Which treatment should I have for stage I nonseminoma testicular cancer?

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Which treatment should I have for stage I nonseminoma testicular cancer?
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Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision
For most men faced with testicular cancer, surgery to remove the affected testicle (radical inguinal orchiectomy) is the first treatment. After you have completed this step, you and your doctor will discuss your options for further treatment.

If you are diagnosed with nonseminoma testicular cancer and tests suggest that it has not spread beyond the testicles (testes), you might have choices. Your options may include a watchful waiting program, chemotherapy to kill any stray cancer cells, or surgery to remove the lymph nodes in your lower back (retroperitoneal lymph node dissection, or RPLND). Consider the following when making your decision:

If your biggest concern is that testicular cancer might come back elsewhere in your body (metastasize), consider RPLND or chemotherapy. These treatments are the best options for completely eliminating the cancer.
RPLND surgery and chemotherapy do have risks. Watchful waiting allows you to avoid these risks, at least for now.
You could be one of the 1 out of 4 men who get cancer again after a period of watchful waiting.1 If so, you may need to have more aggressive treatment than if you have RPLND or chemotherapy right after your orchiectomy.
If you are willing to follow a schedule of regular checkups and tests, you can consider watchful waiting. If cancer comes back, it is important to treat it in its early stage.
If you want to avoid the intense follow-up required for watchful waiting but are worried that RPLND or chemotherapy might harm your fertility, ask your doctor about sperm banking before treatment.
For information about treatment options for stage I seminoma testicular cancer, see:

Which treatment should I have for stage I seminoma testicular cancer?
Medical Information
What is stage I nonseminoma testicular cancer?
Testicular cancer is a disease involving the uncontrolled growth of cells on or inside the testicles, or testes.

There are two main types of testicular cancer: seminoma and nonseminoma germ-cell tumors (also called NSGCTs). Unlike seminomas, nonseminomas tend to be very resistant to radiation therapy. Nonseminoma cells are also more likely to travel through the bloodstream to the lungs, liver, bones, and brain.

Stage I cancers are those that are believed to be confined to the testes, though in some cases they may have spread to the lymph nodes of the lower back (retroperitoneum) but are undetectable.

Both seminomas and nonseminomas are highly curable, especially if they are diagnosed and treated early. When compared to other forms of cancer, even those testicular cancers that have spread beyond the testes to other parts of the body have a very high cure rate.

What are the treatment choices for stage I nonseminoma germ-cell tumors?
Following orchiectomy, stage I nonseminoma germ-cell tumors (NSGCTs) are usually treated with additional surgery (RPLND), chemotherapy, or watchful waiting. NSGCTs are rarely treated with radiation therapy.

Retroperitoneal lymph node dissection (RPLND) is surgery to remove lymph nodes in the lower back and pelvis that may be cancerous. During the early phases of stage I nonseminoma testicular cancer, it can be very difficult to tell whether these lymph nodes are cancerous without surgically removing them first. In the past, RPLND was associated with high rates of infertility. Modern "nerve-sparing" and laparoscopic surgical techniques have lowered the chances of becoming infertile following RPLND.
Chemotherapy. Chemotherapy is the use of very powerful medicines to kill cancer cells. The most common chemotherapy used to treat nonseminoma testicular cancer is called cisplatin combination therapy and involves the use of several different medicines. This treatment varies in intensity and is often used for men whose cancer has spread beyond the testes to lymph nodes or other organs.
Watchful waiting means you are being monitored closely by your doctor but are not receiving active treatment such as surgery or chemotherapy. Men who choose watchful waiting for stage I nonseminomas usually undergo monthly physical exams, chest X-rays, and blood tests for the first year as well as one CT scan every 3 months. Assuming no recurrent cancer is found, the number of physical exams and blood and imaging tests will gradually decrease to about one per year after 5 years following orchiectomy.2 This follow-up work can be difficult for some people to do.
What are the risks of RPLND?
RPLND is a surgical procedure and carries all the risks of any major surgery, including:

Reactions to anesthesia or medicines.
Infection.
Bleeding.
RPLND can cause retrograde ejaculation, which can make you infertile. This can happen as a result of nerve damage caused by the surgery. With retrograde ejaculation, the semen flows from the prostate gland into the bladder rather than out through the penis.

Men with retrograde ejaculation typically do not have erection problems or difficulty enjoying sex.

Laparoscopic and other "nerve-sparing" techniques now used in many RPLND surgeries have greatly lowered the risk of retrograde ejaculation following RPLND. Studies show that 95% of men who have nerve-sparing RPLND have normal ejaculation after surgery.2 Nerve-sparing RPLND surgery may be more difficult or impossible for men who have previously had chemotherapy treatment for cancer. Talk to your doctor about whether nerve-sparing surgery is possible for you.

Other risks associated with RPLND include:1

Postoperative pain.
Chylous ascites, a condition in which digestive fluids collect inside the abdominal cavity. This may lead to abdominal pain and difficulty breathing.
Lymphedema, which is a collection of fluid that causes swelling (edema) in the arms and legs. This type of edema occurs when the amount of lymph fluid in a person's arm or leg exceeds the body's ability to remove it, and the fluid then collects in the tissues of the limb.
Excessive bleeding (hemorrhage).
Pulmonary embolism, which is a sudden blockage of arterial blood flow within the lung.
What are the risks of chemotherapy?
Chemotherapy affects rapidly growing cells in your body. Besides cancer cells, this includes blood cells, hair cells, and the cells that line your digestive tract. Common short-term side effects include nausea and vomiting, hair thinning or hair loss, mouth sores, diarrhea, and an increased chance of bleeding and infection. Many men do not have problems with these side effects. Other men have a great deal of difficulty. If you have problems, your doctor can use other medications to help relieve some of these side effects.

Although uncommon, combination chemotherapy for the treatment of testicular cancer has also been associated with serious long-term side effects including high blood pressure, increased cholesterol levels, kidney, heart, and lung damage, as well as increased risk of secondary cancers including leukemia and melanoma.2 1 (But these long-term side effects have been linked to higher doses of chemotherapy than are usually used for stage I testicular cancers.) Before beginning treatment, talk to your doctor about any concerns you may have regarding the long-term side effects of chemotherapy.

Chemotherapy for treatment of testicular cancer has been connected with permanent infertility in some men. Because the majority of men diagnosed with testicular cancer are younger than 35, fertility issues are often important in determining which treatment they receive. Most chemotherapy does not permanently affect healthy sperm counts, but many health professionals recommend sperm banking prior to any treatment for testicular cancer for those men who may wish to have children in the future. Talk to your doctor about any fertility concerns you may have.

What are the risks of watchful waiting?
About 25% of men (1 out of 4) who choose watchful waiting instead of RPLND following orchiectomy will have their cancer return and require chemotherapy.1 Watchful waiting is a reasonable choice for many men with stage I nonseminoma testicular cancer. However, watchful waiting depends upon diligent follow-up care by you and your doctor.

In most cases of careful watchful waiting, recurrent cancer is confined to lymph nodes in the lower back and pelvis. This can usually be successfully treated when the testing schedule has been closely followed and the cancer is discovered when it first appears.

Cancer that appears in the retroperitoneal lymph nodes during watchful waiting may require more aggressive therapy than if RPLND or chemotherapy had been chosen immediately following orchiectomy.

Your Information
Your choices are:

Have a retroperitoneal lymph node dissection (RPLND).
Have chemotherapy treatment.
Try watchful waiting.
The decision about whether to choose RPLND surgery, chemotherapy, or watchful waiting takes into account your personal feelings and the medical facts.

Stage I nonseminoma testicular cancer treatment choices

Retroperitoneal lymph node dissection (RPLND) Reasons to choose RPLND surgery Reasons not to choose RPLND surgery
Provides a very high rate of cure for stage I nonseminomas. More than 90% of men (9 out of 10) who have RPLND are cured of testicular cancer and require no further treatment.1
Newer "nerve-sparing" surgical techniques have greatly reduced the chance of becoming infertile.
There is a smaller chance that chemotherapy will be needed as a part of future treatment.
Are there other reasons you might want to choose RPLND surgery?
RPLND is considered a major surgery and as such, it involves some risk.
Even with nerve-sparing techniques, retrograde ejaculation and infertility results in 5% of cases (5 out of 100).2
Are there other reasons you might not want to choose RPLND surgery?

Chemotherapy Reasons to choose chemotherapy Reasons not to choose chemotherapy
Chemotherapy provides a very high cure rate for stage I nonseminomas. Nearly 100% of patients who have chemotherapy for stage I nonseminomas are cured of the disease.1
Chemotherapy given for stage I nonseminomas is usually at a low dose, so long-term side effects are rare.
Are there other reasons you might want to choose chemotherapy?
Although uncommon, chemotherapy can cause serious long-term health problems, including secondary cancers. These cancers may not appear until many years after treatment.
Surgery to remove damaged tissue or remaining cancer may be required after chemotherapy. In these cases, nerve-sparing techniques may not be possible.
Are there other reasons you might not want to choose chemotherapy?

Watchful waiting Reasons to choose watchful waiting Reasons not to choose watchful waiting
You may be able to avoid the risks and side effects associated with RPLND surgery and chemotherapy. About 75% of men (3 out of 4) who choose watchful waiting are cured and avoid the possible side effects of other therapies.1
Are there other reasons you might want to choose watchful waiting?
Watchful waiting entails a very intense and prolonged observation schedule that some men find difficult to follow.
If cancer does appear in the lymph nodes during watchful waiting, there is a greater chance that more intensive chemotherapy will be required to cure the disease and that RPLND will be necessary after chemotherapy.
Are there other reasons you might not want to choose watchful waiting?


These personal stories may help you make your decision.

Wise Health Decision
Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about choosing between watchful waiting, chemotherapy, and RPLND surgery. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I am concerned that if I have treatment, I may never be able to have children.
Yes No Unsure
I am willing to put up with the possibility of being unable to have children if it means that my testicular cancer will be cured for good.
Yes No Unsure
I am concerned that I won't be able to stick to my doctor's follow-up schedule if I choose watchful waiting.
Yes No Unsure
I am willing to put up with the stress of a watchful waiting program if it means I may not need additional surgery to cure my cancer.
Yes No Unsure
I am concerned that if I choose watchful waiting and my cancer returns, I may need more aggressive treatment than if I had chosen RPLND or chemotherapy to begin with.
Yes No Unsure

Use the following space to list any other important concerns you have about this decision.












What is your overall impression?
Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to choose watchful waiting, chemotherapy, or RPLND surgery.

Check the box below that represents your overall impression about your decision.

Leaning toward watchful waiting
Leaning toward treatment


Leaning toward RPLND
Leaning toward chemotherapy



Return to the topic Testicular Cancer.

References
Citations
Raghavan D (2003). Bladder, renal, and testicular cancer. In DC Dale, DD Federman, eds., Scientific American Medicine, vol. 3, part 12, chap. 14. New York: WebMD.

Vuky J, Motzer RJ (2003). Testicular germ cell cancer. In B Furie et al., eds., Clinical Hematology and Oncology, pp. 813–824. Philadelphia: Churchill Livingstone.
 

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