Testicular Cancer

What are the testes?

What is cancer?

Cancer is a disease of the cells in the body. The body is made up from millions of tiny cells. There are many different types of cell in the body, and there are many different types of cancer which arise from different types of cell. What all types of cancer have in common is that the cancer cells are abnormal and multiply 'out of control'.

A malignant tumour is a 'lump' or 'growth' of tissue made up from cancer cells which continue to multiply. Malignant tumours invade into nearby tissues and organs which can cause damage. Malignant tumours may also spread to other parts of the body. This happens if some cells break off from the first (primary) tumour and are carried in the bloodstream or lymph channels to other parts of the body. These small groups of cells may then multiply to form 'secondary' tumours (metastases) in one or more parts of the body. These secondary tumours may then grow, invade and damage nearby tissues, and spread again.

Some cancers are more serious than others, some are more easily treated than others (particularly if diagnosed at an early stage), some have a better outlook (prognosis) than others.

So, cancer is not just one condition. In each case it is important to know exactly what type of cancer has developed, how large it has become, and whether it has spread. This will enable you to get reliable information on treatment options and outlook. (See separate leaflet called 'Cancer - What are Cancer and Tumours' for further details about cancer in general.)

What is testicular cancer?

Testicular cancer is a 'germ cell cancer' as the cells which become cancerous are those involved with making sperm. Around half of all cases occur in men under 35 years but testicular cancer rarely occurs before puberty. It is the most common cancer in men aged 15-44 years. There are about 2000 new cases in the UK each year. Testicular cancers are divided into two main types (depending on the exact type of cell causing the cancer):

• Seminomas which occur in about half of cases. They most commonly occur in men between 25 and 55 years.
• Non-seminomas. These make up the rest and are mainly teratomas, but include some other rare types. Teratomas usually affect men aged between 15 and 35 years.

In general, all types of testicular cancer cause similar symptoms and are treated much the same.

What causes testicular cancer?

A cancerous tumour starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal and multiply 'out of control'. (See separate leaflet called 'Cancer - What Causes Cancer' for more detail.)

In many cases testicular cancer develops for no apparent reason. However, certain 'risk factors' increase the chance that testicular cancer may develop. These include:

• Geography. The highest rate of testicular cancer occurs in white men in northern Europe. So, some genetic or environmental factor may be involved.
• Family history. Brothers of affected men have an increased risk.
• Undescended testes. The testes develop in the abdomen and usually descend into the scrotum before birth. Some babies are born with one or both testes which have not come down into the scrotum. This can be fixed by a small operation. There is a large increased risk in men who have not had their 'undescended testis' surgically fixed. There is still some increased risk in men who had an undescended testis fixed when they were a baby.
• Infertility. Infertile men with an abnormal sperm count have an increased risk.
• HIV/AIDS. Men who have HIV or AIDS have an increased risk.

Vasectomy does not increase the risk of testicular cancer. (Several years ago there was a 'scare' linking vasectomy with testicular cancer. Studies have ruled out this link.)

What are the symptoms of testicular cancer?

Lump on a testis

In most cases, the first symptom noticed is a lump that develops on one testis. The lump is usually painless. (Note: most swellings and lumps in the scrotum are not due to cancer. There are various other causes. However, you should always tell a doctor if you discover a swelling or lump in one of your testes. It needs checking out as soon as possible.)

Other symptoms

Sometimes there is general swelling or discomfort in one of the testes. If the cancer is not treated and spreads to other parts of the body then various other symptoms can develop. These may include breast tenderness, back pain or shortness of breath.

How is testicular cancer diagnosed and assessed?

To confirm the diagnosis

Your doctor will examine your testes and refer you to a specialist if he or she suspects that the lump is a tumour. A specialist will examine you again and may advise:

• An ultrasound scan. This is a simple painless test which uses sound waves to scan the testes. (See separate leaflet called 'Ultrasound Scan' for more detail.) This test can tell if the lump is a solid mass (likely to be a tumour) or a benign cyst (a fluid filled lump which is common in the testes).
• Blood tests. Testicular cancers often make chemicals which can be detected in a blood sample. The presence of one or more of these chemicals can help to confirm a testicular cancer. They are a 'marker' of testicular cancer. However, you can still have a testicular cancer without being able to detect 'marker' chemicals in the blood. So, a negative result does not rule out cancer.

On the basis of of the examination, and the above tests, a specialist can be confident whether you have cancer or some other cause for the swelling. If cancer is diagnosed then the usual advice is to have an operation to remove the affected testis. The testis which is removed is examined under the microscope to confirm cancer.

Note: if you have one testis removed, it should not affect your sex life. You should still have normal erections, make sperm and hormones from the other testis and so can still father children. However, if you have chemotherapy or radiotherapy (see below) it may affect your fertility. But, many men find that their fertility returns to normal a year after they have received their chemotherapy or radiotherapy treatment.

Assessing the extent and spread

If you are confirmed to have testicular cancer then further tests are usually advised to assess if the cancer has spread. This assessment is called 'staging' of the cancer which aims to find out:

• Whether the cancer has spread to nearby lymph nodes and lymph nodes in the abdomen.
• Whether the cancer has spread to other areas of the body (metastasised).

By finding out the stage of the cancer it helps doctors to advise on the best treatment options. It also gives a reasonable indication of outlook (prognosis). (See separate leaflet called 'Cancer - Staging and Grading Cancer' for more detail.)

Tests which may be advised to 'stage' the cancer include a CT scan, an MRI scan, chest X-ray or other tests. (See separate leaflets which describe each of these tests in more detail.)

Another useful test is the 'marker' blood test described above. If you had a positive test before an operation to remove the cancerous testis, then the test may be repeated after the operation. If the test becomes negative it means that the cancer was probably confined to the testis. If it remains positive then it means that some cancer cells have spread to somewhere else in your body.

The tumour markers commonly tested for are alpha-fetoprotein (AFP), beta human chorionic gonadotrophin (BHCG), lactic dehydrogenase (LDH) and placental alkaline phosphatase (PALP).

What is the treatment for testicular cancer?

Treatment options which may be considered include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on various factors such as the stage of the cancer, the type of cancer (seminoma or non-seminoma), and your general health.

Surgery

Surgery to remove the affected testis is normally advised in all cases. This alone may be curative if the cancer is in an early stage and has not spread. (Radiotherapy may also be advised for seminomas even at an early stage.)

Further surgery may also be needed for some men after radiotherapy or chemotherapy, to remove any cancer cells present in the lymph nodes of the abdomen or chest.

Chemotherapy

Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stop them from multiplying. See separate leaflet called chemotherapy for more details.

Chemotherapy is often given after surgery, even if the cancer has not spread. (See separate leaflet called 'Chemotherapy' for more detail.)

Radiotherapy

Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. (See separate leaflet called 'Radiotherapy' for more detail.)

Radiotherapy is sometimes given to men with seminoma to prevent the cancer coming back after surgery or to treat any cancer cells that have spread to the lymph nodes at the back of the abdomen.

When chemotherapy or radiotherapy are used in addition to surgery it is known as 'adjuvant chemotherapy' or 'adjuvant radiotherapy'.

Follow up after treatment

You will normally be followed up for several years following successful treatment to check that the cancer has not come back. This may include regular blood tests which check for marker chemicals (see above). You may also have regular chest X-rays or other scans or tests to check that you are free of any recurrence.

What is the prognosis (outlook)?

The outlook is usually very good. Treatment for testicular cancer is usually very successful. During the last 40 years, testicular cancer has become a curable cancer in over 95% of cases.

• If your testicular cancer is diagnosed and treated at an early stage, you can expect to be cured. Most testicular cancers are diagnosed at an early stage.
• Even if the cancer has spread to other parts of the body, there is still a good chance of a cure. For testicular cancer that has spread to other parts of the body the chance of being cured is much higher than for many other types of cancers which have spread. This is because the cancerous cells of testicular cancer often respond well to chemotherapy.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. You should ask the specialist who knows your case about your particular outlook.

Detecting testicular cancer early

Young men and teenage boys should get to know how their testes normally feel. Report any changes or lumps to your doctor. (See separate leaflet called 'Testes - Get To Know Yours' for more detail.)

Further help and information

Macmillan Cancer Support

Tel: 0808 800 1234 Web: www.macmillan.org.uk
They provide information and support to anyone affected by cancer.

Cancer Research UK

Web: www.cancerhelp.org.uk provides facts about cancer including treatment choices.

Orchid

A charity that focuses entirely on the male-specific cancers: prostate, penile and testicular.
Website: www.orchid-cancer.org.uk

Other support groups

See www.patient.co.uk/selfhelp.asp for a list of self help and support groups for cancer patients.