Testicular cancer - Treating testicular cancer

If you have testicular cancer, your recommended treatment plan will depend on two factors:

whether you have a seminoma or a non-seminoma
the stage of your cancer (see diagnosing testicular cancer for more information about staging)

The first treatment option for all cases of testicular cancer, whatever the stage, is to surgically remove the affected testicle (an orchidectomy).

In cases of stage one seminomas, after the testicle has been removed, a single dose of chemotherapy is usually given to help prevent the cancer returning. Sometimes a short course of radiotherapy is recommended.

In stage one non-seminomas, close follow-up (called surveillance) may be recommended, or a short course of chemotherapy using a combination of different medications.

In cases of stage two and stage three cancer, three to four cycles of chemotherapy are given using a combination of different medications. Further surgery may sometimes be needed after chemotherapy to remove any affected lymph nodes.

A similar treatment plan is used to treat stage four cancer. Additional surgery may also be required to remove tumours from other parts of the body, depending on the extent of the spread of the tumour.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out the advantages and disadvantages of particular treatments.

Orchidectomy

An orchidectomy is the medical name for the surgical removal of a testicle. If you have testicular cancer, it is necessary to remove the whole testicle because only removing the tumour may lead to the cancer spreading. By removing the entire testicle, your chances of a full recovery are greatly improved. Your sex life and ability to father children will not be affected.

If you have testicular cancer that is detected in its very early stages, an orchidectomy may be the only treatment you require.

The operation is performed under general anaesthetic. A small incision (cut) is made in your groin and the whole testicle is removed through the incision. If you want, you can have an artificial (prosthetic) testicle inserted into your scrotum so that the appearance of your testicles is not greatly affected. The artificial testicle is usually made from silicone (a soft type of plastic).

After an orchidectomy, you will need to stay in hospital for a few days. If you only have one testicle removed, there should not be any lasting side effects.

If you have both testicles removed (a bi-lateral orchidectomy), you will be infertile. However, it is only necessary to remove both testicles in one in every 100 cases.

You may be able to bank your sperm before having a bi-lateral orchidectomy to allow you to father children if you decide to.

Sperm banking

Some treatments for testicular cancer can cause infertility. For some treatments, such as chemotherapy, infertility may be temporary.

For other treatments, such as a bi-lateral orchidectomy or a ‘traditional’ lymph node removal, infertility will be permanent.

Before your treatment begins, you may want to consider sperm banking. Sperm banking is where a sample of your sperm is frozen so that it can be used at a later date to impregnate your partner during artificial insemination. Before sperm banking, you may be asked to have tests for HIV, hepatitis B and hepatitis C infection.

Not all men are suitable for sperm banking. For the technique to work, the sperm has to be of a reasonably high quality. There may also be circumstances where it is considered too dangerous to delay treatment for sperm banking to take place.

Some NHS cancer treatment centres offer a free sperm banking service. Other centres may not have the facilities available, so you may have to pay a private company. Prices can vary, but on average it will cost £200-400 to have your sperm extracted and frozen, plus a further £125 a year to store the sperm.

Testosterone replacement therapy

Having both testicles removed will also stop you producing testosterone. This means you will have a low libido (a decreased sex drive) and will not be able to achieve or maintain an erection. In this case, you will require testosterone replacement therapy.

Testosterone replacement therapy is where you are given a synthetic version of the testosterone hormone to compensate for the fact that your testicles will no longer produce the natural version.

Testosterone is usually given either as injections or skin patches. If you have injections, you will usually need to have them every two to three months. If you have testosterone replacement therapy, you will be able to maintain an erection and sex drive.

Side effects of testosterone replacement therapy are uncommon and usually mild. They include:

oily skin, which can sometimes trigger the onset of acne
enlargement and swelling of your breasts
a change in normal urinary patterns, such as needing to urinate more frequently or having problems passing urine (caused by an enlarged prostate gland that puts pressure on your bladder)

Lymph node surgery

If your testicular cancer is more advanced, it may spread to your lymph nodes. Your lymph nodes are part of your body's immune system, which help to protect it against illness and infection.

Lymph node surgery is carried out under general anaesthetic. The lymph nodes in your abdomen are the nodes most likely to need removing.

In some cases, the nerves near to the lymph nodes can become damaged, which means that rather than ejaculating semen out of your penis during sex or masturbation, the semen instead travels back into your bladder. This is known as retrograde ejaculation.

If you have retrograde ejaculation, you will still experience the sensation of having an orgasm during ejaculation, but you will not be able to father a child.

As with an orchidectomy, you may wish to bank your sperm before your operation, in case you become infertile.

Nerve-sparing retroperitoneal lymph node dissection

A new type of lymph node surgery, called nerve sparing retroperitoneal lymph node dissection (RPLND), is increasingly being used because it carries a lower risk of causing retrograde ejaculation and infertility.

In nerve-sparing RPLND, the site of the operation is limited to a much smaller area. The advantage of limiting the site of the operation is that there is less chance of nerve damage occurring. The disadvantage is that the surgery is more technically demanding. Because of this, nerve-sparing RPLND is currently only available at specialist centres that employ surgeons with the required training.

Laparoscopic retroperitoneal lymph node dissection

Laparoscopic retroperitoneal lymph node dissection (LRPLND) is a new type of ‘keyhole’ surgery that can be used to remove the lymph nodes. During LRPLND, the surgeon will make a number of small incisions (cuts) in your abdomen.

A special instrument called an endoscope is inserted into one of the incisions. An endoscope is a thin, long, flexible tube that has a light source and a video camera at one end, enabling images of the inside of your body to be relayed to an external television monitor.

Small, surgical instruments are passed down the endoscope and can be used to remove the affected lymph nodes.

The advantage of LRPLND is that there is less post-operative pain and a faster recovery time. Also, as with nerve-sparing RPLND, in LRPLND there is a smaller chance that nerve damage will lead to retrograde ejaculation.

However, as LRPLND is a new technique, there is little available evidence regarding the procedure’s long-term safety and effectiveness. If you are considering LRPLND, you should understand there are still uncertainties about the safety and effectiveness of the procedure.

Radiotherapy

Radiotherapy uses high-energy beams of radiation to help destroy cancer cells. Sometimes, seminomas may require radiotherapy after surgery, to help prevent the cancer from returning.

If your testicular cancer has spread to your lymph nodes, you may require radiotherapy after a course of chemotherapy.

Side effects can include:

reddening and soreness of the skin, which is similar to sunburn
nausea
diarrhoea
fatigue

These side effects are usually only temporary and should improve on completion of your treatment.

Read more information about radiotherapy.

Chemotherapy

Chemotherapy uses anti-cancer medicines to kill the malignant (cancerous) cells in your body or stop them multiplying.

If you have advanced testicular cancer or it has spread within your body, you may require chemotherapy. It is also used to help prevent the cancer returning. Chemotherapy is most commonly used to treat non-seminoma tumours.

Chemotherapy medicines are usually injected or given orally (by mouth). Sometimes, chemotherapy medicines can attack your body’s normal, healthy cells. This is why chemotherapy can have many different side effects. The most common include:

vomiting
hair loss
nausea
sore mouth
loss of appetite
fatigue
breathlessness
infertility (usually temporary)
ringing in your ears (tinnitus)
skin that bleeds or bruises easily
increased vulnerability to infection
numbness and tingling (pins and needles) in your hands and feet

These side effects are usually only temporary and should improve after you have completed your treatment.

You should not father children while you are receiving chemotherapy and for a year after treatment has finished. Chemotherapy medications can temporarily damage your sperm, increasing your risk of fathering a baby with serious birth defects. Therefore, you will need to use a reliable method of contraception, such as a condom, during this time.

Condoms should also be used during the first 48 hours after having a course of chemotherapy. This is to protect your partner from any potentially harmful effects of the chemotherapy medication in your sperm.

Read more information about chemotherapy.

Follow-up

Even if your cancer has been completely cured, there is a risk that it will return. Around 25-30% of people experience a return of the cancer, usually within the first two years after their treatment has finished.

Because of this risk, you will need regular tests to check if the cancer has returned. These include:

a physical examination
blood tests to check tumour markers
chest X-ray
computerised tomography (CT) scan

Follow-up and testing is usually recommended depending on the extent of the cancer and the treatment offered. This is usually more frequent in the first year or two but follow-up appointments may last for up to five years.

If the cancer does return and is diagnosed at an early stage, it will usually be possible to cure it using chemotherapy and possibly also radiotherapy. Some types of recurring testicular cancer have a cure rate of over 95%.

Chemotherapy: Chemotherapy is a treatment of an illness or disease with a chemical substance, such as in the treatment of cancer.
Hormone replacement therapy: Hormone replacement therapy or HRT involves giving hormones to women when the menopause starts, to replace those the body no longer produces.
Lymph nodes: Lymph nodes are small oval tissues that remove unwanted bacteria and particles from the body. They are part of the immune system.
Radiotherapy: Radiation therapy uses X-rays to treat disease, especially cancer.
Testicle: Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones.
Testosterone: Testosterone is a male sex hormone, which is involved in making sperm and sexual characteristics such as the voice getting deeper. Testosterone is also found in small amounts in women.