For most men faced with testicular cancer, surgery to remove the testicle is the first treatment. After surgery, you and your doctor must decide what to do next. For stage I nonseminoma testicular cancer, these are your choices:
This decision aid is about stage I nonseminoma testicular cancer. The treatment decision for stage I seminoma testicular cancer is different.
There are two main types of testicular cancer: seminoma and nonseminoma. Seminomas may be treated with chemotherapy or radiation. But radiation doesn't work well on nonseminomas. Also, nonseminoma cells are more likely to spread to the lungs, liver, and brain.
"Stage I" means that the cancer doesn't seem to have spread. Some stage I cancers actually have spread to the lymph nodes of the lower back but can't be seen.
Both seminoma and nonseminoma are very often cured, especially if they are found and treated early. Compared to other forms of cancer, testicular cancer—even when it has spread to other parts of the body—has a very high cure rate.
The first treatment is surgery to remove the testicle. After that, most men have three choices: surveillance, chemotherapy, and lymph node surgery. About 30 out of 100 men who choose surveillance will need more treatment. But any of the three choices will cure the cancer in about 99 out of 100 men with nonseminoma cancer.1
Surveillance means that you are being watched closely by your doctor but are not having further treatment.
You have exams, chest X-rays, and blood tests regularly during the first few years, as well as CT scans. It can be hard to go to the doctor's office that often. Unless your cancer comes back, the number of checkups and tests will gradually decrease over the next 10 years.
With surveillance, you may be able to avoid the risks and side effects of lymph node surgery or chemotherapy. About 70 out of 100 men with nonseminoma cancer who choose surveillance do not need more treatment later. This means that about 30 of those 100 men do need treatment later.1
Even when cancer is found after a period of surveillance, it is often easy to cure if it's found early. Because of this, many doctors consider it reasonable for some men to choose surveillance.
Chemotherapy, often called "chemo," is the use of very strong drugs to kill cancer cells. The most common chemo for nonseminoma testicular cancer is called cisplatin combination therapy. It uses several different medicines.
Chemo is usually given at a low dose, so long-term side effects are rare.
Lymph node surgery
The full name for this surgery is retroperitoneal lymph node dissection, or RPLND for short. It is surgery to remove lymph nodes in the lower back and pelvis. These lymph nodes may contain cancer.
During the early phases of stage I nonseminoma testicular cancer, it can be very hard to tell if these lymph nodes have cancer without taking them out. In the past, doing this often caused infertility. Modern nerve-sparing methods have greatly lowered the chances of infertility.
Perhaps the greatest risk of choosing surveillance has to do with missing your follow-up tests and exams. Without regular testing and checkups, you can miss cancer that has returned until it spreads beyond the lymph nodes and is harder to cure. If you choose surveillance, it's very important to strictly follow your doctor's schedule of tests and exams.
When cancer does come back during surveillance, it usually hasn't spread any farther than the lymph nodes in the lower back and pelvis. It can usually be treated successfully when the testing schedule has been followed closely.
Chemotherapy for testicular cancer has caused permanent infertility in some men. Because most men diagnosed with this cancer are younger than 35, this is important to think about when you choose which treatment to use.
Some men still need surgery after chemo to remove damaged tissue or remaining cancer. In those cases it is not always possible for the surgeon to use nerve-sparing methods that greatly reduce the chances of infertility.
Men who are going to have chemo should bank their sperm ahead of time if they want to father children in the future. Talk to your doctor about any fertility concerns you may have.
Side effects of chemo
Many men do not have problems with side effects from chemo. Other men have a great deal of trouble with them. If you have problems, your doctor can use other medicines to help you feel better.
Common short-term side effects include:
The chemo used for testicular cancer has also been linked with serious long-term side effects. But these aren't common. These side effects may include:
The risks and side effects of lymph node surgery for testicular cancer include:
Fertility problems after surgery
Men who get lymph node surgery can end up with nerve damage that causes retrograde ejaculation. This means that the semen flows up into the bladder instead of out through the penis. This makes you unable to father children.
In most cases, men with retrograde ejaculation don't have erection problems or trouble enjoying sex.
Nerve-sparing methods have greatly lowered the risk of retrograde ejaculation. Nerve-sparing surgery may be more difficult or impossible for men who have had chemotherapy. Talk to your doctor about whether nerve-sparing surgery is an option for you.
General surgery risks
Like any major surgery, the risks include:
|Try surveillance||Have chemotherapy|
|What is usually involved?|
|What are the benefits?|
|What are the risks and side effects?|
|Have lymph node surgery|
|What is usually involved?|
|What are the benefits?|
|What are the risks and side effects?|
Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
"As a cyclist, I figured the swelling on my testicle was probably caused from over-training. But my wife made me go to the doctor to have it checked out. It's a good thing I did, because the doctor told me I had a stage I nonseminoma. Since we found it at an early stage and my prognosis was good, I was given the options of chemotherapy, RPLND surgery, or surveillance. At the time, I was spending a lot of time traveling to races so I decided that I didn't really have the time for all the checkups and tests that go with surveillance. And I wasn't comfortable with having chemotherapy, so I chose RPLND. After the RPLND, I had some trouble with fluid retention in my legs and postoperative pain, both of which have since improved. I've been able to resume my cycling career. And my doctor says I'm cancer-free, so I have no regrets."
— John, age 28
"After I got over the shock of my diagnosis, we talked about my treatment choices. My doctor told me that because we caught the cancer at an early stage, I had to decide on which treatment option was best for me. After discussing it with my wife, we decided on the RPLND. We also felt the stress of surveillance would be just too much for us, especially since we have a young child and would like to have another. My doctor says that I'm still cancer-free after 2 years, but the surgery did cause me to become infertile. Although I did bank sperm before the surgery, part of me wishes I had given more thought to surveillance."
— Lorenzo, age 37
"When my doctor told me I had testicular cancer, I was devastated. I decided that I would do everything in my power to beat this disease. After discussing it with my doctor I decided to go ahead with chemotherapy. I knew there was a chance that I didn't need it, but I wanted to get it over with as soon as possible so I could continue with my life. Because my cancer was early-stage, the chemotherapy program wasn't very intensive. And the side effects were barely noticeable. That was a year ago, and I feel great. I know I made the right decision for me."
— Michael, age 31
"At first I couldn't believe what the doctor was telling me. How could I have cancer? I thought I was too young for something like that. After going through a period of denial and anger, I decided I was going to do whatever I could to beat it. My doctor said I was fortunate because we had caught it at an early stage. After orchiectomy, I was told I could either go for surgery to remove lymph nodes in my pelvis, have chemotherapy, or try surveillance. I decided to wait and see if my cancer was gone before having other treatment. I'm young and don't like the idea of having major surgery or chemotherapy if I don't have to, especially since they can cause other problems later on. The follow-up schedule has been hard to stick to at times. But it's been over a year, and the doctor says I'm still cancer-free, so I think it's been worth it."
— Sam, age 20
"After being diagnosed with a stage I nonseminoma, I decided to try a surveillance program after my orchiectomy. I made all of my follow-up appointments and felt confident that my cancer was gone for good. Well, about 8 months after I started the program, we found out that my cancer had spread to the lymph nodes in my pelvis. Now my doctor tells me that I'm going to need the surgery anyway and may also need chemotherapy to cure my cancer. I can't believe that the cancer came back. But my doctor says that my chances are really good that I will be cured. I hope he is right."
— David, age 33
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
I'm worried that if I have treatment, I may not be able to have children.
I'm willing to put up with the possibility of not having children if it means that my cancer will be cured for good.
A long schedule of regular checkups and tests during surveillance will be worth it if it means that I won't need to have other treatment.
I want to avoid chemotherapy.
I want to avoid surgery.
My other important reasons:
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
NOT using surveillance
NOT having chemotherapy
NOT having surgery
1. Does surveillance simply mean having a special test during your yearly checkup?
2. Are lymph node surgery and chemotherapy the surest ways to keep cancer from coming back?
3. If you're worried that chemotherapy or surgery will leave you infertile, can you bank your sperm ahead of time?
1. Do you understand the options available to you?
2. Are you clear about which benefits and side effects matter most to you?
3. Do you have enough support and advice from others to make a choice?
1. How sure do you feel right now about your decision?
2. Check what you need to do before you make this decision.
3. Use the following space to list questions, concerns, and next steps.
|Primary Medical Reviewer||E. Gregory Thompson, MD - Internal Medicine|
|Specialist Medical Reviewer||Christopher G. Wood, MD, FACS - Urology, Oncology|