may be called palliative care or supportive care. It is often started soon after diagnosis and continued throughout treatment. Be sure to talk with your health care team about the symptoms you experience, including any new symptoms or a change in symptoms.

The next section in this guide is Diagnosis. It explains what tests may be needed to learn more about the cause of the symptoms. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Diagnosis

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will find a list of common tests, procedures, and scans that doctors use to find the cause of a medical problem. Use the menu to see other pages.

Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. If this happens, it is called metastasis. For example, imaging tests can show if the cancer has spread. Imaging tests show pictures of the inside of the body. Doctors may also do tests to learn which treatments could work best.

This section describes options for diagnosing this type of cancer. Not all tests listed below will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • The type of cancer suspected

  • Your signs and symptoms

  • Your age and general health

  • The results of earlier medical tests

If you develop a testicular lump or something else that could be testicular cancer, it is important to see your primary care doctor. After this visit, your doctor may refer you to a urologist for more tests. A urologist is a doctor who specializes in treating testicular cancer and other conditions of the urinary tract.

The following tests are usually the first performed.

  • Physical examination. The doctor will feel the testicles for any sign of swelling, tenderness, or hardening. The doctor will also feel the abdomen, neck, upper chest, armpits and groin for evidence of enlarged lymph nodes, which may indicate that a cancer has spread. The breasts and nipples will also be examined to look for growth and the legs will be examined for swelling. Leg swelling can be from blood clots in veins in the legs, pelvis, or abdomen.

  • Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. The sound waves produced by the ultrasound bounce off tissue in the scrotum. The echoes of the sound waves produce a series of images called a sonogram. These images of the testicle help the doctor find any tumors or other abnormalities. If there is a tumor large enough to be seen on an ultrasound, then the sonogram will show the size, location, and solidness of the tumor. A solid tumor inside the testicle is very likely to be cancerous.

If these tests show an abnormality that appears to be a tumor, then blood tests are done. In addition, the testicle may need to be surgically removed to look for signs of cancer.

  • Blood tests/tumor markers. The levels of serum tumor markers are measured before surgery to remove a testicle. Tumor markers are substances made by a cancer that are found at abnormally high levels in the blood of some people with cancer. For testicular cancer, serum tumor marker levels are used to find out the cancer’s stage (see Stages) and confirm whether a tumor is a pure seminoma (see Introduction). Different types of cancer make different tumor markers. The following tumor markers are used to help stage and plan treatment for testicular cancer:

    • The alpha-fetoprotein (AFP) level is often, but not always, higher in men with non-seminoma. AFP is not made by a seminoma, so an increased level of AFP is a sign that the tumor is not a pure seminoma.

    • Beta human chorionic gonadotropin (beta-hCG) is often, but not always, higher in men with either seminoma or non-seminoma.

    High levels of these tumor markers may indicate testicular cancer or another type of cancer. However, it is possible to have testicular cancer and have normal tumor marker levels. It is also possible to have higher levels of these markers without having cancer.

    Other tumor markers that may be used for testicular cancer include:

    • Lactate dehydrogenase (LDH), which is only used to determine how much chemotherapy to give for metastatic non-seminoma (see Types of Treatment). This is because many other cancers and non-cancerous conditions can increase LDH levels. LDH is not used to find testicular cancer.

    • Placental alkaline phosphatase (PLAP) is another tumor marker doctors may test for, although it is not commonly measured.

    Learn more about tumor markers for testicular cancer.

  • Orchiectomy/surgical pathology tests. If testicular cancer is suspected, a surgeon will perform a radical inguinal orchiectomy. During this surgery, the entire testicle is removed through an incision in the groin. Then, a pathologist will examine very thin slices of tissue from the testicle under a microscope to diagnose the type of cancer. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. For testicular cancer, the pathologist determines if the tissue from the testicle contains cancer cells. And, if it does, the pathologist determines what type of cancer cells they are. Most testicular cancers are germ cell tumors, which are divided into 2 categories: seminoma and non-seminoma. See the Introduction section for more information on the different types of non-seminoma. If a man has only 1 testicle to begin with or the diagnosis is uncertain, the surgeon may remove only a small sample of tissue from the testicle. The testicle may still need to be removed if there are cancer cells. If the tissue sample does not show cancer, it may be possible to repair the damage from the tissue removal and replace the testicle in the scrotum during the same surgery. However, this procedure is very rare.

Other tests

If cancer is found, other tests will be needed to determine the stage of the cancer and find out if it has spread to other parts of the body (see Stages). Usually, doctors recommend imaging tests of the abdomen, pelvis, and chest. Images of the brain or bones are not as common but may be needed for some patients. This can include patients who have cancer that has spread widely, those who have a type of non-seminoma called choriocarcinoma, and those who have very high tumor marker levels of AFP or beta-hCG (see above).

Tests that may be used to stage testicular cancer and find out if it has spread include:

  • X-ray. An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. A chest x-ray is used to determine the stage of the cancer and for follow-up screening. If a more detailed picture of the lungs is needed, the doctor may recommend a chest CT scan (see below). But in many situations, an x-ray is preferred because it uses less radiation.

  • CT scan. A CT scan takes pictures of the inside of the body using x-rays taken from different angles. A computer combines these pictures into a detailed, 3-dimensional image of the body. This can help doctors find any abnormalities or tumors. If a tumor is visible on the CT pictures, the scan can be used to measure the tumor’s size. Often, a special dye called a contrast medium is given before the scan to provide a clearer image. Some dyes are injected into a patient’s vein while others are given as a pill or liquid to swallow. Many times, both types of dye are given before a CT scan because they help your health care team see different parts of the body. A CT scan can be used to evaluate the abdomen, pelvis, chest/lungs, brain and other areas. A CT scan of the brain is rarely needed for testicular cancer because it is uncommon for it to spread to the brain. However, if a scan of the brain is needed, MRI (see below) is generally preferred because the bones of the skull interfere with the ability of CT scans to show certain parts of the brain.

  • MRI scan. An MRI scan uses magnetic fields to create a 3-dimensional picture of the inside of the body. MRI can be used to measure the tumor’s size. For testicular cancer, MRI is generally only used to examine the brain or the spine. A contrast medium is given before the scan to create a clearer picture. This dye is injected into a patient’s vein. For men with testicular cancer, CT scans (see above) are generally preferred to MRI for viewing the abdomen because accurately reading MRI scans of the abdomen requires extensive experience. When MRIs of the abdomen are needed, contrast medium may be given as a pill or liquid to swallow.

    MRI is used only in specific situations. For instance, an MRI of the brain might be recommended if a patient has symptoms or changes on a physical exam that suggest that the cancer may have spread to the brain. In addition, brain MRIs are often recommended for men who have poor-risk metastatic testicular cancer (see Stages) with very high serum tumor markers or if the cancer has spread to the liver, bones, or lungs. Your doctor will explain which test is appropriate for you.

  • PET scan. PET scans are not generally used for testicular cancer. When PET scans are done, they are usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use more energy than healthy tissue, it absorbs more of the radioactive sugar. A scanner then detects the sugar to produce images showing where the cancer is in the body. Studies of PET scans have shown that they are not helpful for diagnosing or staging testicular cancer and should not be used at these times. However, they can be helpful for men with metastatic pure seminoma that does not entirely disappear after chemotherapy. In such instances, if a PET scan is planned, it should not be done until at least 6 weeks after chemotherapy ends.

  • Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Occasionally, a biopsy may be taken from the lung, retroperitoneum, or other location in the body if it appears that cancer may have spread.

After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer. This is called staging.

The next section in this guide is Stages. It explains the system doctors use to describe the extent of the disease. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Stages

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. Use the menu to see other pages.

Staging is a way of describing if and where a cancer has spread. Doctors use diagnostic tests, including CT scans and blood tests, to find out the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and helps predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. For testicular cancer, an S is added to the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?

  • Node (N): Has the tumor spread to the lymph nodes in the back of the abdomen (retroperitoneum)?

  • Metastasis (M): Has the cancer spread to other parts of the body? If so, where and how much?

  • Serum tumor marker (S): Are the serum tumor markers AFP, beta-hCG, and LDH (see Diagnosis) elevated? If so, how high are they?

The results are combined to determine the stage of cancer for each person. There are 3 stages of testicular cancer: stages I, II, and III (1, 2, and 3). The stage provides a common way of describing how advanced the cancer is so that doctors can work together to plan the best treatment. Stage I is called the least advanced or earlier stage, and stage III is called the most advanced or later stage. Patients with the least advanced stages are more likely to be cured and often need less aggressive treatment than patients with a more advanced stage.

Staging for testicular cancer can also be clinical or pathological:

  • Clinical staging is based on the results of tests done before surgery, which may include physical examinations and imaging tests (see Diagnosis). For example, clinical stage II testicular cancer means that the retroperitoneal lymph nodes are enlarged when viewed with a CT or MRI scan.

  • Pathological staging is based on what is found during surgery. For example, pathological stage II testicular cancer means that cancer has been found when tissue removed from the retroperitoneal lymph nodes is examined under a microscope. In general, pathological staging provides the most information to determine a patient’s prognosis, but it is not always needed.

Here are more details on each part of the TNM system for testicular cancer:

Tumor (T)

Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Tumor size is measured in centimeters (cm). A centimeter is roughly equal to the width of a standard pen or pencil.

Stage may also be divided into smaller groups that help describe the tumor in even more detail. For testicular cancer, the T stage can only be determined when tissue removed during surgery is examined under a microscope. This means that the T stage is only determined after the testicle is removed, and the T stage is always a pathological stage and never a clinical stage. The “p” before the T stage indicates that it is a pathological stage. Specific tumor stage information is below.

pTX: The primary tumor cannot be evaluated. If a man has not had the testicle(s) surgically removed, the term "TX" is used.

pT0 (T plus zero): There is no evidence of a primary tumor in the testicles.

pTis: This stage describes germ cell neoplasia in situ (GCNIS). This is a precancerous condition in which there are germ cells that appear cancerous but are not yet behaving the way cancer cells do. GCNIS becomes cancer when the cells grow into parts of the testicle(s) where they do not normally belong.

pT1: The primary tumor is only in the testicle, which may include the rete testis. It has not grown into blood vessels or lymph vessels in the testicles. The tumor may have grown into the inner membrane layer surrounding the testicle, called the tunica albuginea. It has not spread to the outer membrane layer surrounding the testicle, called the tunica vaginalis.

For a pure seminoma, this stage is further divided based on the side of the tumor:

  • pT1a. The tumor is smaller than 3 centimeters (cm) in size.

  • pT1b. The tumor is 3 cm or larger in size.

pT2: The tumor is in the testicle, which may include the rete testis, and it has grown into 1 or more of the following parts of the testicle:

  • Blood vessels or lymphatic vessels in the testicle

  • The epididymis,

  • The fatty tissue next to the epididymis called the hilar soft tissue

  • The tunica vaginalis

pT3: The tumor has grown into the spermatic cord.

pT4: The tumor has grown into the scrotum.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. These tiny, bean-shaped organs help fight infection. Lymph is a fluid that flows from the different tissues and organs of the body and eventually drains into the blood stream. It passes through specialized tubes called lymphatic vessels and is filtered along the way by the lymph nodes. Cancer cells often build up and grow in lymph nodes before they spread to other parts of the body. The first place the lymphatic fluid from the testicles drains to is the retroperitoneal lymph nodes located in the back of the abdomen in front of the spine, an area called the retroperitoneum. These are called the regional lymph nodes for testicular cancer. Lymph nodes in the pelvis, chest, or other parts of the body are called distant lymph nodes, even though the testicles are closer to the pelvis than to the retroperitoneum.

In men with testicular cancer, lymph nodes usually are not biopsied or removed. Instead, the N stage (lymph node stage) is most often estimated by using CT scans. N stage that is based on CT scans is the clinical stage. When the N stage is based on a biopsy or removal of the lymph nodes, it is the pathological stage. When a stage has been determined pathologically, the letter “p” is added as the first letter of the stage (for example pN1). The letter "c" stands for clinical stage.

NX: The regional lymph nodes cannot be evaluated.

cN0: There is no spread to regional lymph nodes as seen on imaging tests.

pN0: There is no cancer found in lymph nodes removed during a retroperitoneal lymph node dissection (RPLND; see Types of Treatment).

cN1: Imaging tests show signs that the cancer has spread to 1 or more lymph nodes in the retroperitoneum. None of the lymph nodes are bigger than 2 centimeters (cm).

pN1: There is cancer in 1 to 5 lymph nodes, and none are larger than 2 cm.

cN2: Imaging tests show at least 1 enlarged lymph node or lymph node mass in the retroperitoneum that is larger than 2 cm but not larger than 5 cm.

pN2: Either or both of the following conditions:

  • There is cancer in more than 5 lymph nodes, but none are larger than 5 cm.

  • There is cancer in at least 1 lymph node, and the largest lymph node or lymph node mass is between 2 cm and 5 cm in size.

cN3: Imaging tests show at least 1 enlarged lymph node or a lymph node mass in the retroperitoneum larger than 5 cm.

pN3: There is cancer in at least 1 enlarged lymph node or lymph node mass that is larger than 5 cm.

Metastasis (M)

The "M" in the TNM system describes whether the cancer has spread to other parts of the body, called distant metastasis. When testicular cancer spreads, it most commonly spreads to the lung and the lymph nodes of the chest, pelvis, and the base of the neck. More advanced stages may have spread to the liver and bones. Testicular cancer rarely spreads to the brain unless the primary tumor is a choriocarcinoma.

MX: Distant metastasis cannot be evaluated.

M0: The disease has not metastasized to distant lymph nodes or other organs.

M1: There is at least 1 distant metastasis.

  • M1a: There is cancer in the lungs or lymph nodes other than the retroperitoneal lymph nodes.

  • M1b: The cancer has spread to organs other than a lung. The lungs may or may not also be involved. For example, a testicular cancer that has spread to the liver or the bones is stage M1b.

Serum tumor markers (S)

Serum tumor markers also help to stage testicular cancer. Blood tests for tumor markers will be done before and after surgical removal of the testicle(s). Tumor marker levels usually decrease after the surgery. Generally, the levels need to be tested until they stop decreasing or begin to rise to determine the correct "S" stage. For patients who will receive chemotherapy, the tumor marker levels on the first day of chemotherapy are used to determine the patient’s risk group (see below).

SX: Tumor marker levels are not available, or the tests have not been done.

S0: Tumor marker levels are normal.

S1: At least 1 tumor marker level is above normal. LDH is less than 1.5 times the upper limit of the normal range, beta-hCG is less than 5,000 mIu/mL, and/or AFP is less than 1,000 ng/mL.

S2: At least 1 tumor marker level is substantially above normal. This means that LDH is 1.5 to 10 times the upper limit of the normal range, beta-hCG is 5,000 to 50,000 mIu/mL, and/or AFP is 1,000 to 10,000 ng/mL. None of the tumor markers is elevated high enough to qualify as S3 (see below).

S3: At least 1 or more tumor marker level is very highly elevated. This means that LDH is more than 10 times the upper limit of the normal range, beta-hCG is more than 50,000 mIu/mL, and/or AFP is more than 10,000 ng/mL.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications and the S level information.

Stage 0: Refers to carcinoma in situ, also called intratubular germ cell neoplasia (pTis, N0, M0, S0).

Stage I: Cancer is at any T level, and there is no evidence of spread to either lymph nodes or other organs. Serum tumor marker levels have not been done or are not available (any T, N0, M0, SX).

  • Stage IA: The cancer is only in the testicle. It may have grown into the rete testis, but it has not grown into the epididymis, hilar soft tissue, or lymphatic or blood vessels in the testis. It has not spread to lymph nodes or distant sites. The tumor in the testis may have grown into the inner membrane surrounding the testis, called the tunica albuginea, but not the outer membrane, called the tunica vaginalis. If the tumor is pure seminoma, it is smaller than 3 cm. Serum markers are normal (pT1, N0, M0, S0).

  • Stage IB: The testicular tumor has grown into the epididymis, hilar soft tissue, tunica vaginalis, the blood or lymphatic vessels within the testicle, the spermatic cord, or the scrotum. The cancer has not spread to lymph nodes or distant sites. Serum markers are normal (pT2, pT3, or pT4, and N0, M0, S0).

  • Stage IS: Cancer is of any T stage and has not spread to lymph nodes or distant sites. Serum markers remain higher than normal levels after the cancerous testicle has been removed (any T, N0, M0, and S1-S3). Stage IS non-seminoma testicular cancer is treated the same as stage III testicular cancer.

Stage II: The cancer has spread to any number of regional lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable (any T, N1-N3, M0, SX).

  • Stage IIA: Cancer has spread to retroperitoneal lymph nodes, either clinical or pathological stage N1, but none are larger than 2 cm. If a lymph node dissection has been done, no more than 5 lymph nodes contain cancer. In addition, serum tumor marker levels are normal or only slightly high. There are no signs of cancer having spread anywhere other than the retroperitoneum (any T, N1, M0, S0 or S1).

  • Stage IIB: Cancer has spread to lymph nodes in the retroperitoneum, and the largest lymph node with cancer or lymph node mass is between 2 cm and 5 cm in size. If a lymph node dissection has been done, cancer has spread to at least 1 lymph node (or lymph node mass) between 2 cm and 5 cm or to more than 5 lymph nodes, with none larger than 5 cm. Serum marker levels are normal or slightly high. There is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N2, M0, S0 or S1).

  • Stage IIC: Cancer has spread to at least 1 lymph node (or lymph node mass) that is larger than 5 cm. Serum marker levels are normal or slightly high. There is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N3, M0, S0 or S1).

Stage III: Cancer has spread to distant lymph nodes or to any organ. Serum tumor marker levels are unknown (any T, any N, M1, SX).

  • Stage IIIA: Cancer has spread to distant lymph nodes and/or the lungs. Serum marker levels are normal or only mildly increased (any T, any N, M1a, S0 or S1).

  • Stage IIIB: Cancer has spread to any lymph nodes and/or the lungs but not to any other organs. At least 1 serum marker is substantially elevated (any T, N1-N3, M0, S2; or any T, any N, M1a, S2).

  • Stage IIIC: Either or both of the following:

    • At least 1 serum marker is extremely high, and the cancer has spread to at least 1 lymph node or organ (any T, N1-N3, M0, S3; or any T, any N, M1a, S3).

    • The cancer has spread to an organ other than the lungs (any T, any N, M1b, any S).

Recurrent: Recurrent cancer is cancer that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Used with permission of the American College of Surgeons, Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.

Later-stage testicular cancer: risk group classification

If the disease has spread to lymph nodes or other organs, the following system is used to classify a germ cell tumor into a good-risk, intermediate-risk, or poor-risk group. This helps to determine the treatment plan and the likelihood of cure. Patients with a tumor in the intermediate and poor-risk groups usually receive more chemotherapy than patients with a tumor in the good-risk category.

The differences between good-risk, intermediate risk and poor-risk are the same as the differences between stage IIIA, stage IIIB, and stage IIIC (above). Stage IIIA is the same as good risk, IIIB is the same as intermediate risk, and IIIC is the same as poor risk.

Good risk

  • Non-seminoma. The cancer has not spread to an organ other than the lungs and serum tumor marker levels are good, which means:

    • AFP less than 1,000 ng/mL

    • B-hCG less than 5,000 iU/L

    • LDH less than 1.5 x ULN

  • Seminoma. The cancer has not spread to an organ other than the lungs and AFP, any B-hCG, any LDH levels are normal.

Intermediate risk

  • Non-seminoma. The cancer has not spread to an organ other than the lungs and the serum tumor marker levels are intermediate, which means:

    • AFP between 1,000 and 10,000 ng/mL

    • B-hCG between 5,000 and 50,000 iU/L

    • LDH between 1.5 x ULN and 10 x ULN

  • Seminoma. The cancer has spread to an organ other than the lungs and AFP, any B-hCG, any LDH levels are normal.

Poor risk

  • Non-seminoma. The cancer has spread to an organ other than the lungs or the serum tumor marker levels are poor, which means:

    • AFP is 10,000 ng/mL or higher

    • B-hCG is 50,000 iU/L or higher

    • LDH is 10 x ULN or higher

  • Seminoma. There are no patients with poor-risk seminoma

Source: Journal of Clinical Oncology.

Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Types of Treatment. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Types of Treatment

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will learn about the different types of treatments doctors use for people with testicular cancer. Use the menu to see other pages.

This section explains the types of treatments that are the standard of care for testicular cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For testicular cancer, this team includes a urologist and a medical oncologist. A medical oncologist is a doctor who specializes in treating cancer with medication. Sometimes, patients may also see a radiation oncologist. A radiation oncologist is a doctor who specializes in giving radiation therapy to treat cancer. Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of the common types of treatments used for testicular cancer are listed below, followed by treatment options by the cancer’s stage. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.

Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the man’s preferences and overall health. The first treatment for testicular cancer is usually surgery to remove the testicle. Rarely, chemotherapy is given first if the cancer has already spread beyond the testicle when diagnosed.

After surgery, chemotherapy or radiation therapy may be recommended. Germ cell tumors are highly sensitive to chemotherapy and are usually curable even if the cancer has spread. But chemotherapy is not very effective for a type of germ cell tumor called a teratoma. This type needs to be removed with surgery. Because many non-seminomas are a mixture of teratoma and other types of germ cell tumor, successful treatment often requires chemotherapy followed by surgery to remove any of the remaining tumor.

Radiation therapy may be recommended for men with early-stage seminoma or cancer that has spread to the brain.

Men with testicular cancer usually have concerns about how their treatment will affect their sexual health, fertility, and quality of life. Each man should discuss these topics with his doctor before treatment begins because there is often more than 1 treatment option available. The final choice of a treatment plan depends on the patient’s specific situation. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Learn more about making treatment decisions.

Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

Surgery

Surgery for cancer involves the removal of the tumor and, sometimes, some surrounding healthy tissue during an operation. Radical orchiectomy, also called inguinal orchiectomy, is most often the first treatment for testicular cancer. It is also usually the way that the cancer is diagnosed. In addition to a radical orchiectomy, other types of surgery may be done for testicular cancer at different times in the treatment schedule. Each of these types of surgery are described further below. Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Radical inguinal orchiectomy

Treatment of testicular cancer usually starts with surgery to remove the testicle with cancer, called a radical inguinal orchiectomy. This operation is done through an incision in the groin along the beltline. During the surgery, the entire testicle and most of the spermatic cord are removed. The spermatic cord contains the blood supply to the testicle and the channel through which sperm travel from the testicle toward the penis. A man may develop cancer in both testicles at the same time or at different times. However, this is rare, occurring in about 2% of men with testicular cancer. Then, both testicles need to be removed in a procedure called a bilateral orchiectomy.

Orchiectomy is used to diagnose and treat both early-stage and later-stage seminoma and non-seminoma. For later-stage cancer, a radical inguinal orchiectomy may, occasionally, be delayed until after treatment with chemotherapy is finished (see Chemotherapy, below).

If a decision is made to perform an orchiectomy, a sample of blood will be collected before surgery to test for levels of serum tumor markers because they are often helpful in planning treatment and follow-up care. For example, increasing or consistently high AFP or beta-hCG after surgery is a sign that the cancer has spread. In this situation, a patient usually needs chemotherapy (see below) even if the metastases cannot be seen on imaging tests.

Side effects of orchiectomy

The removal of 1 testicle typically does not affect a man’s testosterone level if he still has the other testicle and it is a normal size. If a man’s testosterone level is reduced, symptoms may include depression or other mood changes, fatigue, decreased sex drive, inability to achieve a normal erection especially in the morning, and hot flashes, as well as loss of muscle and bone mass in the long term.

Orchiectomy is unlikely to make a man unable to father a biological child because the remaining testicle will still produce sperm. However, about 25% of men with testicular cancer are infertile even before being diagnosed with cancer. It appears that the cancer itself and/or the reason the cancer developed may cause some men to become infertile. Sperm counts often improve after the testicle with cancer is removed.

If the removal of both testicles is performed, the man will no longer produce sperm or testosterone and will not be able to biologically produce children. If the doctor recommends removing the testicle in a man with 1 testicle, semen is usually analyzed twice before surgery to check if the man’s sperm are fully functioning. If the sperm are functional, then sperm banking is usually recommended, so that he may be able to have children later if he wishes. In addition, for men who have had both testicles removed, testosterone replacement therapy will be needed. Learn more about preserving fertility and sexual health.

Reconstructive surgery after orchiectomy

Men can decide if they want an artificial or prosthetic testicle implanted in the scrotum. A prosthetic testicle generally has a weight and texture that is somewhat like a normal testicle but not exactly the same. Some men find that a prosthetic testicle is uncomfortable, and some prefer not to have one. Each man is encouraged to talk with his doctor about whether he wants one and the best timing for this implantation if wanted. Some men prefer to wait until after the active treatment period is over to give this option full consideration.

Surveillance after orchiectomy

After having a radical inguinal orchiectomy, an option for men with clinical stage I seminoma and non-seminoma may be surveillance. With surveillance, the patient is monitored closely, and active treatment begins only if the cancer recurs. This option involves regular doctor appointments for physical examinations, blood tests for tumor markers, CT scans, and chest x-rays. This approach requires dedication by the doctor and patient to stick to the surveillance schedule so that any recurrence can be detected at an early stage. It is only considered as an option if AFP and beta-hCG levels are normal or return to normal after the cancerous testicle is removed.

The main advantage of surveillance is that it avoids any further treatment after orchiectomy − such as chemotherapy, radiation therapy, or additional surgery − for the 82% of men with seminoma and 75% of men with non-seminoma who are not likely to have the disease return after orchiectomy. For an individual patient, the risk of recurrence may be higher or lower based on risk factors determined by the pathologist’s examination of the tumor after the testicle has been removed.

Retroperitoneal lymph node dissection (RPLND)

This is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen. RPLND is usually performed as an open operation with an incision down the middle of the abdomen. RPLND is a complex surgery requiring experience and skill to remove all of the appropriate lymph nodes and to lessen the side effects of the operation. RPLND should only be done by a surgeon who is highly experienced with this operation. Some surgeons perform laparoscopic RPLND, which uses several smaller incisions instead of the 1 large incision, but that approach is still being studied, requires a surgeon skilled in the procedure, and may not be as effective.

Read below to learn more about when RPLND may be used.

RPLND for stage I and IIA non-seminoma

RPLND as a primary treatment for stage I and stage IIA non-seminoma helps reduce the risk of recurrence and is used to stage the cancer. About 25% of patients with clinical stage I non-seminoma who have an RPLND are found to have lymph nodes with cancer. In other words, the surgery shows that they have stage II disease. The risk of the cancer returning after treatment can be lowered to about 1% by giving 2 cycles of chemotherapy after the RPLND. Doctors are now able to better determine which stage I tumors are more likely to have spread to the lymph nodes or beyond, based on the results of the pathology tests performed on the tumor in the testicle after it is removed. Decisions about whether to have an RPLND may be based on the patient’s risk factors. RPLND is a reasonable treatment option when a patient can see a urologist with extensive experience with RPLND. If an RPLND is chosen for stage I non-seminoma, it is usually done within 6 weeks after orchiectomy.

If 5 or fewer lymph nodes have cancer and none are larger than 2 cm (pN1), this surgery alone is successful for 80% to 90% of men, while about 10% to 20% of men will have a recurrence. If more lymph nodes have cancer (pN2 or pN3), surgery alone is successful for about 50% of patients, while the other 50% will have a recurrence. The advantage of the RPLND is that it can cure most patients with small amounts of cancer in the lymph nodes, provide a more accurate assessment of the extent of disease, and avoid the need for frequent CT scans of the abdomen during follow-up care. It also reduces the chance that a man with early-stage (stage I) testicular cancer will need chemotherapy.

Just as RPLND may show cancer in lymph nodes that appeared normal on CT scans for men with clinical stage I non-seminoma, surgery may also show that there is no cancer in lymph nodes that were enlarged on a CT scan, called clinical stage II disease. For men with clinical stage IIA testicular non-seminomas, as many as 20% to 30% will actually have pathological stage I cancer, meaning that the cancer has not spread to any lymph nodes. In these situations, RPLND can help men avoid unneeded chemotherapy.

The main disadvantage of this surgery for stage I non-seminoma is that 70% of patients are cured by removing the testicle. For these men, a RPLND offers no curative benefit, although it does allow the man to avoid regular CT scans and may give him peace of mind.

Despite the surgery, about 10% of testicular cancers come back even if the lymph nodes were not found to have cancer. If lymph nodes with cancer are found during the RPLND, 2 courses of chemotherapy (see below) can help lower the chance of recurrence to about 1%. However, surveillance is also an option, beginning treatment with chemotherapy only if the cancer recurs. This is because this type of cancer has a greater than 95% chance of being cured with 3 cycles of chemotherapy if the recurrence is diagnosed early through regular monitoring.

RPLND to remove residual tumors after chemotherapy

RPLND is recommended for men with stage II or stage III non-seminoma who have retroperitoneal masses that remain after finishing chemotherapy (see below). In men with non-seminoma, any masses larger than 1 cm that remain after chemotherapy are removed if it is possible. About 35% to 40% of men going through such surgery will have a mass that contains teratoma. About 10% to 15% will have 1 of the other types of germ cell cancers. The other 40% to 50% of men will have no cancer or teratoma found and there will only be scarring and/or normal lymph node tissue. Usually, RPLND after chemotherapy is only needed if there are lymph nodes larger than 1.0 cm seen on scans taken after chemotherapy ends. However, some treatment centers will perform an RPLND after chemotherapy in men who had enlarged retroperitoneal lymph nodes before chemotherapy even if the lymph nodes return to less than 1 cm after chemotherapy. For men with teratoma, no additional treatment is given after RPLND. For men with seminoma, embryonal carcinoma, yolk sac tumor, or choriocarcinoma, 2 additional cycles of chemotherapy are generally recommended after RPLND.

For men with pure seminoma

Masses smaller than 3 cm are usually left in place and monitored for changes with CT scans. Men with pure seminomas who have masses larger than 3 cm after chemotherapy may also have CT scans to monitor the cancer. They may also have surgery to remove the masses or to take a tissue sample or receive a PET scan. If more masses are found during the PET scan, surgery is generally used to find out whether the masses contain cancer.

Side effects of RPLND

Some patients may experience temporary side effects from RPLND, such as bowel obstruction (blockage) or infection. This procedure should not affect a man's ability to have an erection, orgasm, or sexual intercourse. However, it may cause infertility because it can damage the nerves that control ejaculation, which can cause men to be unable to ejaculate. RPLND performed after chemotherapy is a more complex surgery and is more likely to cause the loss of ejaculation and other side effects.

Men are encouraged to consider banking sperm before RPLND. There are surgical techniques that are usually successful at sparing the nerves involved with ejaculation when RPLND is done as the initial treatment for stage I or stage II cancer. However, these techniques are much less effective when RPLND is done to remove residual masses after chemotherapy. Men should talk about these concerns with their doctors before surgery.

Other types of surgery to remove cancer remaining after chemotherapy

After chemotherapy (see below), some men may have cancer remaining in the lungs, liver, other organs, or in the lymph nodes in the pelvis, chest, or neck. These tumors should also be removed if it is safe to do so. This may involve surgery in more than 1 part of the body. This type of surgery is complex and requires an experienced team of surgeons. If only some of the remaining tumors can be removed, then surgery may not be performed.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Chemotherapy for testicular cancer is given directly into a vein so that it enters the bloodstream and reaches cancer cells throughout the body. There are also types of chemotherapy that can be taken by mouth, but they are not generally used for testicular cancer.

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles of treatment given over a set period of time. A cycle of chemotherapy for testicular cancer typically lasts 3 weeks. And men with testicular cancer may receive 1 to 4 cycles of treatment, depending on the stage of the cancer. During treatment, a patient may receive 1 drug at a time or a combination of different drugs given at the same time.

The following drugs are used for testicular cancer, usually in the combinations listed further below. However, the drugs used for testicular cancer change, and drugs other than those mentioned below may be used. Talk with your doctor about your options for chemotherapy.

  • Bleomycin (available as a generic drug)

  • Carboplatin (available as a generic drug)

  • Cisplatin (available as a generic drug)

  • Etoposide (available as a generic drug)

  • Gemcitabine (Gemzar)

  • Ifosfamide (Ifex)

  • Oxaliplatin (Eloxatin)

  • Paclitaxel (Taxol)

  • Vinblastine (Velban)

The following chemotherapy regimens may be used for testicular cancer.

  • BEP: bleomycin, etoposide, and cisplatin

  • Carboplatin (for stage I pure seminoma only)

  • EP: etoposide and cisplatin

  • TIP: paclitaxel, ifosfamide, and cisplatin

  • VeIP: vinblastine, ifosfamide, and cisplatin

  • VIP: etoposide, ifosfamide, and cisplatin

  • High-dose carboplatin and etoposide

In general, patients with later-stage disease receive more chemotherapy. The appropriate chemotherapy regimen depends on the stage of the cancer and whether it is a seminoma or a non-seminoma. In addition, how high AFP and beta-hCG levels are helps the doctor determine how much chemotherapy is needed. Chemotherapy regimens for specific stages are discussed further below.

Learn more about the basics of chemotherapy.

Side effects of chemotherapy

Chemotherapy works very well for testicular cancer but can cause side effects and complications. Common side effects from chemotherapy include fatigue, nausea and vomiting, numbness and tingling in the hands and feet, high-pitch hearing loss, and ringing in the ears. There is also a risk of severe infections, so you should talk with your health care team about how to help prevent infections. The drug bleomycin is linked with dangerous swelling in the lungs, so it is important to tell your health care team immediately if you have shortness of breath, difficulty breathing, or a persistent cough. Men who received treatment for testicular cancer also have a higher risk of blood clots. Tell your health care team right away if you have any signs of a blood clot, such as shortness of breath, chest pain, or swelling in 1 or both arms or legs.

Most of side effects from chemotherapy usually go away after treatment is finished, but some can show up much later. These are called late effects. Late effects from chemotherapy for testicular cancer include long-lasting fatigue, heart problems, and secondary cancers.

Balancing the risks and benefits of chemotherapy is an important issue for men with testicular cancer. However, metastatic testicular cancer (see further below) can generally only be cured with chemotherapy. So, for men with metastatic testicular cancer, the benefits of chemotherapy typically outweigh the risks. On the other hand, men with stage I testicular cancer almost never die of the disease regardless of which treatment they receive, so the risks of chemotherapy may outweigh the benefits for these men. Talk with your health care team about the potential short-term and long-term side effects of chemotherapy for testicular cancer.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. For testicular cancer, the radiation is generally directed at lymph nodes in the abdomen for men with stage I or II pure seminoma. Sometimes, the radiation is directed at the lymph nodes on the same side of the pelvis as the testicle where the cancer started.

Radiation therapy for stage I seminoma is now used less often than in the past. Surveillance or, less commonly, chemotherapy with carboplatin is usually used instead of radiation therapy as the preferred treatment of stage I seminoma at many treatment centers because of the risk that radiation therapy may cause other cancers and heart disease. However, radiation therapy remains an option for stage I, IIA, and IIB pure seminoma. It is also sometimes used to treat brain metastases from either seminoma or non-seminoma, but testicular cancer rarely spreads to the brain.

Side effects from radiation therapy

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and peptic ulcers. Medications may be helpful to prevent or reduce nausea and vomiting during radiation therapy. Most side effects go away soon after treatment is finished. Radiation therapy may cause problems with sperm production, but this is less common now with newer radiation techniques that can help men to preserve fertility.

Radiation therapy increases the risk of secondary cancers many years after treatment and may increase the risk of heart problems and gastrointestinal disease. Talk with your doctor about your risk of long-term side effects before starting radiation therapy.

Learn more about the basics of radiation therapy.

Treatment by stage of the cancer

The treatment choices for testicular cancer depend on whether the cancer is a seminoma or non-seminoma (see Introduction and the stage of the cancer (see Stages). After a physical examination, staging tests, and the removal of the cancerous testicle, you and your doctor will discuss your treatment options. Treatment options for early-stage, later-stage, and recurrent seminoma and non-seminoma are described in more detail below.

Clinical stage I non-seminoma testicular cancer

About 25% of patients with clinical stage I non-seminoma have small areas of metastatic cancer that cannot be seen with CT scans when diagnosed. Over time, these areas can grow unless a man receives additional treatment after orchiectomy. The rest are cured when the testicle with cancer is removed. Most recurrences of stage I non-seminoma occur within 9 months after diagnosis and occur in the retroperitoneum. Men with clinical stage I disease have the following options after surgery:

  • Surveillance. This option involves CT scans of the abdomen and pelvis every 3 to 6 months for the first year, every 4 to 12 months in the second year, and every 6 to 12 months in the third to fifth year. Physical examinations and tumor marker tests to measure beta-hCG and AFP are done every 1 to 2 months for the first 12 months, every 2 to 3 months in the second year, every 3 to 4 months in the third and fourth years, every 6 months in the fifth year, and then yearly. A chest x-ray is usually needed at every other visit. If the cancer recurs, 3 cycles of chemotherapy successfully treats the cancer for more than 95% of men. RPLND may be used to treat recurrent cancer if it is limited to the retroperitoneal lymph nodes.

  • RPLND. As described above, this is surgery to remove the retroperitoneal lymph nodes in the back of the abdomen. After RPLND, the risk of recurrence is less than 10% if no cancer is found in those lymph nodes. Most of these recurrences occur in the lungs or the lymph nodes in the chest and they almost always occur within 2 years after the RPLND.

  • Chemotherapy. This option involves receiving chemotherapy shortly after the testicle has been removed surgically, called adjuvant chemotherapy. The most commonly used approach has been to give 1 cycle of BEP chemotherapy that lasts 3 weeks. Sometimes, 2 cycles of BEP chemotherapy may be used, but 1 cycle is more common. The advantage of this approach is that it lowers the recurrence rate from 25% down to less than 3%. The main disadvantage is that 75% of patients do not need chemotherapy because they have already been cured with the surgical removal of the testicle. Therefore, some doctors recommend against using chemotherapy for clinical stage I non-seminoma, while others may recommend using adjuvant chemotherapy only for men who have a higher risk of recurrence so that fewer men receive unnecessary treatment.

Clinical stage I seminoma testicular cancer

More than 80% of men with clinical stage I seminoma are cured with orchiectomy alone while the remaining 15% to 20% will have a recurrence if given no additional treatment. Most recurrences occur within 12 months after diagnosis and the location of the recurrence is typically in the retroperitoneum. Recurrences of stage I seminoma can almost always be cured with radiation therapy, although a few men will need chemotherapy.

  • Surveillance. Surveillance is the standard method of managing stage I seminoma. Using a surveillance program, the risk of death from stage I seminoma is less than 1%. Unlike surveillance for non-seminoma, a man receiving surveillance for seminoma does not need to visit the doctor as often. While this can vary, a common schedule includes doctor visits every 4 months for the first 2 to 3 years, every 6 months for the next 3 years, and then yearly until at least 5 years after the original diagnosis. The following tests are done at each visit: a CT scan of the abdomen and pelvis, a chest radiograph, and a physical examination. Blood tests to measure the serum tumor markers beta-hCG and AFP may be done at the same time, but more research is needed to determine if testing serum tumor markers is helpful for these men.

  • Adjuvant radiation therapy. This is radiation therapy given after surgery. Seminoma is much different from non-seminoma, and early-stage seminoma can be effectively treated with radiation therapy. The chance of recurrence can be decreased to less than 5% with 10 to 15 treatments of radiation therapy to the retroperitoneum. Additional radiation therapy to the pelvis does not reduce the overall risk of recurrence, but it does reduce the risk of a recurrence in the pelvis. Some doctors prefer to treat only the retroperitoneum. Others prefer to include the pelvis to prevent recurrences in that area, which means that follow-up with imaging tests of the pelvis is not needed to watch for a recurrence.

    The disadvantage of radiation therapy for clinical stage I seminoma is that more than 80% of men receive treatment that they do not need because they were cured with the orchiectomy. This is a concern because radiation therapy increases the risk of developing another type of cancer and heart problems.

  • Adjuvant chemotherapy. This is chemotherapy after surgery. Chemotherapy for stage I seminoma is a newer and more controversial treatment option than surveillance or radiation therapy. Using carboplatin, studies have shown that the risk of recurrence after orchiectomy can be reduced from 18% to about 2% with 2 doses of carboplatin and to about 5% to 6% with 1 dose of carboplatin. Because the use of carboplatin is a newer approach, there is less information on the long-term effects of treatment. Therefore, many experts believe that more information is needed before recommending this treatment approach. On the other hand, many other experts have accepted carboplatin as a new treatment option for stage I seminoma, and it is listed as a standard treatment option in most testicular cancer treatment guidelines. The hope is that carboplatin will cause fewer problems than radiation therapy, but it won’t be known whether this is the case until the health of the men who have received carboplatin has been monitored for a longer period of time. Some problems from cancer treatments do not appear until 10 to 20 years later.

Metastatic testicular cancer

If cancer has spread to another location in the body, it is called metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan. However, testicular cancer is fast-growing, so it is important to start treatment right away. If you want to get a second opinion, talk with the doctor within 1 or 2 weeks after diagnosis.

Your treatment plan is based on many individual factors, including whether the cancer has spread to the brain. In addition, LDH levels may be monitored for men with metastatic disease to determine the stage and how long chemotherapy is needed.

Initial treatment of metastatic testicular cancer is usually chemotherapy except when immediate treatment of the brain is needed, which is rare. Chemotherapy typically shrinks the size of such tumors in the brain and may get rid of them entirely over time. If there are any masses remaining after chemotherapy, surgery may be recommended. Radiation therapy to treat the spread of testicular cancer to the brain is controversial. If immediate treatment of a tumor in the brain is needed due to bleeding, swelling, or other issues, then removing the mass surgically is usually preferred if it can be done safely. But radiation therapy may be recommended instead of or in addition to surgery depending on the situation. Palliative care will also be important to help relieve symptoms and side effects.

For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Descriptions of the treatment options for metastatic testicular cancer are described by stage below:

Clinical stage II non-seminoma testicular cancer

Surgery to remove the testicle is done first, followed by additional treatment. The choice of treatment after orchiectomy depends on a patient’s serum tumor marker levels and the size of retroperitoneal lymph nodes. The treatment options available for men with clinical stage II non-seminoma after surgery are listed below. Men are encouraged to consider sperm banking before these treatments begin due to the risk of infertility.

  • Chemotherapy. Chemotherapy is a standard option for any man with stage II testicular cancer. A combination of drugs is usually given after surgery to remove the testicle in the following situations: If serum tumor markers remain high, there are more than 5 enlarged lymph nodes, or there are lymph nodes larger than 2 cm.

  • RPLND. As described above, this is surgery to remove the retroperitoneal lymph nodes in the back of the abdomen. This is a standard treatment option after orchiectomy when the serum tumor marker levels have returned to normal, none of the lymph nodes are larger than 2 cm, and there are no more than 5 enlarged lymph nodes. Chemotherapy may be recommended after RPLND if a large amount of cancer is found in the removed lymph nodes.

Clinical stage II seminoma testicular cancer

Surgery to remove the testicle and lymph nodes with cancer is done first, followed by additional treatment, usually chemotherapy. The main factor in the treatment decision after surgery for a stage II seminoma is the size of the retroperitoneal lymph nodes. Men are also encouraged to consider sperm banking before the following treatments begin due to the risk of infertility.

  • Chemotherapy. Chemotherapy with a combination of drugs is given after surgery to remove the testicle if the lymph nodes are larger than 3 cm or if there are enlarged lymph nodes spread out over a large area in the back of the abdomen. This is a standard treatment option for all men with stage II seminoma and is preferred for stage IIB and stage IIC as it is more likely to get rid of the cancer.

  • Radiation therapy. When lymph nodes are less than 3 cm (stage IIA and early stage IIB), surgery may be followed by radiation therapy to the lymph nodes in the abdomen and pelvis. Alternatively, chemotherapy may be used instead of radiation therapy. Experts disagree about whether radiation therapy or chemotherapy is the preferred option for patients with stage IIA and early stage IIB. Both approaches cure 90% or more of patients with these stages.

Stage III non-seminoma testicular cancer

The following treatment options are available for men with stage III non-seminoma. Men are encouraged to consider sperm banking before treatment begins due to the risk of infertility.

  • Chemotherapy. Chemotherapy is used for men with non-seminoma that has spread beyond the testicles. The most common regimen given is BEP, which is a combination of bleomycin, etoposide and cisplatin (see chemotherapy, above). The treatments are given as 3-week cycles and patients receive either 3 or 4 cycles of chemotherapy for a total treatment period of 9 to 12 weeks. Each drug is given by IV. Cisplatin and etoposide are given each day on the first 5 days. IV fluid is given before and after the cisplatin to reduce the risk of damaging the kidneys. The treatment takes about 6 hours on these days. Bleomycin is given once each week, typically on the first, eighth, and 15th day of the 21-day cycles. The treatment takes about 30 minutes on the days when only bleomycin is given. An important part of the treatment is surgery to remove any remaining masses after chemotherapy ends. The likelihood of chemotherapy successfully treating this cancer depends on the risk group category (see Stages). More than half of metastatic non-seminoma testicular cancers are classified as good-risk, and more than 90% of these will be successfully treated with 3 cycles of BEP chemotherapy or 4 cycles of EP chemotherapy. EP is a combination of the drugs etoposide and cisplatin. It is given on the first 5 days of a 21-day cycle.

    About 25% of metastatic non-seminomas are intermediate-risk disease, and 80% of these are successfully treated with 4 cycles of BEP plus surgery to remove any remaining masses. About 15% of metastatic non-seminomas are poor-risk disease, and about 50% to 70% of these are cured with 4 cycles of BEP plus surgery to remove any remaining masses. For patients with intermediate-risk or poor-risk disease who cannot have bleomycin due to side effects, 4 cycles of VIP chemotherapy, each lasting 21 days, has been shown to work just as well as 4 cycles of BEP. VIP consists of etoposide, ifosfamide and cisplatin chemotherapy plus a medication called mesna (Mesnex). Each of the medications is given on the first 5 days of the 21-day cycle.

  • Surgery after chemotherapy. After chemotherapy is finished, x-rays and CT scans are done again to see if there are any remaining masses. If there are masses, they are removed with surgery if possible. The chance of the surgery curing the cancer is higher if serum tumor marker levels are normal after chemotherapy. This surgery is difficult and requires an experienced surgeon who regularly performs such operations. Very rarely, if the mass is pressing on the kidney or major blood vessels in the retroperitoneum, the kidney and/or a portion of the blood vessels may need to be removed. Often in this situation the nerves that are responsible for ejaculation cannot be spared.

    During surgery, there is about a 40% to 50% chance that only scar tissue will be found, a 35% to 40% chance there will be a teratoma, and a 10% to 15% chance of some other type of germ cell tumor, such as embryonal carcinoma, seminoma, yolk sac tumor, or choriocarcinoma. If only scar tissue and/or a teratoma is found, then no additional treatment is needed. If cancer is found, 2 more cycles of chemotherapy may be given. The chemotherapy regimen used is typically either EP, TIP, VeIP, or VIP.

  • Clinical trials. Patients with poor-risk disease are also encouraged to consider clinical trials as a treatment option.

Metastatic (stage III) seminoma testicular cancer

The following treatment options are available for men with stage III seminoma. Men should also consider sperm banking before treatment begins because of the risk of infertility.

  • Chemotherapy. Chemotherapy for metastatic seminoma is the same as for metastatic non-seminoma (see above). About 90% of metastatic seminomas are good-risk disease and are successfully treated with 3 cycles of BEP or 4 cycles of etoposide and cisplatin. Approximately 10% of metastatic seminomas are intermediate-risk disease and are generally treated with 4 cycles of BEP.

  • Surgery after chemotherapy/radiation therapy. It is quite common for a mass to be found on imaging tests after chemotherapy or radiation therapy is finished. There is less than a 10% chance that this mass contains cancer and almost no chance that it contains a teratoma. The main treatment options are active surveillance or surgery. Such surgery is often very difficult due to a “scar-like” reaction that makes the mass difficult to remove. This is unique to seminoma. Larger masses are more likely to be cancerous, so some doctors recommend surveillance when a mass is smaller than 3 cm and surgery when a mass is 3 cm or larger. A specific type of positron emission tomography (PET) scan called an FDG-PET scan may be used to learn more about the mass. After the PET scan is done, the surgeon will operate only if the scan showed signs of cancer in the remaining mass. The main benefit of a PET scan is to avoid surgery to remove masses that are not cancerous. But recent studies have suggested that PET scan results in these situations may not be accurate. This is because there are masses that show signs of cancer on the the PET scan, but do not actually contain cancer once they are removed and tested. This means that surveillance for larger masses may be an option instead of surgery. If surgery is recommended but the surgeon determines that the mass cannot be removed, a biopsy is if often done to try to find out whether the mass is cancerous. If cancer (seminoma) is found, then additional chemotherapy is given. This is called "second-line chemotherapy." If active surveillance is recommended and the mass grows, second-line chemotherapy is the preferred treatment. Surgery can be considered if the mass remains after the chemotherapy.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

Regular follow-up examinations to check for signs that the cancer may be returning are extremely important. If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Testicular cancer does not often return as a local recurrence because the entire testicle is removed. Increasing beta-hCG or AFP levels may be a sign that the cancer has returned and more treatment is needed. Men who have had a testicular cancer recurrence are encouraged to see a doctor who is an expert in treating recurrent testicular cancer before choosing a treatment approach.

If testicular cancer come back, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

For recurrent testicular cancer, treatment usually includes chemotherapy and surgery. If the cancer was stage I and returns during active surveillance, then the most common treatment is chemotherapy with 3 or 4 cycles of BEP or 4 cycles of EP depending on the stage of the cancer. If the cancer is only in the retroperitoneal lymph nodes and is a pure seminoma, then radiation therapy is the usual treatment. If the cancer is only in the retroperitoneal lymph nodes and is a non-seminoma, RPLND only may be considered instead of chemotherapy.

The standard treatment for recurrent testicular cancer that has previously been treated with chemotherapy is either 4 cycles of standard-dose chemotherapy or 2 to 3 cycles of high-dose chemotherapy. The standard-dose chemotherapy regimens include VeIP and TIP. High-dose chemotherapy usually includes carboplatin, etoposide, and sometimes other drugs. It is not known if high-dose chemotherapy works better than standard-dose chemotherapy. If chemotherapy is given, any remaining masses are treated the same way that they are after initial chemotherapy (see above). A recurrence more than 2 years after treatment should be removed with surgery if possible. Chemotherapy may or may not be recommended after surgery.

People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with a cancer recurrence.

If treatment does not work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.

Testicular Cancer - About Clinical Trials

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What are clinical trials?

Doctors and scientists are often looking for better ways to care for people with testicular cancer. To make scientific advances, doctors create research studies involving volunteers, called clinical trials. In fact, every drug that is now approved by the U.S. Food and Drug Administration (FDA) was tested in clinical trials.

Clinical trials are used for all types and stages of testicular cancer. Many focus on new treatments to learn if a new treatment is safe, effective, and possibly better than the existing treatments. These types of studies evaluate new drugs, different combinations of treatments, new approaches to radiation therapy or surgery, and new methods of treatment.

People who participate in clinical trials can be some of the first to get a treatment before it is available to the public. However, there are some risks with a clinical trial, including possible side effects and the chance that the new treatment may not work. People are encouraged to talk with their health care team about the pros and cons of joining a specific study.

Some clinical trials study new ways to relieve symptoms and side effects during treatment. Others study ways to manage the late effects that may happen a long time after treatment. Talk with your doctor about clinical trials for symptoms and side effects.

Deciding to join a clinical trial

People decide to participate in clinical trials for many reasons. For some people, a clinical trial is the best treatment option available. Because standard treatments are not perfect, people are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other people volunteer for clinical trials because they know that these studies are a way to contribute to the progress in treating testicular cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with testicular cancer.

Insurance coverage and the costs of clinical trials differ by location and by study. In some programs, some of the expenses from participating in the clinical trial are reimbursed. In others, they are not. It is important to talk with the research team and your insurance company first to learn if and how your treatment in a clinical trial will be covered. Learn more about health insurance coverage of clinical trials.

Sometimes people have concerns that, in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” When used, placebos are usually combined with standard treatment in most cancer clinical trials. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

Patient safety and informed consent

To join a clinical trial, people must participate in a process known as informed consent. During informed consent, the doctor should:

  • Describe all of the treatment options, so that the person understands the standard treatments and how the new treatment differs from the standard treatment.

  • List all of the risks of the new treatment, which may or may not be different than the risks of standard treatment.

  • Explain what will be required of each person in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

Clinical trials also have certain rules called “eligibility criteria” that help structure the research and keep patients safe. You and the research team will carefully review these criteria together.

People who participate in a clinical trial may stop participating at any time, for personal or medical reasons. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that people participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if they choose to leave the clinical trial before it ends.

Finding a clinical trial

Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for testicular cancer, learn more in the Latest Research section.

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

PRE-ACT, Preparatory Education About Clinical Trials

In addition, you can find a free video-based educational program about cancer clinical trials in another section of this website.

The next section in this guide is Latest Research. It explains areas of scientific research for testicular cancer. Use the menu to choose a different section to read in this guide.

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Doctors are working to learn more about testicular cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the best diagnostic and treatment options for you.

Since treatment is successful for most men with testicular cancer, one of the major goals for the future is to reduce the side effects of treatment for men with early-stage or good-risk cancers. In addition, treatments for poor-risk and recurrent cancers are being studied in clinical trials, along with basic research on the causes and genetics of testicular cancer.

  • High-dose chemotherapy followed by stem cell transplantation. Higher doses of chemotherapy can put recurrent testicular cancer into remission. A stem cell transplant is a medical procedure in which diseased bone marrow is replaced by highly specialized cells, called hematopoietic stem cells. Hematopoietic stem cells are blood-forming cells found both in the bloodstream and in the bone marrow. For testicular cancer, a man’s own stem cells are removed from the body before high-dose chemotherapy is given. After chemotherapy, blood stem cells are put back into the patient’s vein to replace the bone marrow and restore normal blood cell levels. Despite many studies, this has not been proven to be better than either the standard chemotherapy combination of BEP as a first-line therapy for patients with poor-risk disease or the standard chemotherapy regimens of VeIP or TIP for men who have a recurrence after BEP. Researchers are currently comparing standard chemotherapy (VeIP or TIP) to high doses of the drug combination TICE, which is paclitaxel, ifosfamide, carboplatin, and etoposide, along with stem cell transplantation, to find out if high-dose chemotherapy works better.

  • New chemotherapy schedules. Researchers are looking into shorter schedules of BEP for patients with advanced disease.

  • Genetic studies. Researchers are analyzing the DNA from tumor samples of men with testicular cancer to find out if any specific genes are associated with testicular cancer. In addition, there are studies underway to look at possible inherited genetic factors leading to cryptorchidism and risk of testicular cancer.

  • Palliative care/supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current testicular cancer treatments that can improve comfort and quality of life for patients. Because more men are surviving testicular cancer, doctors are exploring the long-term effects of high-dose chemotherapy on brain function, such as memory loss, decreased speed of processing information, lowered attention span, anxiety, depression, and fatigue. Other studies focus on sperm quality and heart disease risk for testicular cancer survivors.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding testicular cancer, explore these related items that take you outside of this guide:

The next section in this guide is Coping with Treatment. It offers some guidance in how to cope with the physical, emotional, social, and financial changes that cancer and its treatment can bring. Use the menu to choose a different section to read in this guide.

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Every cancer treatment can cause side effects or changes to your body and how you feel. For many reasons, people do not experience the same side effects even when they are given the same treatment for the same type of cancer. This can make it hard to predict how you will feel during treatment.

As you prepare to start cancer treatment, it is normal to fear treatment-related side effects. It may help to know that your health care team will work to prevent and relieve side effects. Doctors call this part of cancer treatment “palliative care” or "supportive care." It is an important part of your treatment plan, regardless of your age or the stage of disease.

Coping with physical side effects

Common physical side effects from each treatment option for testicular cancer are listed in the Types of Treatment section. Learn more about side effects of cancer and its treatment, along with ways to prevent or control them. Changes to your physical health depend on several factors, including the cancer’s stage, the length and dose of treatment, and your general health.

Talk with your health care team regularly about how you are feeling. It is important to let them know about any new side effects or changes in existing side effects. If they know how you are feeling, they can find ways to relieve or manage your side effects to help you feel more comfortable and potentially keep any side effects from worsening.

You may find it helpful to keep track of your side effects so it is easier to explain any changes with your health care team. Learn more about why tracking side effects is helpful.

Sometimes, physical side effects can last after treatment ends. Doctors call these long-term side effects. They call side effects that occur months or years after treatment late effects. Treating long-term side effects and late effects is an important part of survivorship care. Learn more by reading the Follow-up Care section of this guide or talking with your doctor.

Coping with emotional and social effects

You can have emotional and social effects as well as physical effects after a cancer diagnosis. This may include dealing with difficult emotions, such as sadness, anxiety, or anger, or managing your stress level. Sometimes, people find it difficult to express how they feel to their loved ones. Some have found that talking to an oncology social worker, counselor, or member of the clergy can help them develop more effective ways of coping and talking about cancer.

You can also find coping strategies for emotional and social effects in a separate section of this website. This section includes many resources for finding support and information to meet your needs.

Coping with financial effects

Cancer treatment can be expensive. It is often a big source of stress and anxiety for people with cancer and their families. In addition to treatment costs, many people find they have extra, unplanned expenses related to their care. For some people, the high cost of medical care stops them from following or completing their cancer treatment plan. This can put their health at risk and may lead to higher costs in the future. Patients and their families are encouraged to talk about financial concerns with a member of their health care team. Learn more about managing financial considerations in a separate part of this website.

Caring for a loved one with cancer

Family members and friends often play an important role in taking care of a person with testicular cancer. This is called being a caregiver. Caregivers can provide physical, practical, and emotional support to the patient, even if they live far away.

Caregivers may have a range of responsibilities on a daily or as-needed basis, including:

  • Providing support and encouragement

  • Talking with the health care team

  • Giving medications

  • Helping manage symptoms and side effects

  • Coordinating medical appointments

  • Providing a ride to and from appointments

  • Assisting with meals

  • Helping with household chores

  • Handling insurance and billing issues

Learn more about caregiving.

Talking with your health care team about side effects

Before starting treatment, talk with your doctor about possible side effects. Ask:

  • Which side effects are most likely?

  • When are they likely to happen?

  • What can we do to prevent or relieve them?

Be sure to tell your health care team about any side effects that happen during treatment and afterward, too. Tell them even if you do not think the side effects are serious. This discussion should include physical, emotional, and social effects of cancer.

Also, ask how much care you may need at home and with daily tasks during and after treatment. This can help you make a caregiving plan. Create a caregiving plan with this 1-page fact sheet that includes an action plan to help make caregiving a team effort. This free fact sheet is available as a PDF, so it is easy to print out.

Looking for More on How to Track Side Effects?

Cancer.Net offers several resources to help you keep track of your symptoms and side effects. Please note that these links will take you to other sections of Cancer.Net:

  • Cancer.Net Mobile: The free Cancer.Net mobile app allows you to securely record the time and severity of symptoms and side effects.

  • ASCO Answers Managing Pain: Get this 36-page booklet about the importance of pain relief that includes a pain tracking sheet to help patients record how pain affects them. The free booklet is available as a PDF, so it is easy to print out.

  • ASCO Answers Fact Sheets: Read 1-page fact sheets on diarrhea and rash that provide a tracking sheet to record the timing and severity of the side effect. These free fact sheets are available as a PDF, so they are easy to print out.

The next section in this guide is Follow-up Care. It explains the importance of checkups after cancer treatment is finished. Use the menu to choose a different section to read in this guide.

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Care for people diagnosed with cancer does not end when active treatment has finished. Your health care team will continue to check that the cancer has not come back, manage any side effects, and monitor your overall health. This is called follow-up care.

Your follow-up care may include regular physical examinations, medical tests, or both. Doctors want to keep track of your recovery in the months and years ahead. Men who had testicular cancer usually receive follow-up screening for at least 10 years after their treatment ends. However, even after this specific follow-up period ends, men should let any doctor treating them know that he has a history of testicular cancer. This includes the man’s general or primary care doctor, who can then monitor for possible long-term side effects throughout the man’s lifetime.

Learn more about the importance of follow-up care.

Watching for recurrence

One goal of follow-up care is to check for a recurrence, which means that the cancer has come back. Cancer recurs because small areas of cancer cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms. During follow-up care, a doctor familiar with your medical history can give you personalized information about your risk of recurrence. Your doctor will ask specific questions about your health. Some people may have blood tests or imaging tests done as part of regular follow-up care, but testing recommendations depend on several factors including the type and stage of cancer originally diagnosed and the types of treatment given.

The anticipation before having a follow-up test of waiting for test results can add stress to you or a family member. This is sometimes called “scan-xiety.” Learn more about how to cope with this type of stress.

Managing long-term side effects

Most people expect to experience side effects when receiving treatment. However, it is often surprising to survivors that some side effects may linger beyond the treatment period. These are called long-term side effects. Other side effects called late effects may develop months or even years afterwards. Long-term and late effects can include both physical and emotional changes.

Talk with your doctor about your risk of developing such side effects based on the type of cancer, your individual treatment plan, and your overall health. If you had a treatment known to cause specific late effects, you may have certain physical examinations, scans, or blood tests to help find and manage them.

Below are some of the long-term side effects that are possible after treatment for testicular cancer.

Lung problems. Nine doses of bleomycin cause lung damage for about 5% of men and is fatal for less than 1% of men receiving the drug. Lung scarring is another possible long-term side effect. The risk factors for lung scarring are being older than 70, smoking, previous lung injury, previous radiation therapy to the chest, poor kidney function, or receiving additional doses of bleomycin. It is rare to have lung effects without these risk factors. Therefore, if a man has these risk factors and good-risk disease, 4 cycles of EP can be used instead of 3 cycles of BEP. If 4 cycles of chemotherapy are needed, ifosfamide can be used instead of bleomycin, but it is linked with more short-term side effects, such as infections.

Bleomycin also makes the lungs more sensitive, and patients who need to receive extra oxygen during surgery may have a higher risk of lung damage from bleomycin.

Important issues are:

  • Patients who smoke should stop smoking for many health reasons, but in particular to reduce the risk of lung damage from bleomycin.

  • The doctor should examine the patient’s lungs before each cycle of chemotherapy and stop giving bleomycin if lung damage is seen.

Kidney damage. Cisplatin can cause kidney damage. However, it is a very important drug to treat testicular cancer. Also, cisplatin has fewer side effects than carboplatin, which has also been shown to be less effective. The best way to prevent this problem is for cisplatin to be flushed out by giving the patient at least 1 liter of IV fluid before and after the drug is given. This reduces the risk of kidney damage. Research studies looking at kidney function years after receiving cisplatin have shown low rates of long-term kidney damage and when it does occur, it is generally mild.

Heart and blood vessel problems. A condition called Raynaud’s phenomenon may be caused by bleomycin. This condition is associated with the blood vessels narrowing and the skin turning white, then blue, and then red when exposed to certain triggers, such as cold. This is especially common in the hands. Less than 10% of men develop Raynaud’s phenomenon. However, more men develop this condition when vinblastine and bleomycin are combined. However, this regimen is almost never used now. Avoiding the triggers, such as preventing the fingers from becoming cold, is the main treatment.

Men who receive BEP chemotherapy may have higher cholesterol and blood pressure levels and an increased risk of heart disease and/or stroke. Radiation therapy has also been associated with an increased risk of heart disease. The increased risk is small and outweighed by the fact that it is necessary to treat the cancer. However, these side effects are more important when the doctor considers chemotherapy or radiation therapy to prevent the cancer from coming back for men with clinical stage I disease. A healthy diet, exercise, not smoking, and medications to lower cholesterol, control high blood pressure, or treat diabetes are ways to reduce the risk of heart disease and stroke.

Nerve damage. Cisplatin can sometimes damage the nerves, causing feelings of numbness or “pins and needles.” When this occurs, it most often starts during the chemotherapy and lessens and goes away with time. It may take months or even years to completely go away. Rarely, it can affect a person’s functioning, such as being clumsy when buttoning a shirt.

Hearing problems. Sometimes, men who received cisplatin may notice that they can no longer hear high-pitch sounds. This is more common with higher doses, and it is more likely for older men or men with previous hearing problems. It rarely affects young men but may be relevant for musicians or others who depend on having very fine hearing abilities. Another hearing-related side effect of cisplatin may be tinnitus, which is ringing in the ears.

Secondary cancers. Men who receive chemotherapy and/or radiation therapy for testicular cancer have an increased risk of developing other types of cancer in the future. The thought of developing another cancer can be concerning and difficult to face for many men. However, if the testicular cancer has metastasized (stage II or III), then the cancer is a fatal illness unless it is treated effectively. Chemotherapy and radiation therapy often play important roles in treating testicular cancer when the goal is to cure the disease. Even though they pose some risk, chemotherapy and radiation therapy are sometimes the best options for controlling cancer growth and lengthening your life. The issue of secondary cancers may be particularly important for men with stage I disease and early stage II disease that can be cured with surgery alone. In such cases, men may have a choice between surgery alone versus surgery plus chemotherapy or radiation therapy. Each man needs to talk with his doctor about the role of chemotherapy and radiation therapy in his treatment, including why it is recommended and what the risks and benefits are.

Fertility. The issue of fertility in men with testicular cancer is a complex topic because patients with testicular cancer often have a lower sperm count before any treatment is given. A man who has fertility problems after treatment should talk with his doctor about these factors:

  • Sperm count before chemotherapy

  • Whether he received chemotherapy or radiation therapy

  • How long ago the treatment was given

  • Whether an experienced surgeon performed a nerve-sparing RPLND to preserve ejaculation

A low sperm count does not necessarily mean that a man will be infertile after treatment because most patients will develop very low to no sperm counts while receiving chemotherapy. However, the chance of fertility returning after treatment increases over time but is lower for men with no or low sperm counts before chemotherapy. It is also important to ask about sperm banking before treatment.

Low testosterone. In addition to damage to the ability to make sperm, the cells that make testosterone may be damaged. If a man has a low testosterone level, then hormone replacement therapy can be used. As outlined in the Types of Treatment section, symptoms of a reduced testosterone level include decreased sex drive, inability to achieve a normal erection and orgasm, fatigue, hot flashes, depression, mood changes, muscle and bone loss, as well as metabolic syndrome. Metabolic syndrome is a set of conditions, such as obesity, high levels of blood cholesterol and high blood pressure that increases a person’s risk of heart disease, stroke, and diabetes.

Keeping personal health records

You and your doctor should work together to develop a personalized follow-up care plan. Be sure to discuss any concerns you have about your future physical or emotional health. ASCO offers forms to help keep track of the cancer treatment you received and develop a survivorship care plan when treatment is completed.

This is also a good time to talk with your doctor about who will lead your follow-up care. Some survivors continue to see their oncologist, while others transition back to the general care of their family doctor or another health care professional. This decision depends on several factors, including the type and stage of cancer, side effects, health insurance rules, and your personal preferences.

If a doctor who was not directly involved in your cancer care will lead your follow-up care, be sure to share your cancer treatment summary and survivorship care plan forms with him or her and with all future health care providers. Details about your cancer treatment are very valuable to the health care professionals who will care for you throughout your lifetime.

The next section in this guide is Survivorship. It describes how to cope with challenges in everyday life after a cancer diagnosis. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Survivorship

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will read about how to cope with challenges in everyday life after a cancer diagnosis. Use the menu to see other pages.

What is survivorship?

The word “survivorship” means different things to different people. Common definitions include:

  • Having no signs of cancer after finishing treatment.

  • Living with, through, and beyond cancer. According to this definition, cancer survivorship begins at diagnosis and includes people who continue to have treatment over the long term, to either reduce the risk of recurrence or to manage chronic disease.

Survivorship is one of the most complicated parts of having cancer. This is because it is different for everyone.

Survivors may experience a mixture of strong feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis and have gained a greater acceptance of themselves. Others become very anxious about their health and uncertain about coping with everyday life.

Survivors may feel some stress when their frequent visits to the health care team end after completing treatment. Often, relationships built with the cancer care team provide a sense of security during treatment, and people miss this source of support. This may be especially true when new worries and challenges surface over time, such as any late effects of treatment, emotional challenges including fear of recurrence, sexual health and fertility concerns, and financial and workplace issues.

Every survivor has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:

  • Understanding the challenge you are facing

  • Thinking through solutions

  • Asking for and allowing the support of others

  • Feeling comfortable with the course of action you choose

Many survivors find it helpful to join an in-person support group or an online community of survivors. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the place where you received treatment.

Changing role of caregivers

Family members and friends may also go through periods of transition. A caregiver plays a very important role in supporting a man diagnosed with testicular cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.

However, as treatment is completed, the caregiver's role often changes. Eventually, the need for caregiving related to the cancer diagnosis will become much less or come to an end. Caregivers can learn more about adjusting to life after caregiving.

A new perspective on your health

For many people, survivorship serves as a strong motivator to make lifestyle changes.

Men recovering from testicular cancer are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, and managing stress. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about making healthy lifestyle choices.

It is important to have recommended medical checkups and tests (see Follow-up Care) to take care of your health. Cancer rehabilitation may be recommended, and this could mean any of a wide range of services such as physical therapy, career counseling, pain management, nutritional planning, and/or emotional counseling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent and productive as possible.

Talk with your health care team to develop a survivorship care plan that is best for your needs.

Looking for More Survivorship Resources?

For more information about cancer survivorship, explore these related items. Please note that these links will take you to other sections of Cancer.Net:

  • ASCO Answers Cancer Survivorship Guide: Get this 44-page booklet that helps people transition into life after treatment. It includes blank treatment summary and survivorship care plan forms. The free booklet is available as a PDF, so it is easy to print out.

  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert that provides information about what comes after finishing treatment.

  • Survivorship Resources: Cancer.Net offers an entire area of this website with resources to help survivors, including those in different age groups.

The next section offers Questions to Ask the Health Care Team to help start conversations with your cancer care team. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Questions to Ask the Health Care Team

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will find some questions to ask your doctor or other members of the health care team, to help you better understand your diagnosis, treatment plan, and overall care. Use the menu to see other pages.

Talking often with the health care team is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for a digital list and other interactive tools to manage your care. It may also be helpful to ask a family member or friend to come with you to appointments to help take notes.

Questions to ask after getting a diagnosis

  • What type of testicular cancer do I have?

  • Are other tests or surgery needed to confirm this diagnosis?

  • What stage is my cancer? What does this mean?

  • Can you explain my pathology report (laboratory test results) to me? Could I have a copy?

Questions to ask about choosing a treatment and managing side effects

  • What treatment options do I have?

  • What clinical trials are available for me? Where are they located, and how do I find out more about them?

  • What treatment plan do you recommend?

  • Is this the standard treatment?

  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both

  • How often do you treat men with testicular cancer?

  • Who will be part of my health care team, and what does each member do?

  • Who will be leading my overall treatment?

  • What are the possible side effects of each treatment, both in the short term and the long term?

  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

  • Could this treatment affect my sex life? If so, how and for how long?

  • Could this treatment affect my ability to have children? If so, should I talk with a fertility specialist before cancer treatment begins?

  • If I’m worried about managing the costs of cancer care, who can help me?

  • How can I keep myself as healthy as possible during and after treatment?

  • What support services are available to me? To my family?

  • If I have questions or problems, who should I call?

Questions to ask about having surgery

  • What type of surgery will I have? Will lymph nodes be removed?

  • How experienced is the surgeon in orchiectomy and/or RPLND?

  • How long will the operation take?

  • How long will I be in the hospital?

  • Can you describe what my recovery from surgery will be like?

  • Who should I contact about any side effects I experience? And how soon?

  • What are the possible long-term effects of having this surgery?

Questions to ask about having chemotherapy

  • What specific drugs are recommended?

  • What is the goal of this treatment?

  • How long will it take to give this treatment?

  • What side effects can I expect during treatment?

  • Who should I contact about any side effects I experience? And how soon?

  • What are the possible long-term effects of having this treatment?

  • What can be done to relieve the side effects?

Questions to ask about having radiation therapy

  • What type of treatment is recommended?

  • What is the goal of this treatment?

  • How long will it take to give this treatment?

  • What side effects can I expect during treatment?

  • Who should I contact about any side effects I experience? And how soon?

  • What are the possible long-term effects of having this treatment?

  • What can be done to relieve the side effects?

Questions to ask about planning follow-up care

  • What is the chance that the cancer will come back? Should I watch for specific signs or symptoms?

  • What long-term side effects or late effects are possible based on the cancer treatment I received?

  • What follow-up tests will I need, and how often will I need them?

  • How do I get a treatment summary and survivorship care plan to keep in my personal records?

  • Who will be leading my follow-up care?

  • What survivorship support services are available to me? To my family?

The next section in this guide is Additional Resources. It offers some more resources on this website that may be helpful to you. Use the menu to choose a different section to read in this guide.

Testicular Cancer - Additional Resources

Approved by the Cancer.Net Editorial Board, 02/2019

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Testicular Cancer. Use the menu to go back and see other pages.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond.

Here are a few links to help you explore other parts of Cancer.Net:

This is the end of Cancer.Net’s Guide to Testicular Cancer. Use the menu to choose a different section to read in this guide.