Originally published in The Ottawa Citizen September 20, 2004
Young men rarely see their family doctor (if they have one). There is a tendency to think that nothing can really go wrong in your late teens or 20s.
Yet there is one cancer in men that occurs exactly when men avoid their doctor: testicular cancer.
Testicular cancer is the most common malignancy affecting men 15 to 35 years of age.
Six-time Tour de France champion Lance Armstrong is one of the most illustrative cases of how this cancer can be beaten. When I was in training at the Jewish General Hospital, a 17-year-old boy was found to have a solid tumour on physical exam in one of his testicles. The concern was how far the tumour had spread. He was experiencing abdominal pain and some intestinal complaints.
He was brought to the operating room for exploratory surgery and possible resection of some of the tumour.
We discovered a football-sized tumour extending from his pelvis to mid-abdomen. It had wrapped itself around his abdominal aorta (the main artery of the body) and renal (kidney) arteries. This was an inoperable tumour.
Given his age, the implication is that these tumours grow quickly and metastasize. Early detection is vital for improved survival. These tumours respond well to treatment and are one of the most curable malignant cancers.
Advances in treatment have increased the five-year survival rate from 64 per cent in the early 1970s to more than 90 to 95 per cent (depending on the type of tumour) today.
Detection of the tumour requires palpation of the testicles between the thumb and first two fingers of the examining hand. The testicle normally has a rubbery consistency when palpated. It will move freely within the scrotum. This differs from a tumour that will feel hard and fixed in place. Usually a small nodule or painless swelling is noted in the early stages.
This can progress to a complete solid tumour within the scrotum.
About 30 to 40 per cent of patients will experience a dull ache or felling of fullness in the lower abdomen, scrotum or perianal area. Only 10 per cent will experience acute pain.
Metastatic spread leads to other symptoms and signs. These symptoms will depend on the affected site. Some may have a neck mass due to invasion of the lymph nodes. Lung metastases can cause a cough.
Loss of appetite, nausea, vomiting, or gastrointestinal bleeding may occur when the tumour invades the connection between the stomach and small intestine (retroduodenal zone).
Testicular cancer can spread to the brain and nervous system, as it did in Lance Armstrong’s case. Some may experience loss of limb function or stroke-like effects.
One or both legs can swell because of compression or clots within the veins that provide drainage from the leg into the pelvis. Breast enlargement or growth (gynecomastia) can occur with varying risk that depends on the tumour type. Other hormonal changes can lead to thyroid gland problems.
Any scrotal mass is considered a tumour until proven otherwise. Certain blood tests that look for specific tumour markers in the blood serum done in conjunction with other studies will help diagnose cancerous changes.
Diagnostic imaging studies like scrotal ultrasound, CT scans of the abdomen and pelvis, and a chest X-ray will help determine if the tumour has spread.
Ultrasound examinations are not always able to provide a definitive diagnosis of the stage (or spread) of the tumour. In these situations, an orchectomy, or removal of the cancerous testicle, is done to accurately stage the tumour.
Staging is important because it will allow the oncologist to recommend a specific course of therapy.
Evidence does not support testicular biopsy; studies indicate there is a poorer outcome of the disease with a biopsy procedure.
The prognosis depends upon the tumour stage and type. A patient with a good prognosis has a five-year survival rate of 89 to 93 per cent, intermediate, 75 to 83 per cent, and poor, 42 to 54 per cent. Yearly examination by your doctor and monthly self-examination is the best means of early detection. The earlier the tumour is detected, the better the prognosis.
© Dr. Barry Dworkin 2004