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


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

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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 health professional will discuss your options for further treatment.

If you are diagnosed with seminoma testicular cancer and testing suggests that it has not spread beyond the testicles (testes), you might have choices. Your options may include a watchful waiting program, or radiation therapy or chemotherapy to kill any stray cancer cells. (For this type of cancer, chemotherapy is a newer treatment.1 It is mostly used in Europe.) Consider the following when making your decision:

These treatment options lead to about the same long-term survival in men with stage I seminoma. So your choice can be driven by what you think about the side effects and long-term effects of each.
If your biggest concern is that testicular cancer might come back elsewhere in your body (metastasize), consider radiation therapy. This treatment is the best option for completely wiping out this kind of cancer.
Treatments do have risks. Radiation can cause infertility and raises the risks of getting other cancers later in life. Chemotherapy can make you sick while you take it, and may also cause infertility. Watchful waiting allows you to avoid these risks, at least for now, but it could allow cancer to come back.
You could be one of the 1 in 4 men (about 25%) who get cancer again after a period of watchful waiting.2 If so, you may need to have more aggressive treatment than if you have radiation or chemotherapy right after your orchiectomy.
You can consider watchful waiting if you are willing to follow a schedule of regular checkups and CT scans. 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 you are worried that radiation or chemotherapy might harm your fertility, ask your doctor about sperm banking before treatment.
For information about treatment options for stage I nonseminoma testicular cancer, see:

Which treatment should I have for stage I nonseminoma testicular cancer?
Medical Information
What is stage I seminoma 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 (or NSGCTs). Unlike NSGCTs, seminoma cells die off when treated with radiation therapy.2 Seminomas are also less likely to spread (metastasize) to the lungs, liver, and brain.

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

Unlike many other kinds of cancer, most testicular cancers are slow-growing and respond well to common treatments (adjuvant therapies) such as chemotherapy and radiation therapy. However, adjuvant therapies may cause both short- and long-term side effects.

What are the treatment options for stage I seminomas?
Following orchiectomy, some stage I seminomas may be treated with radiation therapy, chemotherapy, or watchful waiting. (Chemotherapy for stage I seminoma is used mainly in Europe. But this type of medicine is available in the United States.)

Radiation therapy. Radiation is a common treatment for seminomas at all stages of the disease. Because the lymph nodes in the pelvis and lower back are the most common areas of metastasis for testicular cancers, radiation is often focused on that area. During the early phases of stage I seminoma testicular cancer, it can be very difficult to tell whether these lymph nodes are cancerous, which is why radiation may be used even when no cancer can be seen. Although it is uncommon, radiation therapy can cause long-term health conditions including infertility and an increased chance of developing cancer later in life.
Chemotherapy. Chemotherapy is the use of very powerful medicine that kills cancer cells. Carboplatin is considered a good choice for stage I seminoma. This is because its side effects are not as bad as some chemotherapy drugs, and it works well.1
Watchful waiting. This means you are being monitored closely by your doctor but are not receiving active treatment. You have a minimum of one CT scan every 3 months for 2 years following orchiectomy, along with frequent physical exams and blood tests. Assuming no recurrent cancer is found, the number of CT scans needed will gradually drop to about one per year after 4 to 7 years and should be unnecessary after 10 cancer-free years. This follow-up work can be difficult for some men to do. About 25% of men (1 out of 4) who choose watchful waiting for stage I seminomas develop cancer within 3 to 4 years and require additional treatment.3
In some cases of stage I disease, it has been shown that other treatment following surgery (adjuvant therapy) is unnecessary following orchiectomy because the cancer has not spread beyond the testes. In addition, even when cancer is discovered after a period of watchful waiting, it is often easily cured provided the follow-up schedule has been followed closely. Because of this, many health professionals consider watchful waiting a legitimate treatment option for some men with stage I testicular cancers.

What are the risks of radiation therapy?
Radiation therapy for testicular cancer has side effects. Most are short-term and do not pose any serious health threat. Other side effects, although uncommon, can permanently affect your lifestyle and future health. The most serious long-term risks associated with radiation therapy for testicular cancer include:

Infertility. Radiation may cause permanent infertility in some men. Because many men diagnosed with testicular cancer are younger than 35, fertility issues are often important in making treatment decisions. Although most radiation treatment programs do not permanently affect healthy sperm counts, many health professionals recommend sperm banking before orchiectomy for those men who may wish to have children in the future.
Secondary cancer. Cancers resulting from radiation therapy may include leukemia, as well as cancers of the colon, bladder, kidneys, and prostate. Radiation therapy, although focused on cancer cells, also exposes many of the body's healthy cells to harmful radiation. Because many men who undergo successful treatment for testicular cancer go on to live for decades, damage to the body's healthy cells caused by radiation may not become apparent until many years after treatment is completed.
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 health professional can use other medicines to help relieve some of these side effects.

Side effects of carboplatin include:

Decreased white blood counts. Red blood cell counts and platelet counts can also be reduced.
Nausea, vomiting, and loss of appetite.
Diarrhea or constipation.
Numbness and tingling in the hands or feet (peripheral neuropathy).
Hearing changes or hearing loss.
Mild rash.
Hair loss. This is reversible, and hair will grow back when treatment ends.
Mouth sores (stomatitis).
Changes in kidney and liver function tests.
You may not be able to father children after taking carboplatin. Discuss fertility with your doctor before starting treatment.

Carboplatin can cause birth defects. Do not use this medicine if you wish to father a child while you are taking it.

Do not use this medicine if you have:

Kidney or liver disease.
Chickenpox or shingles.
Hearing problems.
What are the risks of watchful waiting?
Perhaps the greatest risk of choosing watchful waiting for testicular cancer has to do with missing your follow-up tests and exams. Without regular testing and check-ups, you can miss recurrent cancer until it spreads beyond the lymph nodes and is more difficult to cure.

If you choose watchful waiting, it is very important to strictly follow your doctor's schedule of tests and exams.

About 25% of men (1 out of 4) who choose watchful waiting instead of radiation therapy following orchiectomy will have their cancer return.3 In most cases, the recurrent cancer is confined to lymph nodes in the lower back and pelvis and can be successfully treated if the follow-up schedule has been closely followed and the cancer is discovered when it first appears. However, cancer that reappears during watchful waiting may require treatment with more aggressive therapy (including chemotherapy or radiation) than if radiation therapy had been chosen immediately following orchiectomy.

Watchful waiting is a reasonable choice for many men with stage I seminoma testicular cancer. However, a successful watchful waiting program depends upon diligent follow-up care by you and your health professional.

Your Information
Your choices are:

Try watchful waiting.
Have radiation therapy.
Have chemotherapy.
The decision about whether to choose watchful waiting, radiation therapy, or chemotherapy takes into account your personal feelings and the medical facts.

Deciding about watchful waiting Reasons to choose watchful waiting Reasons not to choose watchful waiting
Orchiectomy alone cures testicular cancer in about 25% of men (1 out of 4)with stage I seminoma.3
You avoid the possible side effects related to radiation therapy or chemotherapy.
Are there other reasons you might want to choose watchful waiting?
If cancer returns, you may need more aggressive treatment than you would have needed if you had had treatment right after orchiectomy.
Watchful waiting involves a strict schedule of many appointments and tests that you may find difficult to follow.
Watchful waiting can be very stressful for people (patients, family, and friends) who are waiting to see if the cancer returns.
Are there other reasons you might not want to choose watchful waiting?

Deciding about radiation therapy Reasons to choose radiation therapy Reasons not to choose radiation therapy
Radiation therapy following orchiectomy cures stage I seminoma in 98% of men.3 4
The follow-up schedule is much shorter than with watchful waiting.
Are there other reasons you might want to choose radiation therapy?
Long-term side effects are uncommon but may include infertility and an increased chance of developing cancer later in life.
Are there other reasons you might not want to choose radiation therapy?

Deciding about chemotherapy Reasons to choose chemotherapy Reasons not to choose chemotherapy
For stage I seminomas, chemotherapy with carboplatin is as effective as radiation (4 years after treatment).1
Are there other reasons you might want to choose chemotherapy?
You do not have a doctor who offers chemotherapy for stage I seminoma.
Carboplatin can cause infertility.
If you father a child while you are taking carboplatin, your baby has a higher chance of having birth defects.
Are there other reasons you might not want to choose chemotherapy?

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 among watchful waiting, chemotherapy, and radiation therapy. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I am willing to risk having future health problems if it means that my testicular cancer will be cured for good.
Yes No Unsure
Radiation therapy or chemotherapy will fit into my busy life, and I can continue to work without needing to take a lot of time off for doctor visits and tests.
Yes No Unsure
I am concerned that if I have radiation therapy or chemotherapy, I may never be able to have children.
Yes No Unsure
I would like to avoid increasing my chance of developing another type of cancer later in life.
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 might not need radiation or chemotherapy to cure my cancer.
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 radiation therapy.

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

Leaning toward watchful waiting
Leaning toward treatment

Leaning toward chemotherapy
Leaning toward radiation therapy

Return to the topic Testicular Cancer.

Oliver RTD, et al. (2005). Radiotherapy versus single-dose carboplatin in adjuvant treatment of stage I seminoma: A randomized trial. Lancet, 366: 293–300.

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.

Small EJ, Torti FM (2002). Testis. In M Dollinger et al., eds., Everyone's Guide to Cancer Therapy, 4th ed., pp. 770–780. Kansas City: Andrews McMeel.

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