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Testicular Cancer: Which Treatment Should I Have for Stage I Nonseminoma Testicular Cancer After My Surgery?
You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Testicular Cancer: Which Treatment Should I Have for Stage I Nonseminoma Testicular Cancer After My Surgery?
Get the facts
For most men faced with testicular cancer, surgery to remove the testicle is the first treatment. After surgery, you and your doctor must decide what to do next. For stage 1 nonseminoma testicular cancer, these are your choices:
- Try surveillance. This means following a schedule of regular checkups and tests.
- Have chemotherapy. It can kill any stray cancer cells.
- Have surgery to remove the lymph nodes in your pelvis and lower back.
This decision aid is about stage I nonseminoma testicular cancer. The treatment decision for stage I seminoma testicular cancer is different.
Key points to remember
- Testicular cancer is highly curable, especially when it is found early.
- Lymph node surgery and chemotherapy are the surest ways to keep cancer from coming back. But surgery and chemotherapy have risks and side effects. Surveillance lets you avoid these risks and side effects, or at least lets you put them off for a while.
- About 70 to 80 out of 100 men who choose surveillance are cured and don't have to worry about future treatment. This means that 20 to 30 of those 100 men do need treatment later.1
- For surveillance, you must be willing to have frequent checkups and tests. Without this close follow-up, if the cancer comes back, it might not be found until it has spread and is harder to treat.
- If you don't like the surveillance option but are worried that other treatment might harm your fertility, ask your doctor about banking your sperm before treatment.
There are two main types of testicular cancer: seminoma and nonseminoma. Seminomas may be treated with chemotherapy or radiation. But radiation doesn't work well on nonseminomas. Also, nonseminoma cells are more likely to spread to the lungs, liver, and brain.
"Stage I" means that the cancer doesn't seem to have spread. Some stage I cancers actually have spread to the lymph nodes of the lower back but can't be seen.
Both seminoma and nonseminoma are very often cured, especially if they are found and treated early. Compared to other forms of cancer, testicular cancer-even when it has spread to other parts of the body-has a very high cure rate.
The first treatment is surgery to remove the testicle. After that, most men have three choices: surveillance, chemotherapy, and lymph node surgery.
Surveillance means that you are being watched closely by your doctor but are not having further treatment.
You have exams, chest X-rays, and blood tests regularly during the first few years, as well as CT scans. It can be hard to go to the doctor's office that often. Unless your cancer comes back, the number of checkups and tests will gradually decrease over the next 10 years.
With surveillance, you may be able to avoid the risks and side effects of lymph node surgery or chemotherapy. About 70 to 80 out of 100 men who choose surveillance are cured. They don't have to worry about future treatment. This means that about 20 to 30 of those 100 men do need treatment later.1
Even when cancer is found after a period of surveillance, it is often easy to cure if it's found early. Because of this, many doctors consider it reasonable for some men to choose surveillance.
Chemotherapy, often called "chemo," is the use of very strong drugs to kill cancer cells. The most common chemo for nonseminoma testicular cancer is called cisplatin combination therapy. It uses several different medicines.
Chemo has a very high cure rate for this cancer. More than 95 out of 100 men who have chemo are cured.1 This means that chemo doesn't cure the cancer in fewer than 5 out of 100 men.
Chemo is usually given at a low dose, so long-term side effects are rare.
Lymph node surgery
The full name for this surgery is retroperitoneal lymph node dissection, or RPLND for short. It is surgery to remove lymph nodes in the lower back and pelvis. These lymph nodes may contain cancer.
During the early phases of stage I nonseminoma testicular cancer, it can be very hard to tell if these lymph nodes have cancer without taking them out. In the past, doing this often caused infertility. Modern nerve-sparing methods have greatly lowered the chances of infertility.
Lymph node surgery has a very high cure rate. About 98 out of 100 men who have the surgery are cured.1 This means that the surgery doesn't cure the cancer in about 2 out of 100 men.
Perhaps the greatest risk of choosing surveillance has to do with missing your follow-up tests and exams. Without regular testing and checkups, you can miss cancer that has returned until it spreads beyond the lymph nodes and is harder to cure. If you choose surveillance, it's very important to strictly follow your doctor's schedule of tests and exams.
When cancer does come back during surveillance, it usually hasn't spread any farther than the lymph nodes in the lower back and pelvis. It can usually be treated successfully when the testing schedule has been followed closely.
Chemotherapy for testicular cancer has caused permanent infertility in some men. Because most men diagnosed with this cancer are younger than 35, this is important to think about when you choose which treatment to use.
Some men still need surgery after chemo to remove damaged tissue or remaining cancer. In those cases it is not always possible for the surgeon to use nerve-sparing methods that greatly reduce the chances of infertility.
Men who are going to have chemo should bank their sperm ahead of time if they want to father children in the future. Talk to your doctor about any fertility concerns you may have.
Side effects of chemo
Many men do not have problems with side effects from chemo. Other men have a great deal of trouble with them. If you have problems, your doctor can use other medicines to help you feel better.
Common short-term side effects include:
- Nausea and vomiting.
- Hair thinning or hair loss.
- Mouth sores.
- A higher chance of bleeding and infection.
The chemo used for testicular cancer has also been linked with serious long-term side effects. But these aren't common. These side effects may include:
- High blood pressure.
- Increased cholesterol levels.
- Kidney, heart, and lung damage.
- Increased risk of other cancers, such as leukemia.
The risks and side effects of lymph node surgery for testicular cancer include:
- Chylous ascites. With this condition, digestive fluids collect inside the belly. This may cause belly pain and make it hard to breathe.
- Lymphedema. This is a collection of fluid that causes swelling in the arms and legs.
- Pulmonary embolism. This is a sudden blockage of blood flow in the lung.
Fertility problems after surgery
Men who get lymph node surgery can end up with nerve damage that causes retrograde ejaculation. This means that the semen flows up into the bladder instead of out through the penis. This makes you unable to father children.
In most cases, men with retrograde ejaculation don't have erection problems or trouble enjoying sex.
Nerve-sparing methods have greatly lowered the risk of retrograde ejaculation. Nerve-sparing surgery may be more difficult or impossible for men who have had chemotherapy. Talk to your doctor about whether nerve-sparing surgery is an option for you.
General surgery risks
Like any major surgery, the risks include:
- Pain after surgery. Your doctor may give you a prescription for pain medicine or have you try over-the-counter pain medicine.
- Reactions toanesthesia or medicines.
Compare your options
What is usually involved?
What are the benefits?
What are the risks and side effects?
- You have frequent checkups, X-rays, blood tests, and CT scans during the first few years.
- You will need checkups and testing less often as the years go by and your cancer doesn't come back.
- Surveillance works for many men. Out of 100 men who try surveillance, 70 to 80 remain free of cancer.1
- It can be hard to follow the long and intense schedule of checkups and tests that are required with surveillance.
- The cancer may be more likely to come back with surveillance.
- The chemotherapy drug is usually injected into a vein in your hand or arm. This method is called an IV.
- Treatment is most often done in a hospital.
- You have treatments for about 3 months.
- More than 95 out of 100 men who have chemo are cured.1 This means that chemo doesn't cure the cancer in fewer than 5 out of 100 men.
- Side effects of chemotherapy can include nausea and vomiting, hair loss, mouth sores, and diarrhea.
- You may need surgery to remove damaged tissue or remaining cancer after chemotherapy.
- Chemotherapy can cause serious long-term health problems, including secondary cancers, but this isn't common. These cancers may not appear until many years after treatment.
- Chemotherapy causes infertility in some men.
- If you have surgery, the doctor makes a long cut in your belly, from the breastbone to the pubic bone.
- You are asleep during the operation.
- The hospital stay is usually 4 to 8 days for surgery.
- Recovery from surgery takes 6 to 12 weeks.
- About 98 out of 100 men who have the surgery are cured.1 This means that the surgery doesn't cure the cancer in about 2 out of 100 men.
- Even with nerve-sparing techniques, some men will become infertile after surgery.
- Nerve-sparing surgery is not possible for some men.
- Like all major surgeries, lymph node surgery has risks, including infection, bleeding, and blood clots.
Personal stories about choosing RPLND (lymph node surgery), chemotherapy, or surveillance for stage I nonseminoma
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
As a cyclist, I figured the swelling on my testicle was probably caused from over-training. But my wife made me go to the doctor to have it checked out. It's a good thing I did, because the doctor told me I had a stage I nonseminoma. Since we found it at an early stage and my prognosis was good, I was given the options of chemotherapy, RPLND surgery, or surveillance. At the time, I was spending a lot of time traveling to races so I decided that I didn't really have the time for all the checkups and tests that go with surveillance. And I wasn't comfortable with having chemotherapy, so I chose RPLND. After the RPLND, I had some trouble with fluid retention in my legs and postoperative pain, both of which have since improved. I've been able to resume my cycling career. And my doctor says I'm cancer-free, so I have no regrets.
John, age 28
After I got over the shock of my diagnosis, we talked about my treatment choices. My doctor told me that because we caught the cancer at an early stage, I had to decide on which treatment option was best for me. After discussing it with my wife, we decided on the RPLND. We also felt the stress of surveillance would be just too much for us, especially since we have a young child and would like to have another. My doctor says that I'm still cancer-free after 2 years, but the surgery did cause me to become infertile. Although I did bank sperm before the surgery, part of me wishes I had given more thought to surveillance.
Lorenzo, age 37
When my doctor told me I had testicular cancer, I was devastated. I decided that I would do everything in my power to beat this disease. After discussing it with my doctor I decided to go ahead with chemotherapy. I knew there was a chance that I didn't need it, but I wanted to get it over with as soon as possible so I could continue with my life. Because my cancer was early-stage, the chemotherapy program wasn't very intensive. And the side effects were barely noticeable. That was a year ago, and I feel great. I know I made the right decision for me.
Michael, age 31
At first I couldn't believe what the doctor was telling me. How could I have cancer? I thought I was too young for something like that. After going through a period of denial and anger, I decided I was going to do whatever I could to beat it. My doctor said I was fortunate because we had caught it at an early stage. After orchiectomy, I was told I could either go for surgery to remove lymph nodes in my pelvis, have chemotherapy, or try surveillance. I decided to wait and see if my cancer was gone before having other treatment. I'm young and don't like the idea of having major surgery or chemotherapy if I don't have to, especially since they can cause other problems later on. The follow-up schedule has been hard to stick to at times. But it's been over a year, and the doctor says I'm still cancer-free, so I think it's been worth it.
Sam, age 20
After being diagnosed with a stage I nonseminoma, I decided to try a surveillance program after my orchiectomy. I made all of my follow-up appointments and felt confident that my cancer was gone for good. Well, about 8 months after I started the program, we found out that my cancer had spread to the lymph nodes in my pelvis. Now my doctor tells me that I'm going to need the surgery anyway and may also need chemotherapy to cure my cancer. I can't believe that the cancer came back. But my doctor says that my chances are really good that I will be cured-I hope he is right.
David, age 33
What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
I'm worried that if I have treatment, I may not be able to have children.
I'm willing to put up with the possibility of not having children if it means that my cancer will be cured for good.
A long schedule of regular checkups and tests during surveillance will be worth it if it means that I won't need to have other treatment.
I want to avoid chemotherapy.
I want to avoid surgery.
My other important reasons:
Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
NOT using surveillance
NOT having chemotherapy
NOT having surgery
What else do you need to make your decision?
Check the facts
Does surveillance simply mean having a special test during your yearly checkup?
- YesSorry, that's wrong. If you choose surveillance, you must be willing to follow an intense schedule of frequent checkups and tests.
- NoYou're right. If you choose surveillance, you must be willing to follow an intense schedule of frequent checkups and tests.
- I'm not sureIt may help to go back and read "What are the treatment choices for stage I nonseminoma testicular cancer?" If you choose surveillance, you must be willing to follow an intense schedule of frequent checkups and tests.
Are lymph node surgery and chemotherapy the surest ways to keep cancer from coming back?
- YesThat's right. Lymph node surgery and chemotherapy have very high cure rates.
- NoSorry, that's not right. Lymph node surgery and chemotherapy have very high cure rates.
- I'm not sureIt may help to go back and read "What are the treatment choices for stage I nonseminoma testicular cancer?" Lymph node surgery and chemotherapy have very high cure rates.
If you're worried that chemotherapy or surgery will leave you infertile, can you bank your sperm ahead of time?
- YesThat's right. If you're worried that treatment may leave you infertile, you can bank your sperm ahead of time.
- NoSorry, that's wrong. If you're worried that treatment may leave you infertile, you can bank your sperm ahead of time.
- I'm not sureIt may help to go back and read "What are the risks of chemotherapy?" If you're worried that treatment may leave you infertile, you can bank your sperm ahead of time.
Decide what's next
Do you understand the options available to you?
Are you clear about which benefits and side effects matter most to you?
Do you have enough support and advice from others to make a choice?
How sure do you feel right now about your decision?
Use the following space to list questions, concerns, and next steps.
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
|Primary Medical Reviewer||E. Gregory Thompson, MD - Internal Medicine|
|Specialist Medical Reviewer||Christopher G. Wood, MD, FACS - Urology, Oncology|
- National Comprehensive Cancer Network (2010). Testicular Cancer, version 2. Available online: http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf.