How is testicular cancer diagnosed?

When symptoms suggest there might be cancer in a testicle, a personal and family medical history is taken and a complete physical examination is conducted. In addition to checking general signs of health (temperature, pulse, blood pressure and so on), the scrotum will be carefully examined.

The patient will usually have an ultrasound, a chest x-ray, and blood and urine tests. If the ultrasound shows a solid mass inside the testicle, then cancer is presumed because most tumours in the testicles are cancerous.

If the doctor says maybe it is an infection, prescribes antibiotics, and says to come back in two to three weeks, but does not order an ultrasound, be sure to ask why not.

Testicular cancer is missed by the doctor the first time around almost 30% of the time. Since testicular cancer is so rare, they figure it must be something else. In this scenario, it is important that you remember to follow up or ask to be seen by a urologist!

The only sure way to know whether cancer is present is for a pathologist to examine a sample of tissue under a microscope. To obtain the tissue, the affected testicle is removed through the groin. This operation is called inguinal orchiectomy.

The surgeon does not cut through the scrotum and does not remove just a part of the testicle because, if the problem is cancer, cutting through the outer layer of the testicle might cause a local spread of the disease.

Unless otherwise noted, all the information on this topic concerns testicular germ cell tumours.

Treating testicular cancer

Testicular cancer is almost always curable if it is found early. This disease responds well to treatment, even if it has spread to other parts of the body.

Before treatment

If a man has testicular cancer, it is important to find out the extent, or stage, of the disease (whether it has spread from the testicle to other parts of the body). Staging procedures include a thorough physical exam, blood tests, x-rays and scans, and, in some cases, additional surgery.

Most patients will have a CT or CAT scan of their abdomen and chest. A CT scan is a series of x-rays of various sections of the body that gives the doctors a good look to see if the cancer has spread. Special blood tests can also reveal certain substances in the blood - called tumour markers - often found in abnormal amounts in some patients with testicular cancer.

The levels of specific tumour markers can help the doctor determine what type of testicular cancer is present and how advanced it is.

Surgery may be recommended to remove the lymph nodes deep in the abdomen (called RPLND surgery). A pathologist then examines the nodes to determine whether they contain cancer cells. For patients with nonseminoma, removing the nodes can also help stop the spread of their disease.

Seminoma patients do not usually need this surgery because cancer cells in their lymph nodes can be destroyed with radiation therapy.

Treatment methods

Testicular cancer can be treated with surgery, radiation therapy, chemotherapy and surveillance. One method or a combination of methods may used.

Surgery

In most cases, surgery is initially performed to remove the testicle (called an inguinal orchiectomy).

Sometimes it is also necessary to remove lymph nodes in the abdomen (called RPLND - retroperitoneal lymph node dissection - surgery). Additionally, tumours that have spread to other parts of the body may be partly or entirely removed by surgery.

Radiation therapy

In radiation therapy (also called x-ray therapy, radiotherapy, cobalt treatment or irradiation), high-energy irradiation is used to damage cancer cells and stop their growth. Like surgery, radiation therapy is a local treatment and affects only the cells in the treated area. The patient usually receives radiation therapy on an outpatient basis.

Seminomas are highly sensitive to radiation. Following surgery, men with seminomas often have radiation therapy to their abdominal lymph nodes.

Nonseminomas are much less sensitive to radiation. Patients with this type of cancer usually have other types of treatment, such as surgery and/or chemotherapy. The only time radiation is used on nonseminomas now is as a last ditch effort to kill chemotherapy-resistant cancer.

Chemotherapy

The use of drugs to treat cancer is called chemotherapy. Anticancer drugs are recommended when there are signs that the cancer has spread and the type and stage of the tumour is appropriate for this treatment. Chemotherapy is also sometimes used when the doctor suspects that undetected cancer cells remain in the body after surgery or irradiation - this is known as 'adjuvant therapy'.

Chemotherapy may be given by mouth or injected into a muscle or a blood vessel. Chemotherapy is a systemic treatment - the drugs enter the bloodstream and reach cells all over the body.

Depending on the specific drugs and the patient's general age and condition, chemotherapy may be taken: as an outpatient at the hospital or at the doctor's office, but many patients must be hospitalised during chemotherapy so that effects of the treatment can be monitored and fluids can be infused.

Several drugs are typically used to treat testicular cancer: cisplatin, etoposide and bleomycin sulfate. Additionally, ifosamide, vinblastine sulfate and others may be used. Many medical professionals regard cisplatin as the 'magic bullet' for treating testicular cancer. It is the primary reason testicular cancer is considered a curable disease.

Surveillance

For stage I testicular cancer waiting and regular testing, called surveillance, is an option. The theory is that for many stage I patients the cancer was cured by the orchiectomy. Since the doctors know that chemotherapy can cure the patient if the cancer comes back, why not just avoid any further treatment until there is evidence that the cancer has indeed spread.

It cannot be stressed enough that men under surveillance must follow the exact directions of their medical team to ensure that recurrent disease is caught as early as possible! Surveillance is only effective if you actually follow the protocol.

What are the side effects of treatment?

The treatments used for cancer are necessarily very powerful, and that is why some patients may have some unpleasant side effects.

Side effects of surgery

Many men worry that losing one testicle will affect their ability to have sexual intercourse or make them sterile. However a man with one healthy testicle can still have a normal erection and produce sperm. Therefore, an operation to remove just one testicle does not make a patient impotent and seldom interferes with fertility.

Men can also have an artificial testicle, called a prosthesis, placed in the scrotum. The implant has the weight and feel of a normal testicle.

Surgery to remove the lymph nodes does not change a man's ability to have an erection or an orgasm, but the operation can cause infertility because it may interfere with the nerves involved in ejaculation. Severing these nerves causes the bladder neck to relax during an ejaculation allowing the semen to travel backwards into the bladder instead of forward through the penis.

Some men may have temporary stoppage then recover the ability to ejaculate without treatment; others may be helped by medication - for many it will be permanent.

Patients should talk with their doctor about the possibility of removing the lymph nodes using a nerve sparing surgical technique that may protect the ability to ejaculate. This may not be possible in every given case, and not every doctor is capable of performing this surgery.

Side effects of radiation treatment

Radiation therapy affects both normal and cancerous cells, but normal cells are able to recover, and recent developments in radiation therapy have greatly reduced the amount of collateral 'scatter'.

Having treatments five days a week, for several weeks, spreads out the total dose of radiation and gives the patient weekend rest breaks to recover. Nevertheless, the body must work very hard during radiation therapy to repair the tissues injured by the treatment.

Patients may feel unusually tired with periods of nausea, and they should try to rest as much as possible. Radiation therapy does not change the ability to have sex. Radiation therapy may, however, interfere with sperm production. Usually the effect is temporary, and most patients regain their fertility within a matter of months.

Some other unpleasant effects of radiation therapy include diarrhoea and vomiting. These can usually be controlled with medication. There may also be skin reactions in the area being treated, and it is important to treat the skin gently. Lotions and creams should not be used on these areas without the doctor's advice.

Side effects of chemotherapy

Chemotherapy causes side effects because it damages not only cancer cells, but other rapidly growing cells as well, such as hair and gum tissue. Often anticancer drugs are given in cycles, with treatment periods alternating with rest periods. The side effects of chemotherapy depend on the specific drugs given and the response of the individual patient.

These drugs commonly affect hair cells, blood-forming cells and cells that line the digestive tract. As a result, they may cause various problems, including hair loss, lowered resistance to infection, loss of appetite, nausea and vomiting, and mouth sores.

Most men who receive chemotherapy for testicular cancer can continue to function sexually, although some anticancer drugs interfere with sperm production. Although this effect is permanent for some patients, many recover their fertility within a few years. Patients about to have chemotherapy who are interested in having children can consider storing their sperm in a 'sperm bank', just in case.

Loss of appetite can be a serious problem for patients receiving either radiation therapy or chemotherapy. Researchers are learning that patients who eat well are better able to withstand the side effects of their treatment. Therefore, good nutrition is important.

Eating well means getting enough calories to prevent weight loss and having enough protein to build and repair skin, hair, muscles and organs. Many patients find that having several small meals and snacks throughout the day is easier than trying to eat three large meals.

The side effects of cancer therapy vary from person to person and may even be different from one treatment to the next in the same patient. Attempts are made to plan treatment to minimise problems. Fortunately, most side effects are temporary. Doctors, nurses and dietitians can explain the side effects of cancer treatment and suggest ways to deal with them.

What happens after treatment for testicular cancer?

Regular follow-up exams are very important for anyone treated for testicular cancer. A patient who has had testicular cancer should be closely monitored for several years to be sure the cancer is completely gone.

If the cancer does recur, early detection is very important so that additional treatment can be started and the disease contained quickly.

Follow-up care regimens vary for the different types and stages of testicular cancer. Generally, patients are checked and have blood tests to measure tumour marker levels every month or two for the first two years after treatment. They also have regular x-rays and CT scans. After that, checkups may be needed just once or twice a year.

Your doctor will explain the checkups you will need. Nonseminoma seldom recurs (less than 5%) after a patient has been free of the disease for two years. Seminoma seldom recurs (less than 5%) after a patient has been cancer-free for five years.

Patients who have been treated for cancer in one testicle have about a 3% chance of developing cancer in the remaining testicle. If cancer does arise in the second testicle, it is nearly always a new disease rather than a metastasis (spreading) from the first tumour.

Patients should be checked regularly by their doctor and should continue to perform testicular self-examinations every month. Any unusual symptoms should be reported to the doctor without delay.

As with a first cancer, the earlier a new tumour is detected and treated, the greater the chance of cure - which is also very good, even in secondary testicular cancers.

How to cope with testicular cancer

When people have cancer, life can change - for them and for the people who care about them. These changes in daily life can be difficult to handle. When a man learns he has testicular cancer, it is natural to have many different and sometimes confusing emotions. At times, patients and family members may be frightened, angry or depressed.

Their feelings may vary from hope to despair or from courage to fear. Some men will isolate themselves and will become angry when confronted. Patients are usually better able to handle these feelings if they talk about their illness and share their feelings with family members and friends, but they'll need to do this on their own. Forcing them to talk will probably backfire.

Concerns about the future - as well as about medical tests and treatments, hospital stays, medical bills and sexuality - are common. Talking with doctors, nurses or other members of the health care team may help ease fear and confusion.

Patients should ask questions about their disease and its treatment and take an active part in decisions about their medical care. Patients and family members often find it helpful to write down questions as they think of them to prepare for the next visit to the doctor.

Taking notes during talks with the doctor can be a useful aid to memory. Patients should ask the doctor to repeat or explain anything that is not clear.

Most people want to know what kind of cancer they have, how it can be treated and how successful the treatment is likely to be. The patient's doctor is the best person to answer questions and give advice about working or other activities.

If it is difficult to talk with the doctor about feelings and other very personal matters, patients may find it helpful to talk with others facing similar problems. This kind of help is available through support groups. If the patient or his family finds emotional problems become too hard to handle, a mental health counsellor may be able to help.

Adapting to changes brought about by having cancer is easier for patients and those who care about them when they have helpful information and support services.

What does the future hold for testicular cancer?

The outlook for men with testicular cancer is excellent. Because researchers have found better ways to diagnose and treat this disease, the chance of recovering completely has improved dramatically.

Today, a large majority of testicular cancer patients are cured by their initial treatment, while most of those who have a recurrence can be cured too.

Researchers are looking for additional tumour markers that may be present in abnormal amounts in the blood or urine of a person with very early testicular cancer. If such markers are found, it might be possible to detect testicular cancer even before any symptoms are noticed. Researchers are also looking for treatment methods that are more effective and easier for patients to tolerate.

Related topics

What is testicular cancer? See Testicular cancer

For more information about radiation therapy, see Radiation therapy

For more information about chemotherapy, see Chemotherapy

What does that term mean? See Cancer glossary

Testicular Cancer Resource Center
This is a US support organisation with a good amount of quality information on its website: www.acor.org/TCRC/

Original material is provided by the Testicular Cancer Resource Center. Reproduced with permission, and kindly reviewed by New Zealand urologist Dr Peter Gilling. Edited by everybody, February 2005.