TESTICULAR CANCER
( By JASCAP )

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Treatment

Treatment for testicular cancer

Treatment for testicular cancer is usually very successful and most men can now be completely cured, even if the cancer has spread beyond the testicles. The treatment will depend on the type of cancer (whether it is a teratoma or a seminoma) and whether it has spread beyond the testes.

There are three main types of treatment surgery, chemotherapy and radiotherapy.

At the hospital
Benefits and disadvantages of treatment
Giving your consent
Second opinion

At the hospital

If your tests show that you have testicular cancer, you will be looked after by a multidisciplinary team. This is a team of staff who specialise in treating testicular cancer and in giving information and support. It will normally include:

surgeons who are experienced in testicular surgery
specialist nurses who give information and support
oncologists doctors who have experience in testicular cancer treatment using chemotherapy and radiotherapy
radiologists who help to analyse scans and x-rays
pathologists who advise on the type and extent of the cancer.

Other staff will also be available to help you if necessary, such as:

physiotherapists
counsellors and psychologists
social workers.

If you have any questions about your treatment don't be afraid to ask your doctor or a nurse. It often helps to make a list of questions before you go for appointments. You may also like to take a close friend or relative with you when you see the doctor.

If you work, it may be helpful to ask the doctor or specialist nurse, whether the treatment may affect your ability to work.

Benefits and disadvantages of treatment

Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur.

Some people ask what would happen if they did not have any treatment. If no treatment is given, the cancer is likely to continue to grow and develop slowly and spread to other parts of the body. It can then stop these parts of the body working properly.

Although many of the treatments can cause side effects, these can usually be controlled with medicines.

Early-stage testicular cancer

In people with early-stage testicular cancer, surgery alone may cure the cancer. But often, treatment with chemotherapy or radiotherapy is also given to reduce the risk of the cancer coming back. These treatments are successful in curing the cancer in over 95% of men (more than nine out of ten).

If the cancer comes back

If testicular cancer comes back, the treatment can again get rid of the cancer in most men.

Advanced stage

If the cancer comes back again, or has spread widely in the body, further treatment may still be able to get rid of the cancer. In the rare situation where a cure is not possible, treatment may be able to control the cancer, leading to an improvement in symptoms and a better quality of life. However, for some men in this situation the treatment will have little effect upon the cancer and they will get the side effects without any of the benefit.

Making decisions about treatment in this situation can be difficult, and you may need to discuss in detail with your doctor whether you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care with medicines to control any symptoms.

Giving your consent

Before you have any treatment, your doctor will explain its aims to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

the type and extent of the treatment you are advised to have
the advantages and disadvantages of the treatment
any other treatments that may be available
any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.

People often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can't make a decision when it is first explained.

You are also free to choose not to have the treatment. The staff can explain what may happen if you do not have it. It is important to tell a doctor or the nurse in charge, so that they can record your decision in your medical notes.

You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Second opinion

Usually a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for a patient. Even so, you may want to have another medical opinion. Most doctors will be willing to refer you to another specialist for a second opinion, if you feel it will be helpful. The second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information.

If you go for a second opinion, it may be a good idea to take a friend or relative with you, and have a list of questions ready, so that you can make sure your concerns are covered.

Surgery for testicular cancer

Surgical removal of the testicle (orchidectomy) is usually the first treatment for seminoma or teratoma. It also allows your doctor to make an exact diagnosis.

It is uncommon for cancer to affect both testicles. A very small number of men develop a new cancer in the remaining testicle. For this reason, a small biopsy of the unaffected testicle may be done at the time of the initial orchidectomy or at an appointment after the surgery.

The testicular biopsy is a procedure in which a cut is made in the skin of the scrotum. A small sample of cells is taken from the testicle. If no signs of early cancer are present, no treatment needs to be given to that testicle. If the earliest stage of cancer is present (tumour in situ), this can usually be cured by a low dose of radiotherapy to the testicle.

Further surgery is sometimes needed after radiotherapy or chemotherapy, to remove any cancer cells that may still be in the lymph nodes of the abdomen or chest.

Further treatment after surgery for testicular cancer

If the cancer has not spread and was completely removed with the testicle, the operation may be the only treatment you will need.

Monitoring (follow-up)
Teratoma
Seminoma

Monitoring (follow-up)

After your operation, it is very important for you to be seen regularly in the outpatients clinic by your doctor for blood tests, chest x-rays and CT scans. This is because in some men the cancer may come back in the lymph nodes at the back of the abdomen or in the lungs.

If your doctor feels that the risk of the cancer coming back is very low, you will be seen regularly in the clinic and will not have any further treatment unless your tests show that the cancer has come back. This is known as surveillance (monitoring). It is very important to go for these appointments. This is because in the small proportion of men whose cancer comes back, the regular tests will detect the cancer when it is still very small and further treatment can give a very high chance of cure.

If the risk of the cancer returning is thought to be higher, further treatment may be given to help prevent it. This is known as adjuvant therapy. The type of treatment will depend on the type of cancer.

Teratoma

Teratoma is very sensitive to chemotherapy. If the teratoma seems to be contained within the testicle, two sessions of chemotherapy may be given to reduce the chance of the cancer coming back after orchidectomy.

Three or four sessions of chemotherapy may be given if the teratoma has spread beyond the testicle, or if it comes back after orchidectomy.

Seminoma

Seminoma is very sensitive to both chemotherapy and radiotherapy. Even if the seminoma has not spread, men may be offered a single dose of chemotherapy after the surgery. The chemotherapy reduces the chance of the cancer coming back. Radiotherapy to the lymph nodes at the back of the abdomen may be given instead of the chemotherapy.

Chemotherapy and radiotherapy may sometimes be given if the seminoma has spread to the nodes at the back of the abdomen.

If the lymph nodes are large, or if the seminoma has spread beyond the lymph nodes (this is rare), men are treated with three or four sessions of chemotherapy.

Chemotherapy for testicular cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate in the bloodstream and can reach cancer cells anywhere in the body. The drugs most commonly used to treat testicular cancer are cisplatin, etoposide and bleomycin. They are usually used together, which is known as BEP chemotherapy.

When it is given

Side effects

Contraception

When it is given

Chemotherapy may be given to men with teratoma, either to prevent the cancer coming back after surgery or to treat any cancer that has spread to the lymph nodes at the back of the abdomen, or elsewhere in the body.

Men with seminoma usually have chemotherapy if there are a lot of cancer cells in the nodes at the back of the abdomen, or if the seminoma has spread beyond these lymph nodes.

The chemotherapy drugs are given by injection into a vein (intravenously). Two to four sessions of chemotherapy are usually given. Each session involves spending a few days in hospital followed by weekly outpatients visits to be given the chemotherapy drugs. If the cancer has spread to other parts of the body, a longer course of chemotherapy may be necessary, or the treatment may be given weekly.

Chemotherapy using a single dose of just one drug (called carboplatin) is given to treat seminoma if the cancer does not seem to have spread. As an alternative, radiotherapy to the nodes at the back of the abdomen may be given.

Chemotherapy may also occasionally be used to shrink down a large testicular cancer before surgery so that it can be removed more easily. This is known as neo-adjuvant chemotherapy.

Treatment for testicular cancer is very successful, and the cancer does not usually come back after standard chemotherapy.

High-dose chemotherapy may be used if standard chemotherapy does not completely get rid of the cancer cells (which is rare).

Side effects

Chemotherapy drugs can cause unpleasant side effects, but these can usually be well controlled with medicines. Not all drugs cause the same side effects and some people may have very few side effects. Your doctor will tell you about any problems that your treatment may cause.

Lowered resistance to infections

While the drugs are acting on the cancer cells in your body, they also temporarily reduce the number of normal white cells in your blood. When these cells are reduced, you are more likely to get an infection and you may tire easily. During chemotherapy your blood will be tested regularly and, if necessary, you may be given antibiotics to treat any infection.

If your temperature goes above 38C (100.5F), or you suddenly feel unwell, even with a normal temperature, you may have an infection. Contact your chemotherapy nurse or doctor at the hospital straight away.

Anaemia

Chemotherapy may reduce the number of red blood cells (haemoglobin) in your blood; a low level of red blood cells is known as anaemia. If you have anaemia, you will probably feel very tired and lethargic. You may also become breathless.

Anaemia can be very successfully treated with blood transfusions. This should help you to feel more energetic and ease the breathlessness.

Bruising and bleeding

Platelets are a type of blood cell which help to clot the blood. If the number of platelets in your blood is low you will bruise very easily and may bleed heavily from even minor cuts or grazes. If you develop any unexplained bruising or bleeding, contact your doctor or the hospital immediately. We have separate information about platelet transfusions.

Feeling sick

Some of the drugs used to treat testicular cancer can make you feel or be sick (nausea and vomiting), but there are very effective anti-sickness drugs (anti-emetics) to prevent this. It is helpful to avoid eating immediately before and after your chemotherapy. If the sickness is not controlled or continues, even with anti-sickness treatment, let your doctor know. They can prescribe other medicines that may be more effective.

Tiredness

Chemotherapy affects people in different ways. Some people find they are able to lead a fairly normal life during treatment, but many find they have to take things much more slowly. Tiredness can build up over a course of treatment, and if you have a lot of chemotherapy, it can last for several months or more after your treatment has finished. It is best to cope with tiredness by planning ahead. Try to fit in rest periods and don‟t do things that you don‟t need to do. Accept help from others when you need to. There may be times when you feel less tired. A little activity can sometimes help with the symptoms of fatigue.

Sore mouth and loss of appetite

Some chemotherapy drugs can make your mouth sore and cause small ulcers. It is important to rinse your mouth regularly to keep it clean. Using a child‟s soft toothbrush can be helpful. If you don't feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet.

Hair loss

Unfortunately, some chemotherapy drugs will make your hair fall out. People who lose their hair often cover up by wearing wigs, bandanas, hats or scarves. If you are being treated as an inpatient, or you are on income support, you can get a free wig from the NHS. If not, you can still get a subsidised wig from the hospital. Ask the team looking after you if a wig specialist is available to visit you. If your hair falls out it is important to protect your scalp from the sun. If you lose your hair it will start to grow back within three to six months of finishing your treatment.

Breathlessness

The chemotherapy drug bleomycin can occasionally cause inflammation in the lungs and this can lead to breathlessness. This is usually mild, but if it becomes a problem your doctor may stop or change the drug. After having bleomycin you may not be able to take part in certain activities, such as sub-aqua diving. If you need to have an operation after having bleomycin, you should always tell the anaesthetist that you have had bleomycin treatment.

Hearing changes

Another drug, cisplatin, can cause tinnitus (ringing in the ears) and you may lose the ability to hear some high-pitched sounds. This usually improves when treatment ends. Let your doctor know if you have any problems with your hearing. They may want to send you for a hearing test.

Peripheral neuropathy

You may also notice numbness or tingling in your hands and feet or difficulty doing up buttons. Your hands and feet may also become more sensitive to the cold. This is due to the effect of the drug on the nerves and is known as peripheral neuropathy. Let your doctor know if this is a problem for you.

Change in kidney function

Chemotherapy can cause changes in the way that your kidneys work so you will have regular blood tests to see how well your kidneys are working.

Although they may be hard to deal with at the time, these side effects will gradually disappear once your treatment is over.

Contraception

It is not advisable to father a child while having any of the chemotherapy drugs used to treat testicular cancer, as they may harm the developing foetus. It is important to use effective contraception during your treatment and for a year afterwards. You can discuss this with your doctor or specialist nurse.

Condoms should be used during sex within the first 48 hours after chemotherapy to protect your partner from any of the drug that may be present in semen.

Our booklet on chemotherapy discusses the treatment and its side effects in more detail.

High-dose chemotherapy as a treatment for testicular cancer

This treatment involves giving very high doses of chemotherapy to try to destroy all the testicular cancer cells.

As these high doses also damage cells in the bone marrow, certain cells in your blood called peripheral blood stem cells are collected and stored before treatment begins, then returned to the blood afterwards. This is known as stem cell support.

We have a separate booklet on stem cell and bone marrow transplants which gives more detailed information.

Radiotherapy for testicular cancer

Radiotherapy treats cancer by using high-energy rays which destroy the cancer cells, while doing as little harm as possible to the normal cells. It is sometimes used to treat seminoma but not usually to treat teratoma.

When it is given
Planning radiotherapy
Treatment sessions
Side effects

When it is given

Radiotherapy may be given to men with seminoma either 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.

The treatment is normally given in the hospital radiotherapy department as a series of short daily sessions. The treatments are usually given from Monday to Friday as an outpatient, with a rest at the weekend. Each treatment takes 1015 minutes. Your doctor will discuss the treatment and possible side effects with you.

External radiotherapy does not make you radioactive and it is perfectly safe for you to be with other people, including children, after your treatment.

Planning radiotherapy

Radiotherapy has to be carefully planned to make sure that it is as effective as possible.

On your first visit to the radiotherapy department, you will be asked to have a CT scan or lie under a machine called a simulator, which takes x-rays of the area to be treated. The treatment is planned by a clinical oncologist. Planning is a very important part of radiotherapy and may take a few visits.

The radiographer, who gives you your treatment, will draw marks on your skin to help position you accurately and to show where the rays are to be directed. These marks must stay throughout your treatment, and permanent marks (like tiny tattoos) may be used. The marks are very small and will only be done with your permission.

Treatment sessions

Before each session of radiotherapy, the radiographer will position you carefully on the couch, and make sure you are comfortable. During your treatment, which only takes a few minutes, you will be left alone in the room but you will be able to talk to the radiographer who will be watching you from the next room. Radiotherapy is not painful but you do have to lie still for a few minutes while the treatment is being given.

Positioning the radiotherapy machine

Side effects

Radiotherapy to the abdomen can cause side effects such as reddening and soreness of the skin in the treated area, feeling sick (nausea), diarrhoea and tiredness.

These side effects gradually disappear once your course of treatment has finished. The tiredness may continue for some months.

Skin changes

Perfumed soaps, creams or deodorants may irritate the skin and should not be used during the treatment. At the beginning of your treatment you will be given advice on how to look after the skin in the area being treated.

Sickness

Anti-sickness tablets (anti-emetics) may be given at the start of radiotherapy.

It is important to let your doctor know if you are having any problems. Most of the side effects are mild and can be treated successfully with medicines. The side effects should gradually disappear once your course of treatment is over.

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