Testicular cancer

What is testicular cancer?

Cancer that starts in the cells of a testicle is called testicular cancer or cancer of the testis (which means one testicle.

The testicles are two egg-shaped glands that sit in the scrotum. They are part of the male reproductive system, which also includes the penis and prostate. They make and store sperm and also make the hormone testosterone, which is responsible for the development of male characteristics.

Usually, testicular cancer affects only one testicle, but sometimes both are affected. As testicular cancer grows, it can spread to lymph nodes in the abdomen (belly) or to other parts of the body, such as other lymph nodes, lungs or liver. It does not spread to the other testicle. Anyone with a testicle can get testicular cancer, including men, transgender women, non-binary people and people with intersex variations.

Testicular cancer is not common overall, but it is the most common cancer diagnosed in men aged 20–39 (apart from skin cancers).

In Australia, about 1026 people are diagnosed with testicular cancer each year, accounting for about 1% of all cancers in men.

Types of testicular cancer

The most common testicular cancers are called germ cell tumours. There are two main types:

• Seminoma tumours - which tend to develop more slowly than non-seminoma tumours. They usually occur between the ages of 25 and 45 but can also occur in older people.
• Non-seminoma tumours - which tend to develop more quickly than seminoma cancers and are more common in people in their late teens and early 20s. There are 4 main subtypes of non-seminoma tumours: teratoma, choriocarcinoma, yolk sac tumour and embryonal carcinoma.

Sometimes testicular cancer can include a mix of seminoma cells and non-seminoma cells, or a combination of the different subtypes of non-seminoma cells. This is called a mixed germ cell tumour and is treated the same as non-seminoma cancer.

A small number of testicular tumours start in cells that make up the supportive (structural) and hormone-producing tissue of the testicles. These are called stromal tumours.

Most testicular cancers begin as a condition called germ cell neoplasia in situ (GCNIS). In this condition, the cells are abnormal, but they haven’t spread outside the area where the sperm cells develop. GCNIS is not cancer but it may develop into cancer.

Signs and symptoms of testicular cancer

In some people, testicular cancer does not cause any noticeable symptoms, and it may be found during tests for other conditions.

When there are symptoms, the most common ones include:

• a swelling or a lump in the testicle (usually painless)
• a change in a testicle's size or shape.

Less common symptoms include:

• a feeling of heaviness in the scrotum
• a feeling of unevenness between the testicles
• pain or ache in the lower abdomen, testicle or scrotum
• swollen or tender breast tissue
• back pain
• stomach-aches.

Not everyone with these symptoms has testicular cancer. However, it is important to have any lump in your testicles or any ongoing symptoms checked by your doctor.

Risk factors for testicular cancer

The causes of testicular cancer are largely unknown, but certain factors may increase your risk of developing it.

Talk to your doctor if you are concerned about any of the following risk factors:

• Having germ cell neoplasia in situ (GCNIS).
• Diagnosed with testicular cancer previously – if you previously had cancer in one testicle, you are slightly more at risk of developing cancer in the other.
• Undescended testicles – having undescended testicles at birth increases the risk.
• Family history – if your father or brother has had testicular cancer, you are slightly more at risk (2%) of developing testicular cancer.
• Infertility
• HIV or AIDS.
• Hypospadias – a condition when the opening of the urethra is on the underside of the penis. People born with this condition have a slightly higher risk of developing testicular cancer.
• Intersex variations – some types of intersex variations, such as partial androgen insensitivity syndrome, can increase the risk of developing testicular cancer.

Tests for testicular cancer

Your doctor may do some tests to check for testicular cancer:

• Physical examination – A doctor will examine your testicles, scrotum and groin for a lump or swelling.
• Ultrasound to show if a tumour is present and how large it is.
• Blood tests to test for tumour markers, which are proteins made by some cancer cells.

Surgery to remove the testicle

The only way to be sure of the diagnosis is to surgically remove the affected testicle and examine it in a laboratory. This surgery, called an orchidectomy or orchiectomy, is usually done by a specialist called a urologist.

In the laboratory, a specialist doctor called a pathologist looks for cancer cells and works out what type of testicular cancer it is and whether it has spread. This helps doctors plan treatment.

Doctors don’t usually perform a biopsy of the testicle (taking a small amount of tissue to check) because there is a small risk that making a cut through the scrotum can cause cancer cells to spread.

Further tests

If the pathology report on the removed testicle and other test results show that you have cancer, you may have one or more imaging scans. These scans will check whether the cancer has spread to other parts of your body, such as the lymph nodes or other organs.

These tests will usually include a CT scan and possibly an MRI or PET-CT scan.

Having an orchidectomy

An orchidectomy is done under a general anaesthetic to confirm a diagnosis of testicular cancer. It is also the main treatment for testicular cancer.

• The urologist will make a small cut (incision) in the groin above the pubic bone.
• The whole testicle is pulled up and out of the scrotum through this cut.
• The spermatic cord is removed as it contains blood and lymph vessels that could help cancer spread to other areas of the body.
• The scrotum is not removed but, after surgery, it will no longer contain a testicle.
• The surgery takes about an hour. You can usually go home the same day, but you may need to stay in hospital overnight.
• Some people choose to have the removed testicle replaced with a prosthesis. This can be done during the orchidectomy or later.

Stages of testicular cancer

There are several staging systems for testicular cancer, but the most commonly used is the TNM system (below). Based on the TNM scores and the levels of tumour markers in the blood, the doctor then works out the cancer’s overall stage from stage 1 to stage 3:

• stage 1 – cancer is found only in the testicle (early-stage cancer)
• stage 2 – cancer has spread outside the testicle to nearby lymph nodes in the abdomen or pelvis
• stage 3 – cancer has spread to lymph nodes outside the abdomen or pelvis (e.g. in the chest) or other areas of the body.

Testicular cancer is often staged using the TNM system. In this system, letters and numbers are used to describe the cancer, with higher numbers indicating larger size or spread.

• T (tumour) describes whether the cancer is only in the testicle (T1) or has spread into nearby blood vessels or tissue (T2, T3, T4)
• N (nodes) describes whether the cancer has spread to nearby lymph nodes in the abdomen – N0 means it has not and N1–3 means it has
• M (metastasis) describes whether the cancer has spread to distant lymph nodes, organs or bones – M0 means it has not and M1 means it has

Ask your doctor or nurse to explain the stage of the cancer.

Prognosis and survival rates for testicular cancer

When someone is diagnosed with testicular cancer, their doctor will give them a prognosis. A prognosis is the expected outcome of a disease. It is not possible for anyone to predict the exact course of the disease. To assess your prognosis, your doctor will consider:

• your test results
• the type of testicular cancer you have
• the stage of the cancer
• other factors such as your age, fitness and medical history.

If you have testicular cancer, your doctor will talk to you about your individual situation when working out your prognosis. Every person's experience is different, and there is support available to you.

Treatment for testicular cancer

Most people have an orchidectomy to remove the affected testicle, and this is usually done to confirm a diagnosis. If the cancer has not spread, this may be the only treatment needed. After surgery, you will need regular check-ups and tests to monitor for any signs that the cancer has come back. This is called active surveillance.

If the cancer has spread, after an orchidectomy you may have chemotherapy or more surgery to remove lymph nodes in the abdomen (retroperitoneal lymph node dissection or RPLND), or radiation therapy.

Radiation therapy is not used very often to treat testicular cancer. It may be used instead of chemotherapy or surgery to treat cancer that has spread to lymph nodes in the abdomen.

Chemotherapy

Chemotherapy uses drugs to kill or slow the growth of cancer cells. Chemotherapy may be used at different stages of testicular cancer:

• To reduce the risk of cancer coming back – If you have early testicular cancer that has not spread (stage 1), you may be offered chemotherapy after surgery. This is called adjuvant chemotherapy.
• To treat cancer that has spread – Chemotherapy may be recommended after surgery to destroy any cancer cells that have spread.
• Before surgery (neoadjuvant) – Rarely, when the cancer has spread to other parts of the body, chemotherapy may be given before surgery to help control the spread and reduce symptoms.

Surgery to remove lymph nodes

If testicular cancer spreads, it most commonly spreads to the lymph nodes at the back of the abdomen (retroperitoneum). In some cases, an operation called retroperitoneal lymph node dissection (RPLND or lymphadenectomy) is done to remove these lymph nodes. An RPLND is a long and complex operation, which should be performed by an experienced surgeon in a specialist centre. Sometimes, an RPLND is done instead of chemotherapy.

There are two ways to perform an RPLND:

• Open surgery – a surgeon makes a large cut from the breastbone to below the bellybutton. The surgeon then removes the lymph nodes and any remaining cancer from the back of the abdomen.
• Robotic surgery – this is a keyhole surgery where a surgeon inserts surgical instruments through several small cuts in the abdomen with help from a robotic system.

Side effects of treatments for testicular cancer

All cancer treatments can have side effects. Your treatment team will discuss these with you before you start treatment. Talk to your doctor or nurse about any side effects you are experiencing. Some side effects can be upsetting and difficult, but there is help if you need it. Call Cancer Council Tel. 13 11 20 or contact cancer support.

Managing lifestyle changes from testicular cancer

Sex and intimacy - Treatment for testicular cancer may affect your sex life, feelings of pleasure, and intimacy.

Surgery – Removing one testicle will not stop you from having erections or orgasms but can affect testosterone levels. RPLND may damage nerves, causing anejaculation. This still feels like an orgasm, but no semen will come out.

Chemotherapy – Your ability to get and keep an erection may be affected for a few weeks after chemotherapy. This is usually temporary. You may also find you have a lower sex drive (libido).

Radiation therapy – Radiation therapy to the abdomen may temporarily stop you making semen. You will still feel the sensations of an orgasm but will ejaculate little or no semen. In most cases, semen production returns to normal after a few months.

Learn more about Sex, Intimacy and Cancer on the Cancer Council Victoria website.

Fertility

Most people who have had one testicle removed can go on to have children naturally. However, if you have anejaculation after RPLND, you won’t be able to conceive naturally. You may be given medicine to help the semen come out of the penis, or you may be able to have sperm extracted.

Both chemotherapy and radiation therapy can temporarily decrease sperm production and cause unhealthy sperm. These effects may be temporary or permanent. It may take one or more years before there are enough healthy sperm to conceive a child.

Before cancer treatment starts, you may be able to collect and store some sperm. The sperm is frozen until needed. Sperm can be frozen for many years. Although there is a cost involved, most sperm banks have payment plans to make it more affordable. Ask your cancer specialist to refer you to a fertility specialist so you can find out about your options.

How you might feel

If you had a testicle removed, it may affect how you feel about yourself. You may feel less confident and less sexually desirable. Some men adjust quickly to having one testicle, while others find that it takes some time. If you had an RPLND, you may feel self conscious about the scar across your abdomen.

Any type of cancer treatment can change the way you feel about yourself (your self-esteem). You may feel less sure of who you are and what you can do, particularly if your body has changed physically.

Some men find that their sense of identity or masculinity is affected by their cancer experience. You may find it helpful to talk to a psychologist if you are having trouble adjusting to any changes – ask your general practitioner (GP) for a referral.

Give yourself time to get used to any changes to your body. Talk to other people who have had a similar experience. Call Cancer Council 13 11 20 to find out about peer support programs.

Living with advanced cancer

Rarely, testicular cancer is so advanced that treatment cannot make it go away and your doctor may talk to you about palliative treatment. This is treatment that helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease.

Many people think that palliative treatment is for people at the end of their life, but it may help at any stage of advanced cancer. It is about living for as long as possible in the most satisfying way you can. As well as slowing the spread of the cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment options may include radiation therapy, chemotherapy or other medicines.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, practical, emotional, spiritual and social needs. The team also supports families and carers.

Support for carers, family and friends

Caring for someone with cancer can be difficult sometimes. If you are caring for someone with testicular cancer, these organisations can help:

• Cancer Council - Information and support line Tel. 13 11 20 (or 13 14 50 for an interpreter) to speak to a qualified professional
• Cancer Council - Caring for someone with cancer
• Carer Gateway Tel. 1800 422 737
• Carers Australia
• Carers Victoria Tel. 1800 514 854

Where to get help

• Your GP (doctor)
• Cancer Council
  • Information and support line Tel. 13 11 20 (or 13 14 50 for an interpreter) to speak to a qualified professional
  • Testicular cancer
  • Fertility
  • Sexuality and intimacy
  • Cancer Council Victoria, My Cancer Guide - Find support services that are right for you.
• NURSE-ON-CALL Tel. 1300 60 60 24 for expert health information and advice (24 hours, 7 days)
• Healthy Male
• True North - Testicular cancer