Treatment Options for Testicular Cancer
Descriptions of the most common types of treatment used for testicular cancer are listed below, followed by treatment options by the cancer’s stage. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the man’s preferences and overall health. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Most often, testicular cancer can be successfully treated with surgery, chemotherapy, and/or radiation therapy. Men with testicular cancer usually have concerns about how their treatment will affect their sexual function, fertility, and quality of life, and each man should discuss these topics with his doctor before treatment begins because there is often more than one treatment option available. The final choice of a treatment plan depends on the patient’s specific situation. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment.
Depending on the type and stage of the cancer and other factors, treatment options for testicular cancer can include:
Surgery
Surgery is the removal of the tumor and surrounding tissue during an operation. There are different types of surgery used to treat testicular cancer, each is described further below. If a decision is made to perform an orchiectomy, a sample of blood will be collected before surgery to test for levels of serum tumor markers because they are often helpful in planning treatment and follow-up care (see Diagnosis).• Radical inguinal orchiectomy
Treatment of testicular cancer usually starts with surgery to remove the testicle with cancer, called radical inguinal orchiectomy. This is done through an incision in the groin along the beltline. It is used to diagnose and treat both early-stage and later-stage seminomas and non-seminomas. For later-stage cancer, a radical inguinal orchiectomy may, occasionally, be delayed until after treatment with chemotherapy is finished.
The removal of one testicle typically does not affect a man’s testosterone level if he still has the other testicle, and it is a normal size. If a man’s testosterone level is reduced, symptoms may include depression or other mood changes, fatigue, decreased sex drive, inability to achieve a normal erection, especially in the morning, and hot flashes, as well as loss of muscle and bone mass in the long term. Orchiectomy is unlikely to make a man unable to father a biological child because the remaining testicle will still produce sperm. However, about 25% of men with testicular cancer are infertile even before being diagnosed with cancer. It appears that the cancer itself may cause some men to become infertile. Sperm counts may improve after the testicle with cancer is removed.
A man may develop cancer in both testicles either at the same time or at different times. However, this is rare, occurring in about 2% of men with testicular cancer. If the removal of both testicles, called a bilateral orchiectomy, is performed, the man will no longer produce sperm or testosterone and will not be able to biologically produce children. If the doctor recommends removing the testicle in a man with one testicle, semen is usually analyzed twice before surgery to check if the man’s sperm are fully functioning. If the sperm are functional, then sperm banking is usually recommended, so that he will be able to have children later if he wishes. In addition, for men who have had both testicles removed, testosterone hormone replacement therapy will be needed.
Men can choose to have an artificial or prosthetic testicle implanted in the scrotum that has a weight and texture that is somewhat similar to a normal testicle but not exactly the same. Some men find that a prosthetic testicle is uncomfortable. Each man is encouraged to talk with his doctor about the best timing of this implantation. Some men prefer to wait until after the active treatment period is over to give this option full consideration.
• Retroperitoneal lymph node dissection (RPLND)
Depending on the type and stage of your cancer, some lymph nodes at the back of the abdomen (around the large blood vessels known as the aorta and inferior vena cava) may also be removed at the same time as the orchiectomy or during a second operation. Not all patients with testicular cancer need to have lymph nodes removed, so it’s important to discuss this (and the possible alternatives) with your doctor. This is a complex and long operation. A large incision is typically made down the middle of the abdomen to remove the lymph nodes. It should be done by a surgeon who does this often. Experience counts.
Laparoscopic surgery: In some cases, the surgeon can remove lymph nodes through very small skin incisions in the abdomen by using a laparoscope (a narrow, lighted tube with a small video camera on the end that lets doctors see inside the abdomen) and other long, thin surgical tools. The surgeon’s hands are not inside the patient’s body during this type of surgery.
Laparoscopic surgery seems to be a lot easier for the patient, but doctors are not sure if it’s as safe and effective as the standard “open” surgery in removing all of the potentially cancerous lymph nodes. Because of this uncertainty, doctors are more likely to recommend chemotherapy after laparoscopic surgery if cancer is found in the lymph nodes. In laparoscopic surgery, after being put to sleep, the patient is turned onto his side. Several small incisions are made on the abdomen. A laparoscope and long instruments are inserted through the incisions to remove the lymph nodes. The incisions are then closed and the patient is awakened.
Patients recover much more quickly from this operation than the standard open procedure and are walking soon after surgery. There is usually less pain and patients are eating sooner. This procedure is most often used for patients with early stage non-seminomas to see if the lymph nodes contain cancer. As with the standard open procedure, this is a complex operation that should only be done if the surgeon is very experienced.
• Possible risks and side effects of surgery
The short-term risks of any type of surgery include reactions to anesthesia, excess bleeding, blood clots, and infections. Most men will have at least some pain after the operation, which can usually be helped with pain medicines, if needed.
Effects of orchiectomy: Losing a testicle usually has no effect on a man’s ability to get an erection and have sex. But if both testicles are removed, sperm cells cannot be produced and a man becomes infertile. Also, without testicles, a man cannot make enough testosterone, which can decrease sex drive and affect his ability to have erections. Other effects could include fatigue, hot flashes, and loss of muscle mass. These side effects can be avoided by taking testosterone supplements, either in the form of a gel, a patch, or a shot. Pills are generally not reliable sources of testosterone. Usually men with testicular cancer are young and may be concerned that their appearance has changed. They may be dating and worry about a partner’s reaction, or they may be athletic and feel embarrassed by the missing testicle when in locker rooms.
To restore a more natural look, a man can have a testicular prosthesis surgically implanted in his scrotum. The prosthesis approved for use in the United States is filled with saline (salt water) and comes in different sizes to match the remaining testicle. When in place, it can look like a normal testicle. There can be a scar after the operation, but it’s often partly hidden by pubic hair. Some men might want to have a prosthesis, while others might not. You should discuss your wishes with your surgeon before considering this surgery. It could also help to talk with someone who has a testicular prosthesis, to see what their experience has been like.
Effects of lymph node dissection: Surgery to remove retroperitoneal lymph nodes is a major operation. Serious complications are not common, but they can happen. About 5% to 10% of patients have temporary complications after surgery, such as bowel obstruction or wound infections. The standard approach for an RPLND requires a large incision in the abdomen, which will leave a scar and can take some time to heal. Your ability to get up and around after the operation will be limited for some time. This is less likely to be an issue if you have laparoscopic surgery, which uses smaller incisions.
This type of surgery does not cause impotence – a man can still have erections and sexual intercourse. But it might damage some of the nerves that control ejaculation. If these nerves are damaged, when a man ejaculates, the semen is not propelled forward through the urethra to exit the body but rather goes backwards into the bladder. This is known as retrograde ejaculation, and it can make it hard to father children. To save the normal ejaculation function, surgeons have developed a type of retroperitoneal lymph node surgery called nerve-sparing surgery that has a very high rate of success in experienced hands. Testicular cancer often affects men at an age when they may be trying to have children. These men may wish to discuss nerve-sparing surgery with their doctors, as well as sperm banking (freezing and storing sperm cells obtained before treatment). Men with testicular cancer often have lower than normal sperm counts, which can sometimes make it hard to collect a good sperm sample.
Active surveillance for clinical stage I testicular cancer
After having a radical inguinal orchiectomy, one option for men with clinical stage I seminomas and non-seminomas may be active surveillance. With active surveillance, the patient is monitored closely and active treatment begins only if the cancer recurs. This option involves regular doctor appointments for CT scans, chest x-rays, physical examinations, and blood tests for tumor markers. This approach requires dedication by the doctor and patient to stick to the surveillance schedule so that any recurrence can be detected at an early stage. It is only considered as an option if the serum tumor markers are normal or return to normal after the cancerous testicle is removed.The main advantage of active surveillance is that it avoids any further treatment after orchiectomy, such as chemotherapy, radiation therapy, or additional surgery for the 80% of men with seminoma and 70% of men with non-seminoma who do not need more treatment after surgery. For an individual patient, the risk of recurrence may be higher or lower based on certain risk factors determined by the pathologist’s examination of the testicular tumor after the testicle has been removed.
The surveillance schedule for non-seminomas involves testing every one to two months for the first year, every two to three months in the second year, and less often thereafter. The surveillance schedule for seminomas is much less intense, with testing performed every four months for the first two to three years and less often thereafter. Patients generally have follow-up screening for at least ten years after their diagnosis.
Treatment Options for Testicular Cancer
Chemotherapy (chemo)
Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.
The following drugs are used for testicular cancer, usually in the combinations listed further below.
- Bleomycin (Blenoxane)
- Carboplatin (Paraplatin)
- Cisplatin (Platinol)
- Etoposide (Toposar, VePesid)
- Ifosfamide (Ifex)
- Paclitaxel (Taxol)
- Vinblastine (Velban)
- Vinorelbine (Navelbine)
- BEP: bleomycin, etoposide, and cisplatin.
- EP: etoposide and cisplatin
- TIP: paclitaxel, Ifosfamide, and cisplatin
- VeIP: vinblastine, ifosfamide, and cisplatin
- Vinorelbine (Navelbine), etoposide, and cisplatin
- VIP: etoposide, ifosfamide, and cisplatin
Chemotherapy works very well for testicular cancer but can cause side effects and complications. Most of these side effects usually go away once treatment is finished, but some can show up much later. These are called late effects. Balancing the risks and benefits of chemotherapy is an important issue for men with testicular cancer. However, metastatic testicular cancer (see further below) can generally only be cured with chemotherapy, so for men with metastatic testicular cancer, the benefits of chemotherapy typically outweigh the risks. On the other hand, men with stage I testicular cancer almost never die of the disease regardless of which treatment they receive, so the risks of chemotherapy may outweigh the benefits for these men.
The side effects of chemotherapy depend on the individual and the dose used, but they can include the following:
Fatigue. Tiredness and loss of energy are among the most common side effects of chemotherapy. Almost all men who have chemotherapy for testicular cancer will experience some fatigue, but the severity varies widely from person to person.
Fertility problems. Chemotherapy can cause lowered sperm counts and increase the risk of infertility. In addition, chemotherapy can temporarily damage sperm.
Hair loss. For most patients, hair loss occurs after four weeks. However, it grows back about four months after chemotherapy has ended. At times, it may grow back a different texture (such as curly, if it used to be straight) or a different color. However, patients who are balding before chemotherapy do not grow more hair after completing chemotherapy than they had before chemotherapy.
Hearing loss. Chemotherapy can cause loss of hearing for high-pitch sounds and can cause ringing in the ears, which is called tinnitus. Hearing loss, when it occurs, is usually permanent.
Kidney damage. Mild reductions in kidney function are common after chemotherapy, but it is unknown whether mild reductions actually cause any medical problems. Rarely, chemotherapy can cause more severe kidney damage that prevents the kidneys from functioning completely.
Lung damage. Slightly reduced lung function is common after chemotherapy with bleomycin. Rarely, the effects of bleomycin on the lungs can cause death.
Nausea and vomiting. This is common during each cycle of chemotherapy. Vomiting can often be prevented using the appropriate medications. Drugs that prevent vomiting are given before chemotherapy on each of the days the drug cisplatin is given. There are several drugs and drug combinations that work well to reduce or prevent vomiting, although they do not get rid of all nausea. Learn more about preventing vomiting caused by cancer treatment.
Numbness and tingling. Chemotherapy for testicular cancer sometimes causes a partial loss of feeling in the hands and/or feet from nerve damage. Numbness and tingling after chemotherapy often improves over time, but it may be permanent.
Reduction in the number of blood cells. Chemotherapy may cause a reduction in the number of white cells that fight infections, red blood cells that carry oxygen, or platelets, which cause blood to clot. Because lower levels of these cells can interfere with blood clotting and the body’s ability to fight infections, it is important to seek help immediately if you have bleeding, infection, and/or a fever. Infections during chemotherapy can be very serious, and even life-threatening, if they are not treated immediately, and fever is often the only warning of an infection.
Skin marks. Bleomycin can sometimes leave some brown patches on the skin.
Chemotherapy may also increase risk of secondary cancers many years after treatment, as well as cardiovascular disease and infectious diseases. Learn more about common side effects. Other side effects that can last for a long time after chemotherapy are described in the After Treatment section. Talk with your doctor about your risk of long-term side effects before starting chemotherapy.
High-dose chemotherapy and stem cell transplant
In general, testicular cancers respond well to chemotherapy (chemo), but not all cancers are cured. Even though higher doses of chemo might be more effective, they are not given because they could severely damage the bone marrow, which is where new blood cells are formed. This could lead to life-threatening infections, bleeding, and other problems because of low blood cell counts. A stem cell transplant allows doctors to use higher doses of chemo. Blood-forming stem cells are collected from the bloodstream in the weeks before treatment using a special machine. In the past the stem cells were taken from the bone marrow, but this is done less often now. The stem cells are frozen, and then the patient receives high-doses of chemo.After the chemo the patient gets his stem cells back again. This is called a transplant, but it does not involve surgery – the cells are infused into a vein much like a blood transfusion. The stem cells settle in the bone marrow and start making new blood cells over the next few weeks. For testicular cancer, stem cell transplant is most often used to treat cancers that have come back after treatment with chemo. Current studies are exploring whether a stem cell transplant may be valuable in treating some patients with advanced germ cell cancers as part of their first treatment.
A stem cell transplant is a complex treatment that can cause life-threatening side effects because of the high doses of chemotherapy used. Be sure you understand the possible benefits and risks. If the doctors think you might benefit from a transplant, it should be done at a hospital where the staff has experience with the procedure and with managing the recovery phase. Stem cell transplants often require a lengthy hospital stay and can be very expensive. Even if the transplant is covered by your insurance, your co-pays or other costs could easily amount to tens of thousands of dollars. It is important to find out what your insurer will cover before deciding on a transplant to get an idea of what you might have to pay.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. For testicular cancer, the radiation is generally directed at lymph nodes in the abdomen. Often, the radiation is also targeted at lymph nodes on the same side of the pelvis as the testicle where the cancer started.Radiation therapy is more effective for treating seminoma than non-seminoma and is used less often than in the past. Active surveillance or, less commonly, carboplatin chemotherapy is used instead of radiation therapy as the preferred treatment of stage I seminomas at many treatment centers because of the risk that radiation therapy may cause other cancers and heart disease. However radiation therapy remains an option for stage I, IIA, and IIB pure seminomas. It is also sometimes used to treat brain metastases from either seminomas or non-seminomas, but testicular cancer rarely spreads to the brain.
Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and peptic ulcers. Medications may be helpful to prevent or reduce nausea and vomiting during radiation therapy. Most side effects go away soon after treatment is finished. Radiation therapy may cause problems with sperm production, but this is less common now with newer radiation techniques that can help men to preserve fertility. Radiation therapy may increase risk of secondary cancers many years after treatment, as well as cardiovascular disease and gastrointestinal disease. Talk with your doctor about your risk of long-term side effects before starting radiation therapy.
In some cases, more than one of type of treatment might be used. You may have different types of doctors on your treatment team, depending on the stage of your cancer and your treatment options. These doctors may include:
- A urologist: a surgeon who specializes in treating diseases of the urinary system and male reproductive system
- A radiation oncologist: a doctor who treats cancer with radiation therapy
- A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy
Treatment Options for Testicular Cancer