Questions on testicular cancer
Testicular cancers are divided into two main groups depending on the types of cells the tumour originated from. One type is called seminoma and the other type is a mixture of different tumour cells which are bundled together and called non-seminoma germ cell tumours.
Question: What do you mean by germ cell?
Answer: Germ cell has nothing to do with germs in the ordinary sense. Germ cell means a cell that can fertilise another cell to produce a new organism e.g. sperm from the male and eggs in the ovary of females are germ cells.
Question: What is the difference between the two types of testicular tumour?
Answer: Although the initial treatment is the same i.e. removal of the tumour, further treatment can be different and depends if the tumour has spread.
Question: Is one type more common than the other?
Answer: Seminomas and non-seminomas are roughly split 50:50
Question: Can I be cured of my cancer?
Answer: In the large majority of cases, the answer is yes. However, your chances of cure are increased if you catch the tumour at an early stage.
Question: What do you mean by early stage?
Answer: All malignant tumours eventually spread into the surrounding tissues. They can then spread further either to the lymph glands or by the blood stream to other parts of the body. How far the tumour has spread at the time of diagnosis decides what stage you are at.
The stages are as follows:
Stage I: the tumour has not spread out of the testicle.
Stage II: the tumour has spread to lymph glands in the abdomen but has not spread up to the chest.
Stage III: the lymph glands in the chest or neck are also involved.
Stage IV: the tumour has spread outside the lymph glands to other organs such as the lungs.
Question: I have been diagnosed with Stage I seminoma and my cancer specialist says that although the tumour has been removed, there is still a 20% chance of the tumour coming back. Why is this?
Answer: About 15-20% of Stage I seminomas do come back despite the pathologist being unable to find any evidence of spread outside the testicle when the tumour specimen and its surrounding tissue are examined. The reason for this is that some tumour cells have already broken away from the main tumour and travel up to the lymph nodes which normally drain the testicle. As the tumour grows in the lymph glands, it can be seen on a CT scan.
Question: Is there any way the tumour can be prevented from coming back?
Answer: You can reduce the chances of your tumour coming back by having radiotherapy or chemotherapy. The chances of your tumour recurring will decrease to 5%.
Question: Are there any risks involved in these treatments?
Answer: Radiating the glands in your abdomen that drain the testicle can cause problems long term. These problems are rare but include the development of another malignancy such as stomach or pancreatic cancer. There is also an increased risk of atherosclerosis (blocking of the arteries due to radiation induced inflammation of the blood vessels) and this can lead to heart problems 10-15 years later.
The chemotherapy for Stage I seminoma is a single dose of a drug called carboplatin and this can cause problems with blood clotting and the risk of infection for 2-3 weeks afterwards. Some doctors also worry about the long term side effects of this single dose but a recent study showed no evidence of developing another malignancy at least in the next 10 years (but we don't know if this lack of risk is still present in 15-20 years.
The other major side effect of carboplatin is that it can make you infertile. Therefore, you will be offered the chance to save some sperm if you want to consider having children in the future.
Question: Does this mean that if everyone has chemotherapy or radiotherapy for Stage I seminoma that 80-85% are being treated unnecessarily as their tumour would not have come back anyway?
Answer: Unfortunately, yes. The difficult problem is that we do not know which people will have a recurrence of their tumour.
Question: What about the option of keeping a close eye on me by regular check ups for signs of a recurrence?
Answer: This is a definite option and is called surveillance. At regular intervals, you can have a CT scan and blood tests looking for evidence of tumour recurrence. CT scans may be performed at 6 monthly intervals for the first two years and then yearly for the next three years as most but not all recurrences occur during this period. Follow up is usually continued for 10 years.
Question: Is there any way we can improve our odds on deciding whether to have treatment or not?
Answer: There are some studies going on at present that are attempting to subdivide people with Stage I seminoma according to certain characteristics. These include the size of the tumour, whether it has invaded the outer part of the testicle called the rete testis, tumour hormone levels in the blood and if you are less than 30 years of age.
If the tumour was less than 4cms in size with no invasion of the rete testis and you are more than 30 years old, the risk of recurrence without any treatment is considered to be about 12% but a recent study from Spain showed a lower rate of 6%. Those at higher risk of recurrence that are treated with chemotherapy or radiotherapy have a 3-5% risk of recurrence.
Question: If I have a relapse shown by recurrence on my CT scan, what treatment would I have?
Answer: A combination of three drugs called bleomycin, etoposide and cisplatin.
Question: Are there any long term effects of these drugs?
Answer: Yes. There is a higher risk of heart attacks, high blood pressure and high cholesterol. This risk is approximately 4% higher than those of the same age in the population.
Question: Is there an increased risk of secondary cancer following chemotherapy?
Answer: Yes. Again, there is an increased risk similar to a smoker compared to a non-smoker which is approximately twofold.
Question: If I have to take chemotherapy, is there any long term approach I can take to prevent these secondary problems.
Answer: There is no proven approach but common sense says to avoid risk factors such as smoking and excess alcohol. Ensure you have a good diet and exercise regularly.