Testicular cancer

Testicular cancer is a type of cancer that develops in the testicles, a part of the male reproductive system. In the United States, about 8,000 to 9,000 diagnoses of testicular cancer are made each year. Over his lifetime, a man's chance of getting testicular cancer is roughly 1 in 250 (four tenths of one percent, or 0.4%). It is most common among males aged 15–40 years. Testicular cancer has one of the highest cure rates of all cancers: in excess of ninety percent; essentially one hundred percent if it has not spread. Even for the relatively few cases in which the cancer has spread widely, chemotherapy offers a cure rate of at least fifty percent.

Symptoms and early detection

Because testicular cancer is curable when detected early, experts recommend regular monthly testicular self-examination after a hot shower, when the scrotum is looser. Men should examine each testicle, first feeling for lumps and then compare the testicles to each other together to see whether one is larger than the other.

Symptoms may include one or more of the following:

a lump in one testicle
pain and tenderness in the testicles
build-up of fluid in the scrotum
a dull ache in the lower abdomen or groin
an increase, or significant decrease, in the size of one testicle.

Men should report any of these to a doctor as soon as possible.

The extent of testicular cancer and whether the cancer is present are ascertained by ultrasound (of the testicles), X-rays, and/or CT scans, which are used to locate tumors. Blood tests are also used to identify and measure tumor indicators that are specific to the type of testicular cancer.

Pathology

Testicular cancer can be caused by any type of cell found in the testes, but more than 95% of all cancers are from germ cells. (Germ cells produce sperm. They are not pathogenic; i.e., they are not to be confused with the "germs" (viruses, bacteria) that cause illness.) In general, the remainder of this article discusses germ-cell testicular cancer.

Germ-cell tumors are classified as either seminomas or nonseminomas (which may be called teratomas in the UK). Seminomas are slow-growing. Seminomas, when found, tend to be localized (i.e., only in the testicles), simply because they spread relatively slowly. Nonseminomas, on the other hand, tend to spread more quickly. (Nonseminomas are classified as one of three or four subtypes; their rate of spread varies somewhat, but they are treated similarly.) When seminomas and nonseminomas are both present (which is not unusual), the cancer is classified as nonseminoma.

Blood markers for tumours include the beta subunit of human chorionic gondaotrophin HCG and alpha-feto protein (AFP). Seminomatous tumors never have an elevated AFP. Placental alkaline phosphatase and other markers are sometimes used by the pathologist to differentiate between seminoma and nonseminomatous tumors.

A case of testicular cancer is categorized as being in one of three stages (which have subclassifications). Stage one is that in which the cancer remains localized to the testicle. In stage two, the cancer has spread beyond the testicle, but not above the diaphragm or to any visceral organs. In stage three, the cancer typically has spread to the lungs, but it may also have spread to other organs such as the brain or liver. Cases where the tumor markers are elevated without any radiological evidence of disease are also presumed to be stage three. The majority of cases are stage 1 when first identified.

Treatment

The three basic types of treatment are surgery, radiation therapy, and chemotherapy.

Surgery (inguinal orchiectomy) is performed by urologists; radiation therapy is administered by radiation oncologists; and chemotherapy is the work of medical oncologists.

Surgery

While it is possible, in some cases, to remove testicular cancer tumors from a testicle while leaving the testicle functional, this is rarely done. Since only one testicle is typically required to maintain fertility, hormone production, and other male functions, the afflicted testicle is almost always removed completely. More importantly, since removing the tumor alone does not eliminate the precancerous cells that exist in the testicle, it is usually better in the long run to remove the entire testicle to prevent another cancer form. An appropriate exception would be in the case of the second testicle's later developing cancer as well.

In the case of nonseminomas that appear to be stage 1, surgery may be done on the lower lymph nodes (in a separate operation) to accurately determine whether the cancer is in stage 1 or 2. However, this approach, while standard in many places, especially the United States, is falling out of favor due to costs and the high level of expertise required to perform the surgery.

Many patients are instead choosing surveillance, where no further surgery is performed unless tests indicate that the cancer has returned. This approach maintains a high cure rate.

Lymph node surgery may also be performed after chemotherapy to remove masses left behind, particularly in the cases of advanced initial cancer or large nonseminomas.

Radiation therapy

Radiation may be used to treat stage-2 seminoma cancers, or as preventive (adjuvant) therapy in the case of stage 1 seminomas, to minimize the likelihood that tiny, non-detectable tumors exist and will spread (in the inguinal and para-aortic lymph nodes). Chemotherapy as an alternative to radiation therapy is increasing, because radiation therapy has more significant long-term side effects (internal scarring, for example). Radiation is never used as a primary therapy for nonseminoma because a much higher dose is required and chemotherapy is far more effective in that setting.

Chemotherapy

Chemotherapy is the standard treatment, with or without radiation, when the cancer has spread to other parts of the body (that is, stage 2 or 3). It is also an option for stage-1 nonseminomas, as preventive (adjuvant) therapy, particularly for higher-risk cases. The standard chemotherapy protocol is 3 to 4 rounds of Bleomycin-Etoposide-Cisplatin (BEP). This treatment was developed by Dr. Lawrence Einhorn.

While treatment success depends on the stage, the average survival rate after five years is around 95 %, and stage-1 cancers cases (if monitored properly) have essentially a 100-percent survival rate (which is why prompt action, when testicular cancer is a possibility, is so important).

Actions after treatment

For stage-1 cancers that have not had any adjuvant (preventive) therapy, close monitoring for at least a year is important, and should include blood tests (in cases of nonseminomas) and CT-scans (in all cases), to ascertain whether the cancer has metastasized (spread to other parts of the body). For other stages, and for those cases in which radiation therapy or chemotherapy was administered, the extent of monitoring (tests) will vary on the basis of the circumstances, but normally should be done for five years (with decreasing intensity).

A man with one remaining testicle can lead a normal life, because the other testicle takes up the load, and will generally have adequate fertility. However, it is worth the (minor) expense of measuring hormone levels before removal of a testicle, and sperm banking may be appropriate for younger men who still plan to have children, since fertility will certainly be lessened by removal of one testicle, and can be severely affected if extensive chemotherapy is done.

A man who loses both testicles will normally have to take hormone supplements (in particular, testosterone, which is created in the testicles), and is infertile, but can lead an otherwise normal life. Less than five percent of those who have testicular cancer will have it again in the second testicle.

Famous survivors

Decorated cyclist Lance Armstrong is a testicular cancer survivor.
American actor Richard Belzer (b. 1944)
Canadian comedian Tom Green was diagnosed with testicular cancer in 2000 and made a widely acclaimed documentary about his treatment.
In 1997, figure-skater Scott Hamilton survived a bout with testicular cancer.
Four English footballers (soccer players)— England's World Cup winning captain Bobby Moore was treated for tesicular cancer in 1962, soon after his international debut. More recently, Alan Stubbs, Jason Cundy, and Neil Harris have also survived the condition.
José Francisco Molina Jiménez, Spanish football goalkeeper from Real Club Deportivo de la Coruña, in 2001.
Bulgarian footballer Luboslav Penev, from Valencia, in 1994. In 1996 he won the Spanish league and the Spanish Cup with Atletico Madrid.
English Snooker player Jimmy White.
British drummer Philly Morris survived testicular cancer in 2003, since then has set up Europe's biggest testicular cancer web site checkemlads.com
Former Major League Baseball player John Kruk, who played for the Philadelphia Phillies when they won the 1993 National League Pennant, but lost to the Toronto Blue Jays in the World Series (discovered at spring training in 1994 and treated).

Famous victims

Brian Piccolo, an American football player in the late 1960s with the Chicago Bears, died of a germ cell tumor that was not detected until it had metastasized into his lungs. Piccolo would be a major subject of teammate and friend Gale Sayers's autobiography, I Am Third; Sayers's story of their friendship and of Piccolo's struggle with cancer was adapted into the legendary TV movie Brian's Song.

Peter Crimmins, an Australian rules football player in the 1970s with the Hawthorn Hawks, suffering from the cancer was forced to stand down as captain in 1976. An emotional coach inspired the team to do it for the little feller, with the Hawks taking out the 1976 VFL premiership for the courageous small rover. Crimmins died just a few days after the victory. Crimmins (Hawthorn)

Sean Kimerling, born on April 17, 1966, a New York sports anchor for The WB, died of testicular cancer at the age of 37 on September 9, 2003.