One thing is certain about Lance Armstrong – he’s the most famous testicular cancer survivor on the planet. He was 25 when he was diagnosed and treated with an advanced form of the disease that had already spread to his brain.
The vast majority of testicular cancer patients are diagnosed with less extensive disease.
We had the distinct honor of discussing this disease with testicular cancer specialist, Lance C. Pagliaro, MD, professor in the Department of Genitourinary Medical Oncology at The University of Texas MD Anderson Cancer Center.
Dr. Pagliaro has published a number of papers on testicular cancer and is considered one of the nation’s leading experts in the disease.
We talked about a wide range of things – from how a young man will know if he has testicular cancer, what treatment is involved and what follow-up care will be necessary.
Testicular cancer usually develops in one of a man’s two testicles, also known as testes. While there are different types of this cancer, the most common form is found in the germ cells. These cells produce sperm. In the testicles there are also cells involved in the production of testosterone, the male hormone.
So testicles play a big role in a man’s ability to have children and play another role in developing stereotypically 'male' features such as facial chest hair. The loss of one testicle, though, will not affect fertility.
There are two types of germ cell testicular cancers - seminomas or non-seminomas, the latter of which is more aggressive. While the testicles are the most common location, germ cell tumors can appear elsewhere in a man’s body, including his chest and abdomen.
About 8,000 American men will learn they have testicular cancer this year. It’s the most common cancer found in men between the ages of 15-35. According to the latest estimates from the American Cancer Society, the number of cases of testicular cancer have dropped over the past year - from 8,590 in 2012 to an estimated 7,920 this year.
Dr. Pagliaro puts it in perspective, “The reality is that cancer in general is uncommon in young men [and] teenagers…and yet, the peak age of incidence in testicular cancer is in the 20s and 30s.”
The disease can appear in any man – from infancy on, according to Dr. Pagliaro.
dailyRx: What are the risk factors for the disease?
Dr. Pagliaro: There are a few risk factors. Men whose father or brother had testicular cancer are at greater risk. An undescended testicle as a child conveys a lifelong risk of testicular cancer in either of the testes.
dailyRx: Is there a screen or test for testicular cancer?
Dr. Pagliaro: The fact is that the average man on an average day is not going to get testicular cancer. When they do, they know it! They know there’s something wrong. They feel it in the shower.
When caught and treated early, the cure rate for testicular cancer is 95-99 percent. But that doesn’t mean it can be ignored. If a change of any kind is noticed in a testicle, a guy of any age should see his doctor and have it checked out. If ignored, the disease can become life-threatening and will generally require longer, more rigorous treatment.
dailyRx: What are the symptoms of testicular cancer?
Dr. Pagliaro: Any change in the size or feel of a testicle should be evaluated by a primary care or family physician or in the emergency room, if necessary. Changes to be concerned about are often “not dramatic,” but should not be ignored. These include:
- A feeling of discomfort, pressure or heaviness in one testicle
- Swelling, lumps or any enlargement of the testes
- A loss in size of one testicle
- Extreme pain is usually associated with a condition known as testicular torsion. This happens when the spermatic cord (a bundle of ducts, blood vessels and nerves that connect the testicles to the abdomen) twists and blocks blood supply to the testicle.
A painless ultrasound exam of the affected testicle can quickly determine if a solid or fluid-filled tumor is involved.
dailyRx: How is testicular cancer diagnosed?
Diagnosis and treatment begin with the surgical removal of the affected testicle. This avoids spillage or spread of the disease.
When asked why a biopsy isn’t performed, Dr. Pagliaro said, “Needle biopsy results are always limited by the sampling error. Whatever you see may not represent the whole tumor.”
This surgery doesn’t affect normal testicular function, Dr. Pagliaro explained. “To remove one testicle by itself does not affect the reproductive potential or sexual health of the individual unless there’s some intrinsic problem with the other testicle as well.
dailyRx: What’s next after diagnosis?
Dr. Pagliaro: Once the diagnosis is made, patients need to make arrangements for treatment as quickly as possible. They need to make that a priority because not only are they dealing with the rest of their lifespan survival, but delay can result in them needing more treatment, and more burden of therapy and potential adverse effects down the road. If they allow the disease to grow, then they need more chemo, more surgery, and there’s a ton of risks. Most types of testicular cancer can be treated in the community by urologists, oncologists and radiation therapists. All patients with testicular cancer should receive counseling about their fertility and should discuss the option of sperm banking before they begin chemotherapy or radiation.
dailyRx: How is this cancer treated?
Dr. Pagliaro: Removal of the affected testicle is always the first step. In most cases, that also establishes the tissue diagnosis, meaning we go and examine the tissue under a microscope and know what type it is. Additional treatment for control of cancer that has spread can include chemotherapy or radiation or surgery or some combination of the above depending on the type of tumor, its location and whether or not it has spread. In the case of chemotherapy, the need for the additional surgery after chemotherapy depends on the magnitude of response and whether there’s a residual mass.
dailyRx: Do survivors have erectile dysfunction or other sexual problems?
Dr. Pagliaro: Not as a general rule. One of the surgical treatments that is necessary for some but not all patients is called retroperitoneal lymph node dissection or (RPLND). Some patients who develop this condition will have semen that flows back into the urinary bladder instead of out of the body, so it results in what they call a "dry orgasm".
A patient who suffers from retrograde ejaculation can still conceive, but some patients still find it to be a source of distress in terms of their sexual function or satisfaction. Cancer survivors are at risk for other forms of emotional distress that may affect sexual function.
dailyRx: At what point can testicular cancer survivors consider that they have been cured of the disease?
Dr. Pagliaro: As with most cancers, there’s a period of time where patients are at risk of recurrence and you see most recurrences within that window of time. Beyond that the odds are that they’re cured. For non-seminoma, it’s two to three years, and for seminoma, it’s ten years. So seminoma requires a longer period of follow-up and it can reoccur as late as 10 years and still be curable.
dailyRx: Do testicular cancer survivors have increased risks of prostate cancer later in life?
Dr. Pagliaro: There has not been any documented increase in prostate cancer among testicular cancer survivors. Those who received chemotherapy are at increased risk of second cancers in general, and they are at risk for cardiovascular disease later in life. These effects can be measured twenty or thirty years out but it doesn’t specifically apply to prostate cancer.
dailyRx: What's the most important take away message you have for our visitors?
Dr. Pagliaro: I would say to men don’t delay seeking medical attention for testicular pain or swelling at any age, because the causes are largely curable. And in the case of cancer, delaying treatment can be life-threatening but it can also result in more difficult treatment or longer duration of treatment.
We would like to thank Dr. Pagliaro for taking time to visit with us and share his insights.