Testicular cancer
Testicular cancer | |
---|---|
Other names | Testis tumor stem cell transplantation[2] |
Prognosis | Five-year survival rate rates ~ 95% (US)[3] |
Frequency | 686,000 (2015)[6] |
Deaths | 9,400 (2015)[7] |
Testicular cancer is cancer that develops in the testicles, a part of the male reproductive system.[2] Symptoms may include a lump in the testicle or swelling or pain in the scrotum.[2] Treatment may result in infertility.[2]
Risk factors include an
Testicular cancer is highly treatable and usually curable.
Globally testicular cancer affected about 686,000 people in 2015.
Signs and symptoms
One of the first signs of testicular cancer is often a lump or swelling in the testes. The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for testicular cancer in asymptomatic adolescent and adults including routine testicular self-exams.[12] However, the American Cancer Society suggests that some men should examine their testicles monthly, especially if they have a family history of cancer, and the American Urological Association recommends monthly testicular self-examinations for all young men.[13][14]
Symptoms may also include one or more of the following:
- a
- sharp pain or a dull ache in the lower abdomen or scrotum[16]
- a feeling often described as "heaviness" in the scrotum[16]
- firmness of the testicle[16]
- breast enlargement (gynecomastia) from hormonal effects of β-hCG[15][16]
- low back pain (lumbago) due to the cancer spreading to the lymph nodes along the back[15][16]
It is not very common for testicular cancer to spread to other organs, apart from the lungs. If it has, however, the following symptoms may be present:
Testicular cancer, cryptorchidism, hypospadias, and poor semen quality make up the syndrome known as testicular dysgenesis syndrome.[17]
Causes
A major risk factor for the development of testis cancer is cryptorchidism (undescended testicles). It is generally believed that the presence of a tumor contributes to cryptorchidism; when cryptorchidism occurs in conjunction with a tumor then the tumor tends to be large. Other risk factors include inguinal hernias, Klinefelter syndrome, and[18] mumps orchitis.[19] Physical activity is associated with decreased risk and sedentary lifestyle is associated with increased risk. Early onset of male characteristics is associated with increased risk. These may reflect endogenous or environmental hormones. [citation needed]
Higher rates of testicular cancer in Western nations have been linked to the use of cannabis.[20][21][22][23]
Mechanisms
Most testicular germ cell tumors have too many
Diagnosis
The main way testicular cancer is diagnosed is via a lump or mass inside a testis. More generally, if a young adult or adolescent has a single enlarged testicle, which may or may not be painful, this should give doctors reason to suspect testicular cancer.
Other conditions may also have symptoms similar to testicular cancer:[26]
- Epididymitis or epididymo-orchitis
- Hematocele
- Varicocele
- Orchitis
- Prostate infections or inflammations (cystitis), or kidney (renal) infections (nephritis) or inflammations which have spread to and caused swelling in the vessels of the testicles or scrotum
- Testicular torsion or a hernia
- Infection, inflammation, retro-peritonitis, or other conditions of the lymph nodes or vessels near the scrotum, testicles, pubis, anorectal area, and groin
- Benign tumors or lesions of the testicles
- Metastasis to the testicles from another, primary tumor site(s)
The nature of any palpated lump in the scrotum is often evaluated by scrotal ultrasound, which can determine exact location, size, and some characteristics of the lump, such as cystic vs solid, uniform vs heterogeneous, sharply circumscribed, or poorly defined. The extent of the disease is evaluated by CT scans, which are used to locate metastases.
The
Inguinal orchiectomy is the preferred method because it lowers the risk of cancer cells escaping. This is because the lymphatic system of the scrotum, through which white blood cells (and, potentially, cancer cells) flow in and out, links to the lower extremities, while that of the testicle links to the back of the abdominal cavity (the
Blood tests are also used to identify and measure tumor markers (usually proteins present in the bloodstream) that are specific to testicular cancer. Alpha-fetoprotein, human chorionic gonadotropin (the "pregnancy hormone"), and LDH-1 are the typical tumor markers used to spot testicular germ cell tumors.[citation needed]
A pregnancy test may be used to detect high levels of chorionic gonadotropin; however, the first sign of testicular cancer is usually a painless lump.[28] Note that only about 25% of seminomas have elevated chorionic gonadotropin, so a pregnancy test is not very sensitive for making out testicular cancer.[29]
Stressful Experiences Caregivers of Testicular Cancer Patients May Notice
The stressful event of testicular cancer not only affects the patient that is diagnosed but also affects the caregiver.[30] The psychological stress model consists of stressful experiences that a patient with testicular cancer may go through after diagnosis, that caregivers may want to look out for.[30] The stressful experiences consist of 4 main categories:
- Late side-effects
- Fear of tumor relapse
- Fertility problems
- Social and workplace issues[30]
These side effects may need physical and emotional care which in turn can cause the caregiver an emotional burden.[30]
Screening
The American Academy of Family Physicians recommends against screening males without symptoms for testicular cancer.[31]
Staging
After removal, the testicle is fixed with
- Stage I: the cancer remains localized to the testis.
- Stage II: the cancer involves the testis and paraaortic lymph nodes (lymph nodes below the diaphragm).
- Stage III: the cancer involves the testis and paraaortic lymph nodes. Stage 3 is further subdivided into non-bulky stage 3 and bulky stage 3.[35]
Further information on the detailed staging system is available on the website of the American Cancer Society.[36]
Classification
Although testicular cancer can be derived from any cell type found in the testicles, more than 95% of testicular cancers are
Most pathologists use the World Health Organization classification system for testicular tumors:[39]
- Germ cells derived from germ cell neoplasia in situ
- Noninvasive germ cell neoplasia
- Germ cell neoplasia in situ'[40]
- Specific forms of intratubular germ cell neoplasia
- Gonadoblastoma
- The germinoma family of tumors
- Nonseminomatous germ cell tumors
- Embryonal carcinoma
- Yolk sac tumor, postpubertal type
- Choriocarcinoma
- Placental site trophoblastic tumour
- Epithelioid trophoblastic tumour
- Teratoma, postpubertal type
- Teratoma with somatic-type malignancy
- Mixed germ cell tumors of the testis
- Mixed germ cell tumors
- Polyembryoma
- Diffuse embryoma
- Mixed germ cell tumors
- Germ cell tumors of unknown type
- Regressed germ cell tumors
- Noninvasive germ cell neoplasia
- Germ cell tumors unrelated to germ cell neoplasia in situ
- Spermatocytic tumor
- Teratoma, prepubertal type
- Yolk sac tumor, prepubertal type
- Testicular neuroendocrine tumor, prepubertal type
- Mixed teratoma and yolk sac tumor, prepubertal type
- Sex cord-stromal tumors of the testis
- Leydig cell tumor
- Leydig cell tumor
- Sertoli cell tumor
- Sertoli cell tumor
- Large cell calcifying Sertoli cell tumor
- Granulosa cell tumor
- Adult granulosa cell tumor
- Juvenile granulosa cell tumor
- The fibroma thecoma family of tumors
- Mixed and other sex cord-stromal tumors
- Mixed sex cord-stromal tumor
- Signet ring stromal tumor
- Myoid gonadal stromal tumor
- Sex cord-stromal tumor not otherwise specified
- Leydig cell tumor
- Secondary tumors of the testis
Treatment
The three basic types of treatment are surgery, radiation therapy, and chemotherapy.[41]
Surgery is performed by
Testicle removal
The initial treatment for testicular cancer is surgery to remove the affected testicle (orchiectomy). While it may be possible, in some cases, to remove testicular cancer tumors from a testis while leaving the testis functional, this is almost never done, as the affected testicle usually contains pre-cancerous cells spread throughout the entire testicle. Thus removing the tumor alone without additional treatment greatly increases the risk that another cancer will form in that testicle.[citation needed]
Since only one testis is typically required to maintain fertility, hormone production, and other male functions, the affected testis is almost always removed completely in a procedure called inguinal orchiectomy. (The testicle is almost never removed through the scrotum; an incision is made beneath the belt line in the inguinal area.) In the UK, the procedure is known as a radical orchidectomy.[43]
Retroperitoneal lymph node dissection
In the case of
Many patients are instead choosing surveillance, where no further surgery is performed unless tests indicate that the cancer has returned. This approach maintains a high cure rate because of the growing accuracy of surveillance techniques.
Adjuvant treatment
Since testicular cancers can spread, patients are usually offered
Before 1970, survival rates from testicular cancer were low. Since the introduction of adjuvant chemotherapy, chiefly platinum-based drugs like cisplatin and carboplatin, the outlook has improved substantially. Although 7000 to 8000 new cases of testicular cancer occur in the United States yearly, only 400 men are expected to die of the disease.
In the UK, a similar trend has emerged: since improvements in treatment, survival rates have risen rapidly to cure rates of over 95%.[46]
Radiation therapy
Chemotherapy
Non-seminoma
Chemotherapy is the standard treatment for non-seminoma when the cancer has spread to other parts of the body (that is, stage 2B or 3). The standard
Lymph node surgery may also be performed after chemotherapy to remove masses left behind (stage 2B or more advanced), particularly in the cases of large
Seminoma
As an
Since seminoma can recur decades after the primary tumor is removed, patients receiving adjuvant chemotherapy should remain vigilant and not assume they are cured 5 years after treatment.[52]
Prognosis
Treatment of testicular cancer is one of the success stories of modern medicine, with sustained response to treatment in more than 90% of cases, regardless of stage.[53] In 2011 overall cure rates of more than 95% were reported, and 80% for metastatic disease—the best response by any solid tumor, with improved survival being attributed primarily to effective chemotherapy.[4] By 2013 more than 96 per cent of the 2,300 men diagnosed each year in the U.K. were deemed cured, a rise by almost a third since the 1970s, the improvement attributed substantially to the chemotherapy drug cisplatin.[54] In the United States, when the disease is treated while it is still localized, more than 99% of people survive 5 years.[55]
Surveillance
For many patients with stage I cancer, adjuvant (preventative) therapy following surgery may not be appropriate and patients will undergo surveillance instead.
For both non-seminomas and seminomas, surveillance tests generally include physical examination, blood tests for tumor markers, chest x-rays, and
CT scans are performed on the abdomen (and sometimes the pelvis) and also the chest in some hospitals. Chest x-rays are increasingly preferred for the lungs as they give sufficient detail combined with a lower false-positive rate and significantly smaller radiation dose than CT.[57]
The frequency of CT scans during surveillance should ensure that relapses are detected at an early stage while minimizing the radiation exposure.[58]
For patients treated for stage I non-seminoma, a randomized trial (
For patients treated for stage I seminoma who choose surveillance rather than undergoing adjuvant therapy, there have been no randomized trials to determine the optimum frequency of scans and visits, and the schedules vary very widely across the world, and within individual countries. In the UK there is an ongoing clinical trial called TRISST.[60][61] This is assessing how often scans should take place and whether magnetic resonance imaging (MRI) can be used instead of CT scans. MRI is being investigated because it does not expose the patient to radiation and so, if it is shown to be as good at detecting relapses, it may be preferable to CT.[citation needed]
For more advanced stages of testicular cancer, and for those cases in which radiation therapy or chemotherapy was administered, the extent of monitoring (tests) after treatment will vary on the basis of the circumstances, but normally should be done for five years in uncomplicated cases and for longer in those with higher risks of relapse.
Fertility
A man with one remaining testis may maintain fertile. However, sperm banking may be appropriate for men who still plan to have children, since fertility may be adversely affected by
Psychological Factors of Testicular Cancer
Although testicular cancer has a low mortality rate and better prognosis outcomes, psychological factors still affect cancer patients struggling with a diagnosis.[62] This means that the absence of testicles can influence perceptions of masculinity, sexual identity, and body image.[63] Castration or partial removal is associated with fantasies, beliefs, myths, and cultural norms surrounding the testes, which can lead to severe psychological trauma and consequences for the individual.[63] Consequently, worries regarding sexual and reproductive capabilities may induce feelings of despair, inadequacy, and emotional turmoil.[63] Factors that are associated with a decrease in psychological outcomes are early adulthood, partnership status, work status, sexual dysfunction, diminished masculinity, and adaptive mechanisms. [62]
Masculinity and Sexual Identity
Biological ideas about masculinity say that our bodies confirm our gender, so changes or damage to our reproductive system can affect how men feel about being men.[64] Since testicles have long been seen as symbols of strength, bravery, and masculinity, having surgery to remove them can change how men with testicular cancer view themselves and what it means to be a man.[64]
Social Stigma Related to Masculinity and Sexual Identity
Youthful males aged 18-24 encounter distinct gender-specific social factors that are linked to a decrease in mental health outcomes.[64] These social factors include limited access to health services and engagement, stigma related to masculinity, and cultural expectations.[64] Single or unemployed men are at a higher risk of poorer psychological outcomes that are correlated with an impairment of sexual functions and masculinity.[62] Another factor that is related to experiencing negative effects related to masculinity is not having children, due to not being able to meet traditional expectations of being a protector or provider.[64] Men who felt that losing a testicle made them less masculine also felt negative psychological effects.[64]
New research shows that testicular cancer survivors who have low testosterone levels feel less masculine than those with normal testosterone levels.[65] These concerns are important for teenage boys going through puberty or recently experiencing physical changes, which can shape their developing understanding of their sexual identity.[65] For example, gynecomastia, which is when males develop enlarged breasts during puberty, is a common and normal part of growing up.[65] However, only up to 11% of patients diagnosed with testicular cancer have gynecomastia when they first seek medical attention, and about 4% of males checked for gynecomastia turn out to have testicular cancer.[65] After testicular cancer, some men feel less masculine, but how much cancer affects masculinity varies from person to person.[64]
Body Image
New studies show that 16% of survivors have serious concerns about how they look after the removal of a testicle.[66] These survivors worry about feeling awkward and anxious because of their missing testicles, and they feel different from other people.[66] Even though 52% of survivors felt that their bodies had changed a lot because of cancer and treatment, 88% of the spouses didn't think their partners were any less attractive.[66]
How survivors feel about their bodies is a big factor in deciding whether to get a testicular prosthesis.[66] Many worry about losing their masculinity, and how they see themselves, and just want to look and feel normal again.[66] Looking back at how testicular prostheses were used, especially with many teenagers, there were noticeable improvements in how people felt about their bodies and themselves overall one year after getting an implant.[66] They also felt more comfortable during sexual activities.[66]
Anxiety and Depression
After having the testicles removed through orchiectomy, testicular cancer survivors may experience long-lasting feelings of sadness or embarrassment.[63] Research has shown that these emotions are more prevalent among younger and unmarried men compared to older and partnered individuals.[63] The most common psychological problem faced by men diagnosed with testicular cancer is anxiety.[62] New research suggested that there was no direct comparison between people who have been diagnosed with testicular cancer and the general population.[62] Studies show that anxiety is more frequent among testicular cancer survivors of similar gender and age compared to the general population, affecting about 1 in 5 survivors.[62][65] Depression doesn't seem to burden testicular cancer patients as much as anxiety.[62]
Fear of Recurrence
Around one out of every three testicular cancer survivors experience significant fear of the cancer coming back, and this fear is considered the most troubling issue for them.[65] Unmarried men reported they felt less fear of cancer recurrence than men who were in a relationship.[62] Survivors who have a fear of recurrence of their cancer tend to have more:
- Intrusive thoughts
- Feel more depressed
- Stressed
- Experience poorer physical well-being[65]
Being diagnosed with testicular cancer often destroys many men's feelings of being invincible and brings up unexpected questions about life and purpose.[65] They feel a sense of being in between or on the threshold of a new identity.[65] This involves feeling disconnected from those who haven't been through a similar intense experience, questioning the purpose of their existence, and becoming more aware of life's fragility and the certainty of death.[65] New research suggests that certain testicular cancer survivors think their cancer was triggered by their stress sensitivity.[65] This may be why some survivors have a fear of recurrence more than 10 years after treatment, even though the actual risk of recurrence is around 1%.[65]
Biological and Psychological Factors of Sexual Dysfunction
Sexual dysfunction can present as a symptom in people who have been diagnosed with testicular cancer.[63] Sexual dysfunction can stem from biological factors, psychological factors, or a blend of both.[63] Difficulties in physiological aspects such as achieving erection and ejaculation are correlated with the severity of the disease and the methods of treatment employed such as surgery, radiotherapy, or chemotherapy.[63] Conversely, psychological aspects such as libido and satisfaction remain unaffected by the type of treatment received.[63] Nonetheless, treatment approaches for testicular cancer can induce physiological alterations while simultaneously eliciting emotional responses.[63] Therefore, diminished sexual function (such as decreased libido or inhibition) may result from treatment-related physical factors like fatigue, overall discomfort, hair loss, and significant weight fluctuations, as well as emotional factors including concerns about sexual performance, fear of losing control, and ambiguity regarding what lies ahead.[63]
Post-traumatic Growth From Testicular Cancer
Not every survivor of testicular cancer has negative outcomes of depression and some even may gain positive outcomes from their experience.[65] This means that when you look at outcomes across all testicular cancer survivors, the positives and negatives could balance each other out.[65] Many cancer survivors, both young and older adults, have reported benefits and personal growth in the months and even years following their diagnosis.[65] Furthermore, researchers have discovered that while the journey of testicular cancer initially brings physical and emotional challenges, it also leads many survivors to develop a newfound gratitude for life.[65] Besides improving mental outlook, going through testicular cancer might also motivate men to adopt healthier behaviors such as:
- More physical activity
- Reduce or stop smoking[65]
These positive changes in lifestyle could contribute to better psychological well-being, which can offset any initial difficulties they face.[65]
Epidemiology
Globally testicular cancer resulted in 8,300 deaths in 2013 up from 7,000 deaths in 1990.[9] Testicular cancer has the highest prevalence in the U.S. and Europe, and is uncommon in Asia and Africa.[67] Worldwide incidence has doubled since the 1960s,[68] with the highest rates of prevalence in Scandinavia, Germany, and New Zealand.[citation needed]
Although testicular cancer is most common among men aged 15–40 years, it has three peaks: infancy through the age of four as
Germ cell tumors of the testis are the most common cancer in young men between the ages of 15 and 35 years.[70]
United States
In the United States, about 8,900 cases are diagnosed a year.
United Kingdom
In the UK, approximately 2,000 people are diagnosed a year.[71] Over a lifetime, the risk is roughly 1 in 200 (0.5%).[72] It is the 16th most common cancer in men. It accounts for less than 1% of cancer deaths in men (around 60 men died in 2012).[73]
Other animals
Testicular tumors occur also in other animals. In
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External links
- Ball Checker, self-exam app from the Testicular Cancer Society
- Testicular Cancer – detailed guide from the American Cancer Society
- Testicular Cancer – National Health Service information and resource page (UK)
- Testicular cancer statistics from Cancer Research UK
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