Knowing the Signs to Detect and Treat Testicular Cancer Early

Testicular cancer is rare but highly curable, especially with early detection; treatment varies by stage, and follow-up care supports long-term health: © stock.adobe.com

Although testicular cancer is a rare, the disease makes up the most common malignancy in men aged 15 to 44, according to the Testicular Cancer Awareness Foundation, and is often found through early detection prompted by noticeable signs such as lumps, swelling or tenderness.

April serves as Testicular Cancer Awareness Month, and according to Dr. Benjamin Garmezy, although testicular cancer is daunting, it remains highly curable, with cure rates exceeding 90%, and ongoing research continuing to improve the already high numbers of cure.

“Testicular cancer is scary. Cancer is scary. Cancer is a charged term. However, this is one that's highly curable. We say every patient diagnosed with this disease has a chance of cure, and a highly likely chance of cure,” Garmezy, a medical oncologist and the assistant director of Genitourinary (GU) Research at Sarah Cannon Research Institute in Nashville, Tennessee, emphasized.

In an exclusive interview with CURE, Garmezy delved into the topic of Testicular Cancer Awareness Month, highlighting topics like warning signs and symptoms of the disease, as well as the most common treatment options and factors that make someone more likely to develop testicular cancer.

Notably, Garmezy also serves as the co-chair of the GU Research Executive Committee at SCRI Oncology.

CURE: What are the early warning signs and symptoms of testicular cancer that patients should be aware of?

Garmezy: Testicular cancer is actually something that is often caught pretty early because the early warning signs are so obvious. Generally, a young man will feel a mass, bump, tenderness, or swelling — something like that. Testicular cancer is the most common malignancy in young men, typically between the ages of 15 to 35, but it is still quite a rare disease.

Generally, if you feel something, please go to a doctor, and you'll get it identified via, generally, an ultrasound. An ultrasound is a non-invasive imaging test that will look into the testicle and see if it's a concerning mass or not.

What are the most common treatment options for testicular cancer, and how do they impact long-term health?

The most common treatment options depend on the stage of the cancer diagnosis. As I said, most men will catch [their] disease early, and generally, what we call an orchiectomy, or surgical removal of one (not both) of the testicles, is enough to cure that patient. Then, we can just monitor them and hope nothing ever comes back. Oftentimes, the cancer does not return, and that's all that's needed.

However, some patients present with more aggressive disease at the time of diagnosis, whether that's disease that has spread to the lymph nodes (which is very common) or the lungs. These patients may need chemotherapy, radiation or further surgery, which is a dissection of the lymph nodes.

Selecting the appropriate treatment between surgery, radiation and chemotherapy is based on the pathology at the time of surgery, as well as what some of the lab values are telling us about your potential risk. This involves looking at what we call tumor markers in the blood. There are three blood values we follow: LDH, AFP and beta-HCG. We're going to use all that information, and sometimes we'll recommend chemotherapy.

Oftentimes, we don't; oftentimes, we just recommend surveillance with a schedule of scans that become wider and wider intervals as we progress, until we can eventually transition you out of an oncology clinic and have you follow up with just a primary care physician.

Are there specific risk factors that make someone more likely to develop testicular cancer?

Yes, there are a few identifiable risk factors. One of the most important, and perhaps unnoticed, risk factors is undescended testicles. This is not uncommon in young boys and toddlers. Sometimes the testicle is surgically corrected, and [sometimes it descends on its own]. However, having a history of undescended testicles is a risk factor.

For men with this history, we recommend monthly self-exams. This involves using two fingers to gently feel around, making sure the size of the testicles isn't changing and checking for any new lumps, bumps, tenderness or swellings that might indicate the need for a testicular ultrasound or a follow-up with a urologist for diagnosis to ensure it's not a malignancy. I will say that often it is not cancer. Swellings of veins and tubes in that area are more common causes of those sensations than cancer. So, don't panic if you feel something, but of course, we will want you to get it evaluated.

Undescended testicles, or what we call cryptorchidism, is one of those potential causes. Other risk factors are more nuanced, such as a family history of testicular cancer. Obviously, we're going to be more attentive to this for a patient whose parents or another family member had testicular cancer. There are certain genetic syndromes, like Klinefelter syndrome, that can be associated with testicular cancer.

However, generally, this is a disease that just happens sporadically, and one that just pops up due to what we might call bad luck.

For patients in remission, what follow-up care is needed to monitor for recurrence, and how can they maintain their overall health after treatment?

Let’s say you're cured by either surgery or chemotherapy, or maybe both. That's great news. Chances are the cancer is not going to come back. However, there's always that risk, and if it does recur, know that there are still curative options available to you, even if that cancer comes back, which is what's unique about testicular cancer — it's a highly curable disease.

Surveillance is based on your risk features. How high were those tumor markers in the blood that we talked about earlier? What was the actual spread of the disease that led to more aggressive therapy? Or was there no need for more aggressive therapy? Then you'll be followed on at least a five-year plan. Sometimes that means checking in with your physician every two months if you have high-risk features based on labs and exams. Sometimes that spaces out to every three, four or six months.

By the time you move out to year three, year four, year five, you're starting to have fewer and fewer visits with that oncologist, and you start to space out those visits, even potentially annually. So, it gets better; the highest risk of recurrence is in those first two years. But there are other things that need to be discussed at those visits. It's not just, "Is the cancer back? Yes or no," because it's often not. It's how do we continue to heal and take care of someone who has potentially had chemotherapy in the past?

So, one, we're thinking about looking at their cardiac risk factors, making sure their overall health is OK, making sure their wellness is OK, making sure other labs that maybe young men don't often get checked by their primary care doctors — well, maybe we can check some of those health labs at those visits while we have them in our oncology clinics. So, those are things to think about. And the other thing is fertility. If you had chemotherapy, hopefully, you did sperm banking prior to the chemotherapy. That's the gold standard in maintaining your fertility. A few men may still have their fertility after chemo, but we do suggest you do that upfront.

Now, if you had surgery and not chemotherapy, so you have one remaining healthy testicle, oftentimes you will remain fertile. Some providers still recommend fertility preservation prior to surgery, but not everyone does. But then you're also going to want to check for testosterone levels and just make sure that the hormonal balance in that patient is still in check, or if any tweaks need to be made.

What message would you like to impart to patients during Testicular Cancer Awareness Month to help raise awareness and encourage early detection?

Testicular cancer is scary. Cancer is scary. Cancer is a charged term. However, this is one that's highly curable. We say every patient diagnosed with this disease has a chance of cure, and a highly likely chance of cure. Over 90% of these men are going to get cured. What I tell my patients is this is hopefully just going to be a bad dream in your life's rearview mirror, and we're going to get you through it. But even if that frontline chemo doesn't work, there are other options. We can do transplant. We can do higher doses of chemotherapy and still cure patients with those salvage options.

Sarah Cannon Research Institute — where I work — has a whole host of clinical trials available for patients with novel cellular therapies, where we're genetically engineering white blood cells to go into a patient and try to directly attack the tumor, or we have a molecule that will grab onto your own immune cells and bring them into the tumor, called a T-cell engager. We have all sorts of really cool technology as well that can really help, I think, extend life and perhaps achieve more cures in patients with testicular cancer. So, that's the big picture. Understand that this is scary, but also understand that there's a lot of help out there.

Another thing to consider is, how do we catch it early so that we don't have to go through all that? That's the other big goal, and I think that involves, if you're at higher risk, definitely doing monthly self-exams in the shower, in the privacy of your own room, whatever it may be. Feel around the testicle. It's OK if one is a little bit larger than the other; that's normal. It's OK if one is a little bit more descended than the other; again, that's normal. You're looking for changes. You're looking for masses, lumps, bumps, something that doesn't feel right.

Now, you're going to have a little swelling at the top, or somewhere near the top of your testicle on the outside, because you have tubes that connect into the testicle, because the testicle has a biological function — men have them for a reason. But that's normal; you're looking at changes. Remember, if you find swelling, it's probably not cancer, but you should get it evaluated.

The thing is, don't be afraid. Go to a urologist or a primary care doctor. Get an ultrasound if you need one. Find out if you have a cancer that's easily removable before it spreads, or if this is something else, like a hydrocele or a varicocele, some kind of vascular benign swelling of those blood vessels that feed that testicle. So, don't panic, but actually do the exams.

The question is, should everyone be doing self-exams? I think that's a question we get a lot, and the answer is, we don't really know. Now, the United States Preventive Services Task Force says that's not necessary. The reason for that is, whenever they make a recommendation on screening, they consider whether it increases or decreases cure rates. In this case, we're going to cure almost everyone, so it doesn't really check those boxes. However, some oncology guidelines and societies in America and Europe suggest anyone with those risk factors we talked about earlier maybe do monthly self-exams.

To me, what do I tell people who ask me? I say: why not just do them? It takes a minute or two of your time once a month in the privacy of your own home; it doesn't take a lot of work. In the shower, you're washing yourself anyway, so it's just a good time to check, make sure everything feels right, and then ask for help if it doesn't.

Transcript has been edited for clarity and conciseness.

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