Treatment of Testicular Cancer

The first step in treatment is usually an orchiectomy, which consists of the removal of the testicle and its attached plumbing through an incision in the abdomen just below the belt line. The plumbing is clamped off before removal to prevent the cancer from contaminating adjacent tissue. An orchiectomy is an outpatient procedure, during which you go into the hospital in the morning and leave in the afternoon with a bag of ice and some painkillers. The orchiectomy itself takes only about 15-30 minutes; the rest of the time is for anesthesia and recovery.

Before your orchiectomy, it is a good idea to remind your doctor to have your testosterone levels measured. This will establish a baseline hormone level, which will be useful later in diagnosing any hormone-related problems.

You will not be able to drive for two weeks after the surgery, and will need to avoid lifting anything weighing 15 pounds or more during that period. For the first week you should avoid laughing, as you will find it to be excruciatingly painful.

After the orchiectomy the testicles and other tissue are sent to a pathologist for evaluation. In combination with other diagnostic tests, this determines the type and staging of the cancer. The remaining treatment depends on this. Follow-up treatment may include:

  • Lymph Node Dissection (RPLND). This procedure involves removal of the lymph nodes at the back of the abdomen. It is less common these days, since chemotherapy is often as effective without the need for a second surgery.

  • Chemotherapy. Typically this involves three cycles of drugs that kill fast-growing cancerous cells, where each cycle consists of 5 days of a drug regimen followed by two weeks of recovery. The most common form of chemotherapy for testicular cancer is BEP, a combination of three drugs: bleomycin, cisplatin, and etoposide. Chemotherapy is a systemic treatment, meaning that it can treat tumors throughout the body.

  • Radiation Therapy. Radiation therapy is localized, and is most often used to irradiate the abdominal lymph nodes in Stage I Seminomas.

  • Observation. Observation involves regular monthly diagnostic testing with no treatment. The idea is to avoid the need for painful treatment in patients with stage I seminomas. Unfortunately, the cancer does recur in 28% of patients, requiring treatment anyway. Many feel that it is better to get the treatment over with than to go through the worry of "wait and see".

Before beginning chemotherapy, radiation therapy or a RPLND, you may wish to pursue sperm cryopreservation (sperm banking), as these procedures are known to cause sterility. Sperm banking will enable you to have children later. During your first visit you will undergo viral testing, as this is required by law. They will also use a small portion of the sample to conduct a sperm count and measure the number of vials per sample. Typically six vials are required to achieve a pregnancy, and you will probably want more to be on the safe side. The number of vials per sample ranges from 1 to 10, with 4 being average. You will have to wait at least two days between samples, so the entire process can take a few weeks.

Other side effects of treatment can include fatigue, hair loss, mouth/gum sores, difficulty swallowing, nausea, vomiting, constipation, diarrhea, infection, anemia, increased risk of bleeding, hearing loss and tintinitus, skin changes, pain, taste changes, and slow/irregular heart beats. Because of the likelihood of mouth sores, it is a good idea to have a dentist appointment before beginning chemotherapy. You may need to take drugs like neupogen to increase your white blood cell count (to help fight infection) and procrit to increase your red blood cell count (to combat anemia).

Recent evidence suggests that 3 cycles of BEP (3BEP) chemotherapy is as effective as 4 cycles (4BEP) but with less toxicity. There is also some evidence that 4 cycles of EP (4EP) is almost as effective as 3BEP, but the additional cycle of cisplatin is problematic from a toxicity perspective.

Follow-up care usually involves periodic diagnostic tests, such as monthly blood work and chest x-rays and quarterly CT scans. The frequency of the tests will be reduced during subsequent years.

The overall cost of treatment, including the orchiectomy, chemotherapy and follow-up, is typically $45,000 to $55,000. You will likely hit the out-of-pocket limit on your insurance during the first year of treatment.

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