Testicular Cancer Prevention 2

Testicular Cancer Prevention 3

Testicular Cancer Prevention 4

Testicular Cancer Prevention 5

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      Testicular cancer is the most common form of cancer among males age 15 to 44. After motor vehicle accidents and suicide, cancer is the leading cause of death in this age group, followed by homicide, heart disease, and HIV. Testicular cancer is known as the young man's cancer.

Early detection is the key to survival. Testicular cancer has a very fast onset since the tumors can be very aggressive. When the cancer is confined to the testicles, there is often no pain. By the time pain develops, it is often a sign that the cancer has already spread. Survival rates increase significantly if treatment has begun before the cancer has a chance to metastasize.
Upon reaching puberty, all men should conduct testicular self-exams at least monthly and preferably every time they shower. The purpose of a testicular self-exam is to familiarize yourself with the size, shape and texture of your testicles. If you notice any change, especially a lump, it is imperative that you see your doctor immediately. Diagnosis is non-invasive, and involves using ultrasound to look at the density, size and shape of the testicles and other masses in the scrotum.

What is Testicular Cancer?

Testicular cancer, also known as cancer of the testes, occurs when germ cells (the cells that become sperm) experience abnormal growth. Germ cells, like stem cells, have the potential to form any cell in the body. Normally this ability is dormant until the sperm fertilizes an egg. When germ cells become cancerous, they multiply unchecked, forming a mass of cells called a tumor, and invade normal tissue.

Testicular cancer can metastasize, meaning that it can spread to other parts of the body. During metastasis cells leave the original tumor and migrate to other parts of the body through blood and lymph vessels, forming a new tumor. Testicular cancer metastasis most often involves the abdomen, lungs and brain. Testicular cancer can spread rapidly and is deadly if left untreated.

Testicular cancer has a very fast onset. Testicular cancer grows rapidly, with tumors doubling in size in just 10 to 30 days.

There are two main types of testicular cancer: seminomas and non-seminomas.

• Seminomas involve a uniform type of cell and spread less aggressively. Approximately 40% of testicular cancers are seminomas. When testicular cancer is first diagnosed, three-quarters of seminoma cases have not spread beyond the testes.

• Non-seminomas involve a mixture of cell types, and are much more aggressive than seminomas. When testicular cancer is first diagnosed, two-thirds of non-seminoma cases have already spread to the lymph nodes.

Luckily, germ cell tumors involve relatively primitive cells, making them more susceptible to treatment. This is why testicular cancer has one of the highest cure rates of any cancer.

Testicular cancer is a relatively rare form of cancer, representing about 1% of cancers affecting men. However, it is the most common form of cancer between the ages of 15 and 44. 78.7% of testicular cancer cases occur in men between the ages of 20 and 44 and 90.4% between the ages of 20 and 54.

It is estimated that there will be 8,980 new cases of testicular cancer in 2004, and 360 deaths. Testicular cancer incidence rates have been increasing steadily by about 2.1% per year, from 3.3 cases per 100,000 persons in 1974 to 4.0 per 100,000 persons in 1984 to 4.9 cases per 100,000 persons in 1994 and 6.1 cases per 100,000 persons in 2000. At the same time, mortality rates have been dropping. In 1950-54 the five-year survival rate was 57%. This improved to 63% in 1963, 79% in 1974-76, 91% in 1983-85, and 95% in 1992-98. The decline in mortality rates is primarily due to the introduction of more effective treatments, such as the BEP (bleomycin, etoposide and cisplatin) chemotherapy regimen.

Testicular cancer is much more common among white men than black, hispanic, asian and native american men, with 93% of testicular cancers occuring in white men. Five-year survival rates are highest among white men, but overall prognosis for all races is good. (The median age of testicular cancer patients at diagnosis is 34 for white men ant 43 for black men. Black men have 10% fewer stage I cases than white men, and 2% more stage II and 8% more stage III. This probably accounts for the differences in survival rates.) Incidence rates are higher in more developed countries, and also increase with socio-economic status.

The lifetime risk of being diagnosed with testicular cancer is 0.35%. The lifetime risk for white men is 0.42% and for black men it is 0.10%. The lifetime risk of dying of testicular cancer is 0.02%.

Testicular cancer is not contagious.

Testicular Cancer Risk Factors

Although the exact cause of testicular cancer is no known for certain, there are several risk factors that can increase the risk of getting testicular cancer.

• Cryptorchidism. Cryptorchidism occurs when the testicles do not descend from the abdomen to the scrotum before birth. Cryptorchidism increases the risk of developing testicular cancer by a factor of 10-20, even if the condition is corrected by surgery.

• Diethyl-Stilbesterol (DES) exposure in utero. From 1938 to 1971, DES was given to pregnant women to help prevent miscarriage. It was banned for such use by the FDA in 1972, when it was found to cause rare cervical and uterine cancers in female offspring and was also implicated in breast cancer in the mother.

• Personal History of Testicular Cancer. Testicular cancer does not spread from one testicle to the other, as there is no direct connection between the testicles, so it is rare for testicular cancer to affect both testicles simultaneously. Nevertheless, men who have had testicular cancer in one testicle are more likely to develop it in the other testicle later.

• Age. Testicular cancer is most common among men between the ages of 15 and 44, but it can occur at any age.

• Family History. If your father or brother has had testicular cancer, you are at greater risk of developing testicular cancer. Approximately 10% of testicular cancers appear to be genetically linked. It is believed that the genes do not cause testicular cancer, but rather make the man more susceptible to it.

• Race. White men are much more likely to develop testicular cancer, with testicular cancer occuring in white men about 4-5 times more frequently than in black men and about 2 times more frequently than in asian-american men. Incidence rates for white men have doubled in the last 30 years, but remained about the same for black men.

• Occupation. Certain occupations (miners, oil or gas workers, janitors, leather workers, food and beverage workers, or workers involved in the manufacturing or application of pesticides) increase the risk of testicular cancer.

• Klinefelter's Syndrome. Men with Klinefelter's Syndrome have an extra X chromosome, leading to lower levels of male hormones. This can cause sterility, abnormal testicular development, and breast enlargement. It also increases the risk of developing germ cell tumors originating in the chest.

• HIV infection. Men with HIV have a slightly higher risk of developing testicular cancer.
Studies have shown that a vasectomy and the use of electric blankets does not increase the risk of testicular cancer.

Detection of Testicular Cancer

Only 4% of testicular cancer cases are found by a physician during a routine examination, with the rest being self-reported. Most often the patient notices the warning signs of testicular cancer during a testicular self-examination. Occasionally the cancer is discovered by a sexual partner, after an injury, or while diagnosing infertility.
The warning signs of testicular cancer include:

• A lump in a testicle.

• Enlargement of a testicle.

• Testicle feels harder than normal.

• A growth external to the testicle (testicular mass).

• A dull ache or sense of pressure in the groin or lower abdomen.

• A feeling of heaviness or fullness in the scrotum.

• Pain or discomfort in the scrotum or testicle.

• Enlargement or tenderness of the breasts.
In most cases early testicular cancer presents itself in a completely painless manner.

Advanced testicular cancer can be accompanied by:

• Back pain.

• Chest pain, coughing or difficulty breathing.

• Significant weight loss.

• Enlargement of the lymph nodes in your abdomen or neck.

The most common method of early detection is through a testicular self-exam. Testicular self-exams should be conducted at least once a month and preferably every time you shower. (The heat from the bath will cause the skin of your scrotum to relax.) All men age 15 and up should conduct testicular self-exams.

The purpose of a testicular self-exam is to familiarize yourself with the size, shape and texture of your testicles. This will allow you to notice changes in subsequent exams.

Since testicular cancer is usually isolated to a single testicle, comparison of your testicles with each other can often be helpful. (Note: It is normal for one testicle to be slightly larger than the other. Your focus should be on noting changes from one exam to the next, since a testicular cancer tumor can double in size in less than 30 days.)

To conduct a testicular self-exam, do the following:

Place your thumb on top of the testicle, and your index finger and middle finger underneath. Gently roll the testicle between your fingers. Look for any lumps, swelling, or change in size, shape or texture. A normal testicle feels smooth and firm, and is shaped like an egg. Also feel the epididymis, a tube-like structure attached to the top and back of the testicle. Note if there is any change in the epididymis.

If you notice any anomalies or changes, it is imperative that you see your doctor or a urologist immediately. (Most family doctors will encounter testicular cancer only once every ten years. A urologist will have more experience with testicular cancer, encountering a few cases a year.) If your doctor cannot see you immediately or you are experiencing testicular pain, go to the nearest emergency room.

Insist on your doctor ordering a testicular ultrasound immediately. If you futz around with antibiotics for weeks or months, you're only giving the cancer time to grow and spread. An ultrasound is the only sure way to verify or rule out a testicular cancer diagnosis.

There are many good web sites that describe how to do a testicular self-exam. A few of the better ones include:

• CancerNetwork Illustrated Guide to
Testicular Self-Exams

• American Family Physician Illustrated Guide to Testicular Self-Exams

• Lance Armstrong Foundation
o Shower Card
o Testicular Cancer Brochure

• TC-Cancer.com

• TeensHealth Guide for Kids

A good illustrated article that describes various testicular masses can be found on the American Academy of Family Physicians web site. Diagnosis of Testicular Cancer
The most common method of diagnosing testicular cancer is through a testicular ultrasound. The ultrasound is used to look at the density, size and shape of the testicles and other masses in the scrotum. If a testicular mass is solid, it is a sign of a tumor, as most other testicular conditions involve fluid build-up. A testicular ultrasound is 100% accurate in differentiating testicular cancer from other possible diagnoses.

The following images show examples of normal and abnormal ultrasounds. Click on any image for an enlargment.
After an orchiectomy, in which the testicle and its attached plumbing is removed, the diseased tissue is sent to a pathologist for examination. The pathologist will determine whether the tissue is a malignant tumor, and if so, whether it is a seminoma (tumors composed of sperm-producing cells) or non-seminoma. The pathologist will also look for neoplasm (cancerous tumors) in the epididymis, seminal ducts, lymph vessels and blood vessels to gain an indication of whether the cancer has spread beyond the testicles.

Blood and urine tests will be used to check for signs of infection, and to measure tumor serum markers, such as beta-HCG, AFP, and LDH.

A CT scan of the pelvis, abdomen and chest, and a chest x-ray will be used to determine whether the cancer has spread beyond the testicles. This is often referred to as the staging of the cancer.

Testicular cancer is the most common form of cancer among males age 15 to 44. After motor vehicle accidents and suicide, cancer is the leading cause of death in this age group, followed by homicide, heart disease, and HIV. Testicular cancer is known as the young man's cancer.

Early detection is the key to survival. Testicular cancer has a very fast onset since the tumors can be very aggressive. When the cancer is confined to the testicles, there is often no pain. By the time pain develops, it is often a sign that the cancer has already spread. Survival rates increase significantly if treatment has begun before the cancer has a chance to metastasize.

Upon reaching puberty, all men should conduct testicular self-exams at least monthly and preferably every time they shower. The purpose of a testicular self-exam is to familiarize yourself with the size, shape and texture of your testicles. If you notice any change, especially a lump, it is imperative that you see your doctor immediately. Diagnosis is non-invasive, and involves using ultrasound to look at the density, size and shape of the testicles and other masses in the scrotum.

What is Testicular Cancer?

Testicular cancer, also known as cancer of the testes, occurs when germ cells (the cells that become sperm) experience abnormal growth. Germ cells, like stem cells, have the potential to form any cell in the body. Normally this ability is dormant until the sperm fertilizes an egg. When germ cells become cancerous, they multiply unchecked, forming a mass of cells called a tumor, and invade normal tissue.

Testicular cancer can metastasize, meaning that it can spread to other parts of the body. During metastasis cells leave the original tumor and migrate to other parts of the body through blood and lymph vessels, forming a new tumor. Testicular cancer metastasis most often involves the abdomen, lungs and brain. Testicular cancer can spread rapidly and is deadly if left untreated.
Testicular cancer has a very fast onset. Testicular cancer grows rapidly, with tumors doubling in size in just 10 to 30 days.
There are two main types of testicular cancer: seminomas and non-seminomas.
• Seminomas involve a uniform type of cell and spread less aggressively. Approximately 40% of testicular cancers are seminomas. When testicular cancer is first diagnosed, three-quarters of seminoma cases have not spread beyond the testes.
• Non-seminomas involve a mixture of cell types, and are much more aggressive than seminomas. When testicular cancer is first diagnosed, two-thirds of non-seminoma cases have already spread to the lymph nodes.
Luckily, germ cell tumors involve relatively primitive cells, making them more susceptible to treatment. This is why testicular cancer has one of the highest cure rates of any cancer.
Testicular cancer is a relatively rare form of cancer, representing about 1% of cancers affecting men. However, it is the most common form of cancer between the ages of 15 and 44. 78.7% of testicular cancer cases occur in men between the ages of 20 and 44 and 90.4% between the ages of 20 and 54.
It is estimated that there will be 8,980 new cases of testicular cancer in 2004, and 360 deaths. Testicular cancer incidence rates have been increasing steadily by about 2.1% per year, from 3.3 cases per 100,000 persons in 1974 to 4.0 per 100,000 persons in 1984 to 4.9 cases per 100,000 persons in 1994 and 6.1 cases per 100,000 persons in 2000. At the same time, mortality rates have been dropping. In 1950-54 the five-year survival rate was 57%. This improved to 63% in 1963, 79% in 1974-76, 91% in 1983-85, and 95% in 1992-98. The decline in mortality rates is primarily due to the introduction of more effective treatments, such as the BEP (bleomycin, etoposide and cisplatin) chemotherapy regimen.
Testicular cancer is much more common among white men than black, hispanic, asian and native american men, with 93% of testicular cancers occuring in white men. Five-year survival rates are highest among white men, but overall prognosis for all races is good. (The median age of testicular cancer patients at diagnosis is 34 for white men ant 43 for black men. Black men have 10% fewer stage I cases than white men, and 2% more stage II and 8% more stage III. This probably accounts for the differences in survival rates.) Incidence rates are higher in more developed countries, and also increase with socio-economic status.
The lifetime risk of being diagnosed with testicular cancer is 0.35%. The lifetime risk for white men is 0.42% and for black men it is 0.10%. The lifetime risk of dying of testicular cancer is 0.02%.
Testicular cancer is not contagious.
Testicular Cancer Risk Factors
Although the exact cause of testicular cancer is no known for certain, there are several risk factors that can increase the risk of getting testicular cancer.
• Cryptorchidism. Cryptorchidism occurs when the testicles do not descend from the abdomen to the scrotum before birth. Cryptorchidism increases the risk of developing testicular cancer by a factor of 10-20, even if the condition is corrected by surgery.
• Diethyl-Stilbesterol (DES) exposure in utero. From 1938 to 1971, DES was given to pregnant women to help prevent miscarriage. It was banned for such use by the FDA in 1972, when it was found to cause rare cervical and uterine cancers in female offspring and was also implicated in breast cancer in the mother.
• Personal History of Testicular Cancer. Testicular cancer does not spread from one testicle to the other, as there is no direct connection between the testicles, so it is rare for testicular cancer to affect both testicles simultaneously. Nevertheless, men who have had testicular cancer in one testicle are more likely to develop it in the other testicle later.
• Age. Testicular cancer is most common among men between the ages of 15 and 44, but it can occur at any age.
• Family History. If your father or brother has had testicular cancer, you are at greater risk of developing testicular cancer. Approximately 10% of testicular cancers appear to be genetically linked. It is believed that the genes do not cause testicular cancer, but rather make the man more susceptible to it.
• Race. White men are much more likely to develop testicular cancer, with testicular cancer occuring in white men about 4-5 times more frequently than in black men and about 2 times more frequently than in asian-american men. Incidence rates for white men have doubled in the last 30 years, but remained about the same for black men.
• Occupation. Certain occupations (miners, oil or gas workers, janitors, leather workers, food and beverage workers, or workers involved in the manufacturing or application of pesticides) increase the risk of testicular cancer.
• Klinefelter's Syndrome. Men with Klinefelter's Syndrome have an extra X chromosome, leading to lower levels of male hormones. This can cause sterility, abnormal testicular development, and breast enlargement. It also increases the risk of developing germ cell tumors originating in the chest.
• HIV infection. Men with HIV have a slightly higher risk of developing testicular cancer.
Studies have shown that a vasectomy and the use of electric blankets does not increase the risk of testicular cancer.
Detection of Testicular Cancer
Only 4% of testicular cancer cases are found by a physician during a routine examination, with the rest being self-reported. Most often the patient notices the warning signs of testicular cancer during a testicular self-examination. Occasionally the cancer is discovered by a sexual partner, after an injury, or while diagnosing infertility.
The warning signs of testicular cancer include:
• A lump in a testicle.
• Enlargement of a testicle.
• Testicle feels harder than normal.
• A growth external to the testicle (testicular mass).
• A dull ache or sense of pressure in the groin or lower abdomen.
• A feeling of heaviness or fullness in the scrotum.
• Pain or discomfort in the scrotum or testicle.
• Enlargement or tenderness of the breasts.
In most cases early testicular cancer presents itself in a completely painless manner.
Advanced testicular cancer can be accompanied by:
• Back pain.
• Chest pain, coughing or difficulty breathing.
• Significant weight loss.
• Enlargement of the lymph nodes in your abdomen or neck.
The most common method of early detection is through a testicular self-exam. Testicular self-exams should be conducted at least once a month and preferably every time you shower. (The heat from the bath will cause the skin of your scrotum to relax.) All men age 15 and up should conduct testicular self-exams.
The purpose of a testicular self-exam is to familiarize yourself with the size, shape and texture of your testicles. This will allow you to notice changes in subsequent exams.
Since testicular cancer is usually isolated to a single testicle, comparison of your testicles with each other can often be helpful. (Note: It is normal for one testicle to be slightly larger than the other. Your focus should be on noting changes from one exam to the next, since a testicular cancer tumor can double in size in less than 30 days.)
To conduct a testicular self-exam, do the following:
Place your thumb on top of the testicle, and your index finger and middle finger underneath. Gently roll the testicle between your fingers. Look for any lumps, swelling, or change in size, shape or texture. A normal testicle feels smooth and firm, and is shaped like an egg. Also feel the epididymis, a tube-like structure attached to the top and back of the testicle. Note if there is any change in the epididymis.
If you notice any anomalies or changes, it is imperative that you see your doctor or a urologist immediately. (Most family doctors will encounter testicular cancer only once every ten years. A urologist will have more experience with testicular cancer, encountering a few cases a year.) If your doctor cannot see you immediately or you are experiencing testicular pain, go to the nearest emergency room.
Insist on your doctor ordering a testicular ultrasound immediately. If you futz around with antibiotics for weeks or months, you're only giving the cancer time to grow and spread. An ultrasound is the only sure way to verify or rule out a testicular cancer diagnosis.
There are many good web sites that describe how to do a testicular self-exam. A few of the better ones include:
• CancerNetwork Illustrated Guide to Testicular Self-Exams
• American Family Physician Illustrated Guide to Testicular Self-Exams
• Lance Armstrong Foundation
o Shower Card
o Testicular Cancer Brochure
• TC-Cancer.com
• TeensHealth Guide for Kids
A good illustrated article that describes various testicular masses can be found on the American Academy of Family Physicians web site. Diagnosis of Testicular Cancer
The most common method of diagnosing testicular cancer is through a testicular ultrasound. The ultrasound is used to look at the density, size and shape of the testicles and other masses in the scrotum. If a testicular mass is solid, it is a sign of a tumor, as most other testicular conditions involve fluid build-up. A testicular ultrasound is 100% accurate in differentiating testicular cancer from other possible diagnoses.
The following images show examples of normal and abnormal ultrasounds. Click on any image for an enlargment.
After an orchiectomy, in which the testicle and its attached plumbing is removed, the diseased tissue is sent to a pathologist for examination. The pathologist will determine whether the tissue is a malignant tumor, and if so, whether it is a seminoma (tumors composed of sperm-producing cells) or non-seminoma. The pathologist will also look for neoplasm (cancerous tumors) in the epididymis, seminal ducts, lymph vessels and blood vessels to gain an indication of whether the cancer has spread beyond the testicles.
Blood and urine tests will be used to check for signs of infection, and to measure tumor serum markers, such as beta-HCG, AFP, and LDH.
A CT scan of the pelvis, abdomen and chest, and a chest x-ray will be used to determine whether the cancer has spread beyond the testicles. This is often referred to as the staging of the cancer.
Staging of Testicular Cancer
The staging of testicular cancer is an indication of whether the cancer has spread to other parts of the body. Staging is useful in determining a treatment plan for the cancer.
Staging is a measure of the degree to which the cancer has spread. Cancer spreads microscopically and grows into tumors at new locations. The number, location and size of these new tumors can give a sense of the degee to which the cancer is contained to a limited location. Clearly, even when there is just one small tumor in the abdomen (Stage II), there could still be microscopic disease elsewhere. But the likelihood is less than when the tumor is large or there are several tumors or there are tumors outside the abdomen. Thus the staging of the cancer can help the doctor choose an appropriate treatment. Localized treatments like radiation therapy and surgery can be used in the early stages, which systemic treatments like chemotherapy can be used in the later stages.
Staging is usually accomplished through a CT scan. A CT scan, also known as a CAT scan, is a series of X-ray images representing slices of the body. In the case of testicular cancer, usually the CT scan will be limited to the pelvis, abdomen, and chest. Before the CT scan, you will have to drink two quarts of milky white barium sulfate solution which will make you feel like you need to vomit. Typically they will take one series of images without contrast die and one with contrast die. The contrast die is injected into your vein through an IV. When the contrast die is in your system, you will be able to feel the X-rays operating because you will feel very hot. Do not be surprised if you need to go to the bathroom urgently about an hour after the CT scan.
The following images show examples of CT scans. The red arrows indicate the metastasized tumors. Click on any image for an enlargment.
A chest X-ray is often used to determine whether the cancer has spread to the lungs.
Sometimes serum tumor markers are also used to determine the staging and monitor the response to treatment. Serum tumor markers are substances in the blood or urine that are present in higher than normal amounts in people with certain types of testicular cancer, such as non-seminoma cancers. Serum tumor markers include human chorionic gonadotrophin (beta-HCG), alpha-fetoprotein (AFP), and lactic dehydrogenase (LDH). 85% of non-seminomas show elevated levels of beta-HCG or AFP.
The major stages are as follows:
• Stage I (Local). The cancer is limited to the testicles and has not spread to the lymph nodes or a more distant organ. Approximately 72% of testicular cancers are in Stage I.
• Stage II (Regional). The cancer has spread to the lymph nodes in the abdomen, but not to a more distant organ. Approximately 19% of testicular cancers are in Stage II.
• Stage III (Distant). The cancer has spread to the lymph nodes and one or more distant organs (above the diaphragm), such as the liver, lungs and brain. Approximately 9% of testicular cancers are in Stage III.
Impact of Staging on Treatment
The results of the pathology report and the staging CT scan will determine treatment options. Stage I patients often have the option of surveillance (no active treatment, but monitor for signs of relapse), radiation therapy (seminoma) or chemotherapy (non-seminoma). Stage II patients are usually given the option of radiation therapy (seminoma) or chemotherapy (non-seminoma), but may also be given the option of a RPLND (surgical removal of the lymph nodes). The only option for stage III patients is chemotherapy.
Prognosis
In the following table, the LDH scores represent the ratio of the LDH value to the upper limit of the laboratory's normal range.
Risk Status Nonseminoma Stages Seminoma Stages
Good Prognosis No nonlung spread
Good markers
AFP < 1,000
HCG < 5,000
LDH < 1.5 IS (S1)
IIA (S1)
IIB (S1)
IIC (S1)
IIIA No nonlung spread
AFP normal
HCG and LDH can be any level IIC
IIIA
IIIB
IIIC
Intermediate Prognosis No nonlung spread
Intermediate markers
AFP 1000 -10,000
HCG 5000 - 50,000
LDH 1.5 - 10 IS (S2)
IIC (S2)
IIIB Nonlung spread
AFP normal
HCG and LDH can be any level IIIC with Non lung spread
Poor Prognosis Nonlung spread
High markers
AFP >10,000
HCG > 50,000
LDH > 10 IS (S3)
IIC (S3)
All IIIC None
Current cure rates for testicular cancer are as follows:
Stage Seminoma Non-Seminoma Overall
Stage I 99% 98% 98%
Stage II 95% 95% 95%
Stage III 90% 76% 78%
All Stages 96%

Treatment of Testicular Cancer

The first step in treatment is usually an orchiectomy, which consists of the removal of the testicle and its attached plumbing through an incision in the abdomen just below the belt line. The plumbing is clamped off before removal to prevent the cancer from contaminating adjacent tissue. An orchiectomy is an outpatient procedure, during which you go into the hospital in the morning and leave in the afternoon with a bag of ice and some painkillers. The orchiectomy itself takes only about 15-30 minutes; the rest of the time is for anesthesia and recovery.
Before your orchiectomy, it is a good idea to remind your doctor to have your testosterone levels measured. This will establish a baseline hormone level, which will be useful later in diagnosing any hormone-related problems.
You will not be able to drive for two weeks after the surgery, and will need to avoid lifting anything weighing 15 pounds or more during that period. For the first week you should avoid laughing, as you will find it to be excruciatingly painful.
After the orchiectomy the testicles and other tissue are sent to a pathologist for evaluation. In combination with other diagnostic tests, this determines the type and staging of the cancer. The remaining treatment depends on this. Follow-up treatment may include:
• Lymph Node Dissection (RPLND). This procedure involves removal of the lymph nodes at the back of the abdomen. It is less common these days, since chemotherapy is often as effective without the need for a second surgery.
• Chemotherapy. Typically this involves three cycles of drugs that kill fast-growing cancerous cells, where each cycle consists of 5 days of a drug regimen followed by two weeks of recovery. The most common form of chemotherapy for testicular cancer is BEP, a combination of three drugs: bleomycin, cisplatin, and etoposide. Chemotherapy is a systemic treatment, meaning that it can treat tumors throughout the body.
• Radiation Therapy. Radiation therapy is localized, and is most often used to irradiate the abdominal lymph nodes in Stage I Seminomas.
• Observation. Observation involves regular monthly diagnostic testing with no treatment. The idea is to avoid the need for painful treatment in patients with stage I seminomas. Unfortunately, the cancer does recur in 28% of patients, requiring treatment anyway. Many feel that it is better to get the treatment over with than to go through the worry of "wait and see".
Before beginning chemotherapy, radiation therapy or a RPLND, you may wish to pursue sperm cryopreservation (sperm banking), as these procedures are known to cause sterility. Sperm banking will enable you to have children later. During your first visit you will undergo viral testing, as this is required by law. They will also use a small portion of the sample to conduct a sperm count and measure the number of vials per sample. Typically six vials are required to achieve a pregnancy, and you will probably want more to be on the safe side. The number of vials per sample ranges from 1 to 10, with 4 being average. You will have to wait at least two days between samples, so the entire process can take a few weeks.
Other side effects of treatment can include fatigue, hair loss, mouth/gum sores, difficulty swallowing, nausea, vomiting, constipation, diarrhea, infection, anemia, increased risk of bleeding, hearing loss and tintinitus, skin changes, pain, taste changes, and slow/irregular heart beats. Because of the likelihood of mouth sores, it is a good idea to have a dentist appointment before beginning chemotherapy. You may need to take drugs like neupogen to increase your white blood cell count (to help fight infection) and procrit to increase your red blood cell count (to combat anemia).
Recent evidence suggests that 3 cycles of BEP (3BEP) chemotherapy is as effective as 4 cycles (4BEP) but with less toxicity. There is also some evidence that 4 cycles of EP (4EP) is almost as effective as 3BEP, but the additional cycle of cisplatin is problematic from a toxicity perspective.
Follow-up care usually involves periodic diagnostic tests, such as monthly blood work and chest x-rays and quarterly CT scans. The frequency of the tests will be reduced during subsequent years.
The overall cost of treatment, including the orchiectomy, chemotherapy and follow-up, is typically $45,000 to $55,000. You will likely hit the out-of-pocket limit on your insurance during the first year of treatment.
Causes of Testicular Cancer
The most likely causes of testicular cancer are hormone-related. These include estrogen-mimicking chemicals such as DDT, PCBs, nonylphenol, bisphenola, and vinclozolin (commonly found in pesticides) and synthetic hormones such as diethyl-stilbestrol (DES). DES was prescribed to pregnant women from 1938 to 1972, when it was banned by the FDA because it was implicated in birth defects and certain cancers of female offspring. Higher maternal estrogen levels have also been implicated. (Maternal estrogen levels have been associated with birth order, increased bleeding during pregnancy, and excessive nausea during pregnancy.) Workers in certain occupations are also routinely exposed to chemicals that increase the risk of testicular cancer; for example, leather tanning and aircraft workers can be exposed to dimethylformamide, which causes testicular cancer.
DES exposure may also occur through consumption of beef products. The cattle industry did not stop using DES until much later, and continues to use some hormones to increase milk production and make beefier cattle. (DES use in cattle was banned in 1979, but the ban permitted the cattle industry to continue to use existing stockpiles of DES. DES has been detected in supposedly hormone-free beef as recently as 2000. Also, the FDA currently permits the use of six hormones in cattle: estradiol, progesterone, testosterone, trenbolone, zeranol, and melengestrol. Melengestrol and estradioal are similar in some ways to DES. In addition, certain herbicides and pesticides are permitted in corn cultivation and hence in animal feed, including atrazine. Several of these chemicals are known or probable carcinogens.) Since DES and other endocrine disruptors are fat-soluble, long-term consumption of beef from hormone-treated cattle may yield a cumulative effect. This could explain why testicular cancer incidence rates have been increasing and vary according to race and socio-economic status (i.e., differences in typical diet).
About 10% of testicular cancers may be gene-linked. A particular gene has been found in some men with testicular cancer. This gene is believed to make such men more susceptible to testicular cancer, but to not be the primary cause.
Studies have shown that the following are not causes of testicular cancer: vasectomy, injury, hot baths.
Testicular Cancer Checklist
You and your doctors may not anticipate everything that needs to be done before treatment. This checklist is intended to give you the benefit of 20/20 hindsight.
In addition to everything listed below, ask for copies of every medical record -- every radiologist report, every blood test, every scan -- it will be useful later. Let each of your doctors know that you want copies of everything. Ask them to fax you a copy of every result.
If you don't have a fax machine, get one. You'll find that it is easier to get doctors and hospitals to give you copies of reports if you ask them to fax them to you.
As Soon As Cancer is Suspected
o As soon as you suspect you may have cancer, schedule an appointment with your dentist, and have the dentist not only give you a thorough cleaning, but also address any cavities or other problems. It is best to get this all out of the way before you start treatment. If you don't normally brush your teeth, start doing it now. Buy yourself a Sonicare and use it not only to brush your teeth, but also along the gumline. This will stimulate good gum health, which will become important if you undergo chemotherapy. (You will need to switch to a soft bristle toothbrush after starting chemotherapy.)
o Ask your doctor about sperm banking. Cancer therapy (radiation therapy, chemotherapy, and an RPLND) can cause temporary or permanent infertility. Even when the infertility is temporary, it still means a period of a few years after treatment when achieving a pregnancy is more difficult. So to preserve options, testicular cancer patients should consider whether or not to bank sperm as soon as they have a confirmed cancer diagnosis.
You will encounter a catch-22 situation with regard to sperm banking. Since sperm banking is often not covered by insurance, and costs $2,000 to $3,000, you won't want to spend the money until you're sure you have cancer. But as soon as the ultrasound confirms a solid testicular mass (a tumor), your urologist will want to perform an orchiectomy (even the same day, but certainly within a day or two). You won't be able to perform sperm banking for about 10 days after the orchiectomy. By then your oncologist will be itching to begin treatment. Sperm banking requires 5 or 6 sample collection sessions, two days apart, meaning that you'll need two weeks with appointments on Monday, Wednesday and Friday. So you need to be aggressive with your PCP and urologist in getting a referral to the local cryobank and in scheduling the sperm banking, to minimize the delay in your treatment. You absolutely do not want to delay your orchiectomy for the sperm banking, since it is best to get known cancerous tissue out of your body as soon as possible. So there are only two possibilities: getting it done before the ultrasound (and thus before you know for certain that you have cancer) or after the orchiectomy and before the start of chemotherapy or radiation therapy. (If your doctor is talking about a RPLND, you definitely need to get sperm banking done before the RPLND.)
o Get an attorney to draft a durable healthcare power of attorney and healthcare treatment instructions (living will). If you need a regular will, now is a good time to have it updated. You may also want to execute a regular power of attorney, to enable someone else to manage your finances.
o Set up as many of your bills as possible for automatic bank debit and make sure you have plenty of cash in your bank account. Ask someone you trust to open your bills and make sure you don't miss payment deadlines.
o Before you begin treatment (especially before you start chemotherapy or radiation therapy), go to the movie theater and watch all the movies you are interested in. Once you start treatment, you will be avoiding crowds.
o If there are any chores or repairs you've been procrastinating on, take care of them right away. Take your car in for service. Fix the leaky sink. Take care of anything that's wrong. Once you start treatment, you're going to have less energy.
After a Confirmed Diagnosis
o As soon as you have a testicular cancer diagnosis, ask your doctor or oncologist to sign the Department of Motor Vehicles form requesting a disabled parking placard. The most appropriate reason code will probably be the one associated with "unable to walk 200 feet without resting" if there isn't one specifically for cancer patients. It takes the DMV a month to send you the placard, and by then you will need it. Even though you will be avoiding crowds, and may even be too tired to drive, there are times when someone else will be driving you places and it will help to be in a spot closest to the door. It will be helpful if you have a copy of the form right there for the doctor to sign. If your oncologist is reluctant to sign the form, tell him that other testicular cancer patients have told you that it helped a lot, especially for picking up drugs from the pharmacy and for grocery shopping. If the oncologist won't sign it, ask your regular doctor to sign it -- any doctor can sign the form.
o Join the TC-NET mailing list. It is a mailing list for testicular cancer patients and survivors. You will find it very helpful in getting questions answered and help understanding your pathology report and other diagnostic tests.
Before the Orchiectomy
o Before the orchiectomy, have your urologist measure your testosterone levels. This will establish a baseline that can be helpful in diagnosing problems later. They should draw blood for serum testosterone, FSH, LH, SHBG and Prolactin.
o Also insist on having them measure your tumor markers before the orchiectomy. They should draw blood for AFP, Beta HCG, and LDH. This establishes a baseline for comparison with your levels after the orchiectomy. Tumor marker levels will be rechecked about a week after the orchiectomy for beta-HCG and about a month after the orchiectomy for AFP.
o The orchiectomy is usually performed as a same-day surgery (admitted in the morning, discharged in the afternoon). You will need someone to drive you to the hospital and to pick you up afterward. You will not be able to drive, partly because of the surgery (you won't want to stomp on the breaks), partly because of the anesthesia (you shouldn't drive for a few days after receiving anesthesia), and partly because you will be taking pain medication.
After the Orchiectomy
o Use a bag of frozen peas or corn on the incision area (wrapped in a paper towel if it is too cold). It helps with the pain and swelling, and is easy to "mold" to the shape of the abdomen. Get two, so you can refreeze one while using the other.
o Whatever you do, do not laugh. Avoid comedy and humor for several days after the surgery. It hurts to laugh for a few days after the surgery.
o Have them measure your tumor markers about 7-10 days after the orchiectomy (and before any further treatment). Since tumor markers tend to have a halflife of about a day, if the cancer was isolated to the testicle your tumor markers should drop to normal levels about a week after the surgery. (Beta-HCG has a half life of 24-36 hours, so a week should be sufficient to show signs of marker normalization. AFP has a half-life of 5-7 days, so a month should be enough to show signs of marker normalization, although the trend may be apparent after a week. The amount of time until marker normalization will depend, of course, on the initial tumor marker levels.) If the tumor markers do not normalize, it is a sign that there is still active cancer somewhere in your body.
o After the orchiectomy, further care usually switches from the urologist to an oncologist (cancer doctor). Your urologist should give you a referal to an oncologist. There are two types of oncologists: medical oncologists (chemotherapy) and radiation oncologists (radiation therapy). There will be one follow-up visit with the urologist a few weeks after the surgery, to check on how the incision site is healing, but other than that your continued care will be in the hands of an oncologist. Only if you need further surgery, such as a RPLND, would you see the urologist again.
Before Chemotherapy
o There are certain diagnostic tests that should be conducted before chemotherapy starts. Some of them, like a CT scan, are necessary both to diagnose the staging and to establish a baseline. Others are to establish a baseline. The CT scan should include the pelvis, abdomen, and chest in order to properly stage the cancer. Ask your doctor to schedule a pulmonary function test and an audiogram (hearing test). These are important because of common side effects of chemotherapy, and having a baseline is important for comparison later. Also insist on having them measure your tumor markers your first day of chemotherapy before they start the chemotherapy (they will have put in an IV, so it will be easy for them to draw the blood before hooking up the fluids). Also talk to your doctor about possibly having a PET scan, if your insurance will cover it. A PET scan would be in addition to the CT scan. If you're going to have PET scans, it is best to have one before the start of chemotherapy or radiation therapy, in addition to one six weeks after the end of treatment.
o Before you start treatment, pick an extravagant gift that you will give yourself after you complete treatment. It helps when you are experiencing the pain and side effects associated with treatment to think of that gift as a goal.
o If you like to read, go to the bookstore and buy a bunch of books. If you like to listen to music, make sure you have a good portable radio, CD player or MP3 player. If you like to watch movies, get yourself a portable DVD player and a bunch of DVDs. There will be times when you need something to do, and even TV becomes boring after a while.
o Buy a mini fridge or cooler for your bedroom. You will want to keep some beverages nearby, especially ginger ale (good for nausea). Buy a set of walkie talkies (FRS radios) or an intercom if someone else will be helping take care of you. Buy a small plastic bin or pail to keep by your bed in case you need to vomit. (When you need to vomit, you might not be able to make it to the bathroom in time, or even get out of bed.)
o Before treatment begins, go shopping for a nice hat. It should not have any bumps or clasps around the inside rim, because that will be uncomfortable against your skin after your hair falls out. A continuous cloth rim is probably best. Baseball caps that have a snap or buckle in back will not feel good against your skin.
During Treatment
o Get into the habit of weighing yourself and taking your temperature every day. Keep a weight and temperature log.
o Drink at least 8 full glasses of water a day. Drinking a gallon of water helps flush the chemotherapy drugs from your system, thereby minimizing the more toxic side effects. It also helps prevent the chemicals from building up in your kidneys and bladder, thereby preventing health problems such as kidney failure. If you are not urinating at least once an hour, you are not drinking enough water. Gatorade and pedialyte are also good, since they will help restore your electrolytes, especially if you suffer from diarrhea or vomiting.
o If you don't have a port installed, there are several tricks to getting a vein to 'pop' so the nurse can find it. One tip is to have the nurse wrap a hot towel around your arm (microwaving a wet towel for 10 to 30 seconds should do the trick). The heat causes the veins to appear on the surface. Another trick is to pump your fist several times rapidly or to squeeze a stress ball. Wrapping the tourniquet around your should might also work.
o If you are receiving Bleomycin, avoid scratching and bruises. This can lead to "chemo burn", where the skin becomes discolored. It takes a very long time for the skin discoloration to disappear.
o Your sense of taste and smell will change during chemotherapy. It is a good idea to avoid foods you like, since chemotherapy patients can develop an aversion to foods eaten during chemotherapy, even favorite foods. Also avoid anything with a strong smell, such as perfume, cologne and household cleaners.
o Take your antinausea medication even if you feel fine. The anti-nausea medication only works if it is present before the nausea occurs. If you take it after you start feeling nauseous, it won't work.
o If you develop an allergy to Zofran, ask your oncologist about Kytril. If you develop break-through nausea, ask your oncologist about a relatively new drug called Emend.
o Vomiting doesn't make you feel better. You still feel awful and like you need to vomit, even though after the third time there's nothing left to come up.
o If you are receiving Decadron for nausea, ask the nurse to drip it or do the IV-push very slowly. If they give it to you too fast, it can not only make your face hot/flushed and give you an itchy tush, but actually induce vomitting.
o If you are ever hospitalized during your treatment and you aren't in the oncology ward, you will run into a few problems. First, they probably won't have the antinausea medication on the ward, so they will have to order it from the hospital formulary. Remind them a few hours before your next dose, otherwise you may get nauseous during the delay. Nurses who aren't oncology nurses are less familiar with chemotherapy patients and are more likely to push your Decadron all at once. An oncology nurse will sit with you for twenty minutes while pushing your Decadron; a regular nurse will be in a rush to see the next patient.
o During treatment you will be sitting around in the chemotherapy infusion room for 6-7 hours a day. Your oncologist may have a television and some magazines, and there may be other patients to talk to, but you may want to bring some reading material or a friend with you.
o Tell your friends and family to not give you flowers, plants, or fruit baskets. If you become neutropenic during chemotherapy, you will be at risk of infection, and should avoid exposure to these items.
General Tips
• Always ask your doctors for copies of all lab reports, especially pathology reports, imaging reports (CT scans, MRIs, ultrasounds, PET scans), and blood tests (tumor markers, testosterone levels). You will be getting a lot of information all at once, and will not be able to remember everything. So better to have a copy that you can look at later. Also, you can post the text of the report to the TC-NET list to get help understanding what it means.
• The initial staging of the cancer will depend on the pathology report and the CT scan. This is usually sufficient to determine treatment options.
• If you are suffering from mood changes, fatigue, night sweats, difficulty concentrating, or personality changes, talk to your doctor. It is possible that you are suffering from testosterone deficiency. Your doctor should test your testosterone levels (along with FSH, LH and Prolactin levels) at the same time of day as your presurgical test. Some reduction is to be expected, since the orchiectomy removed a source of testosterone production. However, the "normal" ranges are for intact males and span a wide range that is not age-adjusted. A low normal result might be normal for a 70-year-old, but not for a 35-year-old man. If your testosterone levels are within the normal range, but your FSH or LH levels are elevated, that can be a sign of deficiency. But even if your FSH and LH levels are normal, low normal levels can be a sign of deficiency if you are symptomatic. It is generally a good idea to see an endocrinologist for evaluation of your symptoms and endocrine levels.

The staging of testicular cancer is an indication of whether the cancer has spread to other parts of the body. Staging is useful in determining a treatment plan for the cancer.
Staging is a measure of the degree to which the cancer has spread. Cancer spreads microscopically and grows into tumors at new locations. The number, location and size of these new tumors can give a sense of the degee to which the cancer is contained to a limited location. Clearly, even when there is just one small tumor in the abdomen (Stage II), there could still be microscopic disease elsewhere. But the likelihood is less than when the tumor is large or there are several tumors or there are tumors outside the abdomen. Thus the staging of the cancer can help the doctor choose an appropriate treatment. Localized treatments like radiation therapy and surgery can be used in the early stages, which systemic treatments like chemotherapy can be used in the later stages.
Staging is usually accomplished through a CT scan. A CT scan, also known as a CAT scan, is a series of X-ray images representing slices of the body. In the case of testicular cancer, usually the CT scan will be limited to the pelvis, abdomen, and chest. Before the CT scan, you will have to drink two quarts of milky white barium sulfate solution which will make you feel like you need to vomit. Typically they will take one series of images without contrast die and one with contrast die. The contrast die is injected into your vein through an IV. When the contrast die is in your system, you will be able to feel the X-rays operating because you will feel very hot. Do not be surprised if you need to go to the bathroom urgently about an hour after the CT scan.
The following images show examples of CT scans. The red arrows indicate the metastasized tumors. Click on any image for an enlargment.
A chest X-ray is often used to determine whether the cancer has spread to the lungs.
Sometimes serum tumor markers are also used to determine the staging and monitor the response to treatment. Serum tumor markers are substances in the blood or urine that are present in higher than normal amounts in people with certain types of testicular cancer, such as non-seminoma cancers. Serum tumor markers include human chorionic gonadotrophin (beta-HCG), alpha-fetoprotein (AFP), and lactic dehydrogenase (LDH). 85% of non-seminomas show elevated levels of beta-HCG or AFP.
The major stages are as follows:
• Stage I (Local). The cancer is limited to the testicles and has not spread to the lymph nodes or a more distant organ. Approximately 72% of testicular cancers are in Stage I.
• Stage II (Regional). The cancer has spread to the lymph nodes in the abdomen, but not to a more distant organ. Approximately 19% of testicular cancers are in Stage II.
• Stage III (Distant). The cancer has spread to the lymph nodes and one or more distant organs (above the diaphragm), such as the liver, lungs and brain. Approximately 9% of testicular cancers are in Stage III.
Impact of Staging on Treatment
The results of the pathology report and the staging CT scan will determine treatment options. Stage I patients often have the option of surveillance (no active treatment, but monitor for signs of relapse), radiation therapy (seminoma) or chemotherapy (non-seminoma). Stage II patients are usually given the option of radiation therapy (seminoma) or chemotherapy (non-seminoma), but may also be given the option of a RPLND (surgical removal of the lymph nodes). The only option for stage III patients is chemotherapy.
Prognosis
In the following table, the LDH scores represent the ratio of the LDH value to the upper limit of the laboratory's normal range.
Risk Status Nonseminoma Stages Seminoma Stages
Good Prognosis No nonlung spread
Good markers
AFP < 1,000
HCG < 5,000
LDH < 1.5 IS (S1)
IIA (S1)
IIB (S1)
IIC (S1)
IIIA No nonlung spread
AFP normal
HCG and LDH can be any level IIC
IIIA
IIIB
IIIC
Intermediate Prognosis No nonlung spread
Intermediate markers
AFP 1000 -10,000
HCG 5000 - 50,000
LDH 1.5 - 10 IS (S2)
IIC (S2)
IIIB Nonlung spread
AFP normal
HCG and LDH can be any level IIIC with Non lung spread
Poor Prognosis Nonlung spread
High markers
AFP >10,000
HCG > 50,000
LDH > 10 IS (S3)
IIC (S3)
All IIIC None
Current cure rates for testicular cancer are as follows:
Stage Seminoma Non-Seminoma Overall
Stage I 99% 98% 98%
Stage II 95% 95% 95%
Stage III 90% 76% 78%
All Stages 96%

Treatment of Testicular Cancer
The first step in treatment is usually an orchiectomy, which consists of the removal of the testicle and its attached plumbing through an incision in the abdomen just below the belt line. The plumbing is clamped off before removal to prevent the cancer from contaminating adjacent tissue. An orchiectomy is an outpatient procedure, during which you go into the hospital in the morning and leave in the afternoon with a bag of ice and some painkillers. The orchiectomy itself takes only about 15-30 minutes; the rest of the time is for anesthesia and recovery.
Before your orchiectomy, it is a good idea to remind your doctor to have your testosterone levels measured. This will establish a baseline hormone level, which will be useful later in diagnosing any hormone-related problems.
You will not be able to drive for two weeks after the surgery, and will need to avoid lifting anything weighing 15 pounds or more during that period. For the first week you should avoid laughing, as you will find it to be excruciatingly painful.
After the orchiectomy the testicles and other tissue are sent to a pathologist for evaluation. In combination with other diagnostic tests, this determines the type and staging of the cancer. The remaining treatment depends on this. Follow-up treatment may include:
• Lymph Node Dissection (RPLND). This procedure involves removal of the lymph nodes at the back of the abdomen. It is less common these days, since chemotherapy is often as effective without the need for a second surgery.
• Chemotherapy. Typically this involves three cycles of drugs that kill fast-growing cancerous cells, where each cycle consists of 5 days of a drug regimen followed by two weeks of recovery. The most common form of chemotherapy for testicular cancer is BEP, a combination of three drugs: bleomycin, cisplatin, and etoposide. Chemotherapy is a systemic treatment, meaning that it can treat tumors throughout the body.
• Radiation Therapy. Radiation therapy is localized, and is most often used to irradiate the abdominal lymph nodes in Stage I Seminomas.
• Observation. Observation involves regular monthly diagnostic testing with no treatment. The idea is to avoid the need for painful treatment in patients with stage I seminomas. Unfortunately, the cancer does recur in 28% of patients, requiring treatment anyway. Many feel that it is better to get the treatment over with than to go through the worry of "wait and see".
Before beginning chemotherapy, radiation therapy or a RPLND, you may wish to pursue sperm cryopreservation (sperm banking), as these procedures are known to cause sterility. Sperm banking will enable you to have children later. During your first visit you will undergo viral testing, as this is required by law. They will also use a small portion of the sample to conduct a sperm count and measure the number of vials per sample. Typically six vials are required to achieve a pregnancy, and you will probably want more to be on the safe side. The number of vials per sample ranges from 1 to 10, with 4 being average. You will have to wait at least two days between samples, so the entire process can take a few weeks.
Other side effects of treatment can include fatigue, hair loss, mouth/gum sores, difficulty swallowing, nausea, vomiting, constipation, diarrhea, infection, anemia, increased risk of bleeding, hearing loss and tintinitus, skin changes, pain, taste changes, and slow/irregular heart beats. Because of the likelihood of mouth sores, it is a good idea to have a dentist appointment before beginning chemotherapy. You may need to take drugs like neupogen to increase your white blood cell count (to help fight infection) and procrit to increase your red blood cell count (to combat anemia).
Recent evidence suggests that 3 cycles of BEP (3BEP) chemotherapy is as effective as 4 cycles (4BEP) but with less toxicity. There is also some evidence that 4 cycles of EP (4EP) is almost as effective as 3BEP, but the additional cycle of cisplatin is problematic from a toxicity perspective.
Follow-up care usually involves periodic diagnostic tests, such as monthly blood work and chest x-rays and quarterly CT scans. The frequency of the tests will be reduced during subsequent years.
The overall cost of treatment, including the orchiectomy, chemotherapy and follow-up, is typically $45,000 to $55,000. You will likely hit the out-of-pocket limit on your insurance during the first year of treatment.
Causes of Testicular Cancer
The most likely causes of testicular cancer are hormone-related. These include estrogen-mimicking chemicals such as DDT, PCBs, nonylphenol, bisphenola, and vinclozolin (commonly found in pesticides) and synthetic hormones such as diethyl-stilbestrol (DES). DES was prescribed to pregnant women from 1938 to 1972, when it was banned by the FDA because it was implicated in birth defects and certain cancers of female offspring. Higher maternal estrogen levels have also been implicated. (Maternal estrogen levels have been associated with birth order, increased bleeding during pregnancy, and excessive nausea during pregnancy.) Workers in certain occupations are also routinely exposed to chemicals that increase the risk of testicular cancer; for example, leather tanning and aircraft workers can be exposed to dimethylformamide, which causes testicular cancer.
DES exposure may also occur through consumption of beef products. The cattle industry did not stop using DES until much later, and continues to use some hormones to increase milk production and make beefier cattle. (DES use in cattle was banned in 1979, but the ban permitted the cattle industry to continue to use existing stockpiles of DES. DES has been detected in supposedly hormone-free beef as recently as 2000. Also, the FDA currently permits the use of six hormones in cattle: estradiol, progesterone, testosterone, trenbolone, zeranol, and melengestrol. Melengestrol and estradioal are similar in some ways to DES. In addition, certain herbicides and pesticides are permitted in corn cultivation and hence in animal feed, including atrazine. Several of these chemicals are known or probable carcinogens.) Since DES and other endocrine disruptors are fat-soluble, long-term consumption of beef from hormone-treated cattle may yield a cumulative effect. This could explain why testicular cancer incidence rates have been increasing and vary according to race and socio-economic status (i.e., differences in typical diet).
About 10% of testicular cancers may be gene-linked. A particular gene has been found in some men with testicular cancer. This gene is believed to make such men more susceptible to testicular cancer, but to not be the primary cause.
Studies have shown that the following are not causes of testicular cancer: vasectomy, injury, hot baths.
Testicular Cancer Checklist
You and your doctors may not anticipate everything that needs to be done before treatment. This checklist is intended to give you the benefit of 20/20 hindsight.
In addition to everything listed below, ask for copies of every medical record -- every radiologist report, every blood test, every scan -- it will be useful later. Let each of your doctors know that you want copies of everything. Ask them to fax you a copy of every result.
If you don't have a fax machine, get one. You'll find that it is easier to get doctors and hospitals to give you copies of reports if you ask them to fax them to you.
As Soon As Cancer is Suspected
o As soon as you suspect you may have cancer, schedule an appointment with your dentist, and have the dentist not only give you a thorough cleaning, but also address any cavities or other problems. It is best to get this all out of the way before you start treatment. If you don't normally brush your teeth, start doing it now. Buy yourself a Sonicare and use it not only to brush your teeth, but also along the gumline. This will stimulate good gum health, which will become important if you undergo chemotherapy. (You will need to switch to a soft bristle toothbrush after starting chemotherapy.)
o Ask your doctor about sperm banking. Cancer therapy (radiation therapy, chemotherapy, and an RPLND) can cause temporary or permanent infertility. Even when the infertility is temporary, it still means a period of a few years after treatment when achieving a pregnancy is more difficult. So to preserve options, testicular cancer patients should consider whether or not to bank sperm as soon as they have a confirmed cancer diagnosis.
You will encounter a catch-22 situation with regard to sperm banking. Since sperm banking is often not covered by insurance, and costs $2,000 to $3,000, you won't want to spend the money until you're sure you have cancer. But as soon as the ultrasound confirms a solid testicular mass (a tumor), your urologist will want to perform an orchiectomy (even the same day, but certainly within a day or two). You won't be able to perform sperm banking for about 10 days after the orchiectomy. By then your oncologist will be itching to begin treatment. Sperm banking requires 5 or 6 sample collection sessions, two days apart, meaning that you'll need two weeks with appointments on Monday, Wednesday and Friday. So you need to be aggressive with your PCP and urologist in getting a referral to the local cryobank and in scheduling the sperm banking, to minimize the delay in your treatment. You absolutely do not want to delay your orchiectomy for the sperm banking, since it is best to get known cancerous tissue out of your body as soon as possible. So there are only two possibilities: getting it done before the ultrasound (and thus before you know for certain that you have cancer) or after the orchiectomy and before the start of chemotherapy or radiation therapy. (If your doctor is talking about a RPLND, you definitely need to get sperm banking done before the RPLND.)
o Get an attorney to draft a durable healthcare power of attorney and healthcare treatment instructions (living will). If you need a regular will, now is a good time to have it updated. You may also want to execute a regular power of attorney, to enable someone else to manage your finances.
o Set up as many of your bills as possible for automatic bank debit and make sure you have plenty of cash in your bank account. Ask someone you trust to open your bills and make sure you don't miss payment deadlines.
o Before you begin treatment (especially before you start chemotherapy or radiation therapy), go to the movie theater and watch all the movies you are interested in. Once you start treatment, you will be avoiding crowds.
o If there are any chores or repairs you've been procrastinating on, take care of them right away. Take your car in for service. Fix the leaky sink. Take care of anything that's wrong. Once you start treatment, you're going to have less energy.
After a Confirmed Diagnosis
o As soon as you have a testicular cancer diagnosis, ask your doctor or oncologist to sign the Department of Motor Vehicles form requesting a disabled parking placard. The most appropriate reason code will probably be the one associated with "unable to walk 200 feet without resting" if there isn't one specifically for cancer patients. It takes the DMV a month to send you the placard, and by then you will need it. Even though you will be avoiding crowds, and may even be too tired to drive, there are times when someone else will be driving you places and it will help to be in a spot closest to the door. It will be helpful if you have a copy of the form right there for the doctor to sign. If your oncologist is reluctant to sign the form, tell him that other testicular cancer patients have told you that it helped a lot, especially for picking up drugs from the pharmacy and for grocery shopping. If the oncologist won't sign it, ask your regular doctor to sign it -- any doctor can sign the form.
o Join the TC-NET mailing list. It is a mailing list for testicular cancer patients and survivors. You will find it very helpful in getting questions answered and help understanding your pathology report and other diagnostic tests.
Before the Orchiectomy
o Before the orchiectomy, have your urologist measure your testosterone levels. This will establish a baseline that can be helpful in diagnosing problems later. They should draw blood for serum testosterone, FSH, LH, SHBG and Prolactin.
o Also insist on having them measure your tumor markers before the orchiectomy. They should draw blood for AFP, Beta HCG, and LDH. This establishes a baseline for comparison with your levels after the orchiectomy. Tumor marker levels will be rechecked about a week after the orchiectomy for beta-HCG and about a month after the orchiectomy for AFP.
o The orchiectomy is usually performed as a same-day surgery (admitted in the morning, discharged in the afternoon). You will need someone to drive you to the hospital and to pick you up afterward. You will not be able to drive, partly because of the surgery (you won't want to stomp on the breaks), partly because of the anesthesia (you shouldn't drive for a few days after receiving anesthesia), and partly because you will be taking pain medication.
After the Orchiectomy
o Use a bag of frozen peas or corn on the incision area (wrapped in a paper towel if it is too cold). It helps with the pain and swelling, and is easy to "mold" to the shape of the abdomen. Get two, so you can refreeze one while using the other.
o Whatever you do, do not laugh. Avoid comedy and humor for several days after the surgery. It hurts to laugh for a few days after the surgery.
o Have them measure your tumor markers about 7-10 days after the orchiectomy (and before any further treatment). Since tumor markers tend to have a halflife of about a day, if the cancer was isolated to the testicle your tumor markers should drop to normal levels about a week after the surgery. (Beta-HCG has a half life of 24-36 hours, so a week should be sufficient to show signs of marker normalization. AFP has a half-life of 5-7 days, so a month should be enough to show signs of marker normalization, although the trend may be apparent after a week. The amount of time until marker normalization will depend, of course, on the initial tumor marker levels.) If the tumor markers do not normalize, it is a sign that there is still active cancer somewhere in your body.
o After the orchiectomy, further care usually switches from the urologist to an oncologist (cancer doctor). Your urologist should give you a referal to an oncologist. There are two types of oncologists: medical oncologists (chemotherapy) and radiation oncologists (radiation therapy). There will be one follow-up visit with the urologist a few weeks after the surgery, to check on how the incision site is healing, but other than that your continued care will be in the hands of an oncologist. Only if you need further surgery, such as a RPLND, would you see the urologist again.
Before Chemotherapy
o There are certain diagnostic tests that should be conducted before chemotherapy starts. Some of them, like a CT scan, are necessary both to diagnose the staging and to establish a baseline. Others are to establish a baseline. The CT scan should include the pelvis, abdomen, and chest in order to properly stage the cancer. Ask your doctor to schedule a pulmonary function test and an audiogram (hearing test). These are important because of common side effects of chemotherapy, and having a baseline is important for comparison later. Also insist on having them measure your tumor markers your first day of chemotherapy before they start the chemotherapy (they will have put in an IV, so it will be easy for them to draw the blood before hooking up the fluids). Also talk to your doctor about possibly having a PET scan, if your insurance will cover it. A PET scan would be in addition to the CT scan. If you're going to have PET scans, it is best to have one before the start of chemotherapy or radiation therapy, in addition to one six weeks after the end of treatment.
o Before you start treatment, pick an extravagant gift that you will give yourself after you complete treatment. It helps when you are experiencing the pain and side effects associated with treatment to think of that gift as a goal.
o If you like to read, go to the bookstore and buy a bunch of books. If you like to listen to music, make sure you have a good portable radio, CD player or MP3 player. If you like to watch movies, get yourself a portable DVD player and a bunch of DVDs. There will be times when you need something to do, and even TV becomes boring after a while.
o Buy a mini fridge or cooler for your bedroom. You will want to keep some beverages nearby, especially ginger ale (good for nausea). Buy a set of walkie talkies (FRS radios) or an intercom if someone else will be helping take care of you. Buy a small plastic bin or pail to keep by your bed in case you need to vomit. (When you need to vomit, you might not be able to make it to the bathroom in time, or even get out of bed.)
o Before treatment begins, go shopping for a nice hat. It should not have any bumps or clasps around the inside rim, because that will be uncomfortable against your skin after your hair falls out. A continuous cloth rim is probably best. Baseball caps that have a snap or buckle in back will not feel good against your skin.
During Treatment
o Get into the habit of weighing yourself and taking your temperature every day. Keep a weight and temperature log.
o Drink at least 8 full glasses of water a day. Drinking a gallon of water helps flush the chemotherapy drugs from your system, thereby minimizing the more toxic side effects. It also helps prevent the chemicals from building up in your kidneys and bladder, thereby preventing health problems such as kidney failure. If you are not urinating at least once an hour, you are not drinking enough water. Gatorade and pedialyte are also good, since they will help restore your electrolytes, especially if you suffer from diarrhea or vomiting.
o If you don't have a port installed, there are several tricks to getting a vein to 'pop' so the nurse can find it. One tip is to have the nurse wrap a hot towel around your arm (microwaving a wet towel for 10 to 30 seconds should do the trick). The heat causes the veins to appear on the surface. Another trick is to pump your fist several times rapidly or to squeeze a stress ball. Wrapping the tourniquet around your should might also work.
o If you are receiving Bleomycin, avoid scratching and bruises. This can lead to "chemo burn", where the skin becomes discolored. It takes a very long time for the skin discoloration to disappear.
o Your sense of taste and smell will change during chemotherapy. It is a good idea to avoid foods you like, since chemotherapy patients can develop an aversion to foods eaten during chemotherapy, even favorite foods. Also avoid anything with a strong smell, such as perfume, cologne and household cleaners.
o Take your antinausea medication even if you feel fine. The anti-nausea medication only works if it is present before the nausea occurs. If you take it after you start feeling nauseous, it won't work.
o If you develop an allergy to Zofran, ask your oncologist about Kytril. If you develop break-through nausea, ask your oncologist about a relatively new drug called Emend.
o Vomiting doesn't make you feel better. You still feel awful and like you need to vomit, even though after the third time there's nothing left to come up.
o If you are receiving Decadron for nausea, ask the nurse to drip it or do the IV-push very slowly. If they give it to you too fast, it can not only make your face hot/flushed and give you an itchy tush, but actually induce vomitting.
o If you are ever hospitalized during your treatment and you aren't in the oncology ward, you will run into a few problems. First, they probably won't have the antinausea medication on the ward, so they will have to order it from the hospital formulary. Remind them a few hours before your next dose, otherwise you may get nauseous during the delay. Nurses who aren't oncology nurses are less familiar with chemotherapy patients and are more likely to push your Decadron all at once. An oncology nurse will sit with you for twenty minutes while pushing your Decadron; a regular nurse will be in a rush to see the next patient.
o During treatment you will be sitting around in the chemotherapy infusion room for 6-7 hours a day. Your oncologist may have a television and some magazines, and there may be other patients to talk to, but you may want to bring some reading material or a friend with you.
o Tell your friends and family to not give you flowers, plants, or fruit baskets. If you become neutropenic during chemotherapy, you will be at risk of infection, and should avoid exposure to these items.
General Tips
• Always ask your doctors for copies of all lab reports, especially pathology reports, imaging reports (CT scans, MRIs, ultrasounds, PET scans), and blood tests (tumor markers, testosterone levels). You will be getting a lot of information all at once, and will not be able to remember everything. So better to have a copy that you can look at later. Also, you can post the text of the report to the TC-NET list to get help understanding what it means.
• The initial staging of the cancer will depend on the pathology report and the CT scan. This is usually sufficient to determine treatment options.
• If you are suffering from mood changes, fatigue, night sweats, difficulty concentrating, or personality changes, talk to your doctor. It is possible that you are suffering from testosterone deficiency. Your doctor should test your testosterone levels (along with FSH, LH and Prolactin levels) at the same time of day as your presurgical test. Some reduction is to be expected, since the orchiectomy removed a source of testosterone production. However, the "normal" ranges are for intact males and span a wide range that is not age-adjusted. A low normal result might be normal for a 70-year-old, but not for a 35-year-old man. If your testosterone levels are within the normal range, but your FSH or LH levels are elevated, that can be a sign of deficiency. But even if your FSH and LH levels are normal, low normal levels can be a sign of deficiency if you are symptomatic. It is generally a good idea to see an endocrinologist for evaluation of your symptoms and endocrine levels.

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