Testicular (testis) cancer is the most common cancer in males aged 15-40, and with modern treatments has an excellent prognosis, with cure rates over 95% if detected early. The most common reason for diagnosis is a lump within the testicle, usually firm and painless. Nearly all testicular cancers are tumours of ‘germ cells’, which normally give rise to sperm. Testicular cancers are divided into two main types: Seminoma and Non-seminoma. Seminomas generally occur in slightly older men, and are not as rapidly growing as non-seminomas. Overall around 75% of tumours are confined to the testicle at diagnosis (i.e. have not spread to lymph nodes or other organs).
Because the most common early sign is a lump within the testicle, it is important for all men to perform regular testicular self-examination. If men are accustomed to the shape and feel of their testes they will easily detect any significant change such as a new lump. This can be performed in or after a bath/shower, and simply involves rolling the testicle gently between thumb and forefinger from top to bottom, feeling for any irregularity/firmness. This should be performed approximately every 6 months and any change reported to your local doctor for further assessment.
To further investigate a testicular lump, an ultrasound scan of the testicles is performed, and blood taken for ‘tumour markers’ – specific proteins made by some testicular cancers and released into the bloodstream.
While many of the lumps men find turn out to be benign conditions, such as cysts in the structures surrounding the testes, it is vitally important for men to have these lumps examined by a urologist.
Diagnosis of testicular cancer can only be confirmed following removal of the affected testicle and detailed examination under a microscope. Orchidectomy is the surgical removal of a testicle. This procedure is performed in hospital under general anaesthetic. A small incision is made into the groin, where the blood vessels leading to the testicle are first controlled to prevent cancer cells ‘spilling’ into the rest of the body. For cosmetic reasons, insertion of a prosthetic testicle can be performed at the same time if requested.
As in all cancers, a series of tests is necessary to determine the extent, or ‘stage’ of the tumour. This will involve imaging studies such as a CT scan, and blood tests to measure certain proteins made by testicular cancer cells that can subsequently help monitor the success of treatment.
Effect of treatment on fertility
The impact on fertility depends upon the function of the other testicle and the exact treatment received. Overall it is worth considering storage of sperm if any treatment is required after orchidectomy. This gives the option of future in vitro fertilisation (IVF) in the event of sperm production being permanently affected during the course of treatment. Below is a summary of the impact of each treatment on fertility:
Orchidectomy – removal of the cancer should not reduce fertility if the other testicle is normal; in fact it may improve sperm production as testicular cancer may have a dampening effect on the other testicle. In patients with an abnormal or absent other testicle, then sperm storage may be worth considering prior to surgery. In these circumstances, it is also important to monitor the levels of testosterone (the male hormone produced by the testicles) post-operatively as this may need to be supplemented or replaced.
Radiotherapy – is only infrequently used in the current management of testicular cancer. However, if the other testicle is exposed to radiation, this will permanently reduce the production of sperm. To minimize this risk the testicle is shielded during radiotherapy so that the chances of subsequent infertility are low.
Chemotherapy – as a side effect of chemotherapy, sperm production is reduced to zero, and this can take 1-2 years to recover. As there is a chance of permanently lowered sperm count it is advisable to store sperm for future use prior to commencing chemotherapy.
Abdominal surgery – the operation to remove lymph nodes within the abdomen, usually for residual tumour after receiving chemotherapy, can damage the nerves that allow ejaculation. For this reason, after surgery there is the risk of the ejaculated semen going backwards into the bladder (retrograde ejaculation) rather than out the end of the penis, or of failure to ejaculate at all (anejaculation). Again, it is advisable to store sperm for future use pre-operatively.
Whatever the stage of cancer or treatment received, close follow-up with scans and blood tests is required after diagnosis. Review is more frequent in men who undergo surveillance post orchidectomy, than those who are treated with chemotherapy. In addition, regular examination of the other testis should be regularly carried out although the risk of a cancer in the remaining testicle is only about 2%.