Testicular cancer is among the most treatable cancers, with a combination of surgery, chemotherapy, and radiation resulting in a complete cure for many patients.
But because the cancer is often diagnosed at a young age, and because of the treatment’s possible effects on fertility, testosterone levels, and sexual function, survivorship in testicular cancer is often a fraught path.
“Because most people with testicular cancer are diagnosed in their 20s and 30s, we often see more emotional side effects, like higher levels of anxiety and depression,” says University of Colorado Anschutz Cancer Center member Elizabeth Kessler, MD, associate professor of medical oncology in the CU Anschutz School of Medicine. “We're so good at being able to treat the cancer and offer curative intent therapy that much of the focus of clinical care and research is minimizing the risk of side effects and enhancing the support that we offer to this population.”
That support includes social workers, behavioral health counseling, and an awareness of the strong external network that exists for testicular cancer survivors, including the Testicular Cancer Awareness Foundation.
“This group of men are generally at a time in their lives where there may be a lot of things in flux — marriage, family, new jobs, establishing yourself in adulthood,” Kessler says. “Depending on how they best respond to support, we like to alert them to the different resources that are out there.”
Monitoring T levels
Kessler says the cancer and its treatment — which often involves surgically removing a testicle — can result in barely detectable changes in testosterone levels, which can cause mood changes, fatigue, and reduced sex drive. Clinicians have to be careful, however, when prescribing testosterone replacement therapy.
“When you have removal of one testicle, the other one can generally make enough testosterone, but there are some men who get that lower testosterone level,” Kessler says. “We often check hormone levels before the removal of the testicle and follow those on a yearly basis to see if there's a trend of testosterone levels changing. We also can do a very quick, 10-item questionnaire to see if guys are experiencing symptoms of low testosterone as well.
“The problem is that if you are taking supplemental testosterone, then your existing testicle is no longer going to make sperm in the same way,” she explains. “So we actually find that fertility goes down when you're taking testosterone replacement. There are other intermediary medications we can use to stimulate the system to try to make more testosterone before we turn to full replacement.”
Increased risks
There are excellent treatments for testicular cancer, but the young age of men at diagnosis means that those treatments may lead to more potential health concerns down the road, Kessler says, primarily because of the chemotherapy and radiation that go along with treatment.
“Chemotherapy and radiation cause an increased risk of cardiovascular diseases — one-and-a-half to three times the risk of the general population,” she says. “Additionally, any time we alter the way that cells grow and divide to try to kill the cancer, we could stimulate abnormal growth of other cancer cells. So these patients are also at an increased risk of a different type of cancer forming.”
Neuropathy challenges
Another concern for testicular cancer survivors is the development of neuropathy — nerve damage-related symptoms including numbness, tingling, and pain in the hands and feet, as well as hearing loss, as a result of cisplatin-based chemotherapy.
“We also know that men can get Raynaud syndrome, which is an altered vascular flow through the small blood vessels in the hands and feet,” Kessler says. “I take care of people who, even though they've been cured and are 10 years out from their treatment, still need regular support for their Raynaud’s.”
Some neuropathy can be treated with medications, Kessler says, but treatment often involves lifestyle modifications.
“Most of the time, these long-term side effects are not things that we can fix,” she says. “More often, it’s about supporting people in managing the symptoms that they're going to have potentially lifelong.”
Treatment changes
The good news for men with testicular cancer who have not yet undergone treatment is that things are beginning to change as the long-term side effects of chemotherapy and radiation continue to be better understood.
“We now try to de-escalate chemotherapy whenever possible,” Kessler says. “There's also research looking at doing surgery instead of chemotherapy and radiation to spare people some of these long-term side effects.
"And because these younger guys are getting a lot of surveillance and follow-up, there’s other research on, ‘Do you need to do CT scans? Is that excess radiation exposure going to do anything? Could we substitute an MRI, which has zero radiation exposure, and still get good surveillance?’ There's work being done on how we can do better in terms of taking care of the whole person and still being successful at treating the cancer.”
