Testicular cancer


Treating testicular cancer

Friday 11 September, 2020

Your medical team will advise you on the best treatment for you. They will consider several different points:

  • your general health
  • the type of testicular cancer you have
  • the size of the tumour
  • the number and size of any lymph nodes involved
  • whether the cancer has spread to other parts of your body. If testicular cancer does spread, it most commonly spreads to the lymph nodes in the pelvic and lower abdominal regions.

In almost all cases, an orchidectomy is done to remove the affected testicle. If the cancer hasn’t spread, this may be the only treatment you need. After the operation, you will need to have regular check-ups and tests to ensure that the cancer hasn’t come back. This is called surveillance (see below).

If additional treatments are needed, they may include chemotherapy, radiation therapy or a combination of treatments to kill any remaining cancer cells or prevent the cancer from coming back. If the cancer does not respond to chemotherapy, you may need further surgery to remove lymph nodes from the belly (abdomen). This is called a retroperitoneal lymph node dissection (RPLND).

Fertility concerns

Chemotherapy, radiation therapy and retroperitoneal lymph node dissection can cause temporary or permanent infertility. If you may want to have children in the future, ask your doctor for a referral to a fertility specialist before treatment starts. You may be able to store sperm for later use (sperm banking). See Fertility and Cancer.

Surveillance

If you had an orchidectomy and the cancer was completely removed along with your testicle, you may not need further treatment. Instead, you will have surveillance, with regular blood tests (checking tumour markers), chest x-rays and CT (computerised tomography) scans for five to ten years.

Surveillance can help find if there is any cancer remaining (residual cancer). It can also help work out if the cancer has come back (recurrence). How often you will need the check-ups and scans will depend on whether you had seminoma or non-seminoma testicular cancer. Your doctor will set up a surveillance schedule according to your circumstances.

It’s important to follow the surveillance schedule outlined by your doctor. While it may be tempting to skip appointments if you are feeling better or if you were diagnosed with stage 1 cancer, surveillance can help to find cancer early if it comes back.

 

Chemotherapy

Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs. It aims to kill cancer cells or slow their growth while causing the least possible damage to healthy cells.

When chemotherapy is given after surgery, it is known as adjuvant treatment. If the cancer is only in the testicle, it can usually be treated with surgery alone and chemotherapy may not be needed. Sometimes, your treatment team assesses that there is a moderate risk of the cancer spreading or returning. In this case, a single dose (or two cycles) of chemotherapy will be recommended.

After treatment, you will be monitored through surveillance with follow-up appointments and tests for five to ten years.

In rare cases, when the cancer has spread to other parts of the body, chemotherapy may be given before surgery as the main treatment.

There are many types of chemotherapy drugs. Some people are given a drug called carboplatin, which is often used for early stage seminoma cancer after surgery. Other drugs commonly used for testicular cancer are bleomycin, etoposide and cisplatin. When these three drugs are used together, the treatment is called BEP chemotherapy.

Chemotherapy is usually put into a vein (intravenously) through a drip. Bleomycin may also be given by injection into a muscle (intramuscularly). In either case, chemotherapy is given in cycles, which means you will receive the drugs for a period of time and then have a rest period of a few weeks before starting a new cycle.

The number of treatment cycles you have will depend on the type and stage of the cancer. Your doctor will give you more information. You will probably have to visit the hospital as an outpatient each time you have chemotherapy.

See ways to prevent or reduce the side effects of chemotherapy. See Understanding Chemotherapy  for more detailed information about this treatment.

Bradley’s story

I was 24 when I started feeling lethargic and developed a lot of pimples on my back, which was unusual for me. My left testicle was also increasing in size and felt hard.

At first I thought it was some kind of hormonal change, but as the testicle was becoming heavy and uncomfortable, I told my dad. He took me straight to the doctor, who did a physical examination and sent me for an ultrasound.

After the ultrasound, the technician said to see my doctor right away. So my dad and I went back to my GP, and he told me I had testicular cancer. I was shocked and emotional, but tried to keep calm.

The GP referred me to a urologist, who said the testicle would need to be removed. Within 12 hours of seeing him, I’d had the operation. It was sent to the lab for testing and it was confirmed as stage 1 seminoma testicular cancer.

I had a little inflammation but otherwise I felt good. I only had to stay in hospital overnight.

A month after the surgery, I had two rounds of chemotherapy in case the cancer spread. The chemotherapy made me feel tired and left a funny taste in my mouth. These side effects passed quickly and it helped to drink a lot of water.

My urologist suggested that I store some sperm before the chemotherapy began because there was a small chance it would make me sterile.

I saw my doctor for regular follow-up appointments and had blood tests as well as a CT scan and ultrasound. I also examined the other testicle regularly for any hardness. It’s been five years now and there’s been no recurrence of the cancer.

My life has now returned to normal and I don’t really think about the cancer much.

Tell your cancer story.

Side effects of chemotherapy

Chemotherapy drugs damage cells as they divide. This makes the drugs effective against cancer cells, which divide more rapidly than most normal cells do. Some normal cells – such as hair follicles, blood cells and cells inside the mouth or bowel – also divide rapidly. Side effects can occur when chemotherapy damages these normal cells.

Everyone reacts differently to chemotherapy. Some people don’t experience any side effects, while others have a few. Side effects are usually temporary. You can take medicines to help reduce your discomfort. Talk to your doctor or nurse about any side effects you have and ways to manage them.

Fatigue

Most people feel tired during chemotherapy, particularly as treatment progresses.

Low white blood cell count

About a week after a treatment session, your white-blood-cell levels may drop, making you more likely to get infections. If you feel unwell or have a fever higher than 38°C, call your doctor immediately or go to the nearest hospital emergency department.

Nausea and vomiting

It is common to feel ill or vomit within a few hours of chemotherapy treatment. Anti-nausea medicines can prevent or at least reduce this feeling. In most cases, an anti-nausea medicine will be injected at the same time as the chemotherapy is given. You may be given other anti-nausea medicines to take home in case nausea occurs. These medicines are available in many forms, including tablets that you swallow, wafers that dissolve on the tongue, and suppositories to put into your bottom (rectum). Tell your medical team if you still feel nauseous as you may be able to try a different medicine.

Constipation

Sometimes chemotherapy can affect the nerve endings in the bowel, making it hard for you to poo and causing constipation. More often, constipation occurs as a side effect of the anti-nausea medicines. Your medical team can prescribe medicines to help with constipation.

Hair loss

Chemotherapy often causes hair loss from the head and body. Hair usually grows back once treatment is over.

Erection problems

Chemotherapy can affect erections, but this is usually temporary. You may also find you have a lower sex drive (libido). See information about sexuality.

Lower sperm production

The chemotherapy drugs may reduce the number of sperm you produce and their ability to move (motility). This can cause temporary or permanent infertility. Speak with your doctor about sperm banking before starting chemotherapy. You will still need to use contraception to protect your partner from any drugs in your semen and to avoid pregnancy.

Using contraception during treatment

Even if treatment lowers sperm production, there is still a chance your partner could become
pregnant. Because chemotherapy and radiation therapy can damage sperm, you will need to use  contraception during treatment and sometimes for some months afterwards to prevent pregnancy. Your doctor will discuss this with you in more detail. See more information on managing fertility changes of treatment.

Peripheral neuropathy

Some drugs affect the nerves, causing numb or tingling fingers or toes. This is called peripheral neuropathy. It usually improves after treatment is finished.

Ringing in the ears

Some types of chemotherapy drugs can cause short-term ringing or buzzing in the ears. This is known as tinnitus.

Breathlessness, cough or unexplained symptoms

Some drugs can damage the lungs or kidneys. You may have lung and kidney function tests to check the effects of the drugs on your organs before and after treatment.

Risk of heart disease

Having chemotherapy for testicular cancer increases the risk of developing heart (cardiovascular) disease. You will have tests to check your heart function before and after treatment.

Risk of other cancers

People who have chemotherapy for testicular cancer are at a slightly higher  risk of developing leukaemia, which is a blood cancer. This outcome is extremely rare, so the benefit of receiving treatment outweighs this risk. You will have regular check-ups after treatment to test for cancer.

 

Radiation therapy

Also known as radiotherapy, radiation therapy uses a controlled dose of radiation to kill cancer cells or damage them so they cannot grow, multiply or spread. The radiation is usually in the form of focused, high-energy x-ray beams.

Radiation therapy is sometimes given to people with seminoma cancer after surgery to prevent the cancer from coming back or to destroy any cancer cells that may have already spread from the cancer to the lymph nodes.

Treatment is carefully planned to make sure as many cancer cells as possible are destroyed while causing the least possible harm to normal tissue. During a radiation therapy session, you will lie under a machine called a linear accelerator.  It directs the radiation beams at lymph nodes in the back of the belly (abdomen) or in the pelvis. The unaffected testicle may be covered with a lead barrier to help preserve your fertility.

Radiation therapy is painless and can’t be felt. It is just like having an x-ray taken. The treatment itself takes only a few minutes, but each session may last 10 to 15 minutes because of the time it takes to set up the equipment and place you in the correct position.

Most people have outpatient treatment sessions at a radiation therapy centre from Monday to Friday for two to four weeks. Your doctor will let you know how many sessions you need.

Side effects of radiation therapy

Radiation therapy can cause a range of side effects, including skin reactions, fatigue and stomach problems. Most side effects disappear within a few weeks of finishing treatment.

Skin reactions

In most cases, radiation therapy for testicular cancer won’t irritate the skin in the treatment area. If the skin does become red or sore, talk to your treatment team about using a moisturising cream, such as sorbolene.

Fatigue

Some people find they become very tired and lack energy for everyday tasks. Try doing some gentle exercise as this can help with the tiredness (fatigue). Plan your activities so you can rest regularly during the day. Talk to your family and friends about how they can help you. The tiredness often lasts for a few weeks after treatment is finished.

Stomach problems

If the treatment area includes your belly (abdomen), you could have some minor stomach-aches, nausea or bloating. Your doctor may prescribe medicines to prevent these symptoms from occurring or to treat them if they do occur.

Bowel problems

Radiation therapy sometimes causes diarrhoea and cramping. These bowel irritations are usually minor and do not need treatment. If they are bothering you, talk to your doctor about adjusting your diet or taking medicines.

Hair loss

You may lose pubic and abdominal hair in the treatment area. After treatment, your hair will usually grow back.

Bladder irritation

In some people, the bladder and urinary tract may become irritated and inflamed. Drinking plenty of fluids will help, but you should avoid alcoholic or caffeinated beverages (such as tea and coffee), as they can irritate the bladder further.

Infertility

Radiation therapy may reduce sperm production or damage sperm. The effect on sperm may be temporary or permanent (see sexuality and fertility). Speak with your doctor about sperm banking before starting radiation therapy. You will still need to use contraception.

Risk of heart disease

People who have radiation therapy for testicular cancer have a higher risk of heart (cardiovascular) disease. You will have heart function tests before and after treatment.

Risk of other cancers

People who have radiation therapy for testicular cancer are at a slightly increased risk of a secondary cancer in the area exposed to radiation. If these cancers do occur, they appear many years after treatment. Because of this small risk, you will have regular check-ups after radiation therapy to test for cancer.

Monitoring side effects

Your radiation oncologist will see you at least once a week to monitor and treat any side effects during the course of your treatment. You can also talk to a nurse if you are concerned about side effects. See Understanding Radiation Therapy for more detailed information.

Surgery to remove lymph nodes

In some cases, an operation called a retroperitoneal lymph node dissection (RPLND or lymphadenectomy) is done to remove lymph nodes at the back of the abdomen that may contain cancer cells.

Non-seminoma cancer

Your doctors may recommend an RPLND if scans after chemotherapy show that the lymph nodes have not returned to normal size, as this may mean that they still contain cancer cells.

Seminoma cancer

Chemotherapy or radiation therapy can usually destroy seminoma cancer cells in the lymph nodes, so an RPLND is rarely used. The operation may be offered for advanced seminoma cancer if there are no other treatment options.

An RPLND is a long, complex operation and should be done by a surgeon with a lot of experience in the procedure. The standard approach involves open surgery, with a large cut made from the breastbone to below the bellybutton. The surgeon moves the organs out of the way, then removes the affected lymph nodes from the back of the abdomen (the retroperitoneum). Your surgeon can give you more information about this operation.

Side effects of RPLND

Fatigue and pain

It can take many weeks to recover from an RPLND. At first, you will probably be very tired and may not be able to do as much as you are used to. The main side effects are pain and tenderness in the belly. Tell your doctor or nurses if you are in pain, as they can prescribe medicines to make you more comfortable.

Ejaculation and fertility

An RPLND may also damage the nerves that control ejaculation. This can cause retrograde ejaculation, which is when semen travels backwards into the bladder, rather than forwards out of the penis. Your surgeon may be able to use a technique called nerve-sparing surgery that avoids damaging these nerves, but this is not always possible.

Although retrograde ejaculation is not harmful to the body, it causes infertility. If having children is important to you, you can store some sperm before you have the operation. Talk to your surgeon for more information.

Palliative treatment

In the rare situation that testicular cancer is so advanced that treatment cannot make it go away, your doctor may talk to you about palliative treatment.

Palliative treatment helps to improve people’s quality of life by managing symptoms of cancer without trying to cure the disease. Many people think that palliative treatment is only for people at the end of their life but it can help people at any stage of advanced cancer. It is about living for as long as possible in the most satisfying way you can.

As well as slowing the spread of the cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment options may include radiation therapy, chemotherapy or other medicines.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, practical, emotional, spiritual and social needs. The team also supports families and carers. See Understanding Palliative Care and Living with Advanced Cancer.

Managing treatment effects

Treatments for testicular cancer can have short-term and longer-term side effects. Short-term side effects are discussed with each treatment earlier in this section. Some people find that their sexuality, fertility and body image are affected in the longer term. It may take time to adjust to any changes. The information below offers some tips.

Effect on sexuality and intimacy

Surgery

The removal of one testicle won’t affect erections or orgasms. An RPLND (retroperitoneal lymph node dissection) operation may damage nerves, causing semen to travel backwards into the bladder instead of forwards into the penis (retrograde ejaculation). This still feels like an orgasm, but no semen will come out.

Chemotherapy

The drugs may remain in your system and be present in your semen for a few days. For a few weeks after chemotherapy, you may have some trouble getting and keeping an erection.

Radiation therapy

Treatment to the pelvis may temporarily stop semen production. You will still feel the sensations of an orgasm, but will ejaculate little or no semen (dry orgasm). In most cases, semen production returns to normal after a few months.

Managing changes to sexuality and intimacy

  • Protect your partner from any drugs in your semen by using barrier contraception, such as condoms, during chemotherapy and for a number of days afterwards, as advised by your doctor. See the next section for information about avoiding pregnancy.
  • Accept that tiredness and worry may lower your interest in sex, and remember that sex drive usually returns when treatment ends.
  • Be gentle the first few times you are sexually active after treatment.
  • Start with touching, and tell your partner, if you have one, what feels good.
  • Talk openly with your doctor or sexual health counsellor about any challenges. They may be able to help and reassure you.
  • See Sexuality, Intimacy and Cancer.

Effect on fertility

Surgery

Most people who have had one testicle removed can go on to have children naturally. If you have had both testicles removed (rarely required), you will no longer produce sperm and will be infertile. People who experience retrograde ejaculation after retroperitoneal lymph node dissection (see above) will also be infertile.

Chemotherapy  and radiation therapy

Both chemotherapy and radiation therapy can temporarily decrease sperm production and cause unhealthy sperm. It may take one or more years before there are enough healthy sperm to conceive a child. In some cases, infertility may be permanent.

Managing fertility changes

  • Use sperm banking to store sperm before cancer treatment for use at a later date. Samples can be stored for many years. Although there is a cost involved, most sperm-banking facilities have various payment plans to make it more affordable. Ask your cancer specialist to refer you to a fertility specialist so you can find out more about your options.
  • Avoid pregnancy until sperm are healthy again by using contraception for 6 to 12 months after chemotherapy or radiation therapy, as advised by your doctor. You may need a sperm analysis test to determine this.
  • If infertility appears to be permanent, talk to a counsellor or family member about how you are feeling. Infertility can be very upsetting for you and your family, and you may have many mixed emotions about the future.
  • See Fertility and Cancer.

Effect on body image

Surgery

If you have had a testicle removed, it may affect how you feel about yourself and your sexuality. You may have less confidence and feel less sexually desirable. Some people adjust quickly to having one testicle, while others find that it takes some time.

Chemotherapy  and radiation therapy

Any type of cancer treatment can change the way you feel about yourself (your self-esteem). You may feel less confident about who you are and what you can do, particularly if your body has changed physically. Some people find that their sense of identity or masculinity is affected by their cancer experience.

Adjusting to appearance changes

  • Give yourself time to get used to any changes to your body. Try to see yourself as a whole person (body, mind and personality) instead of focusing on the parts of you that have changed.
  • Talk to other men who have had a similar experience. You can call Cancer Council 13 11 20 to find out about our peer support programs or visit the Cancer Council Online Community.
  • Let your partner, if you have one, know how you are feeling. Show your partner any changes and let them touch your body, if you are both comfortable with this.
  • If you continue to be concerned about your appearance, you may wish to speak to your medical team about getting an artificial testicle ( prosthesis).
  • You may also find it helpful to talk to a psychologist if you are having trouble adjusting to any changes. Ask your doctor for a referral.

Key points about treating testicular cancer

Treatment options

Your medical team will advise you on treatment based on the type of testicular cancer, its stage, your general health and your preferences.

Surveillance

After surgery to remove the testicle (orchidectomy), you may not need further treatment. Instead, you will need regular check-ups, blood tests, chest x-rays and CT scans. This surveillance has to be continued for five to ten years. It will help detect any return of the cancer early.

Further treatments

Some people also have chemotherapy, radiation therapy, more surgery or a combination.

  • Chemotherapy uses drugs to kill cancer cells or slow their growth. Most side effects are temporary, but can include a risk of infection, fatigue, nausea, hair loss and erection problems.
  • Radiation therapy uses targeted radiation to damage or kill cancer cells. Common side effects include fatigue and stomach pain.
  • A retroperitoneal lymph node dissection (RPLND) is an operation to remove lymph glands from the abdomen. It may be used if the cancer has spread to those lymph glands.
  • Palliative treatment can be used at any stage of advanced cancer to control symptoms and stop the cancer from spreading further.

Treatment effects

Treatment for testicular cancer can affect body image, fertility and sexuality, but there are ways to manage any changes.

Expert content reviewers:

Professor Declan Murphy, Urologist and Director of Genitourinary Oncology, Peter MacCallum Cancer Centre, Vic.; Gregory Bock, Urology Cancer Nurse Coordinator, WA Cancer and Palliative Care Network, North Metropolitan Health Service, WA; Associate Professor Nicholas Brook, Senior Consultant Urological Surgeon, Royal Adelaide Hospital and the University of Adelaide, SA; Clinical Associate Professor Peter Grimison, Medical Oncologist, Chris O’Brien Lifehouse and the University of Sydney, NSW; Dr Tanya Holt, Senior Radiation Oncologist, Radiation Oncology Princess Alexandra Hospital Raymond Terrace (ROPART), Qld; Brodie Kitson, vonsumer; Elizabeth Medhurst, Genitourinary and Stereotactic Ablative Body Radiotherapy (SABR) Nurse Consultant, Peter MacCallum Cancer Centre, Vic; Rosemary Watson, 13 11 20 Consultant, Cancer Council Victoria

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