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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
Shower Card
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.
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.
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.
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.
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