Testicular Cancer

Survival High with Early Treatment
by John Henkel

Glenn Knies wasn't thinking the worst when he felt the abnormality in his groin area 11 years ago. It was probably a hernia, he guessed.

He had just finished working out. In the shower, he noticed his right testicle seemed enlarged."I thought I had strained something," says Knies, an insurance adjuster in Schwenksville, Pa. He was 23 and barely out of college at the time."I wasn't having any discomfort or symptoms to speak of," he says. "I was strong as ever, and there was nothing else to indicate a problem."He mentioned the condition to his mother, a nurse, who urged him to see a urologist quickly. She suspected something more serious than a hernia was bothering her son.

His doctor determined the enlargement was cancer, and he removed Knies' right testicle, the standard first-line treatment for testicular tumors. Later, after tests showed that cancer may have spread to the lymph nodes deep within the abdomen where the testicles drain, doctors also removed the nodes.

But the lymph nodes were "clean," free of cancer, Knies says. It was the first sign that he probably was going to be OK, that his doctor likely had gotten all the cancer after removing the testicle. To make sure, a regimen of regular examinations followed--monthly at first, tapering off to annually after five years. Eleven years later, he still has a yearly exam but considers himself a cancer survivor.

Most Common Cancer in Young Men

Cancer of the testicles--egg-shaped sex glands in the scrotum that secrete male hormones and produce sperm--accounts for only about 1 percent of all cancers in men, according to the National Cancer Institute. About 7,000 Americans were expected to get the disease in 1995, with an estimated 325 deaths. Compared with prostate cancer, estimated to kill 40,400 of its 244,000 victims in 1995, testicular cancer is relatively rare. However, in men aged 15 to 34, it ranks as the most common cancer. For unknown reasons, the disease is about four times more common in white men than in black men.

Only 15 years ago, a diagnosis of testicular cancer was grim news. Ten times as many patients died then as now. But dramatic advances in therapeutic drugs in the last two decades, along with improved diagnostics and better tests to gauge the extent of the disease, have boosted survival rates remarkably. Now, testicular cancer often is completely curable, especially if found and treated early.

The Food and Drug Administration has approved several drugs to treat testicular cancer, including Ifex (ifosamide), Vepesid (etoposide), Velban (vinblastine sulfate), Blenoxane (bleomycin sulfate), and Platinol (cisplatin).

Many medical professionals regard Platinol as the "magic bullet" for treating certain forms of testicular cancer. FDA approved the platinum-based drug for use after surgery or radiation. Platinol almost always is used in combination with other chemotherapy drugs.

"[Platinum-based treatment] is truly the great success story for solid-tumor chemotherapy," says S. Bruce Malkowicz, M.D., co-director of urologic oncology at the University of Pennsylvania Medical Center. These drugs have helped cut testicular cancer's death rate and bolster its cure rate, he says, adding that many patients "respond very nicely" to platinum-based drug treatments, which are effective even when cancer has spread beyond the testicle.

"That is not a death sentence," Malkowicz says. About 70 percent of men with advanced testicular cancer can be cured, according to the National Cancer Institute.

Detection and Diagnosis

Most testicular tumors are discovered by patients themselves--either by accident, as Knies did, or while performing a self-examination on each testicle. "The usual presentation is of an enlarged, painless lump," says Malkowicz. "Occasionally there can be pain." The lump typically is pea-sized, but sometimes it might be as big as a marble or even an egg.

Besides lumps, if a man notices any other abnormality--an enlarged testicle, a feeling of heaviness or sudden collection of fluid in the scrotum, a dull ache in the lower abdomen or groin, or enlargement or tenderness of the breasts--he should discuss it with a physician right away. These symptoms can be caused by conditions other than cancer. But only a doctor can tell for sure, and it is critical to seek attention promptly.

Physicians have various methods to help diagnose testicular cancer. Often a physical exam can rule out disorders other than cancer. Imaging techniques can help indicate possible tumors. One such method is ultrasound, which creates a picture from echoes of high-frequency sound waves bounced off internal organs. Malkowicz calls this method "a painless, noninvasive way to check for a mass."

But the only positive way to identify a tumor is for a pathologist to examine a tissue sample under a microscope. Doctors obtain the tissue by removing the entire affected testicle through the groin, a procedure called inguinal orchiectomy. Surgeons do not cut through the scrotum or remove just a part of the testicle, because if cancer is present, a cut through the outer layer of the testicle may cause the disease to spread locally. Besides enabling diagnosis, testicle removal also can prevent further growth of the primary tumor.

Nearly all testicular tumors stem from germ cells, the special sperm-forming cells within the testicles. These tumors fall into one of two types, seminomas or nonseminomas. Other forms of testicular cancer, such as sarcomas or lymphomas, are extremely rare.

Seminomas account for about 40 percent of all testicular cancer and are made up of immature germ cells. Usually, seminomas are slow growing and tend to stay localized in the testicle for long periods. It was a seminoma that struck former Philadelphia Phillies first baseman John Kruk at age 33 in 1994. His right testicle was removed, and doctors say his prognosis is good.

Nonseminomas are a group of cancers that sometimes occur in combination, including choriocarcinoma, embryonal carcinoma, and yolk sac tumors. Nonseminomas arise from more mature, specialized germ cells and tend to be more aggressive than seminomas. According to the American Cancer Society, 60 to 70 percent of patients with nonseminomas have cancer that has spread to the lymph nodes.

Cancer Stages

Physicians measure the extent of the disease by conducting tests that allow the doctor to categorize, or "stage," the disease. These staging tests include blood analyses, imaging techniques, and sometimes additional surgery. Staging allows the doctor to plan the most appropriate treatment for each patient.

There are three stages of testicular cancer:

• Stage 1--Cancer confined to the testicle.
• Stage 2--Disease spread to retroperitoneal lymph nodes, located in the rear of the body below the diaphragm, a muscular wall separating the chest cavity from the abdomen.
• Stage 3--Cancer spread beyond the lymph nodes to remote sites in the body.

Through blood tests, doctors can check for tumor-associated markers, substances often present in abnormal amounts in cancer patients. Comparing levels of markers before and after surgical treatment helps doctors determine if cancer has spread beyond the testicles. Likewise, measuring marker levels before and after chemotherapy treatment can help show how well the chemotherapeutic drugs are working.

FDA has approved a test that checks blood levels of alpha-fetoprotein (AFP) as a tumor-associated marker. Other tests, such as those that gauge levels of beta-human chorionic gonadotropin (bHCG) or lactate dehydrogenase (LDH), are widely used as tumor-associated markers, but FDA has insufficient data to approve these tests.

Imaging techniques provide doctors with pictures of internal organs, giving visual clues to cancer staging. Chest x-rays can tell doctors if disease has spread to the lungs. Lymphangiography allows the lymph nodes to be visualized on an x-ray. CT scans create detailed views of cross sections of the body and can indicate possible tumors at various body sites.

Surgery to remove the retroperitoneal lymph nodes, into which the testicles drain, often is necessary for testicular cancer patients. Doctors examine lymph tissue microscopically to help determine the stage of the disease. Also, removing the tissue helps control further cancer spread.

Testicular Cancer Treatment

No one treatment works for all testicular cancers. Seminomas and nonseminomas differ in their tendency to spread, their patterns of spread, and response to radiation therapy. Thus, they often require different treatment strategies, which doctors choose based on the type of tumor and the stage of disease.

Because they are slow growing and tend to stay localized, seminomas generally are diagnosed in stage 1 or 2. Treatment might be a combination of testicle removal, radiation, or chemotherapy. But surgical removal of lymph nodes usually is not necessary for seminoma patients because this type of tumor is what the University of Pennsylvania's Malkowicz calls "exquisitely sensitive" to radiation. Normally directed to the retroperitoneal lymph nodes but sometimes to other lymph nodes, radiation can effectively remove cancer cells there. Stage 3 seminomas are usually treated with multidrug chemotherapy.

Though most nonseminomas are not diagnosed at an early stage, cases confined to the testicle may need no further treatment other than testicle removal. These men must have careful follow-up for at least two years because about 10 percent of stage 1 patients have recurrences, which then are treated with chemotherapy. Stage 2 nonseminoma patients who have had testicle and lymph node removal may also need no further therapy. Some doctors opt for a short course of multidrug chemotherapy for stage 2 patients to reduce the risk of recurrence. Most stage 3 nonseminomas can be cured with drug combinations.

Side Effects

Any kind of cancer treatment can cause undesirable side effects. But not all patients react the same way or to the same degree. One of the main concerns of young men is how treatment might affect their sexual or reproductive capabilities.

Removing one testicle does not impair fertility or sexual function. The remaining testicle can produce sperm and hormones adequate for reproduction. Removal of the retroperitoneal lymph nodes usually does not affect the ability to have erections or orgasms. It can, however, disrupt the nerve pathways that control ejaculation, causing infertility.

Modern "nerve-sparing" surgical techniques have increased the odds of retaining fertility. Many surgeons are abandoning a "total scorched-earth policy where you take out every single lymph node," Malkowicz says.

"We now can limit the amount of dissection necessary to get a good therapeutic cure, but not overdissect to disrupt every bit of nerves," he says, adding that "ejaculation can be preserved" in as many as 80 percent of cases.

Testicular cancer patient Knies points to his twin sons as proof that though his reproductive capacity was temporarily lost, it was restored.

Chemotherapy can cause increased risk of infection, nausea or vomiting, and hair loss. Not all patients experience these. Some drugs may cause infertility, but studies have shown that many men recover fertility two to three years after therapy ends. Radiation patients may experience fatigue or lowered blood counts. Infertility may also occur, but this usually is temporary.

Doctors emphasize that even though the cure rate is very high for all types and stages of testicular cancer, many of the drastic measures taken to cure later-stage disease can be avoided if the tumor is caught early enough. The best way to do this is through regular self-examination, a message that Knies says might be difficult to convey to the prime risk group.

"You have a real sense when you're in your late teens and early 20s of invincibility," he says. "The last thing you're thinking then is that something can stop you. But as I know, it can."

John Henkel is a staff writer for FDA Consumer.

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How to Examine the Testicles
"I never examined myself."

Pennsylvania resident Glenn Knies, 34, says he wasn't consciously looking for possible cancer 11 years ago. He calls it "pure luck" that he noticed an abnormality in the shower and sought medical attention.

Now a survivor of testicular cancer, Knies strongly urges men to examine their testicles regularly.

Medical professionals say men can greatly increase their chances of finding testicular tumors by testicular self-examination, or TSE. Locating a tumor this way can boost the odds of early intervention and total cure.

"Diagnosis of testicular cancer usually starts with self-discovery," says S. Bruce Malkowicz, co-director of urologic oncology at the University of Pennsylvania Medical Center. He advises men of all ages to do TSEs, not just those in the prime risk group of ages 15 to 34.

TSE is best performed after a warm bath or shower. Heat relaxes the scrotum, making it easier to spot anything abnormal. The National Cancer Institute recommends following these steps every month:

• Stand in front of a mirror. Check for any swelling on the scrotum skin.
• Examine each testicle with both hands. Place the index and middle fingers under the testicle with the thumbs placed on top. Roll the testicle gently between the thumbs and fingers. Don't be alarmed if one testicle seems slightly larger than the other. That's normal.
• Find the epididymis, the soft, tube like structure behind the testicle that collects and carries sperm. If you are familiar with this structure, you won't mistake it for a suspicious lump. Cancerous lumps usually are found on the sides of the testicle but can also show up on the front.
• If you find a lump, see a doctor right away. The abnormality may not be cancer, but if it is, the chances are great it can spread if not stopped by treatment.

Only a physician can make a positive diagnosis.
Knies says fear shouldn't keep men from doing the TSE. "And men need not feel self-conscious about touching themselves there. It only takes a few seconds for them to tell if everything's fine. If they find something, they shouldn't be afraid to say something. Wishing it away isn't going to make it go away."

--J.H.