Hit below the belt

In the western world, testicular cancer is one of the most common cancers among young men between the ages of 20 and 40. One in every thousand young men is expected to contract the disease. Nevertheless, many men put off going to the doctor, because they are embarrassed or afraid of the diagnosis. Dr. Ronen Rub, Deputy Director of Urology at Hillel Yaffe Medical Center, explains the disease and stresses the importance of early detection, which increases the chances of recovery and is likely to prevent fertility problems.

Imagine a typical man in his late twenties, early thirties. He looks and feels vital and young. He is usually a college student, just starting a career, in a new relationship. Sometimes he has already started planning and having a family. The last thing he would ever imagine is that the swelling he discovered in a testicle several weeks ago will prove to be a malignant tumor.

"I remember," said Dr. Rub, Deputy Director of Urology at Hillel Yaffe Medical Center, "a young couple in their late twenties that came to see me. They’d just undergone several failed attempts at becoming pregnant. The man arrived complaining of a swollen testicle with CT results that didn't leave much room for doubt that it was a tumor. The news of the tumor was surprising and difficult. They suddenly had to contend with the shock of discovery, fear of the surgery, radiation and/or chemotherapy, thoughts of the potential problems down the road with sexual function and fertility. The damage is actually to all systems: the man's health, their relationship, self-confidence, job security, etc."

"I don't know if many young men delay seeking medical attention due to embarrassment, complacency, fear or a lack of awareness," continued Dr. Rub, "but it’s important for me to send a message to young men that testicular cancer can be cured. Men with the disease could increase their chances of recovery by more than 90% if only they were aware of the disease and symptoms, and would seek medical attention when necessary."

What are the causes of the disease?

Testicular cancer is a disease that strikes young men of between 20 and 35 years old. It is uncommon (in Israel about 120 cases a year are diagnosed), but can be fatal if not treated in time.

The frequency of the disease has increased in recent years, either simply due to a rise in the number of patients and/or due to earlier detection than in the past. In the US, for example, the values have almost doubled in the last 30 years.

The causes of testicular cancer, like other types of cancer as well, are not clear and absolute. In recent studies, nutritional and environmental factors are being investigated (such as ionizing radiation) as contributors. Genetics is also clearly a factor. When dealing with a first-degree relative, the risk increases, especially with a sick brother, more so than a father. There is a more pronounced risk group where the frequency of the disease is higher (four to six times more). Men who were born with a retractile testicle (a testicle that does not descend into its proper position, but resides in the groin) belong to this group. Babies diagnosed with a retractile testicle must undergo surgery by the age of one, because after this age the chances of the testicle descending into the scrotum are negligible. Dr. Rub Ronen explained, "The surgical procedure, won't significantly reduce the chance of a tumor forming in future, but will allow diagnosis and follow-up of the testicle by palpation."

What are the symptoms?

"Usually, in the initial stage of the disease," said Dr. Rub, “no pain is felt.” The appearance of the testicle changes; It grows, becomes hard and heavy, and when examined, a lump is felt. In the more advanced stages, if the cancer spreads, abdominal pain, back pain, shortness of breath, etc. are likely to appear." The diagnostic procedure includes performing blood tests to identify markers, a testicular ultrasound, and a chest, abdomen and pelvis CT, because the initial spread of a tumor is to the lymph nodes in the retroperitoneum (the space behind the abdomen).

How is it treated?

"The rate that the cells multiply in testicular cancer is higher than other types of cancer," stated Dr. Rub, "therefore, surgery is performed in a matter of days following the diagnosis. Treatment must not be delayed."

Dr. Rub continued to explain that the therapeutic approach is determined by the type of tumor and the degree of spread in collaboration with the medical team from the Oncology and Urology Departments. At first, surgery is performed to remove the testicle in which the tumor was discovered. To prevent the tumor from spreading, the testicle is removed through the groin and not the scrotum. Therefore, a biopsy is not taken before the operation. "Despite the fact that no biopsy is taken," stated Dr. Rub, "there is no concern of mistaken diagnosis, because the best diagnostic tool to identify a testicular tumor is a testicular ultrasound."

During the surgery to remove the tumor, a silicone prosthesis may be implanted in place of the amputated testicle in post-puberty males, i.e. around age 18-20 and older.

After removal of the tumor, it is sent for pathological testing and a decision is made as to whether supplementary radiation therapy or chemotherapy is required. If a metastasis (spreading) process has started in the lymph nodes, removal of the lymph nodes will be considered, depending on the type of tumor and the stage of the disease. Whether supplementary treatment is called for or not, the patient must undergo active and orderly follow-up every several months, in which a physical examination, chest X-ray and a blood marker test are performed.

What about fertility?

All testicular cancer patients are advised to save sperm before surgery. According to Dr. Ron, theoretically it is also possible to be fertile with one testicle, but at this stage the condition of the other testicle, in terms of fertility is unknown. Also, if the patient undergoes supplementary chemotherapy and/or radiation therapy, this could affect the erection, ejaculation and sperm formation.

Self-diagnosis saves life

The issue of early diagnosis is extremely important, because it leads to a success rate of over 90%. "So," summarized Dr. Rub, "just like women are educated to perform breast self-examination, it is important for young men to be aware of the disease, perform testicular self-examination every few months and, naturally, see a urologist if any question arises. Undoubtedly, heightening awareness and overcoming any sense of embarrassment is what makes the real difference."