Testicular cancer

What is testicular cancer?#

Cancer that develops in a testicle is called testicular cancer, or cancer of the testis (plural: testes). The testicles are two egg-shaped glands that sit behind the penis in a pouch of skin called the scrotum. They produce and store sperm.

Usually only one testicle is affected, but in some cases both are. About 90 to 95% of testicular cancers start in the cells that develop into sperm, which are known as germ cell tumors. Anyone with a testicle can develop testicular cancer, including transgender women, non-binary people and intersex people.

Testicular cancer accounts for around 1% of all cancers in men, and it occurs most often in men aged 20 to 39.

Types of testicular cancer#

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

• Seminoma tumors tend to develop more slowly. They usually occur between the ages of about 25 and 45, but can also occur in older people.
• Non-seminoma tumors tend to develop more quickly and are more common in people in their late teens and early 20s.

There are four main subtypes of non-seminoma tumor: teratoma, choriocarcinoma, yolk sac tumor and embryonal carcinoma. Sometimes a tumor contains a mix of seminoma and non-seminoma cells, or a combination of non-seminoma subtypes; these are called mixed tumors.

A small number of testicular tumors start in the cells that make up the supportive (structural) and hormone-producing tissue of the testicles.

Most testicular cancers begin as a condition called germ cell neoplasia in situ (GCNIS), previously known as intratubular germ cell neoplasia (ITGCN). In this condition the cells are abnormal but have not spread outside the area where sperm cells develop. GCNIS is not cancer, but it may develop into cancer after many years.

Signs and symptoms#

Some people have no noticeable symptoms, and the cancer may be found during tests for another condition. When there are symptoms, they can include:

• A change in the size or shape of a testicle, such as hardness or swelling
• A swelling or lump in the testicle (usually painless)
• A feeling of heaviness in the scrotum
• A feeling of unevenness between the testicles
• Pain or ache in the lower abdomen, testicle or scrotum
• Enlargement or tenderness of the breast tissue
• Back pain

Not everyone with these symptoms has testicular cancer#

These symptoms can have many causes. If you have any of them or are worried, always see your doctor.

Risk factors#

Some things can make testicular cancer more likely. Having a risk factor does not mean you will develop cancer, and often there is no clear reason for it. Known risk factors include:

• Undescended testicles at birth
• Personal history — if you have previously had cancer in one testicle, you are more likely to develop it in the other
• Family history — if your father or brother had testicular cancer, your risk is slightly higher
• Infertility — difficulty conceiving a baby can be associated with testicular cancer
• HIV and AIDS — there is some evidence of an increased risk
• Physical features — being born with the penile abnormality known as hypospadias
• Intersex variations — the risk is higher with some intersex variations, such as partial androgen insensitivity syndrome, particularly when the testicles remain in the abdomen
• Cannabis use — there is some evidence linking regular cannabis use with testicular cancer

If you are worried about your risk, ask your doctor for advice.

Tests and diagnosis#

Your doctor may arrange tests to check for testicular cancer and to assess your general health and how well your organs are working. These can include:

• Ultrasound to show whether a tumor is present and how large it is
• Blood tests

The only way to be sure of the diagnosis is to surgically remove the affected testicle and examine it in a laboratory. This operation, called an orchidectomy, takes about 60 minutes. In most cases only one testicle needs to be removed; it is rare for both to be affected at the same time. You may decide to replace the removed testicle with an artificial one called a prosthesis.

Your doctor might ask you to have further tests to see whether the cancer has spread, such as:

• CT scans, which use x-rays to build a detailed cross-sectional picture of the inside of the body
• MRI scans, which use a powerful magnet
• PET-CT scans

Stages of testicular cancer#

The stage describes how far a cancer has spread. Doctors commonly use the TNM system (Tumor–Nodes–Metastasis), which describes whether the cancer is only in the testicle or has spread to nearby blood vessels, tissue, lymph nodes or other parts of the body.

Cancer can also be staged using numbers:

• Stage 1 means the cancer is found only in the testicle (early-stage cancer).
• Stage 2 and above mean the cancer has spread outside the testicle — to the lymph nodes in the abdomen or pelvis, or to other areas of the body.

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

Prognosis#

A prognosis is the expected outcome of a disease. No one can predict the exact course of an illness, but testicular cancer has the highest survival rates of any cancer (other than common skin cancers).

To assess your prognosis, your doctor will consider your test results, the type of testicular cancer you have, its stage, and other factors such as your age, fitness and medical history. Regular monitoring is a major factor in good outcomes, so it is vital to attend all your follow-up appointments. Your doctor will talk with you about your individual situation.

Treatment#

Every person’s experience is different.

Surveillance#

If you had an orchidectomy and the cancer was completely removed with the testicle, you may not need further treatment. Instead you will have surveillance — a schedule of regular blood tests, chest imaging and CT scans for 5 to 10 years. This helps detect any remaining cancer or a return of the cancer.

Chemotherapy#

Chemotherapy treats cancer with drugs that aim to kill cancer cells or slow their growth. If your treatment team assesses a moderate risk of the cancer spreading or returning, chemotherapy may be recommended. In rare cases, when the cancer has spread to other parts of the body, chemotherapy may be given before surgery as the main treatment.

Radiation therapy#

Radiation therapy uses a controlled dose of radiation to kill cancer cells or stop them growing, multiplying or spreading. It is sometimes given to people with seminoma cancer after surgery to prevent the cancer returning or to destroy cancer cells that may have spread to the lymph nodes.

Surgery to remove lymph nodes#

A retroperitoneal lymph node dissection (RPLND, or lymphadenectomy) removes lymph nodes at the back of the abdomen that may contain cancer cells.

• Non-seminoma cancer — Your doctors may recommend an RPLND if scans after chemotherapy show the lymph nodes have not returned to normal size, as this may mean they still contain cancer cells.
• Seminoma cancer — Chemotherapy or radiation therapy can usually destroy seminoma cells in the lymph nodes, so RPLND is rarely used; it may be offered for advanced seminoma if there are no other options.

Side effects#

All cancer treatments can have side effects. Some can be upsetting and difficult, but help is available. Talk to your doctor or nurse about any side effects you experience.

Living with and after treatment#

Sexuality and intimacy#

Having testicular cancer and its treatment can change how you feel about yourself, other people and relationships. These changes can be hard to talk about, but doctors and nurses are understanding and can offer support. You can ask for a referral to a counselor or therapist who specializes in body image, sex and relationships.

• Removing one testicle won’t affect erections or orgasms, but it can affect testosterone levels.
• RPLND may damage nerves, causing semen to travel backwards into the bladder instead of out of the penis. This still feels like an orgasm, but no semen comes out.
• Chemotherapy drugs may remain in your semen for a few days, and for a few weeks afterwards you may have some trouble getting and keeping an erection.
• Radiation therapy to the pelvis may temporarily stop semen production, causing a dry orgasm. Semen production usually returns to normal after a few months.

Tips for managing changes to your sexuality:

• Be gentle the first few times you are sexually active after treatment. Start with touching, and tell your partner what feels good.
• Talk openly with your doctor or a sexual health counselor about any challenges.
• Protect your partner from any drugs in your semen by using barrier contraception, such as condoms, during chemotherapy and for the number of days afterwards advised by your doctor.
• Accept that tiredness and worry may lower your interest in sex, and remember that sex drive usually returns when treatment ends.

Fertility#

Most people who have had one testicle removed can go on to have children naturally. If both testicles are removed (rarely required), you will no longer produce sperm and will be infertile. People who experience retrograde ejaculation after RPLND will also be infertile.

Both chemotherapy and radiation therapy can temporarily reduce sperm production and damage sperm. It may take one or more years before there are enough healthy sperm to conceive a child, and in some cases infertility may be permanent.

Tips for managing changes to your fertility:

• Use sperm banking to store sperm before cancer treatment for use later. Samples can be stored for many years.
• A semen analysis test can help show whether your fertility has returned.
• If infertility appears to be permanent, talk to a counselor or family member about how you are feeling. This can be very upsetting, and you may have mixed emotions about the future.

Appearance and identity#

Any cancer treatment can change how you feel about yourself, particularly if your body has changed physically. Some people find their sense of identity or masculinity is affected.

• Give yourself time to get used to any changes to your body.
• Try to see yourself as a whole person — body, mind and personality — rather than focusing on the parts that have changed.
• Talk to other men who have had a similar experience, and let your partner know how you are feeling.
• A psychologist may help if you are having trouble adjusting.
• If you remain concerned about your appearance, you can ask your medical team about an artificial testicle (prosthesis).

Advanced cancer and palliative care#

Rarely, testicular cancer is so advanced that treatment cannot make it go away. Palliative treatment helps improve quality of life by managing the symptoms of cancer without trying to cure the disease. Although many people associate it with the end of life, it may help at any stage of advanced cancer. It is about living 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. Options may include radiation therapy, chemotherapy or other medicines. It is one part of palliative care, in which a team of health professionals aims to meet your physical, practical, emotional, spiritual and social needs, and also supports families and carers.

Support for carers, family and friends#

Caring for someone with cancer can be difficult. If you are caring for someone with testicular cancer, support services and counseling are available to help you too.

Key points#

• The most common testicular cancers are germ cell tumors, with two main types: seminoma and non-seminoma.
• Testicular cancer is the most commonly diagnosed cancer in young men aged 20 to 39 (apart from common skin cancers) and has very high survival rates.
• Common symptoms include a change in the size or shape of a testicle, swelling or a usually painless lump, and heaviness in the scrotum.
• Not everyone with these symptoms has testicular cancer, but if you notice them or are worried, always see your doctor.
• The only way to confirm the diagnosis is to remove the affected testicle and examine it; treatment may include surveillance, chemotherapy, radiation therapy or surgery to remove lymph nodes.

Where to get help#